When Enough Really is Enough: Overuse of Antibiotics Increases Risks and Costs

By Michael J. Alkire

Antibiotic-resistant bacteria, considered one of the world’s most urgent public health problems, infect more than 2 million people in the U.S. each year and cause at least 23,000 annual deaths. The Centers for Disease Control and Prevention (CDC) estimates that antibiotic resistance results in direct healthcare costs of $20 billion annually.

In fact, the issue is so concerning that the Obama administration recently announced an executive order and national strategy to combat the growth of bacteria resistant to antibiotics – so-called “superbugs.” The Administration’s National Strategy to Combat Antibiotic-Resistant Bacteria punctuates the need for a coordinated effort to slow or prevent the spread of resistant infections and improve national surveillance, notification and diagnostics. It also points to a need for greater antibiotic stewardship to ensure we’re not overprescribing these drugs and inadvertently contributing to their resistance.

Antibiotics used to treat infections can reduce mortality and save lives. Administering a combination of antibiotics that fight different types of infections may increase the chances of lessening symptoms while waiting for disease culture results to be returned. A typical disease culture can take up to two days – a long time for someone with painful or uncomfortable symptoms – so physicians often prescribe a combination of antibiotics when a patient is first admitted and the type of infection is not yet known.

However, according to the CDC, up to half of patients treated in the U.S. receive unnecessary or inappropriate treatment, including the use of multiple intravenous (IV) antibiotics to treat the same infection when either one or neither would be the best approach.

New research conducted by the CDC and Premier, published in Infection Control and Hospital Epidemiology, affirms the need for targeted solutions to reduce overuse.

Using data from more than 500 U.S. hospitals to identify 23 potentially redundant or inappropriate combinations of antibiotics administered from 2008-2011, the research showed that 78 percent of hospitals had evidence of potentially unnecessary combinations of antibiotics being administered for two or more days over the time period. Most of these (70 percent of the cases) were for three specific IV drug combinations used to treat anaerobic infections. All of these drugs, used solely, treat the same types of bacteria. Thus, these instances are considered “never combinations,” as they have no added patient benefit than either of the antibiotics used alone.

These combinations resulted in nearly $13 million in potentially avoidable costs for IV antibiotics for the 500 hospitals, excluding the additional supply or labor costs in nursing or pharmacy or the costs associated with adverse drug events or complications. Administering unnecessary combinations of antibiotics could account for more than $165 million in spending that could have been saved if the sample is representative and extended across all U.S. hospitals. 

But overuse of antibiotics isn’t just an issue of cost. Unnecessary use of multiple antibiotics can also be harmful. Each antibiotic has side effects and risks of adverse drug events. The use of more than one antibiotic increases the risk of an adverse event and each combination may introduce risk for other complications, which in turn, further burdens healthcare costs. Inappropriate or overuse of antibiotics can also accelerate the growth of antibiotic-resistant bacteria, especially among antibiotics that are frequently prescribed to treat a wide range of infections. Research published this month in the Journal of the American Medical Association shows that, in a review of more than 11,000 patients at 183 hospitals, 1 in 7 were prescribed vancomycin, one of the antibiotics often associated with building resistance. 

Antimicrobial stewardship, a combination of coordinated interventions to monitor and improve the appropriate use of antibiotics, is an effective way to reduce resistance, patient harm and unjustified variation in healthcare costs. Hospitals that leverage antimicrobial stewardship programs, a key initiative behind the Administration’s new strategy, have consistently demonstrated decreases in antibiotic use with annual savings of up to $900,000.

The key to a comprehensive antimicrobial stewardship program, as well as reducing unnecessary variation in healthcare, is data. Without patient, supply and pharmacy data, it would be difficult or impossible to determine what care is redundant versus that which is worthwhile.

Data helps focus antimicrobial stewardship efforts by pointing clinicians to the conditions and antibiotics that are potentially being used inappropriately. Hospitals can use data to target a limited number of antibiotic combinations, such as those identified in the Premier/CDC research, to decrease unnecessary antibiotic use. Clinical surveillance systems that provide real-time alerts are an effective strategy to help health systems combat the growing threat of antimicrobial resistance. Clinicians can flag when “never combinations” or other potentially unnecessary combinations are ordered within their clinical surveillance solution to prevent overuse from occurring.

The “more is better” approach to providing medical care can result in increased costs without improving quality. Given the pressures on the healthcare industry and our health as a nation, it’s important we use the tools at our fingertips to determine when enough is enough. By using data to identify, target and eliminate the areas in which variation in care does not result in better outcomes, we can ensure equally strong clinical and financial health for patients and society.

Michael J. Alkire is chief operating officer (COO) for Premier, Inc., a healthcare performance improvement alliance helping hospitals and health systems provide better patient care while reducing costs. As COO, Alkire leads the continued integration of Premier’s clinical, financial, supply chain and operational performance improvement offerings helping member hospitals and health systems provide higher quality care at a better cost. Prior to serving as COO, Alkire was president of Premier Purchasing Partners, which offers group purchasing, supply chain and resource utilization services to hospitals and health systems.