Antibiotics Can Be Dangerous and Costly

Today the CDC released a report on their web site on the overuse of antibiotics and the dangers that poses.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0304a1.htm?s_cid=mm63e0304a1_w.  The infectious disease community has been aware of this problem for decades but has been unable to mobilize systemic action to address it because of the perception that generally antibiotic therapy is safe, relatively inexpensive, easy to prescribe, and critically important to save lives to be administered early.  With the CDC's announcement, the ongoing focus on patient safety and cost of healthcare,  and the additional funding by the federal government to address the concern also announced today, we the infectious diseases community are poised to deal with this issue. Lets briefly review the misperceptions

First antibiotics are generally safe.   Although broadly speaking and at first blush this appears to be true. The report by the CDC points out that one particularly bad complication of antibiotic therapy, Clostridium difficile, is epidemic in our country with over 250,000 cases developing in US hospitals, associated with up to 14,000 deaths and nearly $9 billion in excess costs.   Since most cases of Clostridium difficile are antibiotic associated they are not so safe for those people getting them.

Second although many antibiotics now in use in hospitals are generic and so the direct cost of antibiotic therapy has dropped, it is the indirect costs or downstream cost of the complications that we are concerned about.  Clostridium difficile is one striking example of the downstream cost of antibiotic therapy incorrectly used.   Another highlighted by the CDC is the impact of antimicrobial therapy on the development of "superbugs" bacteria resistant to all antibiotics.    This problem is part of the natural selection process that occurs in hospitals where antibiotics are overused.   When these superbugs cause infection patients are isolated costing more to provide care, they have limited or no options for treatment costing lives, and act as a vector for transmission to others costing even more.   These are not inexpensive therapies but indeed rather costly treatments when these downstream costs are included.

Unlike cancer chemotherapy, antibiotics are prescribed by clinicians with all types of training.  Indeed you can get antibiotics over the counter in many countries outside the US without a prescription.  Here in the US some antibiotics have been available at no cost in some of the large national pharmacies.  So indeed antibiotics have been easy to prescribe.  However it is not the prescribing we should be worried about.  It is the diagnosing we need to understand and here is the rub.   Many patients are given antibiotics for conditions that do not require antibiotic therapy.  The report highlights that more than 50% of hospitalized patients receive an antibiotic during their stay.  More than 1/3 receive them unnecessarily.   How many people get antibiotics for colds or flu, the majority of which are viral infections that do not require antibiotic therapy.   In the hospital the challenges are the use of antibiotics for too long a time period, for infections that do not require antibiotics, for conditions that are not infections, and the use of "broad spectrum" antibiotics when a more focused treatment would be appropriate.  These examples are more about making and understanding the right diagnosis to provide the right care which is not easy.

My last point, antibiotic treatment early in the setting of serious infection is important to saving lives underlies a lot of the concern of clinicians in over prescribing.   This critical and very true point again emphasizes the problem of the right diagnosis or circumstance to using antibiotics.  Many patients are continued on antibiotic therapy for no good reason simply because a patient appears improved, a major problem outlined in the report.  This pattern is borne from the uncertainty of a diagnosis, the uncertainty of risk to patient from infection and lack of recognition of risk from this approach - collectively all as a result of the unclear diagnosis.  A clinician skilled in diagnosis and consequences of serious infection will know what to start, how long to treat, and when to stop antibiotics treatment safely.

What are we to do?  The CDC has outlined a number of steps toward improving antibiotic use in hospitals, an Antibiotic Stewardship checklist.   It provides a roadmap toward improving use of antimicrobial therapy.   http://www.cdc.gov/getsmart/healthcare/implementation/checklist.html.  The top line items incorporated include senior leadership, clinical leadership, pharmacy leadership and appropriate team members.   All are critically important to the success but of absolute certainty is the role of the infectious disease clinician as the clinical leader on this team for the reasons I mentioned.  Now is the time for the leadership of the ID clinicians   We are the ones best able to create clarity from the uncertainties mentioned above.