Antibiotic Stewardship

Did you realise that at least 50 per cent of antibiotic use in Irish hospitals is inappropriate? One of the foremost concerns in modern medicine is antibiotic resistance. Antibiotics are the first line of defence against many infections but overusing or misusing them can cause more harm than good.

The HSE Health Protection Surveillance Centre (HPSC) has published an updated set of expert guidelines, to promote rational antibiotic prescribing in Irish hospitals. The recommendations range from the relevant structures and personnel that should be in place in all hospitals, to specific interventions that should be considered once essential structures are in place. The guidelines, if adhered to, will save money in the long run.

The Guidelines for Antimicrobial Stewardship in Hospitals in Ireland aim to cut antibiotic resistance and improve patient safety. They represent huge savings as the costs associated with people being infected with a resistant bug, can be enormous. Antibiotic stewardship, which implies quality prescribing, is distinguished from antibiotic control, which implies limiting use. The primary rationale for antibiotic stewardship is the prevention or reduction of antibiotic resistance.

The guidelines recommend the appointment of teams of clinical microbiologists, infectious disease consultants and antimicrobial pharmacists in every acute hospital across the country. Approximately 20 hospitals already have antibiotic pharmacists in place and these hospitals have seen the biggest reductions in antibiotic use. This scheme has the potential to make a real difference in the fight against hospital infections. I welcome it with open arms.

15 Responses to Antibiotic Stewardship

  1. Mike says:

    Hi Steph
    Do we know what causes Irish hospitals (and presumably Irish GPs too) to undertake irrational prescribing of antibiotics? Bad training in pharmacology? Pressure from patients to receive a ‘magic pill’?
    As the arms race against bacteria intensifies, (in the same way that use of chemicals in agriculture seems to never defeat the pests, for long) those nasty antiobiotic-resistant bacteria seem to effortlessly keep pace with human intervention.
    Mike

  2. Annb says:

    Your last paragraph hits the nail on the head and may in some way go to answer Mike’s questions. Most antibiotics prescribed are what’s known as broad spectrum, in other words non specific to the micro-organism which is present in the patient. Doctors don’t often have the expertise of antibiotic pharmacists who can isolate the exact strain in order to establish particular antibiotic efficacy. This results in a ‘Ready, Fire, Aim’ style of prescription where broad spectrum drugs are literally thrown at the problem, in the hope they might work. When they don’t work, a process of elimination is started, exposing the patient and their resident bug to a whole range of antibiotics thus reducing efficacy, increasing the risk of debilitating side effects (on which you could write a book, I’m sure) but also increasing the bug’s ability to resist whatever we throw at it.

    In germ warfare, we need to identify the enemy, identify its weak-spot and zap it with the most appropriate weapon. Otherwise, the bugs are only laughing at us!

  3. Grannymar says:

    The aim to cut antibiotic resistance needs to start in the GPs surgery. We have a campaign running for many years in NI that you don’t need a pill for every ill! Yet patients think in the health centre or the hospitals that if no pill or potion is prescribed, then the Drs are no good.

    How often is a patient exposed to two if not three antibiotics before being referred on to the next level. But then 60% of all prescribed medication does not work. The meds are prepared for MR & Mrs AVERAGE – but how many of us are average? Not many.

  4. Steph says:

    Mike – Lack of a rolling education programme on drug protocols, failure to have a multidisciplinary approach to antibiotic prescribing, lack of expert advice, overworked NCHDs, budget restrictions – I could on and on – these are all contributory factors to inappropriate prescribing.

    Some of the common errors with antibiotic usage include… administering antimicrobials for non-infectious syndromes; using broad-spectrum antibiotics instead of the appropriate narrow-spectrum antibiotics; and extending therapy durations beyond the recommended time frames.

    Research has shown that prudent antiobiotic prescribing needs a multidisciplinary approach, rather than an individual ‘expert’ approach. Lack of consultation results in inappropriate prescribing practices, including the wrong choice of antibiotics with incorrect dosage and duration of treatment. Interestingly, having 24 hour access to expert advice is considered the most important factor in promoting good antibiotic prescribing.

    The guidelines recommend the establishment of clear structures of responsibility and accountability for prescribing, the creation of multi-disciplinary antibiotic management teams and standard procedures for collecting information on antibiotic resistance.

