Combating Resistance: Getting Smart About Antibiotics

Combating Resistance: Getting Smart About Antibiotics


WELCOME TO THE NOVEMBER SESSION
OF PUBLIC HEALTH GRAND ROUNDS. NEXT MONTH WE WILL HAVE TWO
GRAND ROUND SESSIONS INCLUDING A SPECIAL SESSION IN TWO WEEKS ON
ADVANCED DETECTION OF MOLECULAR DISEASES.
CONTINUATION CREDITS ARE AVAILABLE FOR PHYSICIANS,
NURSES, PHARMACISTS, HEALTH EDUCATEERS AND OTHERS.
GRAND ROUNDS IS ALSO AVAILABLE ON FACEBOOK, TWITTER AND
YOUTUBE. WE HAVE A NEW FEATURED VIDEO
SEGMENT CALLED BEYOND THE DATA POSTED SHORTLY AFTER THE
SESSION. SO OUR REGULAR AUDIENCE IS USED
TO COMPARISONS OF OUR SPEAKERS WITH MOVIE STARS.
FOR THIS MONTH WE HAVE SPEAKERS, MOST OF THEM WHO HAVE STARRED ON
TV OR THE WEB. LAURIE HICKS, DR. SHERRY LING.
SHE LOOKS PRETTY GOOD, PRETTY FASHIONABLE I WOULD SAY ON THAT.
AND THEN DR. FINKALSTEIN. THIS IS WHAT HE TOLD ME WHEN I
ASKED HIM FOR A VIDEO CLIP. AS YOU WILL HEAR ABOUT GRAND
ROUNDS IS PLEASED TO BE PART OF GET SMART ABOUT ANTIBIOTICS
WEEK. LOOK FOR MORE ON SCIENCE CLIPS,
CDC.GOV/GETSMART AND PRETTY MUCH EVERYWHERE, EVEN ON MY COFFEE
MUG. IMMEDIATELY FOLLOWING OUR FOUR
SPEAKERS WE WILL HAVE CONCLUDING REMARKS BY OUR DIRECTOR FOLLOWED
BY A Q&A SESSION. IT IS MY PLEASURE TO INTRODUCE
DR. LAURIE HICKS. [ APPLAUSE ]
THANK YOU, JOHN. GOOD AFTERNOON.
I AM LAURIE HICKS, MEDICAL DIRECTOR OF CDC’S GET SMART KNOW
WHEN ANTIBIOTICS WORK PROGRAM. I AM HERE TO DISCUSS THE
UNINTENDED CONSEQUENCES OF ANTIBIOTIC USE.
THE LIFE SAVING BENEFITS OF ANTIBIOTIC USE ARE UNDENIABLE.
SUBSTANTIALLY REDUCING DEATHS COMPARED TO ANTIBIOTIC ERA.
ALARMINGLY WE ARE FACING THE END OF THE ANTIBIOTIC ERA.
NO NEW ANTIBIOTIC CLASSES HAVE BEEN DEVELOPED IN OVER TEN YEARS
AND THE FREQUENCY OF ANTIBIOTIC INFECTIONS ARE DECREASING.
IN SOME INSTANCES THERE ARE SIMPLY NO OPTIONS FOR TREATMENT.
THAT IS WHY WE MUST TREAT ANTIBIOTICS AS PRECIOUS RESOURCE
TO ONLY BE USED WHEN ABSOLUTELY NECESSARY.
BEFORE WE DIG INTO SOME OF THE DETAILS ABOUT PRESCRIBING FOR
ADULTS AND CHILDREN WE SHOULD RECOGNIZE WHAT CONSTITUTES
APPROPRIATE PRESCRIBING. THERE IS BROAD CONSENSUS FOR
MULTIPLE PROFESSIONAL CERTIFIES AND CDC WITH SUPPORT MORE
TARGETED ANTIBIOTIC PRESCRIBING. IN PARTICULAR CONDITIONS FOR
WHICH ANTIBIOTICS ARE NOT ROUTINELY INDICATED ARE VIRAL
INFECTIONS INCLUDING COLDS AND BRONCHITIS.
RESEARCH HAS HELPED US CLARIFY THAT SOME TYPES OF INFECTIONS
FOR WHICH ANTIBIOTIC TREATMENT HAD BEEN ROUTINE CAN BE MANAGED
WITH WATCHFUL WAITING. WHENEVER POSSIBLE DIAGNOSTIC
TESTING SUCH AS A RAPID STRESS TEST SHOULD BE USED TO
DIFFERENTIATE BACTERIAL FROM VIRAL INFECTIONS TO GUIDE
PRESCRIBING. WHEN AN ANTIBIOTIC IS INDICATED
IT IS CRITICAL TO CHOOSE THE RECOMMENDED ANTIBIOTIC DOSE AND
DURATION TO TREAT THE INFECTION. THERE ARE UNINTENDED
CONSEQUENCES OF ANTIBIOTIC USE. ANTIBIOTIC ASSOCIATED ADVERSE
EVENTS RANGE FROM MINOR CONDITIONS SUCH AS RASH TO MUCH
MORE SEVERE SUCH AS SYSTEMIC ALLERGIC REACTION INCLUDING
ANAPHYLAXIS. ANTIBIOTICS ARE RESPONSIBLE FOR
ALMOST ONE OUT OF EVERY FIVE VISITS TO EMERGENCY ROOM VISITS
FOR ADVERSE DRUG EVENTS. THIS IS ESPECIALLY TRUE FOR
PEDIATRIC VISITS. THERE ARE SOME RECENT
FASCINATING BUT PRELIMINARY INFORMATION SUGGESTING A
POTENTIAL LINK BETWEEN ANTIBIOTIC USE AND OBESITY AND
CHRONIC DISEASE. ONE STUDY FOUND EXPOSURE TO
ANTIBIOTICS DURING THE FIRST SIX MONTHS OF LIFE WAS ASSOCIATED
WITH ELEVATED BODY MASS INDEX OR BMI LATER IN CHILDHOOD.
FURTHER STUDIES ARE NEEDED TO UNDERSTAND WHETHER THERE ARE
LONG-TERM IMPLICATIONS FOR BMI AND CARDIOVASCULAR DISEASE RISK
AND OTHER CHRONIC DISEASES. — A TYPE OF ADVERSE EVENT THAT
OCCURS AS A RESULT OF DISRUPTION OF NORMAL GUT BACTERIA.
LIKE OTHER SERIOUS COMPLICATIONS OF ANTIBIOTIC USE IT CAUSES
SIGNIFICANT MORBIDITY. LEADING TO AN ESTIMATED BILLION
DOLLARS IN MEDICAL COSTS. PERHAPS THE MOST IMPORTANT
UNINTEND UNINTEND CONSEQUENCE OF
ANTIBIOTIC USE IS ANTIBIOTIC RESISTANCE.
UNDER NORMAL CIRCUMSTANCES OUR BODIES ARE POPULATED WITH
MILLIONS OF BACTERIA AND A FEW ARE DRUG RESISTANT.
WHEN WE TAKE ANTIBIOTICS THE BACTERIA CAUSING THE ILLNESS IS
KILLED. NOW THE DRUG RESISTANCE BACTERIA
THAT ARE LEFT CAN GROW AND TAKE OVER.
FINALLY SOME BACTERIA CAN TRANSFER THEIR DRUG RESISTANCE
INFORMATION TO OTHER BACTERIA MAGNIFYING THE PROBLEM.
ANTIBIOTIC RESISTANCE IS INCREASINGLY COMMON PROBLEM
CAUSING AN ESTIMATED TWO MILLION ILLNESSES.
ANTIBIOTIC RESISTANT INFECTIONS ADD CONSIDERABLE COST TO THE
ALREADY OVERBURDENED U.S. HEALTH CARE SYSTEM.
THE TOTAL COST OF ANTIBIOTIC RESISTANCE TO THE U.S. ECONOMY
HAS BEEN DIFFICULT TO CALCULATE. THE CURRENT ESTIMATE IS $30
BILLION ANNUALLY IN EXCESS HEALTH CARE COSTS.
WHEN ADDITIONAL COSTS ARE ADDED THE TOTAL COST MAY BE AS HIGH AS
$35 BILLION FOR LOST OF PRODUCTIVITY PER YEAR.
AS THAT MULTIBILLION-DOLLAR FIGURE INDICATED THE DIRECT COST
OF ANTIBIOTIC RESISTANT INFECTIONS THAT WE PAY GOES
BEYOND JUST THE COST OF ANOTHER ANTIBIOTIC.
RESISTANT INFECTIONS REQUIRE PROLONGED AND COSTLIER
TREATMENTS, EXTEND HOSPITAL STAYS AND NECESSITATE ADDITIONAL
HEALTH CARE PROVIDER VISITS. TO HELP UNDERSTAND HOW WE GOT
HERE AND WHERE IMPROVEMENT IS NEEDED WE NEED TO LOOK AT WHAT
WE KNOW ABOUT ANTIBIOTIC PRESCRIBING IN THE U.S., THE
WHO, WHAT, WHEN AND WHERE. IN 2009 ANTIBIOTIC PRESCRIPTION
COSTS TOTALLED 10.7 BILLION. 62% OF THE COST AS THE RESULT OF
ANTIBIOTIC PRESCRIBING IN THE COMMUNITY FOLLOWED BY 3.6
BILLION IN HOSPITALS AND 527 MILLION IN NURSING HOMES AND
LO LONG-TERM CARE.
LET’S TAKE A CLOSER LOOK AT COMMUNITY PRESCRIBING PRACTICES.
PROVIDERS INCLUDING PHYSICIANS, PHYSICIAN ASSISTANTS AND NURSE
PRACTITIONERS PRESCRIBED 833 PRESCRIPTIONS PER 1,000 PERSONS,
ON AVERAGE MORE THAN 4 PRESCRIPTIONS FOR EVERY FIVE
PERSONS IN 2010. PRESCRIBING RATES BY AGE GROUP
WERE HIGHEST FOR PERSONS LESS THAN 10 AND GREATER THAN OR
EQUAL TO 65 YEARS OF AGE. WE WANTED TO UNDERSTAND HOWIOTIY
REGION SO WE LOOKED AT ANTIBIOTIC PRESCRIPTIONS PER
1,000 PERSONS OF ALL AGES BY STATE IN 2010.
