What physicians need to know about antibiotic resistance

In late March, the White House released a new national plan to fight antibiotic resistance. The plan outlines goals for reducing antibiotic use and antibiotic-resistant infections over the next five years, including cutting Clostridium difficile cases by half and decreasing inappropriate antibiotic use by half in outpatient settings and by 20% in inpatient settings, according to Medscape.

The White House also detailed some of the ways President Barack Obama will use the $1.2 billion he has allocated to fighting and preventing antibiotic resistance in fiscal year 2016. Major priorities include advancing research and development of new antibiotics and alternative treatments as well as the development of rapid diagnostic tests to help health care professionals easily determine whether an infection is viral or bacterial.

To put together this plan, President Obama relied on the expertise of federal public health authorities, including Lauri Hicks, DO, the medical director of the CDC’s antibiotic use program. Dr. Hicks’ office assisted in the effort to assemble the White House’s plan.

For National Public Health Week (April 6-12), The DO talked to Dr. Hicks, who also serves on the AOA’s Bureau on Scientific Affairs and Public Health. Dr. Hicks spoke about her career, the CDC’s efforts and what physicians need to know about antibiotic resistance.

Before running an antibiotic use program, you worked in infectious diseases, epidemic intelligence and respiratory outbreak response. What drew you to these issues, and what specifically drew you to antibiotic resistance?

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I’ve always enjoyed the challenge of trying to solve a mystery or puzzle, and both infectious diseases and outbreak response require detective work. During my infectious diseases fellowship I was really surprised and overwhelmed by how many patients I treated who had antibiotic-resistant infections. When I returned to the CDC after my infectious diseases training, I really wanted to do something about this problem.

You’ve been running the CDC’s antibiotic-use program since 2008. What developments have you seen during that time in the world of antibiotic resistance, and what progress has the CDC made?

I run the CDC’s Get Smart: Know When Antibiotics Work program. Since 2008, we’ve encountered new forms of antibiotic-resistant bacteria, some of which have resulted in infections for which we have few or no options for treatment. This is a really scary problem.

The CDC has done a lot of work to put a number on the problem of antibiotic resistance in the U.S. for the first time. We now know that at least 2 million people here develop antibiotic-resistant infections each year, and 23,000 people die. We’ve made important progress toward understanding the scope of the problem. We’ve also made a lot of progress related to tracking antibiotic use and introducing antibiotic stewardship in health care.

What is antibiotic stewardship, and how can it help facilities reduce antibiotic resistance?

Antibiotic stewardship is all about making sure that the patient is getting an antibiotic only when he or she needs it, and if an antibiotic is needed, making sure that the right drug is prescribed at the right dose for the right duration. Stewardship can be implemented in any health care setting, whether we’re talking about a hospital or emergency department, urgent care center or a physician’s office.

There are many different types of approaches to antibiotic stewardship. Clinical decision support is one example: Health care professionals are provided with information that helps them decide whether an antibiotic is needed when they are seeing patients and making that decision. With the transition to electronic health records, prompts and information can be incorporated as physicians are entering information into the system. Clinical decision support can also be in the form of paper, where the prescriber has the information needed for that syndrome on paper.

Clinical decision support is just one example among the many different types of stewardship activities. Hospitals often put together a stewardship team, in which a number of different folks are evaluating antibiotic use and overseeing antibiotic prescribing in the hospital setting.

What are the top three things primary care physicians should know about antibiotics and antibiotic resistance?

First, historically we viewed antibiotics as miracle drugs, and they really are miracle drugs. But we also have to remember that they are not harmless. Approximately 500,000 Americans develop C. difficile infections each year. Most of these infections are caused by antibiotic use. Antibiotics are also the most common reason for visits to the emergency department for drug-related adverse events, particularly in children. We need to remember that antibiotics are important for the treatment of infections. We need to reserve them for the times when patients really need them, and avoid giving them in situations where they are not needed because they can contribute to the antibiotic resistance problem.

Secondly, upper respiratory infections are the most common reason an antibiotic is prescribed, yet most of these infections are caused by viruses, which should not be treated with antibiotics. Health care professionals often assume patients are seeking an antibiotic, and in some cases that’s true. But the majority of patients are just looking for an explanation and for some advice about what to do.

Finally, inappropriate antibiotic use and antibiotic resistance is not just a problem for very sick people in hospitals. Antibiotic resistance is now a common problem, and we are seeing it in young healthy people as well. The perception that this was just a problem in facilities where people are very sick is not necessarily true anymore. We’re seeing a lot of infections in the community now that are resistant to antibiotics.

Which physicians most need to be aware of and take steps to reduce antibiotic resistance? Why?

All physicians should be aware of this problem because most physicians do prescribe antibiotics. However, in terms of volume, primary care physicians prescribe more antibiotics than any other type of physician. So in terms of reducing the overuse of antibiotics that we’re seeing in the country, primary care physicians have an important role to play. They are often the physicians seeing the patients with upper respiratory infections. They are in a position to educate patients about when an antibiotic is not needed.

What advice would you give to medical students or young physicians who would like to one day be in your shoes?

I encourage medical students and young physicians to research the different types of career paths you can take. Public health is a very rewarding path, and I didn’t know much about it when I was in medical school. I learned more about it when I entered the Epidemic Intelligence Service program here at CDC, which is the disease detective program.

I’ve encountered very few DOs working in public health during my career, which is surprising. Osteopathic training is focused on prevention; our training provides a good foundation for a career in public health. More students and physicians in training should look into a career in public health as a possibility. I’d like to see more DOs taking this path.