Getting Serious About Antimicrobial Stewardship
It’s been over a half-century since the medical community first heard a cautionary reminder from Sir Alexander Fleming (who discovered penicillin) about avoiding overuse of antibiotics.
In the last decade, the clarion call for judicious antibiotic use swelled to world-wide attention with the emergence and rapid rise of resistant infections and the simultaneous drought in pharmaceutical research and development to find new therapies. The World Health Organization WHO), the Centers for Disease Prevention and Control (CDC) and a growing number of professional societies have mounted impressive campaigns to raise awareness, educate medical practitioners, stimulate commercial investment in new drug development and pose solutions to improve stewardship of our last antibiotic arsenal.
Despite this clear consensus about what we “should” do, it’s evident that the concept is not yet firmly rooted in practice. Not every hospital sustains a dedicated antibiotic stewardship program and most long-term care facilities lack the expertise to do so. Diagnostic testing to confirm the need for an antibiotic (or inform which antibiotic is best) is neither universally available nor used. One can visit any pediatrician’s office, parent blog site, local emergency room or primary care doctor’s office and hear varying recommendations for appropriate use of antibiotics.
The Vital Signs report from CDC called on local hospitals, clinics, long-term care facilities and public health departments to improve collaboration on infection surveillance, infection control and antibiotic stewardship. This is an important step forward and puts all actors in a community’s system of care on notice that they are responsible (and mutually at risk) for effective stewardship.
We need to see correlating investment in stimulating and replicating rapid transformation within these communities. With millions invested in comparative effectiveness work by PCORI, it’s hard to understand why an equally large funding pool is not available for this immediate threat to our health. Major hospitals, government agencies, foundations, pharmaceutical companies and corporate healthcare entities should emulate the collaboration they seek on the front line. The financial investment from these sectors to establish a central resource of leadership, expert technical assistance, best practice and research would be a legacy to future generations and proof that we didn’t waste the last moments of opportunity in endless dialogue.
Changing the culture of care to deemphasize the “prescribe first” and “just in case” approach to medicine will take time. It will challenge both provider autonomy and a patient’s sense of what is in their best interest. It’s vital that all stakeholders look beyond immediate self-interest and join together to change attitudes and behavior, demand professional accountability, and become stewards of a precious resource before it’s too late.
All Hands On Deck
This month brings a worldwide focus on hand hygiene and infection prevention. Recent articles and blog posts have reiterated the importance of this small action, but also highlighted the never-ending lament that compliance is not 100%. The CDC recently emphasized the role of patients and families in spurring better adherence to this seemingly simple task. The ensuing discussion threads are a mix of bewilderment that we have to remind anyone to wash their hands and outrage that patients and families have to police this issue.
Atul Gawande recently wrote a New Yorker piece in which he explored the often lengthy period of adoption of evidence into practice. A key point was that until a procedure or action is seen as beneficial to the individual patient and the caretaker, there will be gaps in adherence. Do our healthcare workers not care? No — they have multiple patients, wash their hands hundreds of times a day, may have already done it out of our line of sight, or simply forgot. It’s time to stop wasting our collective energy on indignation and blame and accept our responsibility in making it clear that we see this small action as a fundamental element of quality care.
I believe that many voices together are more effective than any guideline, WHO or CDC infographic, Joint Commission checklist or fancy monitoring technology. Like I do with my children, I will remind anyone to wash their hands before they touch me or someone I love – that’s my part of helping ensure good health care practice. Frankly, it feels good to be able to do something to make a difference. This is especially true when you are in the throes of your own new diagnosis, a medical emergency or the long-term health care of a loved one. So today, resolve to be the individual voice that makes a difference. Remind a colleague/friend/loved one/child/parent/doctor/nurse/technician – anyone – that clean hands matter to you and to all of us. And if you see the right thing? Remember to acknowledge that too. Positive reinforcement and validation is something we all seek. That’s the true community vigilance that it will take to wash our hands of this endless (and fruitless) debate.