WE LEARNED THAT STATE PRESCRIBING RATES VARY MARKEDLY
AND THAT SOME STATES HAD MORE THAN DOUBLE THE PRESCRIBING
RATES OF OTHERS. FOR EXAMPLE, THERE WERE 1,237
PRESCRIPTIONS PER 1,000 PERSONS IN WEST VIRGINIA COMPARED TO 529
PRESCRIPTIONS PER 1,000 PERSONS IN ALASKA.
A RECENT ANALYSIS OF PROVIDER PRESCRIBING PRACTICES FOR ADULTS
IN A COMMUNITY FIND ACUTE RESPIRATORY INFECTION IS THE
MOST COMMON REASON AN ADULT RECEIVES ANTIBIOTIC.
EVEN WHEN ANTIBIOTICS WERE INDICATED THE WRONG DRUG WAS
FREQUENTLY PRESCRIBED. GEOGRAPHIC VARIATION IN
PRESCRIBING WAS APPARENT. PROVIDERS IN THE SOUTH WERE MORE
LIKELY TO PRESCRIBE FOR CONDITIONS THAT DO NOT WARRANT
ANTIBIOTIC USE. PRESCRIBER’S PRESCRIBING
PRACTICES REVEAL SOME GOOD NEWS. PEDIATRIC PRESCRIBING HAS THE
DECLINED BY A FOURTH IN THE PAST DECADE.
MORE THAN HALF ARE FOR RESPIRATORY INFECTIONS LIKE
COMMON COLDS AND BRONCHITIS WHICH DON’T WARRANT ANTIBIOTIC
TREATMENT. IN AN EFFORT TO IMPROVE
ANTIBIOTIC USE IN THE COMMUNITY AND REDUCE UNINTENDED
CONSEQUENCES OF ANTIBIOTIC USE INCLUDING ANTIBIOTIC RESISTANCE
CDC LAUNCHED THE NATIONAL CAMPAIGN FOR APPROPRIATE
ANTIBIOTIC USE IN THE COMMUNITY IN 1995.
AND THIS WAS SUBSEQUENTLY RENAMED GET SMART, KNOW WHEN
ANTIBIOTICS WORK IN 2003. THE PROGRAM WORKS CLOSELY WITH A
VARIETY OF PARTNERS TO REDUCE UNNECESSARY ANTIBIOTIC USE IN
THE COMMUNITY AND THE CAMPAIGN FOCUSES ON INCREASING AWARENESS
ABOUT ANTIBIOTIC RESISTANCE AND APPROPRIATE USE AMONG HEALTH
CARE PROVIDERS AND THE GENERAL PUBLIC.
OUR ANNUAL OBSERVANCE, GET SMART ABOUT ANTIBIOTICS WEEK IS THIS
WEEK. THE OBSERVANCE IS INTENDED TO
INCREASE AWARENESS OF ANTIBIOTIC RESISTANCE AND THE IMPORTANCE OF
APPROPRIATE USE OF ANTIBIOTICS IN BOTH IN PATIENT AND OUT
PATIENT SETTINGS. USING COMMUNICATIONS AND WITH
OUR PARTNERS WE WORK TO ENGAGE THE MEDIA TO DISSEMNATE MESSAGES
USING TRADITIONAL AND SOCIAL MEDIA.
WE PARTNERED WITH A VARIETY OF ORGANIZATIONS INCLUDING PUBLIC
HEALTH AGENCIES IN THREE CONTINENTS IN MORE THAN 40
COUNTRIES HOSTING OBSERVANCES THIS WEEK.
EFFORTS TO IMPROVE ANTIBIOTIC USE IN THE COMMUNITY ALSO
INVOLVE ESTABLISHING NATIONAL HEALTHY PEOPLE GOALS FOR
PRESCRIBING. WE ARE BEGINNING TO SEE SOME
BENEFITS FROM EDUCATIONAL CAMPAIGNS LIKE GET SMART BUT
FURTHER IMPROVEMENT IS NEEDED. WHILE THE RATE OF ANTIBIOTIC
PRESCRIBING FOR PEDIATRIC EAR INFECTIONS IS DECREASES ON
TARGET TO MEET THE HEALTHY PEOPLE 2020 GOAL ANTIBIOTIC
PRESCRIBING FOR COMMON COLDS REMAINS JUST UNDER 30%.
WE SHOULD REMIND OURSELVES THAT IN AN IDEAL WORLD THIS NUMBER
SHOULD BE ZERO. SEPARATE FROM THE HEALTHY PEOPLE
GOALS CDC PLANS TO ESTABLISH A NATIONAL GOAL FOR REDUCTION IN
OUTPATIENT ANTIBIOTIC USE FOR PATIENTS OF ALL AGES BECAUSE
WHAT GETS MEASURED GETS DONE. IN SUMMARY WHILE ANTIBIOTICS
RETAIN THEIR STATUS OF ESSENTIAL MEDICAL TOOLS ANTIBIOTIC
RESISTANT INFECTIONS CONSTITUTE AN IMPORTANT PUBLIC HEALTH
PROBLEM REQUIRING AN URGENT PUBLIC HEALTH RESPONSE.
WHILE STUDIES IN OUTPATIENT SETTINGS SHOWED SOME PROGRESS IS
BEING MADE IN CURBING INAPPROPRIATE PRESCRIBING OUR
WORK HAS JUST BEGUN. IMPROVEMENT IS NEEDED.
CONTINUED MONITORING OF ANTIBIOTIC PRESCRIBING PATTERNS
TO IDENTIFY WHERE INTERVENTIONS ARE NEEDED, AN ON GOING MULTI
FACETTED EDUCATIONAL EFFORTS ARE CRUCIAL COMPONENTS OF A
RESPONSE. I WOULD LIKE TO INTRODUCE DR.
JONATHAN FINKELSTEIN.>>THANK YOU.
IT’S WONDERFUL TO BE HERE BOTH AS A PEDIATRICIAN AND RESEARCHER
IN THIS AREA TO TALK TO YOU BRIEFLY BOTH ABOUT SOME OF THE
PROGRESS WE HAVE MADE IN THE LAST DECADE AND POSSIBLE NEXT
STEPS IN PROMOTING JUDICIOUS ANTIBIOTIC USE IN THE COMMUNITY.
FIRST, LET’S STEP BACK AND THINK ABOUT THE GOAL WE ARE TRYING TO
REACH. NONE OF US IS TRYING TO
ELIMINATE ANTIBIOTIC USE, RATHERER WE SEEK TO ELIMINATE
THEIR USE IN SITUATIONS WHEN THERE IS ABSOLUTELY NO BENEFIT
TO THE PATIENT, FOR EXAMPLE, FOR VIRAL COLDS AND COUGHS INCLUDING
WHAT IS OFTEN REFERRED TO AS BRONCHITIS.
IN OTHER CASES WHERE ANTIBIOTICS MAY BE A VALUE WE WANT TO
BALANCE THE INDIVIDUAL BENEFITS THAT ARE OFTEN RELATIVELY SMALL
AGAINST BOTH INDIVIDUAL AND POPULATION RISKS.
BENEFITS MIGHT INCLUDE FASTER RESOLUTION OF AN ILLNESS AND WE
BALANCE IT AGAINST RISKS OF ALLERGIC REACTIONS, SIDE
EFFECTS, DEVELOPMENT OF ANTIBIOTIC ASSOCIATED INFECTIONS
AND OTHERS. IN ADDITION WE NEED TO CONSIDER
THE RISKS TO THE POPULATION OVERALL OF THE DEVELOPMENT OF
RESISTENT ORGANISMS. WE NEED TO FIND NEW WAYS TO
INCLUDE PATIENTS IN INFORMED DECISIONS ABOUT ANTIBIOTIC USE.
WE HAVE KNOWN FOR YEARS THAT PATIENT EXPECTATIONS AND
PREFERENCES AFFECT MEDICAL CARE. IN ONE STUDY IN PEDIATRIC
OFFICES IN 2003 MORE THAN 2 OUT OF 3 PARENTS OF CHILDREN WITH
RESPIRATORY ILLNESSES BELIEVED ANTIBIOTICS WERE NEEDED FOR
THEIR CHILD. IT IS NOT SURPRISING THAT
PHYSICIANS IN THOSE OFFICES WERE 21% MORE LIKELY TO PRESCRIBE AN
ANTIBIOTIC WHEN THEY PERCEIVED PARENTS WANTED ONE AND 32% MORE
LIKELY TO PRESCRIBE ONE FOR A VIRAL ILLNESS FOR WHICH
TREATMENT WAS FRANKLY UNNECESSARY.
MORE RECENTLY WE DID FOCUS GROUPS WITH PARENTS IN
MASSACHUSETTS. WHAT WAS STRIKING A DECADE AFTER
MANY OF THOSE STUDIES WAS THE DIVERSITY OF VIEWS WE HEARD.
WE SPOKE WITH 31 PARENTS FROM DIVERSE SOCIAL AND EDUCATIONAL
BACK GROUNDS. WE HEARD A NUMBER OF COMMENTS ON
THE LEFT THAT SUGGESTED PARENTS WOULD WANT ANTIBIOTICS EVEN IN
CASES WHERE WE MIGHT NOT THINK THEY ARE NEEDED.
ONE SAID WHEN YOUR KID IS SCREAMING AND GETTING FEVERS I
WOULDN’T FEEL COMFORTABLE FOR A DOCTOR TO TELL ME LET IT RUN ITS
COURSE. AND IN CONTRAST WE HEARD ABOUT
THE CONSEQUENCES AND FEARS OF ANTIBIOTIC OVERUSE.
WE ALSO SEE SIGNS OF PROGRESS IN SURVEYS WE DID OF PARENTS IN 20
O00 AND 2013. WE ASKED IF ANTIBIOTICS WERE
NEEDED FOR COLDS AND FLU, GREEN NASAL DISCHARGE AND DEEP COUGH
OR BRONCHITIS. THIS CHART SHOWS THE PERCENT
ANSWERING NEVER OR ALMOST NEVER, THE CORRECT ANSWER FOR ALL OF
THESE. ON THE LEFT YOU SEE MOST PARENTS
UNDERSTAND COLD AND FLU DO NOT RESPOND TO ANTIBIOTICS.
