Antibiotic use decreasing!!!
the CDC
just published their findings on antibiotic use in the US, showing significant
decreases (see https://www.cdc.gov/getsmart/pdf/stewardship-report.pdf
)
Details:
-- outpatient settings (clinics, doctors' offices, ERs):
--47 million unnecessary antibiotic prescriptions/yr
--overall antibiotic scripts decreased by 5% in period 2011-14 from 75 million scripts to 64 million in children <19 yo, though has increased from 192 to 198 million in adults (especially high prescribing rates in kids <2 and adults >65). however, more often antibiotics prescribed may be "less effective and carry more risk over more targeted first-line drugs recommended by national guidelines" (in 2010-11, only 37% of adults received guideline-recommended antibiotics for sinus infection or pharyngitis, more like 60% in kids for these infections and otitis media.)
--the CDC still feels that 30% of outpatient antibiotic prescriptions are unnecessary, and 50% of those for acute respiratory conditions (URIs, viral sore throats, bronchitis; as well as some bacterial infections that do not always need antibiotics, such as many sinus and ear infections)
--in 2011, 1/3 of the 500,000 C difficile infections were community-associated.
--there is large variability in antibiotic prescribing by different regions in the US
--highest in nebraska, iowa, arkansas, louisiana, mississippi, tennessee, alabama, kentucky, west virginia, at 1,018-1319/1000 people
--lowest in california, montana, colorado, vermont at 511-668/1000 people
--in nursing homes:
--a small CDC study of 9 nursing homes found that 11% of patients were on antibiotics on any single day and that 40% of antibiotic orders lacked "important prescribing information"
--1/3 of the antibiotics were for UTIs, but 1/2 of these were for either the wrong drug, dose or duration.
--of the 4 million in nursing homes, antibiotics are given to 50-70% over the course of a year, and up to 75% are prescribed incorrectly
--in hospitals:
--use of very powerful antibiotics has increased significantly from 2006 to 2014 (40% for carbapenems and >30% for vancomycin), and 30% of antibiotic usage overall in hospitals "are unnecessary or prescribed incorrectly"
--antibiotic stewardship programs seem to help (eg, see blog on hospital antibiotic stewardship programs which have reduced infections with antibiotic-resistant bacteria and C difficile)
--there are geographical differences in % of hospitals with stewardship programs:
--the content of these stewardship programs vary significantly, with 7 core elements defined by the CDC; 41% of hospitals implementing all 7 in 2014, increasing to 48% in 2015).
--programs in 55-77% of hospitals in california, arizona, utah, massachusetts, new york, rhode island, maryland, virginia, north and south carolina, florida); and down to 7-33% in montana, north and south dakota, minnesota, iowa, nebraska, kansas, wyoming, louisiana, mississippi
--larger hospitals are more likely to have programs with all 7 elements: 66.1% if >200 beds and down to 31.1% if 1-50 beds
--by using the Standardized Antimicrobial Administration Ratio (SAAR), a calculation of observed vs predicted antibiotic use and comparing similar facilities [but NOT a measure of antibiotic appropriateness, only a gross calculation -- and perhaps some hospitals are using too few antibiotics???], but this SAAR could be used as a marker for which hospitals should develop stewardship programs (see https://www.cdc.gov/getsmart/healthcare/pdfs/Strategies-to-assess-antibiotic-use-in-hospitals-508.pdf )
--the document does have specific suggestions for antibiotic stewardship programs overall, ranging from leadership commitment to education to accountability, to action plans/reporting, etc. the report also highlights some successful programs, such as one by the Massachusetts Dept of Public Health, leading to a 28% decrease in unnecessary urine cultures for patients, 37% reduction in antibiotics given to patients with asymptomatic bacteriuria, and 47% reduction in healthcare-acquired C difficile infections
Commentary:
--This study highlights some small progress recently in decreasing the prescription for antibiotics. Another relevant assessment: see http://edition.pagesuite.com/popovers/article_popover.aspx?guid=743ffeab-72f7-4346-964c-b9411a296374 , an article from the Boston Globe which highlights a Blue Cross Blue Shield study of 31 million commercially insured people/yr (ie, not patient-specific data) of those <65 yo who had prescriptions filled from 2010-16, finding that there was a 16% drop in antibiotic prescriptions for kids and 6% drop for adults, with scripts for infants falling 22%. Finding similar geographical discrepancies as per the CDC report. And the greatest drop was for broad-spectrum antibiotics. So, much more impressive. Different group of patients than the CDC report and somewhat longer time interval, but this report is more striking both in the quantity of antibiotic prescriptions (more dramatic decreases) as well as the quality (fewer resistance-creating broad-spectrum antibiotics).
--see blog on taking full course of antibiotics, which notes that many of the most drug-resistant strains we see now are from "normal" commensal bacteria which develop resistance largely through plasmids (which can then migrate to other bacteria and confer antibiotic resistance for them), and that even very short courses of antibiotics can do this (this is pretty different from the old warning that people should finish their full course of antibiotics to decrease developing resistance)
--see blog on antibiotic-resistant bacteria of concern, per the WHO, including that half of the high priority bugs fall into this group of resistant commensals:
--will add the following, from prior blog as a perspective here:
Details:
-- outpatient settings (clinics, doctors' offices, ERs):
--47 million unnecessary antibiotic prescriptions/yr
--overall antibiotic scripts decreased by 5% in period 2011-14 from 75 million scripts to 64 million in children <19 yo, though has increased from 192 to 198 million in adults (especially high prescribing rates in kids <2 and adults >65). however, more often antibiotics prescribed may be "less effective and carry more risk over more targeted first-line drugs recommended by national guidelines" (in 2010-11, only 37% of adults received guideline-recommended antibiotics for sinus infection or pharyngitis, more like 60% in kids for these infections and otitis media.)
