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Arjun Srinivasan, MD: “There’s a lot of potential for synergy between the infection prevention program and the antibiotic stewardship program.”
Arjun Srinivasan, MD, recently sat down with Infection Control Today® to discuss an effort led by the Centers for Disease Control and Prevention (CDC) to decrease inappropriate prescribing of antibiotics for community-acquired pneumonia (CAP) and urinary tract infections (UTIs) by 90% and the overprescribing of the antibiotics fluoroquinolones and vancomycin by 95% in hospitals. Srinivasan, the CDC’s associate director for health care association infection prevention programs, told us that one of the keys to reaching these goals in the next five years is robust antibiotic stewardship programs, which will need to include infection preventionists (IPs). “I think that the key is for the infection preventionists to make sure that they’re connected with their stewardship programs,” Srinivasan tells ICT®. “And I think in almost every instance where I interact with hospitals, that connection is already present, and it’s very strong.” To cite just one example: Clostridioides difficile. Srinivasan points out that “here’s a target that is very much a focus for the infection preventionist and an intervention that is very much a focus for the antibiotic stewardship programs. Both of them can come together to make progress on that outcome.”
Infection Control Today®: In broad strokes, could you explain to this beat reporter what the problem is and what the CDC plans to do about it?
Arjun Srinivasan, MD: You know, I think you summarized it very well. We know that antibiotics are overprescribed, overused in all health care settings in the United States, whether that’s hospitals, nursing homes, outpatient settings. But the question becomes: In order to really improved prescribing, the question that we need to ask is, well, where are antibiotics being overprescribed? For what conditions? And why are they being overprescribed? This study that was undertaken was really an attempt to answer those important questions. Because that gives us data for action. If we know where they’re being overprescribed and why they’re being overprescribed, we can then take steps and the providing community can take steps to make improvements. What we found in this study is that two of the reasons why antibiotics are most commonly prescribed in hospitals for respiratory tract infections, particularly community-acquired pneumonia, and urinary tract infections. Those are numbers one and two of the reasons why antibiotics are prescribed in hospitals. There is considerable opportunity to improve prescribing for both of those conditions. What this study found is that in over 70% of prescriptions for both community-acquired pneumonia and urinary tract infections, the therapy was not prescribed and delivered in a way that is in accordance with best practice guidelines. And that’s really what’s being measured here. What we say when you say we want to improve prescribing by 90%; what we’re saying is that 90% of the time we should be following the best practice guidelines. That’s the goal that you see set there. It’s to bring us in concordance with what the experts are telling us is the best way to prescribe.
Infection Control Today®: What’s fascinating is how much human nature comes into play here. Hand hygiene compliance has been dismal for decades. Does human nature come into play when it comes to overprescribing of antibiotics? Doctors just give in and give the patients what they’re demanding?
Srinivasan: You’re right. Behavior is front and center of what we work on in health care. Because so much of what we need to do in health care relies on human behavior. People have to do things. And we work very hard to help human behavior and, where we can, to even to remove remembering and behavior from the equation as best we can. But many of these actions—like you're saying hand hygiene, how you prescribe antibiotics—those are actions that people have to do. And anytime you have an action that someone has to do over and over again, it’s a system that needs support. When we think about antibiotic prescribing in the hospital setting, I really don’t think that patient requests for antibiotics factor in significantly there. I think that is a big
issue when you talk about outpatient settings, but much less so in hospitals. What we see in hospitals is some degree of inertia. This is the way we prescribed for a long time, people were taught, “Oh, give ten days or fourteen days of antibiotics. And the new data says that that’s overkill. You know, five to seven days is really enough. Five days in most cases of community acquired pneumonia. Some of this is education. It’s helping providers know. And then some of it is maybe building in systems. We’ve seen some places that have done things at the time of discharge. They have someone review the chart for the duration of prescription. A pharmacist takes a look and says, “Hey, you know, this person is diagnosed with community-acquired pneumonia. They’ve gotten five days of antibiotics, so they don’t need anything after they’ve been discharged.” And that’s a key gap that we saw in this study with most of the excess duration of therapy. In many cases the therapy is not in accordance with guidelines. The antibiotics are being given for too long. And in many cases, that excess therapy happens after the patient is gone. The patient’s been in the hospital, say, an average of four days. They need about one more day of antibiotics. But what happens is they oftentimes get a prescription for ten more days, or seven more days. So, some of it is building systems. You could think of alerts and prompts like when a patient has an admitting diagnosis of community-acquired pneumonia. We’ve got electronic health records in many hospitals now. When the provider goes in to do the discharge paperwork, maybe a prompt could come up and say, “Hey, this person’s gotten four days of therapy for antibiotics. Guidelines recommend just one more day. Would you like to prescribe guideline concordant therapy?” I think there’s a lot that we can do to help with human behavior and to build systems that will support the optimized therapy.
ICT®:You set some pretty high goals. But there’s no deadline, I noticed. Are you thinking about a deadline?