HOWEVER, IF YOU LOOK IN THE MIDDLE THERE IS IMPROVED
KNOWLEDGE ABOUT GREEN NASAL DISCHARGE AND THE FACT THAT THAT
DOES NOT REQUIRE ANTIBIOTIC TREATMENT.
BRONCHITIS IS ON THE RIGHT. WE SEE THAT KNOWLEDGE THAT
BRONCHITIS DOES NOT REQUIRE ANTIBIOTICS IS STILL QUITE LOW,
THAT WE ARE MAKING SMALL PROGRESS.
WHATEVER WE DO TO PROMOTE JUDICIOUS PRESCRIBES HAVE TO
ADDRESS PATIENT PERSPECTIVES ON THE LEFT AND CLINICIAN
PERSPECTIVES ON THE RIGHT. PATIENTS WANT SYMPTOMS RESOLVED
QUICKLY. THEY VALUE CLEAR EXPLANATIONS
AND HARBOR MISCONCEPTIONS. WE ARE SEEING INCREASING CONCERN
AMONG PATIENTS AND PARENTS WITH OVERUSE AND RESISTANCE.
CLINICIANS ON THE RIGHT RESPOND IN PART TO PERCEIVED PATIENT
EXPECTATIONS. DIAGNOSTIC UNCERTAINTY MAY
CONSIST OF OVERPRESCRIBING. CLINICIANS, TOO, ARE VERY
CONCERNED WITH OVERUSE AND RESISTANCE AS THEY SEE THE
CONSEQUENCES IN THEIR PATIENTS FIRST HAND, THE FACT THAT THESE
VIEWS ARE SHARED BY PATIENTS AND THOSE WHO PROVIDE HEALTH CARE IS
REAL REASON FOR HOPE. SO LET ME MOVE NOW TO AN EXAMPLE
IN WHICH WE HAVE REALLY MADE GREAT PROGRESS.
OVERALL THERE HAS BEEN A 25% TO 30% DECREASE IN ANTIBIOTIC USE
FOR YOUNG DECADE.
THIS HAS BEEN LARGELY DRIVEN BY A DECREASE IN PRESCRIPTIONS FOR
MIDDLE EAR INFECTIONS. WHAT IS INTERESTING IS THAT ONCE
A CHILD IS DIAGNOSED WITH AN EAR INFECTION, THE LIKELIHOOD THEY
WILL BE PRESCRIBED AN ANTIBIOTIC HAS REMAINED QUITE STABLE.
SO, THEN, HOW HAS THERE BEEN A DECREASE IN PRESCRIBING FOR
OTITUS OVERALL? THE ANSWER IS WE CLINICIANS HAVE
STOPPED MAKING THE DIAGNOSIS SO FREQUENTLY.
HOW DID THAT HAPPEN? HOW DID IT GO AWAY?
PROFESSIONAL GUIDE LINES HAVE HELPED.
AND THERE HAVE BEEN CONTRIBUTION OF THE INTRODUCTION OF
PNEUMOCOCCAL VACCINE RECOMMENDED IN 2000.
MOSTLY CLINICIANS HAVE CHANGED THEIR THRESHOLD FOR MAKING THIS
DIAGNOSIS LARGELY FOR CONCERNS OF ANTIBIOTIC OVERUSE.
DECREASING PRESCRIBING FOR BRONCHITIS IN ADULTS IS LESS
SUCCESSFUL. WHILE MOST RECOVER FROM
BRONCHITIS WITHOUT ANTIBIOTICS IT REMAINS THE LEAD REASON FOR
PRESCRIBIC. INTERVENTIONS HAVE INCLUDED
PATIENT EDUCATION IN CLINICAL SETTINGS AND CLINICAL DECISION
SUPPORT. WHILE SOME OF THESE HAVE HAD
SOME AFFECT RATES HAVE REMAINED HIGH.
DEEPLY HELD BELIEVES WILL BE GRADUAL.
GETTING PATIENTS TO FWLEEV T S MEDICINE WILL TAKE TIME AND
GETTING CLINICIANS TO CHANGE PRESCRIBING WILL OCCUR
GRADUALLY, AS WELL. HOW DO WE CHANGE PATIENT
EXPECTATIONS? PUBLIC HEALTH MESSAGES CAN HELP.
EDUCATION THROUGH PHYSICIAN OFFICES CAN BE PARTICULARLY
THE TRUST THAT IS ALREADY ESTABLISHED AS A SOURCE
FOR MEDICAL INFORMATION. THERE MAY BE A ROLE FOR
DISTRIBUTION OF MESSAGES IN PHARMACIES, CHILD CARE CENTERS
AND WORK PLACES, ALL OF WHICH HAVE AN INTEREST IN DECREASING
USE OF ANTIBIOTICS. THERE HAVE BEEN A NUMBER OF
LOCAL AND STATEWIDE PROGRAMS THAT HAVE DECREASED.
IN MASSACHUSETTS WE DID ONE EARLY IN THE DECADE AND FOUND IN
THE CONTROL COMMUNITIES ANTIBIOTIC USE WAS DECREASING
RAPIDLY, UP TO 20% OVER THE THREE YEARS LIKELY BECAUSE OF
ATTENTION IN THE PRESS AND PROFESSIONAL PRESS.
OUR MULTI-CHANNEL EFFORT ADDED A LITTLE MORE TO THE DOWNWARD
TREND WITH A 4% TO 7% DECREASE SEEN IN TODDLERS AND PRESCHOOL
CHILDREN. ON THE PROVIDER SIDE THERE HAVE
BEEN A RANGE OF STRATEGIES USED TO TRY TO DECREASE UNNECESSARY
PRESCRIBING ALL OF WHICH HAVE DEMONSTRATED SOME IMPACT.
CLEARLY SOME ARE MORE POTENT THAN OTHERS.
FEEDBACK OF CURRENT PRACTICE TO CLINICIANS IS BETTER SO THEY CAN
COMPARE THEMSELVES TO PEERS AND TO GOALS FOR APPROPRIATE
PRESCRIBING. ACADEMIC DETAILING AND OPINION
LEADER EDUCATION ARE STRATEGIES USED BY PHARMACEUTICAL
COMPANIES. THEY HAVE BEEN SUCCESSFUL, AS
WELL, IN THIS AREA. SO ARE COMPUTERS THE ANSWER?
ELECTRONIC DECISION SUPPORT DEMONSTRATED HERE HAS SOME
PROMISE BUT WE ARE STILL REALLY IN THE EARLY STAGES OF
UNDERSTANDING HOW IT CAN BE HELPFUL IN THIS CONTEXT.
A VERY RECENT STUDY IN EUROPE SHOWED SUCCESS IN DECREASING
ANTIBIOTIC PRESCRIBING THROUGH WEB-BASED TRAINING IN USE OF
DIAGNOSTIC TOOLS AND ADVANCED COMMUNICATION STRATEGIES FOR
PATIENTS WITH RESPIRATORY TRACT INFECTIONS.
WHILE EACH HAS HAD IMPACT WHAT WE LEARNED IS THAT COMBINING
SEVERAL INTERVENTIONS CONCURRENTLY OR PRESCRIBER
INTERVENTIONS WITH PATIENT EDUCATION HAVE BEEN MOST
SUCCESSFUL. WE HAVE LEARNED WHATEVER
STRATEGY IS USED IT WILL BE MOST EFFECTIVE IF TAILORED TO THE
SPECIFIC SETTING AND ATTITUDE OF TARGET AUDIENCE.
SO IN SUMMARY WE HAVE MADE SUBSTANTIAL PROGRESS IN REDUCING
UNNECESSARY ANTIBIOTIC PRESCRIBING FOR CONDITIONS AND
AGE GROUPS. AS DR. HICKS NOTED A VERY HIGH
FRACTION OF PRESCRIBING CONTINUES TO BE FOR LOW RISK
RESPIRATORY CONDITIONS FOR WHICH SYMPTOMATIC TREATMENT MAY BE
MORE APPROPRIATE. IT IS IMPORTANT THAT WE MOVE TO
THE NEXT LEVEL. DEVELOPMENT OF GUIDE LINES BY
CDC AND PROFESSIONAL SOCIETIES IS A GOOD FIRST STEP BUT DON’T
EXPECT THEM TO PASSIVELY DIFFUSE INTO PRACTICE.
WIDE SPREAD ADOPTION WILL REQUIRE ACTIVE IMPLEMENTATION
USING A MENU OF APPROACHES AND NEWER METHODS OF QUALITY
IMPROVEMENT CAN HELP US ACCELERATE THE SPREAD AND DESIGN
LOCALLY TAILORED INTERVENTIONS TO COMPLIMENT BROADER HEALTH
EFFORTS. AS WE MAKE HEALTH SYSTEMS
ACCOUNTABLE FOR CARE FOR LARGE POPULATIONS THEY SERVE WE HAVE
THE OPPORTUNITY TO DEVELOP NEW QUALITY MEASURES BOTH FOR
SPECIFIC CONDITIONS AND ALSO FOR ANTIBIOTIC PRESCRIBING RATES
OVERALL. ONCE WE HAVE THOSE WE CAN
COMPARE RATES BETWEEN INDIVIDUAL PRESCRIBEERS AND PRACTICES.
THIS WILL ALLOW US TO BENCHMARK PERFORMANCE ACROSS SYSTEMS AND
LEARN FROM THOSE WHO ARE KEEPING ANTIBIOTIC USE RATES LOW AND
ACHIEVING OPTIMAL HEALTH OUTCOMES.
FINALLY, WE HAVE TO KEEP WORKING TO ALIGN PATIENT EXPECTATION
WITH THE GOALS OF JUDICIOUS ANTIBIOTIC USE.
IT IS PROMISING THAT PATIENTS HOLD GENERAL BELIEVES CONSISTENT
WITH PRUDENT USE OF THE DRUGS BUT THEY SIMULTANEOUSLY CONTAIN
SOME MISCONCEPTIONS. WE HAVE TO REINVIGORATE
PARTNERSHIP BETWEEN PUBLIC HEALTH AND CLINICIANS.