--the CDC still feels that 30% of outpatient antibiotic prescriptions are unnecessary, and 50% of those for acute respiratory conditions (URIs, viral sore throats, bronchitis; as well as some bacterial infections that do not always need antibiotics, such as many sinus and ear infections)
--in 2011, 1/3 of the 500,000 C difficile infections were community-associated.
--there is large variability in antibiotic prescribing by different regions in the US
--highest in nebraska, iowa, arkansas, louisiana, mississippi, tennessee, alabama, kentucky, west virginia, at 1,018-1319/1000 people
--lowest in california, montana, colorado, vermont at 511-668/1000 people
--in nursing homes:
--a small CDC study of 9 nursing homes found that 11% of patients were on antibiotics on any single day and that 40% of antibiotic orders lacked "important prescribing information"
--1/3 of the antibiotics were for UTIs, but 1/2 of these were for either the wrong drug, dose or duration.
--of the 4 million in nursing homes, antibiotics are given to 50-70% over the course of a year, and up to 75% are prescribed incorrectly
--in hospitals:
--use of very powerful antibiotics has increased significantly from 2006 to 2014 (40% for carbapenems and >30% for vancomycin), and 30% of antibiotic usage overall in hospitals "are unnecessary or prescribed incorrectly"
--antibiotic stewardship programs seem to help (eg, see blog on hospital antibiotic stewardship programs which have reduced infections with antibiotic-resistant bacteria and C difficile)
--there are geographical differences in % of hospitals with stewardship programs:
--the content of these stewardship programs vary significantly, with 7 core elements defined by the CDC; 41% of hospitals implementing all 7 in 2014, increasing to 48% in 2015).
--programs in 55-77% of hospitals in california, arizona, utah, massachusetts, new york, rhode island, maryland, virginia, north and south carolina, florida); and down to 7-33% in montana, north and south dakota, minnesota, iowa, nebraska, kansas, wyoming, louisiana, mississippi
--larger hospitals are more likely to have programs with all 7 elements: 66.1% if >200 beds and down to 31.1% if 1-50 beds
--by using the Standardized Antimicrobial Administration Ratio (SAAR), a calculation of observed vs predicted antibiotic use and comparing similar facilities [but NOT a measure of antibiotic appropriateness, only a gross calculation -- and perhaps some hospitals are using too few antibiotics???], but this SAAR could be used as a marker for which hospitals should develop stewardship programs (see https://www.cdc.gov/getsmart/healthcare/pdfs/Strategies-to-assess-antibiotic-use-in-hospitals-508.pdf )
--the document does have specific suggestions for antibiotic stewardship programs overall, ranging from leadership commitment to education to accountability, to action plans/reporting, etc. the report also highlights some successful programs, such as one by the Massachusetts Dept of Public Health, leading to a 28% decrease in unnecessary urine cultures for patients, 37% reduction in antibiotics given to patients with asymptomatic bacteriuria, and 47% reduction in healthcare-acquired C difficile infections
Commentary:
--This study highlights some small progress recently in decreasing the prescription for antibiotics. Another relevant assessment: see http://edition.pagesuite.com/popovers/article_popover.aspx?guid=743ffeab-72f7-4346-964c-b9411a296374 , an article from the Boston Globe which highlights a Blue Cross Blue Shield study of 31 million commercially insured people/yr (ie, not patient-specific data) of those <65 yo who had prescriptions filled from 2010-16, finding that there was a 16% drop in antibiotic prescriptions for kids and 6% drop for adults, with scripts for infants falling 22%. Finding similar geographical discrepancies as per the CDC report. And the greatest drop was for broad-spectrum antibiotics. So, much more impressive. Different group of patients than the CDC report and somewhat longer time interval, but this report is more striking both in the quantity of antibiotic prescriptions (more dramatic decreases) as well as the quality (fewer resistance-creating broad-spectrum antibiotics).
--see blog on taking full course of antibiotics, which notes that many of the most drug-resistant strains we see now are from "normal" commensal bacteria which develop resistance largely through plasmids (which can then migrate to other bacteria and confer antibiotic resistance for them), and that even very short courses of antibiotics can do this (this is pretty different from the old warning that people should finish their full course of antibiotics to decrease developing resistance)
--see blog on antibiotic-resistant bacteria of concern, per the WHO, including that half of the high priority bugs fall into this group of resistant commensals:
--will add the following, from prior blog as a perspective here:
--90% of antibiotics go
to animals, largely to improve their growth and not to treat infections, and
this practice seriously augments the incidence of antibiotic-resistant bacteria (see WHO report of the scary increase in antibiotic resistance, targeting the 12 bacterial families with the
greatest threat to
humans; and on
the emergence of untreatable superbugs such as colistin-resistant E coli
--studies suggest that >70% of antibiotics prescribed in humans are for inappropriate
indications (eg, acute
bronchitis, non-strep pharyngitis, acute rhinosinusitis, upper
respiratory infections), and 85% of antibiotic prescriptions are
written in primary care (see )
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