Combating overuse of antibiotics remains a major public health concern. Their use is the most important factor leading to antibiotic resistance around the world, according to a Centers for Disease Control and Prevention alert issued last year. The CDC listed drug-resistant forms of Clostridium difficile, Enterobacteriaceae and Neisseria gonorrhoeae, as urgent threats to the healthcare system. Twelve others—including drug-resistant Staphylococcus aureus (MRSA), Enterococcus (VRE) and the fungus Candida—were listed as serious threats.
The federal agency estimates at least 2 million people in the U.S. each year become infected with drug-resistant bacteria and at least 23,000 die as a direct result. Over the past few years, the CDC, Food and Drug Administration and several medical specialty organizations through the Choosing Wisely campaign have issued warnings or recommendations to encourage safe use of antibiotics.
Using administrative data from Premier, the company’s researchers and the CDC’s associate director for Healthcare Associated Infection Prevention Programs, Dr. Arjun Srinivasan investigated the incidence and economic impact of potentially overused antibiotics used by hospitals between Jan. 1, 2008, and Dec. 31, 2011. Of the 505 hospitals included, researchers found evidence of “potentially inappropriate, redundant antimicrobial coverage” for 23 antimicrobial combinations in 78%, or 394 of the hospitals. This accounted for 32,507 individual cases of patients who received at least two consecutive days of one or more of the antibiotic combinations.
“Although there may be rare instances where the combinations we examined were appropriate, we believe that the vast majority of these cases represent avoidable duplication,” concluded the analysis published Wednesday in the journal Infection Control and Hospital Epidemiology. “There is no evidence to support the routine use of any of the combinations we analyzed.”
The study looked at three categories of drug combinations: antianaerobics, anti-MRSA and dual b-lactams.
High-frequency redundancies were observed in three antianaerobic regimens, accounting for 22,701 (70%) of the cases. Combinations of metronidazole and piperacillin-tazobactam accounted for 53% of all potentially redundant antianaerobic use.
For the anti-MRSA treatments, the vancomycin and linezolid combination accounted for 5% of total patients and use of the vancomycin and daptomycin combo accounted for 3%.
High-frequency dual b-lactam combinations accounted for 5% of all patients receiving dual therapies.
Researchers estimated that the total potential cost savings in drug costs that could be achieved by reducing use of the 17 most frequently overused combinations exceeded $12.9 million for the 398 hospitals. They estimate the cost savings could exceed $163 million if generalized to all U.S. community hospitals.
“This is all about using data to reduce costs and improve performance. And this study identified where providers should be looking at reducing IV antibiotic use first and foremost,” said Leslie Schultz, director of the Premier Safety Institute. The study did find that there was a decrease in the use of one combination (metronizadole & ampicillin-sulbactam) during the study period, which Shhultz says speaks to the effectiveness of guidelines to addess resistance of E coli to ampicillin-sulbactam issued in 2010 (PDF) by the Surgical Infection Society and the Infectious Diseases Society of America.
The Premier study authors support recommendations that encourage hospitals to develop lists of “never-combinations” that can be used to help flag when the drugs are ordered so that their use can be re-evaluated. Using two or more antibiotics to treat the same class of bacteria is rarely necessary, the researchers said. The findings can help focus and improve hospitals’ antimicrobial use by pointing clinicians to areas where potential overuse is highest, Schultz said.
A CDC Vital Signs report from March (PDF) found doctors in some hospitals may prescribe three times as many antibiotics as doctors in other hospitals for patients receiving the same type of care. Federal health officials this spring urged every hospital in the country to develop strong antibiotic stewardship programs that include commitment from hospital leadership; a physician who can act as an accountability leader; regular reporting on antibiotic use; and a way of monitoring prescribing and resistance patterns.
The presence of “nightmare bacterial infections” can be reduced dramatically by following best practices, said CDC Director Dr. Thomas Frieden. “We're not saying don't use them (antibiotics), we're saying to assess them systematically.”
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