OUR PATIENTS LEARN WHAT WE TEACH THEM ONE BY ONE.
WE NEED TO SEE CONTINUING EDUCATION OF THE PUBLIC AS A
WHOLE AS A LONGER TERM INVESTMENT BUT ONE THAT IS
ABSOLUTELY NECESSARY FOR SUCCESS IN DECREASING UNNECESSARILY
ANTIBIOTIC USE. THANK YOU.
OUR NEXT SPEAKER IS — [ APPLAUSE ]
>>>THANK YOU. I WOULD LIKE TO SHIFT OUR FOCUS
FROM TALKT ABOUT ANTIBIOTIC USE IN OUTPATIENT SETTINGS TO
ANTIBIOTIC USE IN INPATIENT SETTINGS LIKE HOSPITALS AND
NURSING HOMES. CDC’S GET SMART FOR HEALTH CARE
CAMPAIGN IS AIMEDT AT INPATIENT HEALTH CARE SETTINGS.
WE KNOW ANTIBIOTICS ARE USED FREQUENTLY IN HOSPITALS.
IN 2011 IN A SINGLE DAY POINT PREVALENCE SURVEY OF 200
HOSPITALS IN THE CDC’S EMERGING INFECTIONS PROGRAM WE FOUND
FULLY HALF OF ALL OF THE PATIENTS HOSPITALIZED ON THE DAY
OF THE SURVEY WERE RECEIVING ANTIBIOTICS.
THIS PERCENTAGE IS VERY CONSISTENT WITH MANY OTHER
STUDIES. AS YOU HEARD FROM DR. HICKS
ANTIBIOTIC OVERUSE HAS CONSEQUENCES.
THESE CONSEQUENCES CAN BE MORE SERIOUS IN HOSPITAL SETTINGS
WHERE PATIENTS ARE CONFINED TO THE SPACE.
IT HAS BEEN RECOGNIZED FOR MANY DECADES THAT ANTIBIOTIC USE IN
HOSPITALS IS FREQUENT AND OFTEN INAPPROPRIATE.
IT HAS BEEN ESTIMATED THAT UP TO 50% OF ANTIBIOTIC USE IN
HOSPITAL SETTINGS IS EITHER INAPPROPRIATE OR SUBOPTIMAL.
THE AUTHORS OF THIS STUDY EXAMINED THE COMMON CAUSES FOR
INAPPROPRIATE OR SUBOPTIMAL ANTIBIOTIC THERAPY AND FOUND
THEY TENDED TO FALL INTO THREE CATEGORIES, GIVEN FOR LONGER
THAN NEEDED, GIVEN TO TREAT INFECTIONS THAT DO NOT RESPOND
TO ANTIBIOTICS OR GIVEN IN RESPONSE TO CULTURE RESULTS THAT
DID NOT REPRESENT INFECTIONS. THE GOOD NEWS IS THAT THERE ARE
IMPRESSIVE BENEFITS THAT CAN COME FROM IMPROVING THE WAY WE
USE ANTIBIOTICS IN HOSPITALS. ONE OF THESE IS ONE THAT DR.
HICKS DESCRIBED. ONE OF THE MOST SERIOUS ADVERSE
EVENTS IS THE DEVELOPMENT OF ASSOCIATED DIARRHEA.
EVEN A BIGGER PROBLEM IN HOSPITALS WHERE IT CAN BE SPREAD
BETWEEN PATIENTS ON EQUIPMENT OR THE HANDS OF HEALTH CARE
WORKERS. WHEN PATIENTS WHO ARE EXPOSED
ALSO GET ANTIBIOTICS THAT KILL THEIR NORMAL GUT BACTERIA THE
RISK INCREASES DRAMATICALLY. GIVEN THE ANTIBIOTIC EXPOSURE IS
SUCH AN IMPORTANT RISK FOR GETTING IT IT STANDS TO REASON
THAT IMPROVING ANTIBIOTIC USE CAN REDUCE IT AND THIS HAS
INDEED BEEN DEMONSTRATED IN SEVERAL STUDIES.
THE DATA HERE ARE FROM ONE OF THE LARGEST AND MOST RECENT OF
THE STUDIES IN AROUND TO A NATIONAL EPIDEMIC OFFICIALS IN
ENGLAND HAVE MADE A EFFORT TO REDUCE THE RISK OF ANTIBIOTICS
COMMONLY CONNECTED WITH IT. THE GRAPH SHOWS SUBSTANTIAL
REDUCTIONS THEY HAVE SEEN IN THE USE OF THESE TWO ANTIBIOTICS
THROUGH EDUCATION AND IMPROVEMENT EFFORTS.
THE LIGHT BLUE LINE SHOWS THE DRAMATIC IMPACTS THIS HAS HAD IN
PATIENTS OVER 65 AT HIGH RISK FOR SEVERE COMPLICATIONS.
IN THE PAST SEVEN YEARS IMPROVEMENTS OF ANTIBIOTIC USE
IN ENGLAND HAVE LED TO 70% REDUCTION IN OLDER PATIENTS.
THIS REPRESENTS THOUSANDS OF PATIENTS WHO DID NOT GET
INFECTED AND LIKELY MANY LIVES SAVED.
WE KNOW THAT RESISTANCE ANTIBIOTICS WILL DEVELOP EVEN IF
WE USE ANTIBIOTICS PERFECTLY. STUDIES HAVE SHOWN THAT
OVERUSING ANTIBIOTICS SPEEDS THE DEVELOPMENT OF RESISTANCE.
CAN IMPROVEMENTS IN ANTIBIOTIC USE ACTUALLY REVERSE ANTIBIOTIC
RESISTANCE? THERE ARE A NUMBER OF STUDIES
THAT SUGGEST THE ANSWER TO THIS QUESTION IS YES.
HERE WE SEE THE RESULTS OF ONE SUCH STUDY WHERE INVESTIGATORS
LOOKED AT THE IMPACT OF A NEW POLICY THAT RESTRICTED THE USE
OF SEVERAL KEY ANTIBIOTICS AT ONE HOSPITAL.
THEY FOUND THAT RESISTANCE IN ONE KEY NEGATIVE BACTERIA
ACTUALLY WENT DOWN SIGNIFICANTLY AS ANTIBIOTIC USE DECLINED
FOLLOWING ANTIBIOTIC USE RESTRICTIONS.
IMPROVING THE USE OF ANTIBIOTICS CAN ALSO IMPROVE THE TREATMENT
OF OFTEN COMPLEX INFECTIONS SEEN IN HOSPITALIZED PATIENTS.
THIS DATA IS FROM A STUDY LOOKING AT INFECTION CURE RATES
AND TREATMENT CURE RATES FOLLOWING THE CREATION OF A
HOSPITAL PROGRAM DESIGNED TO HELP IMPROVE THE USE OF
ANTIBIOTICS. WITH INPUT FROM THIS PROGRAM
CLINICIANS WERE MORE LIKELY TO GIVE PATIENTS THE RIGHT
ANTIBIOTIC, RESULTING IN TWICE AS MANY PATIENTS GETTING CURED
OF INFECTIONS AND ALMOST FIVE TIMES PATIENTS SUFFERING A
TREATMENT FAILURE. IMPROVING USE ON ANTIBIOTICS IN
HOSPITALS HAS THE ADDED BENEFIT OF SAVING HOSPITALS MONEY.
MANY STUDIES DOCUMENTS INDICATE SIGNIFICANT SAVINGS.
OFTEN THE SAVINGS RUN INTO THE HUNDREDS OF THOUSANDS OF DOLLARS
PER YEAR. THE STUDY I HAVE SHOWN HERE AND
MANY OTHERS NOT ONLY DEMONSTRATE THE BENEFITS OF GETTING
ANTIBIOTIC USE IN HOSPITALS BUT HELP SHOW US SPECIFIC WAYS TO
ACCOMPLISH THAT TASK CONSISTENTLY ONE OF THE MOST
EFFECTIVE WAYS TO IMPROVE ANTIBIOTIC USE IN HOSPITALS IS
TO IMPLEMENT A PROGRAMT THAT IS FOCUSED ON THIS GOAL.
THESE PROGRAMS ARE CALLED ANTIBIOTIC STEWARDSHIP PROGRAMS.
GIVEN THE URGENT NEED TO IMPROVE ANTIBIOTIC USE IN HOSPITALS AND
THE PROVEN BENEFITS OF ANTIMICROBIAL PROGRAMS IN
ACCOMPLISHING THIS GOAL CDC BELIEVES ALL HOSPITALS SHOULD
HAVE SUCH PROGRAMS. WE RECOGNIZE HOSPITALS VARY IN
SIZE AND COMPLEXITY AND THESE WOULD LOOK DIFFERENT IN
DIFFERENT HOSPITALS. CDC IS WORKING ON A VARIETY OF
RESOURCES TO HELP MAKE HEALTH HOSPITALS START AND EXPAND
PROGRAMS INCLUDING GUIDANCE TO HELP DEFINE THE ELEMENTS AND
DEVELOPING TOOLS THAT WILL HELP HOSPITALS IMPLEMENT AND EXPAND
PROGRAMS. IN 2012 CDC LAUNCHED THE
ANTIBIOTIC USE MODULE OF A NATIONAL HEALTH CARE SAFETY
NETWORK. THIS ALLOWED HOSPITALS TO TRACK
ANTIBIOTIC USE, TO HELP FOCUS ON AN AREA OF A HOSPITAL WHERE USE
MIGHT BE TOO HIGH AND MONITOR EFFECTIVENESS OF EFFORTS TO
REDUCE USE. ANTIBIOTIC STEWARDSHIP PROGRAMS
ARE AN IMPORTANT STEP IN IMPROVING ANTIBIOTIC USE BUT
THEY ARE ONLY ONE PART OF A BIGGER SOLUTION.
TO ACHIEVE THE DRAMATIC IMPROVEMENTS OF ANTIBIOTIC USE
THAT WE SEEK WE NEED ALL HEALTH CARE PROVIDERS TO BECOME PART OF
EFFORTS TO IMPROVE ANTIBIOTIC USE.
PUBLIC HEALTH HAS A VITAL ROLE TO PLAY HERE.
