Antibiotic Resistance Forecasting Suggests We Are In Danger

Dr. James Wilson, the Director of the National Infectious Disease Forecast Center contributed this article.  Full bio at the end of this post.

The above figure is an example of a real hospital that is, right now, losing the fight with antibiotic resistance.  Think of each red bar as equivalent to a deadly car crash in your community.  Think of the orange bars as big collisions where everyone is lucky to walk out alive, but plenty of damage and things were scary.  Red and orange are bad, and represent the full or partial loss of a drug to treat is a disease.  Green is good, and drugs that are being prescribed are working.

To keep things “in the green”, patients and clinicians need to have a new dialog that accounts for the threat of antibiotic resistance.

The chart above is from one of Ascel Bio’s clients, a hospital in a community that is no longer “in the green”.  The dialog between patient and provider over antibiotic stewardship needs to work much better than it is.  This figure is an antibiogram for E. coli bacteria isolated from patients’ blood cultures since 2004.  E. coli is a leading cause of blood borne infection (sepsis) and associated with significant morbidity and mortality.

In this figure, the date of report is on the left hand column, and the antibiotics tested are listed along the top of the chart.  Green boxes indicate susceptibility (i.e. a given antibiotic will be effective); orange boxes indicate borderline susceptibility; and red boxes indicate resistance.  The analogy would be the lights of a traffic light: green means go, yellow means caution, and red means stop.  Failure to heed these signals can result in injury or death.  The very bottom bar indicates what a physician’s general reference such as the latest copy of the Sanford Guide would recommend; it is clear use of this reference would be inappropriate in this setting.

Nine antibiotics in about two years have now been taken off the table for use in treating blood borne E. coli infection.  This hospital has lost the use of the following Sanford-recommended antibiotics to treat E. coli systemic infection over the last couple of years:

• Augmentin and Unasyn
• Ancef, Mefoxin, and Zinacef
• Cipro, Levoquin, and Avelox
• Gentamicin

This is should be a serious wake-up call for this community.  It is “ground truth” that supports the U.S. Centers for Disease Control and Prevention declaration that antibiotic resistance “pose[s] a catastrophic threat to people in every country in the world”.  The CDC estimates 23,000 people die in the United States every year due to drug-resistant bacterial infections.[1]

In a recent poll conducted jointly by the largest physician social network in the country, Sermo, and the Ascel Bio National Infectious Disease Forecast Center, physicians were asked:

How do you decide what antibiotic to use for a given disease?

The answers were deeply concerning:

The bottom line is an astounding 83% of physicians do not use local antibiograms to guide their decision-making when it comes to the prescription of antibiotics.  The reasons for this include:

• lack of familiarity with antibiograms and their importance in decision making
• the amount of time it takes to analyze and draw conclusions[??1]  from complex antibiograms
• availability of antibiograms- one physician indicated his local hospital’s laboratory refused to provide him with the antibiograms
• but perhaps the most important factor was the pressure from current changes in healthcare to see a high volume of patients whose satisfaction surveys effect physician behavior- many physicians basically give in to patient demand for antibiotics

Antibiotic resistance is a real life disaster happening in real time.

►   Once a given bacterial pathogen has acquired multi-drug resistance, it is able to survive for longer periods of time in the hospital, which contributes to its further spread to patients who are hospitalized.

►   In the intensive care setting, blood infection with bacteria (sepsis) is a $14 billion dollar problem in this country.  The mortality rate is high: up to one in four patients with severe sepsis.[2]

►   While on the surface this appears to be primarily a problem of the hospitalized elderly, it is not.  We now routinely see the problem is more widespread: drug-resistant bacterial infections in infants and children in the community setting.

►   The risks posed by anti-microbial resistance are insidious and not easily noticed if one is not paying attention.  And right now, we have no effective real-time surveillance system for antibiotic resistance, have grossly outdated clinical guidance for antibiotic stewardship[3], and have allowed the problem to progress for years without effective societal oversight.

The entire world is losing the fight to preserve our access to life-saving antibiotics.  According to a new report, the reasons include:

• Inappropriate prescribing behaviors
• Delayed antibiotic treatment
• Advanced age of the patient
• Longer hospital stays
• Chronic disease
• Prolonged stay in intensive care units or nursing homes
• Importation of drug-resistant organisms from foreign countries[4]

In my public speeches and writing I have previously highlighted community-based observations of the patient-provider factors that are pushing our country toward this oblivion of multi-drug resistance.[5]  These observations were gathered in the context of deploying the first operational antibiotic resistance forecast capability in a hospital setting.  As we have often observed in our discipline of infectious disease forecasting and warning, it is not a question of whether we are able to forecast threats to our medical infrastructure, it is managing human behavior in a way that uses this information to our best advantage.  Therefore, we have observed several additional factors contributing to this silent disaster of antibiotic resistance:

• Patient expectation for access to antibiotics, whether they are being prescribed appropriately or not.
• Lack of awareness and education of the consequences of antibiotic overuse both among patients and healthcare providers.
• Economic and regulatory pressure on healthcare providers to please patients.
• Lack of federal regulation regarding the use of antibiotics.

This last point is the central issue now.  It is time, before it is too late, to call for more federal action.[6]

Before becoming a disease forecaster, I was tasked with monitoring the world for dangerous disease such as Ebola, influenza pandemics, and biological terrorism.  So, I find this trend deeply concerning because it represents a serious erosion of our ability to respond to routine infectious disease.  This is not a fictional Hollywood story but an issue present in every community in America.

Recommendations

As a patient, we encourage you to ask your physician whether the use of an antibiotic is appropriate.  Do not pressure your physician to inappropriately prescribe antibiotics.  Consider carefully taking antibiotics and be sure to use them in precisely the manner prescribed.  Ask your physician if they have access their local antibiograms, which determines whether a given antibiotic will successfully treat your condition.  Awareness of and use of antibiograms is a recommended Standard of Care in the United States.  If you or a loved one is hospitalized for an infection that failed antibiotic treatment, ask why and ask to see the antibiograms that guided that decision.

For healthcare providers, we encourage you to utilize your local antibiograms.  Ask your local hospital’s clinical microbiology department for the latest copy of their antibiogram.  If they refuse to release this crucial, life-saving information, contact your local public health authority.  Ask questions if you do not understand how to read an antibiogram.  Be wary of using general references when deciding which antibiotics to prescribe, because your local antibiogram may reflect a dramatically different resistance pattern.  As mentioned above, it may cost a patient an unnecessary hospitalization due to antibiotic therapy failure.  And lastly, engage in collaborative discussions with your local hospital about antibiotic stewardship.

For hospital administrators, we encourage you to support your physicians in taking a stand against the inappropriate prescription of antibiotics.  Do not allow patient satisfaction surveys to dictate policy in this dangerous crisis.  This particular issue demands that a physician provides the patient what they need, not sometimes what they want.

For federal authorities, it is time to begin serious debate now to regulate antibiotics as we have narcotics.  The United States needs a federally mandated antibiotic stewardship program that includes transparent reporting of local antibiograms.  Other countries such as Canada have shown dramatic improvement in antibiotic resistance patterns with commitment from their government authorities.  We too can reverse this trend if we act now.

We stand at risk of losing this war if we do not take definitive action now against antibiotic resistance.