    Ann – You’re spot on as always! Quality prescribing is the name of the game here.

    The guidelines state: “Targeted therapy should be used in preference to broad-spectrum antimicrobials unless there is a clear clinical reason (for example, mixed infections or life-threatening sepsis). The prescription of broad-spectrum antimicrobials should be reviewed as soon as possible and promptly switched to narrow-spectrum agents when sensitivity results become available. Mechanisms should be in place to control the prescribing of all new broad-spectrum antimicrobials.”

    I could indeed write a book about my personal experience of antibiotic resistance. The hospital where I receive treatment, already has a multidisciplinary team of clinical microbiologists and antimicrobial pharmacists in place. They are the reason why I’m still here to tell the tale!

    Grannymar – You’re absolutely right that there is a major problem with misuse and overuse of antibiotics in primary care. We, also, already have an antibiotic education programme operating in GPs practices. GPs are having to learn news ways to increase patient satisfaction without picking up their prescription pen.

    The guidelines published this week, relate purely to antibiotic prescribing in hospitals. Combined with aggressive infection control efforts, antibiotic stewardship programmes represent the best chance for the prevention and reduction of antibiotic resistance.

  5. Ian says:

    It would be interesting to know the level of self-medication that is additional to the over-prescription. Because of the exorbitant cost of seeing a GP – €60 around here – and the heretofore very expensive cost of medicines at pharmacies – there is an unknown number of people who stock up in Spain and other holiday destinations. I know of at least two families who buy Spanish antibiotics because they say it is too expensive to see the doctor.

  6. Steph says:

    Ian – You make a good point.

    I hope this survey carried out by SARI (Strategy for the Control of Antimicrobial Resistance in Ireland), goes some way to answering your question…

    http://short.ie/uqsq8d

    From what I’ve read, self-medication occurs most frequently in people with chronic conditions i.e. based on past prescriptions from a health professional. It’s highest in the southern and eastern countries of Europe which fits in with your theory of ‘over-the counter’ availability. Self-medication from ‘left-overs’ from a previous antibiotic prescription, is also significant.

    A study published in 2008 on – Determinants of self-medication with antibiotics in Europe, concluded…

    “Interventions aimed at preventing self-medication should include public education, enforcing regulations regarding the sale of antibiotics, and implementing laws for dispensing exact prescribed tablet quantities in pharmacies. Future studies to increase our understanding of determinants of self-medication with antibiotics should focus on individual-level factors such as doctor–patient relationships and patient satisfaction.”

    Note, there’s no mention of the high cost of seeing a GP which, I’m in agreement with you, is highly relevant.

  7. Baino says:

    I think it starts long before people are hospitalised. Some GP’s out here prescribe antibiotics ‘just in case’. I can’t tellyou the number of times I’ve declined them for something as simple as a cold. My son is already resistent to some of the broad spectrum antibiotics due to overprescription as a child. Why is it expensive to see a GP? Isn’t there a medicare rebate for those who do? We get 85% of the fee back and if you’re really short, the doctor will ‘bulk bill’ Medicare direct rather than charge the patient.

  8. The Irish (and everyone else) sound like they need to start taking a leaf out of the Norwegian’s books when it comes to the prescription of antibiotics.

  9. Steph says:

    Baino – GPs should be taught to limit the prescription of antibiotics to those who really need them and to educate patients on the dangers of antibiotic resistance, both to the individual and to society generally. Research has shown that pressure from patients is a major influence on prescribing patterns.

    As regards the cost of seeing a GP… health insurance in Ireland tends to be aimed at giving good inpatient cover while outpatient expenses are only partially covered. You can choose to focus on good outpatient cover instead of in-patient but it costs a fortune to be well-covered for both. Almost 50% of the population have no insurance cover at all.

    Everyone in my family has their own policy which has been prioritised according to individual needs. My own health insurance policy covers 100% in-patient expenses (public/private hospital) but when I consult my GP, I pay €55 upfront, of which the insurance company only considers €20-30 eligible. Eligible expenses are also subject to a significant annual excess before any reimbursement is made, so in effect you receive nothing back until/unless you’ve run up fairly major out-patient expenses.

    In reality, ‘private’ patients (non-medical card holders) are subsidising the smaller fee that GPs receive from the State for medical card patients.