WE MAY NOT PRESCRIBE ANTIBIOTICS TO HOSPITALIZED PATIENTS BUT CAN
HELP IMPROVE HOW THEY ARE PRESCRIBED.
ONE WAY WE CAN DO THAT IS TO HELP SHIFT THE VERY WAY WE
APPROACH THE PROBLEM OF ANTIBIOTIC MISUSE IN HOSPITALS.
FOR TOO LONG IMPROVING HOSPITAL ANTIBIOTIC USE HAS BEEN VIEWED
AS SOLE RESPONSIBILITY OF ANTIBIOTIC STEWARDSHIP PROGRAMS.
IN ORDER TO MAKE MAJOR IMPROVEMENTS IN ANTIBIOTIC USE
THAT WE SEEK WE NEED TO LEARN FROM OUR MODEL OF CONTROLLING
INFECTIONS IN HOSPITALS. HISTORICALLY PREVENTING
INFECTIONS IN HOSPITALS WAS CONSIDERED THE SOLE
RESPONSIBILITY OF A HOSPITAL’S INFECTION CONTROL PROGRAM.
HOWEVER, THESE PROGRAMS HAVE LIMITED STAFF AND, HENCE,
LIMITED IMPACT. THERE HAS RECENTLY BEEN A MAJOR
SHIFT IN THE WAY WE THINK ABOUT INFECTION PREVENTION IN
HOSPITALS. WE RECOGNIZE THAT PREVENTING
INFECTIONS IS A PRIMARY JOB OF THE CLINICIANS PROVIDING CARE.
THE INFECTION CONTROL PROGRAM IS RESPONSIBLE FOR TEACHING
CLINICIANS HOW TO PREVENT INFECTIONS AND THEN HELPING THEM
DO IT. THIS CHANGE IN PHILOSOPHY HAS
BEEN ONE OF THE KEY FACTORS IN THE DRAMATIC REDUCTIONS IN
HEALTH CARE ASSOCIATED INFECTIONS.
WE IN PUBLIC HEALTH NEED TO HIGHLIGHT THIS MODEL AND URGE
HOSPITALS TO FOLLOW IT TO IMPROVE ANTIBIOTIC USE.
PUBLIC HEALTH CAN PLAY A KEY ROLE IN CHANGING EFFORTS TO
IMPROVE ANTIBIOTIC USE IN HOSPITALS.
JUST AS WE HAVE DONE FOR INFECTION PREVENTION WE CAN WORK
TO RAISE AWARENESS OF THE PROBLEMS POSED BY ANTIBIOTIC
OVERUSE AND PROVEN SOLUTIONS TO THOSE PROBLEMS.
WE CAN ALSO PROVIDE EDUCATION AND TRAINING TO HELP HOSPITALS
AND PROVIDERS IMPROVE ANTIBIOTIC USE.
AND FINALLY WE CAN EXPAND EFFORTS TO IMPROVE ANTIBIOTIC
USE BY INVOLVING NEW PARTNERS. ONE KEY GROUP OF NEW PARTNERS
ARE HOSPITALS. PHYSICIANS WHO SPECIALIZE IN THE
TREATMENT OF HOSPITALIZED PATIENTS.
THEY ARE THE FASTEST GROWING MEDICAL SPECIALTY IN THE UNITED
STATES AND PROVIDE MORE THAN HALF OAF NONSURGICAL HOSPITAL
CARE FOR HOSPITAL PATIENTS. THIS MEANS THEY ALSO PRESCRIBE
THE MAJORITY OF ANTIBIOTICS IN HOSPITALS MAKING THEM AN
ESSENTIAL PARTNER IF WE WANT TO EXPAND EFFORTS TO IMPROVE
ANTIBIOTIC USE. BECAUSE HOSPITALS VIEW QUALITY
IMPROVEMENT EFFORTS AS PART OF THEIR CORE MISSION THEY ARE AN
IDEAL PARTNER IN HELPING WITH EFFORTS TO IMPROVE ANTIBIOTIC
USE. STATE HEALTH DEPARTMENTS CAN
PLAY A KEY ROLE IN OUR EFFORTS. OUR EXPERIENCE WITH PREVENTING
HEALTH CARE-ASSOCIATED INFECTIONS DEMONSTRATE STATE AND
LOCAL HEALTH CARE PERSONNEL CAN MAKE SIGNIFICANT CONTRIBUTIONS TO IMPROVING CARE.
THESE CAN BE BROUGHT TO BEAR TO IMPROVE ANTIBIOTIC USE IN
HOSPITALS. A 2013 SURVEY BY THE ASSOCIATION
OF STATE AND TERRITORIAL HEALTH OFFICERS REVEALED THAT ALREADY
SEVERAL STATE HEALTH DEPARTMENTS ARE ENGAGED.
ONE STATE, CALIFORNIA, HAS PASSED LEGISLATION REQUIRING
THAT HOSPITALS TAKE ACTION TO ENSURE JUDICIOUS USE OF
ANTIBIOTICs AND MANY OTHER STATES ARE EVALUATING SUCH
POLICIES. IN SUMMARY I HOPE I HAVE
CONVINCED YOU THAT ANTIBIOTICS ARE USED COMMONLY IN HOSPITALS,
THAT ANTIBIOTICS ARE OFTEN MISUSED IN HOSPITALS AND THAT
THERE ARE IMPORTANT BENEFITS TO IMPROVING THE USE OF ANTIBIOTICS
IN HOSPITALS. ANDT THAT PUBLIC HEALTH CAN PLAY
A KEY ROLE IN EXPANDING EFFORTS TO IMPROVE ANTIBIOTIC USE IN
HOSPITALS. I WOULD LIKE TO TURN IT OVER TO
DR. SHERRY LING. [ APPLAUSE ]
>>>THANK YOU AND GOOD AFTERNOON.
SO LET ME BEGIN BY SAYING THANK YOU FOR INCLUDING US IN THIS
REALLY LANDMARK PRESENTATION. AND I AM DELIGHTED TO HAVE THE
OPPORTUNITY TO TALK ABOUT PROGRAMS AS MECHANISMS TO
PROMOTE APPROPRIATE ANTIBIOTIC USE.
SO IN THE NEXT FEW MINUTES I WILL PROVIDE AN OVERVIEW OF THE
REASONS THATTAC USE AND APPROPRIATE USE OF ANTIBIOTICS
IS IMPORTANT TO THE CENTER FOR MEDICARE AND MEDICAID SERVICES
AND TO OUR HEALTH SERVICE IN GENERAL.
I WILL COVER APPROACHES AND STRATEGIES THAT ARE AVAILABLE TO
INFLUENCE ANTIBIOTIC USE. AND I MAKE THE CONCLUDING POINT
OF A BALANCED APPROACH IS NEEDED THAT RECOGNIZES THE REALITIES OF
CLINICAL PRACTICE AND BUILT ON STATE-OF-THE-ART EVIDENCE.
SO I REMIND YOU THAT THE CENTERS FOR MEDICAID AND MEDICARE
SERVICES ARE RESPONSIBLE FOR THE CARE AND KEEPING OF ROUGHLY ONE
IN THREE AMERICANS. AND THAT NUMBER IS ACTUALLY
INCREASING DAY TO DAY. AND THAT THE CENTERS TR MEDICAID
AND MEDICARE MISSION IS TO PURSUE THREE AIMS TO DELIVER
BETTER CARE, PROVIDE CARE OF HIGHER QUALITY, TO BE ABLE TO
ATTAIN HEALTHIER POPULATIONS. I THINK THAT IS WHERE OUR
COLLABORATION REALLY CAN BE FRUITFUL IN IMPROVING THE HEALTH
OF THE POPULATION. AND THE THIRD OF WHICH BEING
REDUCING THE QUALITY OF COST OF CARE THROUGH IMPROVEMENT IN
QUALITY. SO THE NATIONAL QUALITY STRATEGY
REALLY HELPS US FOCUS OUR MEASUREMENT ALONG THE PATH TO
ACHIEVING THE THREE AIMS JUST ARTICULATED, THAT IS BETTER
CARE, HEALTHIER POPULATIONS AND LOWER COSTS THROUGH IMPROVEMENT
OF QUALITY BUT ALSO ALIGNS ACCORDING TO SIX PRIORITIES.
THOSE PRIORITIES BEING MAKING CARE SAFER BY REDUCING THE HARM
THAT IS CAUSED IN THE DELIVERY OF CARE.
THIS LIKELY IS THE PRIORITY THAT IS MOST CLOSELY LINKED TO
ENCOURAGING APPROPRIATE ANTIBIOTIC USE.
BUT JUST BY WAY OF CONTEXT WE ALSO POINT OUT THAT PRIORITIES
INCLUDE INSURING THAT EACH PERSON AND FAMILY ARE ENGAGED AS
PARTNERS IN THEIR CARE, IN PROMOTING EFFECTIVE
COMMUNICATION COORDINATION STRATEGIES AS PATIENTS AND
FAMILIY IES TRAVERSE THE HEALTH CARE SYSTEM.
TO PROMOTE PREVENTION FOR LEADING CAUSES OF MORTALITY.
AND WORKING WITH COMMUNITIES TO PROMOTE WIDE SPREAD USE OF BEST
PRACTICES TO ENABLE HEALTHY LIVING.
AND FINALLY, PRIORITY OF MAKING CARE MORE AFFORDABLE TO
INDIVIDUALS AND FAMILIES BY IMPROVING THE QUALITY OF THAT
CARE. SO THERE ARE PRINCIPLES THAT ARE
IMPLICIT IN THE CMS PROGRAM THAT INCLUDE THAT THE PROGRAMS AND
POLICIES WIWILL HONORER AND BE BUILT UPON A FOUNDATION OF
STATE-OF-THE-ART EVIDENCE. AND THAT EVIDENCE CAN COME BY
WAY OF CLINICAL GUIDE LINES, BEST PRACTICES AND RESEARCH
FINDINGS AND FINDINGS FROM THE FIELD THROUGH QUALITY
IMPROVEMENT BUT ALSO CMS WELCOMES INPUT FOR THE SELECTION
FOR MEASURES FOR IMPLEMENTATION AND CONSTRUCTIVE MEASURES FROM
THE EXPERTS. THAT IS EXPERT GUIDE LINES.