Srinivasan: Yes, we do have a national action plan for combating antibiotic resistance by bacteria. And that’s been done in phases, right? The first phase of that so-called CARB action plan was from 2015 to 2020. And the second phase is 2020 to 2025. In my opinion, I know it’s ambitious, but I think we should line up with that. I would love to see that by 2025 that we reach these targets of having 90% of prescribing be in accordance with best practice guidelines. I think our patients deserve that. These guidelines are written for a reason. They’re evidence based. This is the therapy that experts are telling us is the right therapy. It’s also important to note that the data in that study is older data. That is from 2015. It really predates a tremendous amount of work that’s been done on antibiotic stewardship and hospitals. Like if you go back to 2015, only about half the hospitals in the country had an antibiotic stewardship program that implemented all of what we call the CDC’s Core Elements of Antibiotic Stewardship programs. For 2019, the most recent year we have data for, that number was [85%]. So nearly a doubling [since 2014 in which it was 41%] of the number of hospitals that had stewardship programs that incorporated all of our core elements. I think that we’re probably in a much better place than we were in 2015. I think those goals, they remain ambitious, but like I said, every patient who comes into the hospital deserves to get the best therapy. And for these conditions, the best therapy is what’s put forward in the guidelines. And we think though there are situations where providers need to deviate from the guidelines, we think those situations should be rare—less than 10% of the time. That’s why we set that goal.
ICT®: As you know, a good portion of my readership comprises infection preventionists, many of whom have a nursing background. Do you envision them participating in stewardship programs in any way?
Srinivasan: Do you mean infection preventionists?
Srinivasan: Yes, very much. What we really envision is a kind of a stewardship program and the infection prevention program; they’re kind of equal partners in efforts to address antibiotic resistance. There’s a lot of, I think, co-dependencies between these programs. There’s a lot of potential for synergy between the infection prevention program and the antibiotic stewardship program. So absolutely, our vision is that those programs are working very, very closely together on all of these issues.
ICT®: How has antibiotic prescribing been during the COVID-19 pandemic?
Srinivasan: We have some data that’s been presented, and I believe it’s been posted. It was data that was presented to the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria—the PACCARB committee. And we at CDC have done some analysis of antibiotic prescribing during the COVID pandemic, and that data was shared. And I believe those slides are available on the PACCARB website. And what we found is exactly what you’re saying: That in the hospital setting, antibiotics that are commonly used for community-acquired pneumonia [azithromycin]—the use of those agents did rise a bit as COVID rates went up in the country. But they did go back down as COVID activity began to decrease. So there definitely was an increase in the prescribing of agents that we would think are probably being used for community-acquired pneumonia. I think a lot of that represents the fact that you had a lot more patients presenting to the hospital with signs and symptoms consistent with pneumonia. They had cough, they had fever, they had chest X-ray infiltrates. And in some of those instances, it was likely difficult to distinguish who had a true respiratory tract bacterial infection, and whose symptoms were only due to COVID. So not very surprising that we did see a rise in prescribing of those agents.
ICT®: How much of this do you attribute to defensive medicine?
Srinivasan: I don’t know. I think more of it is attributable to a either a lack of awareness of the guidelines, or people who are practicing medicine as they maybe learned it, and not as the experts are recommending it today. I don’t think a lot of it is: “Oh, I need to treat this patient for fourteen days. Because otherwise something bad is going to happen.” I think it’s largely people who aren’t aware that there are many, many studies that have been done. There’s a lot of evidence to say five days is sufficient. I am optimistic that we can really make great strides in improving prescribing by, one, educating people and letting them know, “Hey, these are the best practices that need to be in place.” And by, as we were talking about earlier, building better systems. How can we take advantage of electronic health records of these new stewardship programs of the expanded role of pharmacists in stewardship practices? How can we take advantage of all of that? To fix the system so that the system is built to deliver optimized prescribing.
ICT®: When you say guidelines, are you talking about CDC guidelines?
Srinivasan: The treatment guidelines are the Infectious Diseases Society of America guidelines. Those were the guidelines that we used as the benchmark comparison for appropriate antibiotic prescribing. Those guidelines are updated on a regular basis. And the updates, of course, are intended to bring in the latest and greatest information. And that’s why we really want people to be prescribing in accordance with those guidelines.
ICT®: The median age of the people from whom data were collected in the study was 67? Is this a problem for older people or does it cut across all demographics?
Srinivasan: It does cut across all age groups. The age bias in the data is because those are the people who tend to get hospitalized. What we see for overprescribing in younger people is that’s more reflected in outpatient settings. Because younger people, when they develop community-acquired pneumonia more often can be managed as outpatients. And so that’s where you see prescribing for younger people tends to be more outpatient prescribing. And we know that there’s a lot of opportunity to improve outpatient prescribing for respiratory tract infections as well.
ICT®: If you don’t mind, I’m going to circle back around to infection preventionists. The study came out. What do you suggest that they do with the data? How do they fit in? I guess it depends on the particular hospital.
Srinivasan: I think that the key is for the infection preventionists to make sure that they’re connected with their stewardship programs. And I think in almost every instance where I interact with hospitals, that connection is already present, and it’s very strong. But I think these data do help us understand that there are some great opportunities here. You know, when you think about it from an infection prevention standpoint: C diff is a big target. That’s an infection where antibiotic prescribing is a huge driver. This is a great opportunity to say, “Look, let’s take a look at our prescribing for community-acquired pneumonia or for urinary tract infections. Let’s see if we can improve that prescribing. And if we do that it may have a big impact on our C diff rates. So, here’s a target that is very much a focus for the infection preventionist and an intervention that is very much a focus for the antibiotic stewardship programs. Both of them can come together to make progress on that outcome.
This interview has been edited for clarity and length.