Update from ECCMID: Infectious disease and medical overuse

This is a guest post by Dan Morgan, MD MS. He's an Associate Professor of Epidemiology and Medicine at the University of Maryland, Baltimore.

At the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) meeting last week in Vienna, Austria, a session was dedicated to Medical Overuse and Infectious Disease. To me, it was great to hear smart people thinking about my job, infectious diseases, in the context/language of my hobby, medical overuse.  Medical overuse has been defined as the provision of care in which harms outweigh benefits or the benefits are so small that informed patients would not want care. Although it was the last session of the meeting, it was surprisingly well attended. A few high points follow:

Céire Costelloe from the UK presented work showing 80% of antibiotics are given as outpatients and promote risk of resistance greatest in the first week but antibiotics have a persistent effect six months after use. Targeting overuse of antibiotics in outpatient settings is likely key to address antibiotic resistance.

Alexander Friedrich from the Netherlands, presented a balanced view of how tests can drive overuse—such as blood cultures or rapid malaria testing, but also that testing may have a role in reducing overuse in the use of procalcitonin to stop antibiotics. If clinicians default to antibiotics, then testing may help them step back. However, if clinicians aren’t prone to empiric treatment, testing may increase treatment.

Stephan Harbarth from Switzerland then gave a great overview of how implanted devices like urinary, central-venous catheters and endotracheal tubes are risks for HAIs, MDRO colonization and are often overused. His message was that reducing use of devices is the primary way of reducing infections. (Although note, CDC and other agencies use rates per catheter day, which discourages removal of low risk catheters, so we may need a better metric—like “days of utilization”)

Finally I spoke, closing the session and the conference. My talk focused on what do we know about Overuse more generally and what can we do to prevent Overuse? To me, the basis of Overuse is a skewed view of testing and treatment. I reviewed the evidence of physician over-enthusiasm for benefits of testing and treatment and tendency to underestimate harms of both. I presented a general model for how to address overuse, the Choosing Wisely campaign and how CW could be used by those encouraging stewardship. On the theme of stewardship, there have been interesting studies showing the benefits of diagnostic stewardship, identifying what seems to be a growing trend to modify testing to improve antibiotic use.


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