New findings spur call to reduce improper antibiotic use in hospitals

Doctor examining chest x-ray
Doctor examining chest x-ray

Drazen Zigic / iStock

A national panel of experts is calling for steep reductions in inappropriate antibiotic use in hospitals in response to a new study that found that antibiotic treatments in hospital patients frequently deviates from recommendations.

The study, led by researchers from the Centers for Disease Control and Prevention (CDC) and published yesterday in JAMA Network Open, found that 56% of antibiotic use was unsupported in patients being treated at US hospitals in 2015 because the patients didn't have specific signs or symptoms of infections, the wrong antibiotic was prescribed, or the length of treatment was too long.

Specifically, the study found that 79% of all antibiotic treatments for community-acquired pneumonia (CAP) and 77% for urinary tract infections (UTIs) were inappropriate, while 46% of all fluoroquinolone and 27% of all intravenous vancomycin treatment was inappropriate.

Based on these findings, a panel convened by the Pew Charitable Trusts that includes infectious disease, public health, and antibiotic stewardship experts from the CDC and medical centers across the country has determined that inappropriate antibiotic treatments for CAP and UTIs could be reduced by 90%, while unnecessary fluoroquinolone and vancomycin use could be reduced by 95%.

Establishing a baseline

For the study, researchers from the CDC and health departments across the country analyzed data from a 2015 prevalence survey of patients in hospitals in 10 states that are part of the CDC's Emerging Infections Program (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee). Each hospital conducted the surveys from May to September 2015. The researchers collected medical data on eligible patients who had CAP, a UTI, or were treated with fluroquinolones or vancomycin, then evaluated the treatment using an antimicrobial quality assessment (AQUA).

The aim was to not only assess the appropriateness of these treatments, but to establish a baseline against which future hospital prescribing data, and antibiotic stewardship efforts,  can be measured. Nearly 60% of US hospital patients receive antibiotics during their stay, but this kind of large-scale study on the appropriateness of antibiotic prescribing in US hospitals has not been done before.

"Efforts to evaluate antimicrobial stewardship programs' effect on hospital antimicrobial use typically focus on volume rather than prescribing quality; it is not clear whether the volume of antimicrobial use correlates with appropriateness," the authors wrote.

David Hyun, MD, who directs Pew's antibiotic resistance project and was part of the panel that reviewed the results of the study, says those four categories were selected based on input from the panel and previous CDC research on the most common antibiotic prescribing events in US hospitals.

"Community-acquired pneumonia and urinary tract infections, and vancomycin and fluoroquinolones, were chosen because they were the most common indications and most common agents that are typically used across various US hospital settings, regardless of size and other hospital characteristics," he said.

More than half of treatment unsupported

Out of 12,299 patients, 1,566 from 192 hospitals were included in the AQUA analysis. A total of 219 were included on the CAP analysis, 452 in the UTI analysis, 550 in the fluoroquinolone analysis, and 403 in the vancomycin analysis.

Antibiotic treatment was considered supported—a proxy for appropriateness—if there was medical record evidence that the treatment was clinically indicated for the diagnosed infection, the selected antibiotic was consistent with guideline recommendations, and the duration was consistent with guideline recommendations. If the treatment did not meet one of these criteria, it was labeled unsupported.

Overall, the researchers determined that treatment was unsupported in 55.9% of patients. Among the CAP patients, antibiotic use was classified as unsupported in 79.5%, either because they were treated for 8 or more days (guidelines recommend 5 to 7 days) or because they were treated with an antibiotic that was not consistent with guideline recommendations. For UTI patients, antibiotic use was classified as unsupported in 76.8%, most commonly for lack of documented signs or symptoms of UTI, continued treatment without qualifying microbiologic evidence of infection, or excessive treatment duration.

Among the patients treated with fluoroquinolones, antibiotic prescribing was unsupported in 46.5%, most commonly because patients received more than 8 days of treatment without supporting microbiologic data. Intravenous vancomycin use was unsupported in 27.3% of patients, mainly because it was used in patients who did not appear to require it; they either didn't have vancomycin-susceptible pathogens or they could have been treated with another antibiotic.

The study authors note that the data are from just 10 states, and the results may not be generalizable. In addition, the data were collected in 2014, when only 41% of acute care hospitals had all seven of the core elements that the CDC recommends for successful stewardship programs in hospitals. As of 2018, 85% of hospitals reported having all seven elements.

Still, the findings indicate that antibiotic stewardship programs clearly need to be focused on tracking not just the overall quantity of antibiotic use, but also the quality of prescribing for specific conditions, said Lori Hicks, DO, Director of the CDC's Office of Antibiotic Stewardship and a member of the panel that reviewed the results.

"We anticipated there would be opportunity to improve antibiotic prescribing practices for the four prescribing scenarios, but we were a little surprised by the magnitude of the problem," she said. 

"These findings reinforce the need for robust hospital antibiotic stewardship programs that can help clinicians select recommended antibiotics for treatment, use the shortest effective duration of therapy, and re-assess the need for antibiotic therapy when results of diagnostic testing become available."

Targets aim to reduce unnecessary treatment

In their evaluation of these data, the panel of experts concluded that most of this inappropriate prescribing could be eliminated if treatment guidelines are followed, with exceptions.

For example, in the CAP and UTI patients who received unsupported treatment, they estimated that, in 10% of these cases, secondary complications or severe infections may have allowed for exceptions to treatment recommendations. They estimate that 5% of the patients who received fluoroquinolones or vancomycin unnecessarily may have had reason to be treated with these antibiotics.

"We were trying to take into consideration how much of this antibiotic prescribing that was observed may have been attributable to a clinically justifiable reason," Hyun said.

Hicks said that ensuring the appropriate duration of antibiotic treatment for CAP, and accurate diagnosis for UTIs, which are frequently over-diagnosed, will ensure progress toward these reduction targets. But she noted that the targets are intended to be ambitious.

"Targets can be a very useful call to action, and they send a unifying message to partners and stakeholders to work together to tackle a problem," she said.

The study authors say that one of the important outcomes of the study is that it establishes that this type of standardized assessment of prescribing quality can be used for large groups of hospitals and help gauge the success of national antibiotic stewardship initiatives. Hyun agrees.

"This gives us a method to track progress of antibiotic stewardship activities that are now coming online at a national level," he said. "And more importantly, with this baseline, we now have a target to shoot for and define what the finish line might look like…in terms of reducing inappropriate antibiotic use."

To reach these reduction targets, the panel suggests that public agencies and organizations that oversee quality of care at hospitals create policies that require specific standards for those programs, with an emphasis on reducing antibiotic prescribing in the four categories. Two such organizations are the Centers for Medicare and Medicaid Services and the Joint Commission, which both require US hospitals to have stewardship programs.

They also recommend that the CDC continue to encourage hospitals to report their antibiotic use to the National Healthcare Safety Network (NHSN). The NHSN's Antimicrobial Use option enables hospitals to track and compare their antibiotic use with other hospitals, and allows public health agencies to identify and monitor inappropriate prescribing patterns at national, state, and local levels.

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