Drug-resistant infections plaguing hospitals and nursing homes are a product of antibiotic resistance, and improper use of antibiotics can often start in the doctor's office, an expert panel said here.
The issue is far more complicated than a mere "knowledge deficit" about improper prescribing or overprescribing of antibiotics, but is far more complex and deals with everything from patient expectations to lack of self-awareness about prescribing habits to even "the Yelp factor" in fearing bad reviews.
As part of The Forum at the Harvard T.H. Chan School of Public Health in Boston, the panel discussed the topic entitled "Drug-Resistant Infections: Confronting an Escalating Crisis."
While the problem is widely known for hospitals and nursing homes -- a video clip discussing the emergence of fungal infection, Candida auris was shown -- experts on the panel emphasized the importance of antibiotic stewardship in reducing the risk of these drug-resistant infections. And often, that starts in the clinic.
"Just educating providers [about proper antibiotic use] is not enough. This is a social issue," said Lauri Hicks, DO, of the CDC. "If a doctor thinks [a patient] expects antibiotics for themselves or their child, [the doctor] will be more likely to prescribe it."
Hicks said that the CDC looked at the frequency of unnecessary antibiotic use in the doctor's office and emergency departments, and found that 30% of the antibiotics prescribed in these settings were completely unnecessary.
"Doctors have poor insight into their own prescribing patterns," she said. "If you ask any doctor, nurse practitioner, or physician assistant, they're going to tell you ... 'my prescribing patterns are not contributing to the problem. It's the surgeons, my partners, the urgent care facility.'"
She said that the goal is for doctors to be able to communicate to patients so that the patients are satisfied with potentially not receiving an antibiotic if one isn't needed, to have plans to manage symptoms whether or not an antibiotic is prescribed.
Speaking from the clinician's point of view, Helen Boucher, MD, of Tufts Medical Center in Boston, said that new diagnostics could potentially help with this problem -- specifically a type of test that could determine whether the patient had a viral or bacterial infection. Otherwise, clinicians are forced to use their own judgment.
"Sadly, in 2019, we don't have [this] technology," she quipped.
Ultimately, Boucher said that the goal of antibiotic stewardship is making sure that patients get the "best antibiotic at the best dose at the right time," and that every patient gets this "optimal treatment."
But that could be a problem when even manufacturing new antibiotics is a challenge. Kevin Outterson, JD, of Boston University and executive director of BU's global partnership for antibiotic development, Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) said that developing new antibiotics to help combat drug-resistance has been difficult, because there's little economic incentive for companies to do so.
Outterson told the story of one company who developed an antibiotic for 12 years, got FDA approval for it, and 9 months later was bankrupt, because the drug wasn't selling.
"Small companies are filing for bankruptcy [and] scientists are moving on. Most people have left to [go to companies] where they can make money," he said. "We are losing the global capacity to do research."
There are a couple of solutions to this problem outside of the medical field, Outterson said. The first is the DISARM Act, a bill currently in Congress that "changes the way that Medicare pays for antibiotics." He also suggested an incentive called "Market Entry Rewards," which he described as "a giant payment for a really amazing antibiotic that reaches the market, knowing you're going to use as little of it as possible in the first decade."
"[That will] get us the drug we want, but not give any company an incentive to over-market it," Outterson said.
Ultimately, Marc Lipsitch, PhD, of the Harvard T.H. Chan School of Public Health, summed up the problem of antibiotic overuse with an amusing, if not slightly depressing history lesson.
"When antibiotics were invented, it was difficult to make enough for one patient, and now sometimes you can get them for free at Kroger," he said.