A new federal report on antibiotic use and stewardship in the United States stresses the need for an all-hands-on-deck approach, calling on all stakeholders to commit to stewardship efforts.
The 40-page report outlines progress and challenges for antibiotic use in outpatient settings, nursing homes, and hospitals and describes the CDC's strategies for improving stewardship in all three sectors. It also cites examples of effective stewardship initiatives by a number of states, institutions, and health systems.
"The United States has made progress in understanding antibiotic prescribing and use in health care and in the community. But there are many opportunities to improve," says the report, titled Antibiotic Use in the United States: Progress and Opportunities. It notes previous CDC estimates that antibiotic resistance contributes to 2 million illnesses and 23,000 deaths annually.
Mixed findings in outpatients
On the outpatient side, the report says antibiotic prescribing decreased by 5% from 2011 to 2014, but it restates the CDC's estimate that about 30% of all antibiotic prescriptions in outpatient settings—47 million per year—are unnecessary. The agency includes hospital emergency departments in the outpatient category.
Prescribing rates and trends vary considerably by age-group and region, the CDC reports. For example, prescriptions for children (ages 0 to 19) declined from 2011 to 2014, but rates for adults rose slightly. Also, rates were generally higher in the South and Appalachia than in the rest of the country.
Besides the problem of needless antibiotics, patients who need an antibiotic don't always get the most appropriate one, the report says. For example, a study by the CDC and the Pew Charitable Trusts of outpatient prescribing in 2010 and 2011 found that for sinus and middle ear infections and sore throats, recommended first-line antibiotics were used only 52% of the time.
The CDC released recommendations on antibiotic stewardship in outpatient settings last year, listing the "core elements" as commitment, action for policy and practice, tracking and reporting, and education and expertise.
Among examples of state health department programs to improve outpatient antibiotic stewardship, the report cites the Utah Department of Health's practice of publicly sharing data on one stewardship criterion. The department uses a Web site to report which clinics had the best and worst performance on antibiotic treatment for adults with acute bronchitis, which usually does not require antibiotics.
Prescription miscues in nursing homes
Data on antibiotic use in nursing homes are limited to a few small studies, but 50% to 75% of nursing home residents are treated with an antibiotic each year, the CDC says. The agency estimates that up to 75% of antibiotics prescribed in nursing homes are prescribed incorrectly.
One small CDC study, covering nine facilities, showed that 1 in 11 residents were on antibiotics on any given day, and nearly 38% of orders for antibiotics lacked important prescribing information. The report notes that inappropriate prescribing for nursing home residents can increase the already high risk of Clostridium difficile infection.
CDC recommendations on the core elements of antibiotic stewardship for nursing homes were released in 2015. The new report lists three examples of state and institutional programs to strengthen stewardship in nursing homes, including a California law that requires skilled nursing facilities to adopt and implement stewardship policies.
Increased vancomycin use in hospitals
As for hospitals, a 2016 study showed that overall antibiotic use didn't change between 2006 and 2012, but more than half of patients received at least one such drug, the report states. Moreover, use of some of the most powerful antibiotics increased significantly over that time, eg, 37% for carbapenems and 32% for vancomycin. Another study indicated that a third of hospital antibiotic prescriptions involve problems such as prescribing needlessly or without proper testing.
A CDC survey revealed that two out of three antibiotic courses in hospitals targeted one of three conditions: pneumonia, urinary tract infections, and skin infections. Because a number of ways to improve prescribing for these infections are already known, targeting this area could yield big improvements in antibiotic use, according to the report.
The CDC published its seven recommended core elements of hospital antibiotic stewardship in 2014, and it has set a goal of establishing stewardship programs in all US hospitals by 2020. In 2015, 48% of hospitals had programs including all seven elements. But full compliance is much more common among large hospitals than small ones, so the CDC worked with other groups to write guidance on implementing stewardship programs in small hospitals, the report notes.
The document gives several examples of health system and state efforts to improve hospital antibiotic use. For example, Ascension, the country's largest nonprofit health system, has made "swift progress" by embracing four strategies to support implementation of the CDC's core elements. As a result, Ascension hospitals have decreased their antibiotic use and logged a 15.9% drop in C difficile infections.
All hands on deck
For each of the three healthcare sectors (outpatient, nursing homes, hospitals), the report presents a page of information on how providers, patients, and families can support the optimal use of antibiotics and prevent infections. Outpatient providers, for example, are advised to talk with patients and families about when antibiotics are and are not needed and to discuss the risks of unnecessary prescribing, among other steps.
In conclusion, the report emphasizes that participation by all stakeholders is essential for improving antibiotic use: "Success will depend upon coordinated efforts to promote and adopt principles of responsible antibiotic prescribing and use across the globe, from government agencies, foundations, professional organizations, companies, health systems, hospitals, clinics, nursing homes, patients, and healthcare providers."
See also:
Full text of CDC report
CDC report landing page with links to related fact sheets