WE CERTAINLY HAVE EMBRACED AND IMPLEMENTED MEASURES OF QUALITY
ACROSS THE CARE SETTING IN CLOSE COLLABORATION WITH OUR PARTNERS
HERE AT CDC AND ALSO MEDICAL SPECIALTIES, IMPORTANTLY PROGRAM
PRINCIPLES, ALSO, ARE BUILT UPON A DATA-DRIVEN APPROACH TOWARDS
IMPROVEMENT. IMPROVEMENT IN HEALTH CARE
TOWARDS BETTER OUTCOMES FOR THE PATIENTS AND FAMILIES THAT WE
SERVE. WE HAVE STARTED WITH BUILDING
AND IMPLEMENTING MEASURES OF QUALITY, QUALITY OF CARE WITH A
FOCUS ON HEALTH CARE-ACQUIRED CONDITIONS AND OF ANTIBIOTIC
USE. WHAT I HAVE DEPICTED HERE IS THE
LANDSCAPE OF QUALITY REPORTING. AND TO MY LEFT AND YOUR LEFT IS
THE HOSPITAL REPORTING THAT HAS EXPANDED FROM IN PATIENT AND OUT
PATIENT SETTINGS TO NOW INCLUDE IN PATIENT PSYCHIATRIC
FACILITIES INCLUDING THOSE THAT SERVE FOR HIGH QUALITY CANCER
CARE AND PHYSICIAN RECORDING PROGRAMS INCLUDING THE PHYSICIAN
QUALITY REPORTING SYSTEM AND MEANINGFUL USE TO ENCOURAGE USE
OF HEALTH INFORMATION AND TECHNOLOGY AND POST ACUTE CARE
SETTINGS WHICH INCLUDE HOME HEALTH AGENCIES, END STAGE RENAL
FACILITIES, IN PATIENT REHAB FACILITIES, LONG-TERM CARE ACUTE
HOSPITALS AND ARE VENTURING INTO THE AREA OF POPULATION
HEALTH-BASED QUALITY REPORTING WITH MINDFUL ATTENTION TO THE
NEED TO BE ABLE TO MEASURE AT THE LEVEL OF COMMUNITIES AND
HEALTH PLANS. I HAVE ALSO HIGHLIGHTED FOR YOU
THAT QUALITY REPORTING IS ACTUALLY THE FOUNDATION UPON
WHICH VALUE-BASED PURCHASING IS BEING CONSTRUCTED.
THE FIRST TWO SETTINGS OF WHICH HAVE BEEN THE QUALITY INCENTIVE
PROGRAM FOR END STAGE RENAL FACILITIES AND ACUTE HOSPITALS.
BUT AS FAR AS THE COMPLETE LANDSCAPE OF CMS PROGRAMS I WANT
TO HIGHLIGHT A COUPLE. I HAVE ALREADY MENTIONED THE
QUALITY REPORTING PROGRAMS FOR IN PATIENT AND OUT PATIENT
FACILITIES THAT MINDFULLY ALREADY INCLUDE MEASUREST THAT
ADDRESS APPROPRIATE ANTIBIOTIC USE EITHER IN CONTEXT OF
SURGICAL CARE IMPROVEMENT PRACTICES OR MORE GENERALLY,
DATA AND QUALITY MUST BE AVAILABLE AND USABLE AT THE SITE
OF CARE AND DRAW TOWARDS IMPROVEMENT OF QUALITY.
SO IMPROVEMENT OF QUALITY CAN BE IMPLEMENTED THROUGH OUR WORK
WITH QUALITY IMPROVEMENT ORGANIZATIONS AND ALERTING AND
ACTION NETWORKS THAT CAN ENCOURAGE APPROPRIATE USE
INCLUDING DISCUSSIONS AND TOOLS TO UTILIZE INCLUDING ANTIBIOTIC
STEWARDSHIP PROGRAMS. AND FINALLY, CONDITIONS OF
PARTICIPATION WHICH DESCRIBE THE MINIMUM STANDARDS AND
EXPECTATIONS FOR ALL CARE FACILITY TYPES FROM HOSPITALS TO
POST ACUTE CARE SETTINGS, ESRD FACILITIES AND ALL POST-ACUTE
CARE SETTINGS BEYOND THAT. AND THAT SURVEY AND
CERTIFICATION PROGRAM THEN FOLLOWS SUIT AND CAN ENFORCE
THOSE CONDITIONS OF PARTICIPATION THROUGH THEIR
STATE SURVEYOR AND FEDERAL SURVEYOR EFFORTS.
WE HAVE VENTURED INTO VALUE-B E VALUE-BASED PURCHASING BY VIRTUE
OF AFFORDABLE CARE ACT. FIRST TWO EFFORTS INCLUDE END
STAGE RENAL DISEASE FACILITIES AND HOSPITALS.
THIS IS SIMPLY A TOOL FOR CMS TO BEGIN TO CONVERGE QUALITY WITH
PAYMENT AND QUALITY WITH COST. IMPORTANTLY, TO DRIVE
IMPROVEMENT TOWARDS DELIVERING HIGHER VALUE CARE, NOT JUST
HIGHER VOLUME CARE WE MUST REMAIN FIXED ON A SHARED FOCUS
OF IMPROVING OUTCOMES, REALLY ENGAGING ALL PROVIDERS AND
PATIENTS IN THAT EFFORT, COLLABORATIVELY.
AND WE HAVE MADE GREAT STRIDES IN THIS AREA.
IMPORTANTLY PERTINENT TO THIS CONVERSATION IS THAT HEALTH CARE
ASSOCIATED INFECTIONS HAVE BEEN INCLUDED NOT ONLY IN QUALITY BUT
ALSO IN VALUE-BASED PURCHASING CONSTRUCT WHEREBY HOSPITALS ARE
AVAILABLE TO IN ATTAINING AND IMPROVING ON QUALITY PERFORMANCE
AND ENJOY HIGHER PAYMENTS AS OPPOSED TO LOWER PAYMENTS IF NOT
TO ATTAIN OR IMPROVE IN THESE IMPORTANT AREAS.
WE HAVE ENJOYED A GREAT COLLABORATION AND SUCCESS IN
REDUCING HEALTH CARE-ASSOCIATED INFECTIONS THANK YOU TO OUR CDC
COLLEAGUES. AND MADE GREAT STRIDES IN
REDUCING CATHETER-ASSOCIATED BLOOD STREAM INFECTIONS ACROSS
OUR COUNTRY AND ARE ALSO MAKING GREAT STRIDES IN THE AREA OF
REDUCING CATHETER-ASSOCIATED URINARY TRACT INFECTIONS L S BY
CONSISTENTLY MEASURING AND PROVIDING TECHNICAL ASSISTANCE
AND TOOLS AVAILABLE TO ENABLE PROVIDERS TO PROVIDE EFFECTIVE
CARE THAT REDUCES THESE EVENTS OF HARM.
WE HAVE ALSO IMPLEMENTED OUR QUALITY IMPROVEMENT
ORGANIZATIONS, OUR PARTNERSHIP FOR PATIENTS EFFORT.
THIS HAS BEEN A SYNERGISTIC TOUR DEFORCE FOCUSING ON IMPROVING
RISK OF HARM AND ARE ABLE TO TRANSLATE THAT INTO SUCCESS.
AS MENTIONED EARLIER UNINTENDED CONSEQUENCES ARE CERTAINLY THOSE
THAT WE NEED TO BE ABLE TO ANTICIPATE AND PREEMPT.
AND THEREFORE ALTHOUGH CMS PROGRAMS ARE ENCOURAGING EARLY
DETECTION AND EARLY TREATMENT OF INFECTIOUS PROCESSES, OF HEALTH
CARE-ASSOCIATED INFECTIONS, REDUCING THAT HARM AND WHERE
QUALITY REPORTING TRANSITIONS INTO REPORTING THAT IS NOW
ATTACHED TO INCENTIVES OR PAYMENT REDUCTIONS SHOULD YOU
NOT BE ABLE TO ATTAIN THESE METRICS THERE IS A CONCERN THAT
THE UNINTENDED CONSEQUENCE OF THIS WILL BE OVERUSE OF
ANTIBIOTICS. AND THIS REQUIRES A THOUGHTFUL
ATTENTION AND STRATEGIC INCLUSION OF MEASURES AND
EFFORTS THAT BALANCE THIS NATURAL TENDENCY TOWARDS OVERUSE
THAT WOULD INCLUDE PAIRING ANTIBIOTIC START MEASURES WITH
THOSE OF STOP MEASURES. THAT WOULD INCLUDE THE DETECTION
OF — THAT CAN RESULT IN MORBIDITY AND DEATH AND BUILDING
IN QUALITY MEASURES NOT ONLY WITHIN A CARE SETTING BUT ACROSS
CARE SETTINGS WHERE THIS CONDITION MAY MANIFEST AS
PATIENTS TRAVERSE FROM ONE SETTING TO ANOTHER.
AND THEN, OF COURSE, ANTIBIOTIC STEWARDSHIP AS A CONSIDERATION
AS A CONDITION OF PARTICIPATION OR THROUGH A SURVEY OR GUIDANCE
WOULD BE THAT ONE IMPLICITLY PROVIDES THE BALANCE THAT IS
SOUGHT. SO I WOULD LIKE TO CONCLUDE BY
EMPHASIZING THAT APPROPRIATE ANTIBIOTIC USE IS AN IMPORTANT
ASPECT OF ACHIEVING CARE THAT IS SAFER, OF HIGH QUALITY AND, OF
COURSE, LESS COSTLY AND THEREFORE AN INTEGRAL PART OF
ACHIEVING THE THREE PART AIM THAT CMS REALLY HAS MARCHED
TOWARDS IN TRANSFORMING HEALTH CARE, THAT APPROPRIATE
ANTIBIOTIC USE BY HEALTH CARE PROVIDERS AND FACILITIES ACROSS
ALL CARE SETTINGS REALLY REQUIRES A DATA-DRIVEN APPROACH.
DATA AVAILABLE AT THE SITE OF CARE THAT IS ACTIONABLE FOR
PROVIDERS AND THAT CAN ENCOURAGE LEARNING ON SITE AND AS A SYSTEM
IN A WAY THAT IS FAIR AND BALANCED.
