Antimicrobial Stewardship: The President, PCAST and Beyond
There's been a lot of excitement the past couple of weeks surrounding the release of several overlapping documents: the PCAST Report, the National Strategy for Combating Antibiotic Resistant Bacteria, and the President's "Combating Antibiotic-Resistant Bacteria" Executive Order. The Order is interesting in that the effort is to be coordinated by the National Security Council staff and guided by a task force co-chaired by the Secretaries of Defense, Agriculture and HHS. By next February 15th, The Task Force is to submit a 5-year National Action Plan and The Secretary of HHS is to establish a Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria. The additional components include improved antimicrobial stewardship, promoting novel antibiotic and diagnostic discovery, strengthening national surveillance, and finally preventing outbreaks and transmission through identifying and evaluating additional strategies in the healthcare and community settings for the effective prevention and control of antibiotic-resistant infections. Woo woo! Infection Control was mentioned!
The primary focus of the Executive Order and related reports, if you go by length and depth of recommendations, is antimicrobial stewardship. The orders include: (1) requiring hospitals (including DOD and VA) and other inpatient healthcare delivery facilities to implement robust antibiotic stewardship programs (2) monitoring stewardship through NHSN (3) encouraging USDA, FDA and EPA to continue efforts to reduce antimicrobial use in animals. I encourage you to read all three documents.
One of the best reasons to blog is that it forces you to read the literature, so when I finished reading the PCAST report, I grabbed the latest issue of JAMA. Toward the end of the issue there is a Clinical Challenge case of a 32-year-old man with recent travel to Venezuela and a skin and soft tissue infection. Without giving away the case (although the diagnosis is obvious), I wanted to highlight the fact that the proper diagnosis was missed by 10 clinicians "who collectively prescribed oral amoxicillin, cefadroxil, cephalexin, azithromycin, clindamycin, and cefdinir as well as intramuscular ceftriaxone and topical bacitracin, mupirocin, and polymyxin B." Of course, since the diagnosis was missed by all 10, none of these treatments had any effect. Thus, all of these antibiotics were unnecessary and when multiplied by the thousands of cases just like it that occur every single day, you get a sense of the scope of the antimicrobial overuse/misuse problem.
Now, this is just one random case but I think it highlights several major challenges facing antimicrobial stewardship. First, it shows that proper diagnosis requires proper training in infectious diseases and not just new diagnostics. Given that infectious diseases is a specialty in decline, it is likely that proper training in the recognition of infectious syndromes will not exist in the future. No new PCR test would have helped this poor patient since none of the clinicians thought to order the existing PCR in the first place. Second, medical students, residents and fellows are not adequately trained in antimicrobial prescribing. They can't learn how to prescribe antibiotics after a few (non-standardized lectures) and without the supervision of ID physicians (since they won't exist in the near future) during their clinical rotations. It has gotten so bad for the field of infectious diseases that many antimicrobial stewardship programs are now managed by non-ID clinicians.
So here are my recommendations for what needs to be included in the next Action Plan:
1) Improved reimbursement for Infectious Disease clinical activities since the major reason residents are choosing not to do an additional 2-3 years in ID fellowship training is that the additional training actually LOWERS their salary compared to non-ID boarded hospitalists
2) Increased funding for ID training programs
3) Federal support for a 3rd year ID fellowship (after the 2-year clinical fellowship) in either Hospital Epidemiology, Antimicrobial Stewardship or both
4) Increased research funding to identify barriers to infection control and proper antibiotic prescribing and interventions to improve both
The Reports last week were an amazing step. However, it will not be enough to have antimicrobial stewardship programs without infectious diseases physicians available to guide their implementation and train the next generation of non-ID clinicians. And of course, without the proper science guiding the selection and implementation of interventions, stewardship and infection prevention programs will have limited utility. A long way to go, but exciting to finally get started.
image source: recent Field Museum (Chicago) Exhibit