    AV – I’ve no specific knowledge of prescribing practices in Norway though I’m aware that rates of antibiotic resistance are low in northern European countries, while rates are reaching disturbing levels in southern and central Europe. This fits in with Ian’s point (above) re over-the-counter availability of antibiotics in southern holiday destinations. The threat to public health from antibiotic resistance, should no longer be regarded as a national problem but rather a global problem that requires a coordinated effort.

  10. Pixie says:

    There was a prolific case in Canada a few years ago (if I can find a link to it I will add it later), where several patients successfully sued a GP who refused to prescribe them antibiotics for a common cold. This may have caused a lot of GPs to prescribe antibiotics unnecessarily.

    I also feel that patients need to be pro-active in their antibiotic usage. There is enough infromation out there in this day and age for us to start taking responsibility for our own health.

  11. Steph says:

    Pixie – Hello and welcome.

    I’d be really interested to read about that case. As I said above, research (see link below) carried out in Ireland (2009) into ‘antibiotic prescription practices of GPs’, has shown that pressure from patients is a major influence on prescribing patterns.

    http://www.imj.ie/Issue_detail.aspx?issueid=%20&pid=2636&type=Papers

    I agree with you entirely that patients need to become more pro-active in their own care and especially where antibiotic usage is concerned.

  12. Pixie says:

    Hi,

    Unfortunately I can’t find a link to that case I mentioned above. I remember reading about it in college as part of our nursing law classes.

    Working as a nurse, there have been times when I feel that a patient does not need antibiotics and have voiced my opinion. (eg: a patient with a wound infection with no systemic signs of infection was prescribed an antibiotic when an antimicrobial dressing and close monitoring would have sufficed). Usually, my opinion is deemed null and void by the medical staff, and then I have to go another route to try and avoid antibiotic usage, (contact pharmacist/microbiologist for a second opinion).

    I think they feel like conservative therapy is sometimes not enough and I think a lot of healthcare staff need to be educated on the appropriate use of antibiotics.

  13. Steph says:

    Pixie – Sorry for the delay in responding.

    In the scenario you describe, I wonder if fear of litigation is the real reason behind the decision to prescribe antibiotics? Could the pressure to discharge patients be to blame? Conservative therapy needs time. Or perhaps it’s simply a case of sticking to ‘text book’ medicine? You’re absolutely right though about the need for education re appropriate prescribing and this is exactly why antibiotic stewardship is to be welcomed.

    As a patient, I’m all for questioning medical decisions and I’m delighted to hear that nurses, like you, act on behalf of patients in this regard.

  14. Pixie says:

    Well Steph, I wouldn’t be doing my job as the patient’s advocate if I didn’t speak up!

    It’s funny that you mention “text book medicine”. I’ve observed that in most cases, healthcare staff often feel that they have to introduce antibiotics as a “pre-emptive strike” against infection, “just in case” it may spread into the blood stream, from a wound etc. Or sometimes a broad spectrum antibiotic is introduced, (maybe to initially treat a chest infection while we wait for culture and sensitivity to come back from the lab), and never adjusted when we know exactly what bacteria is causing the infection. This may be through human error or just plain old complacency, “ah sure it’s broad spectrum, it will be fine”…which leads to a whole new set of problems such as C.diff, MRSA, developing a sensitivity to antibiotics etc.

    As a nurse, it is often difficult to challenge this. More often then not I have been berrated for refusing to give antibiotics unnecessarily and contacting a second opinion. (Apparently nurses are not supposed to have opinions). That’s why I think it’s vital that patients know exactly what their treatment is and why it is being administered. I’m all for empowering patients, and I love to hear them asking questions.

  15. Steph says:

    Pixie – You’re talking to the already converted 🙂

    Having suffered an MRSA surgical wound infection and osteomyelitis as a result of antibiotic resistance, I question antibiotic prescribing very carefully. Any doctor who shows complacency when treating me with antibiotics, gets told (by me) in no uncertain terms to make sure they’ve done their homework.

    As a result of the emergence of antibiotic bugs, doctors are gradually taking more care not to use broad spectrum antibiotics but there is still a long way to go. Some members of the medical profession are not noted for their flexibility but with goodwill and the implementation of the new guidelines and procedures, patient care can be improved.

    Thanks for taking the time to join in the debate.

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