AND FINALLY THAT THROUGH QUALITY IMPROVEMENT SYSTEMS AND MEASURES
THAT CDC AND CMS TOGETHER ALONG WITH OTHER PARTERNERS ARE ABLE
TO WORK TO IMPROVE APPROPRIATE ANTIBIOTIC USE IN HOSPITALS AND
ACROSS ALL CARE SETTINGS. SO I SAY THANK YOU FOR YOUR
ATTENTION. [ APPLAUSE ]
>>>WE WILL NOW HAVE CONCLUDING REMARKS BY DR. FREIDEN FOLLOWED
IMMEDIATELY BY Q&A SESSION LED BY DR. HICKS.
>>THANK YOU FOR SPEAKERS. THE AREA OF HOW CAN PUBLIC
HEALTH AND HEALTH CARE WORK TOGETHER SYNERGISTICALLY IS SO
IMPORTANT TO ALL OF US AND SOCIETY AND OUR PARTNERSHIP WITH
CMS HAS BEEN TERRIFIC. WE APPRECIATE YOU BEING HERE AND
WE APPRECIATE THE MANY LINKAGES BETWEEN THE AGENCIES WHICH HAVE
GROWN. JUST TO HIGHLIGHT A COUPLE OF
THINGS THAT MIGHT HAVE GONE BY A LITTLE QUICKLY.
THE NATIONAL HEALTH CARE SAFETY NETWORK IS NOW ACTIVE IN
ESSENTIALLY EVERY HOSPITAL IN THE COUNTRY IN LARGE PART
BECAUSE OF THE COLLABORATION BETWEEN CDC AND CMS.
AS WAS SAID THERE IS A MODULE THAT WILL TRACK ANTIMICROBIAL
USE AND RESISTANCE AND ULTIMATELY BE ABLE TO PULL THAT
EXCLUSIVELY FROM ELECTRONIC HEALTH RECORDS REDUCING THE
BURDEN OF DATA COLLECTIONS, INCREASING CONSISTENCY AND
SPEED. AND WITH THE AREA OF ELECTRONIC
RECORDS WE HAVE POSSIBILITIES OF CLINICAL DECISION SUPPORT.
WE NEED TO EXPLORE THOSE AND FIGURE OUT HOW TO MAKE THEM WORK
EFFECTIVELY. WE KNOW THAT PROMPTS MAY NOT
ALWAYS BE EFFECTIVE BECAUSE IF THERE ARE TOO MANY DOCTORS TURN
THEM OFF. HOW DO YOU MEET THE BALANCE
BETWEEN WHAT IS REALLY IMPORTANT AND ALL OF THE GOOD THINGS WE
WANT TO GET DONE. WE ALSO HEARD THE IMPORTANCE OF
MEASURING AND THE UNIQUE OPPORTUNITY TO REALLY CHANGE
MEDICAL PRACTICE BY BETTER MEASURING WHAT IS HAPPENING IN
PRACTICE BOTH INPATIENT AND OUTPATIENT AND FEEDING IT BACK
IN REAL TIME TO IMPROVE THE QUALITY OF CARE.
WE HAVE ALSO HEARD ABOUT ANTIMICROBIAL STEWARDSHIP
PROGRAMS AND THE CDC RECOMMENDATION THAT EVERY
HOSPITAL IN THE COUNTRY HAVE ONE.
WE THINK IT WILL NOT ONLY SAVE LIVES BUT ALSO SAVE MONEY.
WE NEED TO FURTHER UNDERSTAND EXACTLY WHAT THAT MEANS AND HOW
TO OPTIMIZE PROGRAMS LIKE THAT AND WORK WITH CMS TO SUPPORT
HOSPITALS IN ESTABLISHING SUCH PROGRAMS.
WE HEARD THE IMPORTANCE OF CLINICIANS AND PATIENTS BEST
UNDERSTANDING THAT MORE ANTIBIOTICS DOESN’T MEAN BETTER
TREATMENT, THAT MORE IS NOT ALWAYS BETTER, THAT OFTEN BETTER
IS BETTER AND BETTER MIGHT WELL MEAN WAITING FOR MANY PATIENTS.
ULTIMATELY I THINK WE SHOULD THINK OF ANTIBIOTICS AS A GIFT
HANDED DOWN TO US, AN INHERITANCE FROM A GENERATION OF
DOCTORS GOING BACK TO MORE THAN 100 YEARS AGO UNTIL WE HAD
WONDERFUL DRUGS THAT CAN SAVE LIVES AND ARE SAVING LIVES.
BUT OUR RESPONSIBILITY IS TO PRESERVE THAT RESOURCE, SOME OF
THEM ARE NATURAL AND SOME ARE MAN MADE, TO PRESERVE THE
RESOURCE SO OUR CHILDREN, THEIR CHILDREN AND CHILDREN’S CHILDREN
CAN BENEFIT FROM THIS WONDERFUL LIFE SAVER.
THANK YOU SO MUCH TO ALL OF OUR SPEAKERS.
[ APPLAUSE ]>>>SO I WOULD NOW LIKE TO OPEN
THE FLOOR TO QUESTIONS. I ASK YOU TO COME TO THE
MICROPHONE IF YOU ARE IN THE BACK AND PLEASE STATE YOUR
QUESTION BRIEFLY. SINCE I DON’T SEE ANYONE AT A
MICROPHONE — THERE IS A HAND RAISED.
I AM GOING TO START OFF WITH A QUESTION BECAUSE I HAVE THE
PREROGATIVE AS THE MODERATOR HERE.
I AM GOING TO HAND THIS ONE OVER TO DR. FINKELSTEIN, GIVEN
CHANGES IN HEALTH CARE DELIVERY WHAT CAN WE DO DIFFERENTLY TO
IMPROVE ANTIBIOTIC USE ESPECIALLY IN THE OUTPATIENT
SETTING?>>SO I THINK WE HAVE HEARD A
LOT OF THINGS THAT POINT US TOWARDS A NEW FUTURE.
THE DEVELOPMENT OF LARGER CARE SYSTEMS REALLY RESPONSIBLE FOR
POPULATIONS WHETHER THEY ARE CALLED ACCOUNTABLE CARE
ORGANIZATIONS OR SOMETHING ELSE AND THE PAYMENT AND QUALITY
INITIATIVES THAT GO ALONG WITH THOSE REALLY GIVE US NEW
OPPORTUNITIES. WE DON’T HAVE TO JUST KEEPEP
THINKING OF CAMPAIGNS IN SCHOOLS AND CAMPAIGNS IN COMMUNITIES.
WE CAN WORK THROUGH HEALTH SYSTEMS AND REALLY HOLD THEM
ACCOUNTABLE, WHAT IS YOUR ANTIBIOTIC USE RATE OVERALL.
IF IT IS HIGHER THAN OTHERS WHO ARE GETTING BETTER OUTCOMES WHAT
ARE YOU GOING TO DO WITHIN YOUR CONTEXT TO BRING IT DOWN?
AND AS WAS SAID I THINK WE CAN LEVERAGE ELECTRONIC HEALTH
RECORDS AND OTHER SOURCES OF DATA TO MEASURE MORE EFFICIENTLY
AND FEEDBACK.>>I SEE A QUESTION IN THE BACK
OF THE ROOM.>>THANKS.
THIS WAS WONDERFUL. ACTUALLY, MY QUESTION WAS ALSO
ABOUT THE CHANGES IN HEALTH CARE DELIVERY.
BUT MORE SPECIFICALLY, I THOUGHT IT WAS VERY INTERESTING THAT THE
IDEA OF FOCUSING ON HOSPITAL FOR ALL OF THE REASONS YOU
MENTIONED. I WAS WONDERING MORE
SPECIFICALLY THE MENTION HAS BEEN HOSPITALS OR OUTPATIENTS.
WHAT ABOUT THE BLURRING OF THAT, THE TENDENCY FOR SHORTER
HOSPITAL STAYS FOR OUTPATIENT SURGICAL PROCEDURES?
AND HAS THAT AFFECTED THE ANTIBIOTIC USE OR MISUSE RATE?
AND IN PARTICULAR I GUESS I WANT TO ASK ABOUT THE QUESTION WHERE
IT IS A GRAY AREA AND THE CONCERN FOR GOOD FOLLOWUP IS
UNCERTAIN BECAUSE MAYBE THE POST-OP PATIENT IS NOW AN
OUTPATIENT. MAYBE THE MOTHER OF THE SICK
CHILD, YOU KNOW, THE DOCTOR ISN’T SO CLEAR ABOUT IF THE
CHILD WILL COME BACK IN TIME IF HE GETS WORSE.
SO THE TRANSITION, THE BLURRING OF INPATIENT AND OUTPATIENT, HOW
HAS THAT AFFECTED ANTIBIOTIC USE AND WHAT ARE THE ISSUES THERE?
>>I WILL MAKE ONE COMMENT AND THEN I WILL HAND IT OVER.
ONE THING THAT COMES TO MIND IS THIS INCREASE IN FREQUENCY OF
OUTPATIENT PARENTAL THERAPY. SO THERE ARE A LOT OF PATIENTS
THAT ARE NOW BEING DISCHARGED ON THERAPY FROM HOSPITALS FOR
LONG-TERM TREATMENT IN THE OUTPATIENT SETTING.
WE ARE DEFINITELY SEEING A LOT MORE ANTIBIOTIC USE THAT WOULD
HAVE TRADITIONALLY BEEN USED IN HOSPITALS IN THE COMMUNITY.
SO THERE IS NO QUESTION THAT THERE IS A BLURRING OF THE LINES
BETWEEN INPATIENT AND OUTPATIENT.
IT IS A VERY FLUID SITUATION. SO I THINK ONE THING THAT WE SAY
ALL THE TIME IS ANTIBIOTIC USE ANYWHERE IS REALLY ANTIBIOTIC
USE EVERYWHERE. AND ANTIBIOTIC RESISTANCE
ANYWHERE IS ANTIBIOTIC RESISTANCE EVERYWHERE.
SO WE HAVE TO KIND OF THINK ABOUT IT IN ALL HEALTH CARE
SEGMENTS. WE CAN’T JUST LOOK AT HOSPITALS
ONLY. THIS IS A WIDE SPREAD PROBLEM.
