Fighting antibiotics abuse with cycling, rotation
Traditional restrictions just aren’t working
Last year’s headline-making cases of vancomycin resistance have made a lot of pharmacists nervous, and with good reason. Despite the quickly drawn Centers for Disease Control and Prevention guidelines for the drug’s use and the hype over potential saviors like Synercid, pharmacists have had to assume leading roles in programs to prevent the overuse of vancomycin and other antibiotics. (See "FDA fast-tracks antibiotic for staph treatment," p. 200, Drug Utilization Review, December 1997.)
But while the oversight strategies are many, a foolproof solution has remained elusive. The effectiveness of stop orders, order forms, mandatory pharmacist approval, formulary restrictions, and departmental protocols is debatable. However, some combination of these with the latest trend, antibiotic cycling or rotating, may hold the key to preventing antibiotic abuse.
The scope of that abuse is daunting. While about $7 billion a year in health care dollars are spent on prescriptions for the 150 or so antimicrobials available, $4 billion of that total is spent just to treat resistant bacteria, says a Virginia pharmacist researching anti-resistance techniques.
"What’s big now is antibiotic cycling aimed at stopping resistance among different classes of drugs, but not within the same class. The strategy is to avoid prolonged use and therefore resistance, but it won’t break established resistance. Instead, the goal is not to let new resistance start," says Marianne Billeter, PharmD, associate professor at the Shenandoah University School of Pharmacy in Winchester, VA.
Billeter says the challenges or pitfalls of this approach are varied. "You have to figure out what drug to rotate with what drug; and within what to what departments; and what time factors, every six months or a year; and then how to keep the prescribers up to speed on the changes," she says.
Despite all that, Billeter says it’s a new approach worth considering. It can encompass existing formularies and, equally important, is a strategy physicians may swallow more easily than others like a prescription-by-prescription approval process, especially if the final approval rests with a pharmacist.
Order forms, for example, have not proven a very successful approach so far, she says. "Order forms are designed to make doctors think. A checklist can ask whether the drug is prophylactic, empiric, or therapeutic, but doctors will put absolutely anything on a form just to get the agents," she warns, pointing to cases in which the "right" level of patient serum creatinine was recorded on a form, but the lab tests were never ordered.
As to formulary controls, Billeter has found that extremes have not worked well. "In the past, antimicrobial formularies were designed to control costs, while little attention was given to bacterial resistance," she says. Even worse, antibiotics can routinely take up 30% of a hospital’s budget, while up to 50% of their use is inappropriate.
"Closed formularies can promote resistance with those single workhorse agents, but open formularies can promote an anything goes’ attitude, and doctors will use them all," she says. After an open formulary with no restrictions was installed at the University of North Carolina, the use of formerly restricted drugs increased 158%, and costs increased 103%. That experiment was ended quickly, she adds. (Imipenem and ceftazidime were the most abused drugs to come out of that short-lived effort, Billeter says.)
Finding success in the middle ground
So what can work? Billeter recommends a criteria-based formulary, enhanced by computer monitoring and controls centered around specific units, indications, physicians, or specialties.
"It’s a nonadversarial system of drug and use criteria," she says. For example, protocols citing ceftriaxone for bacterial meningitis or substitution rules like cefotetan for cefoxitin, or cefmetazole for cefotetan, are commonly used.
Billeter adds that computer monitoring of resistant organisms linked to specific drugs and therapy has a level of acceptance that human recommendations may not. She knows of one study using WalkAway 40 and pharmLINK systems that resulted in 83% acceptance by physicians of the software recommendations and a savings of $32,000. Conversely, the success of most on-site educational efforts, she says, are hard to factor. "Unfortunately, educational efforts are a real unknown as to their true impact." In-house newsletters are disregarded, seminars suffer from lack of attendance, and medication use evaluations suffer from time lag. "One-on-one is the best, and pharmacists have to try to work with infectious disease doctors, but it’s one of the most difficult tasks we have, to make it a nonadversarial relationship."
Billeter does offer several tips. "Start with trying to improve surgical prophylaxi; that’s where overdoses are common. Your patient population must be determined, and your population’s disease patterns, and then finding the local resistance patterns. The susceptibility of nosocomial pathogens must be considered, and drug restrictions should be based on indications, toxicity, and financial outcomes."
Victor Lampasona, PharmD, director of clinical pharmaceutical research at Emory University Medical Center in Atlanta, says education is paramount education of the patient as much as the physician.
"We’ve got to tell people that antibiotics don’t work for colds and flu and the consequences of using them too much," he says, citing a survey in which 66% of respondents thought antibiotics kill colds and flu. He also cites a study of office visits to 5,000 physicians for a year. During that time, of the prescriptions for antibiotics given, 51% were for colds, 52% for upper respiratory tract infections, and 66% for bronchitis.
The problem is not just with prescribing physicians: It falls largely on the shoulders of the public. Of the doctors responding to the same survey, 72% said patients asked to be given an antibiotic, and Lampasona allows that doctors can feel duty-bound to give the customers what they want.
"Pharmacists have to push for immunizations, for people to finish their prescriptions, and to find easier ways to treat common illnesses. Hospital risk guidelines and in-house surveillance are important while pushing for the right formulary for your population," he says, echoing a point stressed by Billeter. "If we don’t control our use of antibiotics, we will lose our, quote, super drugs. Preserving the use of the power of antibiotics is key."
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