I WILL HAND IT OVER.>>I WILL JUST ECHO THAT I THINK
THAT THE SHIFT TOWARDS GROUPS LIKE ACCOUNTABLE CARE
ORGANIZATIONS WHERE THE UNIT OF INTEREST AND THE PERSON IS THE
FOCUS, NOT THE SETTING. AND I THINK INCREASINGLY THAT IS
THE SOLUTION TO THE PROBLEM. IT IS NOT JUST WITH ANTIBIOTIC
USE. IT RELATES TO ANTIBIOTIC
RESISTANCE AND HEALTH CARE-ASSOCIATED INFECTIONS.
INCREASINGLY YOU HAVE THE REPERCUSSIONS OF CARE IN ONE
SETTING BEING SEEN IN ANOTHER SETTING.
IT IS PARTICULARLY TRUE IN LONG-TERM CARE SETTINGS, NURSING
HOMES. WE KNOW PATIENTS GET CARE AT A
VARIETY OF DIFFERENT SETTINGS. SO FOCUSING EXCLUSIVELY ON ONE
PIECE OF THE PUZZLE IS NOT GOING TO SOLVE THE OVERALL PROBLEM.
WE HAVE TO TAKE A MORE HOLISTIC APPROACH.
>>I WOULD LIKE TO ADD TO THAT. WE HAVE A HEALTH CARE SYSTEM.
WE HAVE AN INCREDIBLE OPPORTUNITY FOR US TO BEHAVE AS
A SYSTEM. NOW, WHAT IS REQUIRED — AND
THAT IS PART OF THE BEAUTY OF THE NATIONAL HEALTH AND SAFETY
NETWORK. IT IS A NETWORK.
IT IS NOT JUST A STOVE PIPE DATA COLLECTION VEHICLE WITHIN A
SINGLE SYSTEM. IT ACTUALLY ACKNOWLEDGES THE
FACT THAT PEOPLE WILL TRAVERSE FROM ONE CARE SETTING TO THE
NEXT. THEY WILL START IN THE HOSPITAL.
THEY WILL GO — THE SAME PEOPLE WILL GO, THEN, TO A HOME HEALTH
AGENCY CARE IF THEY ARE HEALTHY ENOUGH OR TO A SKILLED NURSING
FACILITY OR PERHAPS TO A LONG-TERM CARE ACUTE HOSPITAL OR
CYCLE BACK TO THE ACUTE HOSPITAL.
THIS IS A SYSTEMT THAT PATIENTS ARE REQUIRED TO NAVIGATE AND
TRAVERSE. AND I THINK ONE OF THE BIGGEST
CHALLENGES FOR US IS FOR OUR INDIVIDUAL PROVIDERS TO START TO
THINK ABOUT HOW THEY FIT INTO THE SYSTEM AND HOW THEY FIT INTO
THE TEAM THAT PROVIDES THE CARE TO ANY GIVEN PATIENT.
IT MAY NOT BE THAT WE EXPECT ALL PROVIDERS TO DO THE EXACT SAME
THING FOR A MEASURE, FOR INSTANCE.
IT MAY BET THAT WE EXPECT SOME PROVIDERS TO START AN ANTIBIOTIC
BUT WE MAY EXPECT THAT THAT CARE PLAN AND THAT TREATMENT IS
CONTINUED TO ANOTHER PROVIDER. AND THAT IS WHAT CARE
COORDINATION IS ABOUT. T THAT IS A FUNDAMENTAL DOMAIN
WITHIN THE NATIONAL QUALITY STRATEGY TO IMPROVE OUTCOMES BUT
WE MUST DO IT AS A SYSTEM.>>>I KNOW YOU HAD A QUESTION
FROM SOCIAL MEDIA.>>THANK YOU FROM OUR ONLINE
AUDIENCES. DO DRUG COMPANIES CONSIDER
ANTIBIOTIC RESISTANCE MECHANISMS ASSOCIATED WITH LONG TERM USE OF
THEIR DRUGS DURING RESEARCH AND DEVELOPMENT?
>>WELL, I HOPE SO. I ACTUALLY THINK THAT IS ONE OF
THE CHALLENGES WITH ANTIBIOTIC DEVELOPMENT IS THE POTENTIAL FOR
DRUG RESISTANCE TO DEVELOP PRETTY RAPIDLY.
AND PRACTICALLY FOR ALL OF THE ANTIBIOTICS WE USE WE HAVE SEEN
ANTIBIOTIC RESISTANCE DEVELOP PRETTY RAPIDLY FOR EACH AND
EVERYONE OF THOSE DRUGS. SO I WOULD HOPE THAT DRUG
COMPANIES THAT ARE DEVELOPING NEW DRUGS ARE TAKING THAT INTO
CONSIDERATION. BUT ON THE OTHER HAND I’M GOING
TO TURN IT AROUND AND SAY WHEN THESE DRUGS ARE LAUNCHED THE
MOST IMPORTANT THING IS THAT WE ARE USING THEM APPROPRIATELY.
BECAUSE IF WE DON’T USE THEM APPROPRIATELY WE LOSE THEM.
I THINK THAT IS WHAT HAS HAPPENED WITH OUR CURRENT DRUGS.
WE REALLY LOST A LOT OF POWER IN THE ANTIBIOTICS THAT WE HAVE.
I DON’T KNOW IF ANYONE ELSE WANTS TO COMMENT?
>>>AM I ALLOWED TO HAVE ANN ASK ONE MORE QUESTION?
>>DO YOU SEE ANOTHER QUESTION?>>LAST QUESTION.
>>>I WAS REALLY STRUCK WITH YOUR MAP THAT SHOWED THE
DIFFERENCES AMONG STATES, IN PARTICULARLY THAT WEST VIRGINIA
HAD THE HIGHEST AND ALASKA THE LOWEST GIVEN THEY BOTH HAVE
IMPORTANT RURAL POPULATIONS AND PRETTY HEAVY DISADVANTAGED
CHILDREN. I REMEMBER BACK IN THE ’90s
ALASKA DID INTENSIVE INTERVENTIONS TO PROMOTE
APPROPRIATE ANTIBIOTIC USE. IN THAT ERA WE WERE REALLY
STRUGGLING WITH THE ABILITY TO TAKE THE INTERVENTIONS TO SCALE
AND MAKE THEM SUSTAINABLE AND WONDER ABOUT WHETHER YOU HAD TO
REDOSE. I AM WONDERING IF YOU HAVE DATA
THAT SAY WHY THINGS LOOK BETTER IN ALASKA AND WHETHER THEY ARE
REDOSING OR WHETHER THEY WERE ALWAYS LOWER?
>>SO REALLY GREAT QUESTION. AND I THINK WE ARE JUST LEARNING
ABOUT WHY WE ARE SEEING THESE GEOGRAPHIC DIFFERENCES.
ONE OF THE FIRST COMMENTS I RECEIVED ABOUT THAT MAP IS THAT
IT RESEMBLED THE ELECTORAL COLLEGE MAP.
I HAVE ACTUALLY RECEIVED THAT SAME E-MAIL OR COMMENT AT LEAST
A DOZEN TIMES SINCE THAT FIRST COMMENT.
WE HAVEN’T LOOKED AT THE POLITICAL NATURER OF PRESCRIBING
BUT WE HAVE LOOKED AT THINGS LIKE OBESITY, SOCIOECONOMIC
STATUS. WE HAVE LOOKED AT OTHER HEALTH
FACTORS AND GENDER, THOSE KINDS OF THINGS.
WHAT WE SEE IS THERE ARE CERTAIN THINGS THAT DO TEND TO FALL OUT.
FIRST OF ALL, WE KNOW THAT IN THE SOUTH DRUGS ARE MORE
COMMONLY USED FOR CONDITIONS FOR WHICH THERE IS NO BENEFIT.
WE KNOW THERE IS OVERUSE IN THE SOUTH RELATIVE TO OTHER PARTS OF
THE COUNTRY. WE HAVE ALSO SEEN THAT THERE IS
A RELATIONSHIP BETWEEN OBESITY AND WE DON’T KNOW HOW THEY
RELATIONSHIP, WHETHER IT IS A DIRECT RELATIONSHIP OR INDIRECT
RELATIONSHIP OR WHICH DIRECTION THE RELATIONSHIP IS, WHETHER
CHICKEN OR EGG. WE SEE OBESITY SEEMS TO BE
ASSOCIATED WITH HIGH ANTIBIOTIC USE.
FINALLY, FEMALE SEX BECAUSE FEMALES TEND TO USE THE HEALTH
CARE SYSTEM QUITE A BIT MORE THAN MALES SO IF YOU COMPARE
MALES AND FEMALES YOU SEE A LOT MORE ANTIBIOTIC USE IN THAT
POPULATION. I THINK WE HAVE TO BETTER
UNDERSTAND WHY WE ARE SEEING THESE DIFFERENCES BECAUSE THEN
WE CAN BETTER FIGURE OUT HOW TO IMPROVE RATES IN THOSE STATES
WITH HIGH USE.>>THANK YOU, AGAIN, TO ALL OF
OUR SPEAKERS. PLEASE JOIN US AGAIN IN TWO
WEEKS FOR OUR NEXT SPECIAL SESSION ON GRAND ROUNDS ON
ADVANCED DETECTION OF DISEASES.

5 Replies to “Combating Resistance: Getting Smart About Antibiotics”

  1. The CDC lies to us all the time, and you are going to believe them? So many people, including the young, are dying, because they are not prescribing antibiotics in time. I took chemical and biological warfare for 12 years, and I believe these drug resistant germs are biological warfare. I know that most people go along with the thinking of the CDC regarding antibiotics. I do, however, that some antibiotics may kill you. The key is that we have to get our immune systems strong. The problem is that the CDC and FDA continues to allow the chemical and pharmaceutical companies to destroy our health.  I also believe that vaccinations are one of the ways that drug resistant germs are being spread.  Read the vaccine inserts. 

  2. Most people do not die from viral infections.  They die from secondary bacterial infections from the viral infections. 

  3. Re. question "Do drug companies consider resistance when developing antibiotics" at 1:00:20. My comment – I can't think of anything that would make an antibiotic "resistance proof". 

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