Antibiotic resistance issues and options
Better surveillance, behavior changes needed
Improving surveillance and altering behavior were among the interventions recently identified by the Institute of Medicine in Washington, DC, as necessary to stem rising antibiotic resistance.1 The IOM findings were presented as issues and options rather than formal recommendations. The findings are summarized as follows:
Surveillance issues: No country, including the United States, has a reliable, longitudinal, full-service antimicrobial resistance surveillance program with comprehensive focus, nor is there a comprehensive database for monitoring trends in antimicrobial usage. Research and information on the impact of rapidly increasing antimicrobial resistance in the community are lacking. Antibiotic use is widespread, not just in hospital and community settings, but also on farms, yet knowledge of the magnitude of all these uses depends largely on estimation and extrapolation. Multiple surveillance activities around the globe are attempting in different ways and at different speeds to move toward the ideal depicted in this report, but these systems, as a group, are uncoordinated and unstandardized. Thus, the magnitude of the resistance problem and its impact are unknown and may be considerably understated.
Options: Funding, implementation, assumption or assignment of leadership, and formation of partnerships for implementing the 1995 American Society for Microbiology's detailed recommendations for a comprehensive resistance surveillance program.
· Improving data gathering and analysis, perhaps through national systems that would continuously monitor antimicrobial usage in hospital, community, and farm environments.
· Including information about the effects of resistance on the outcome of infections in data collection systems.
· Selecting and strengthening the laboratories in a set of sentinel hospitals as bases for global assessment of the prevalence and transmission of the most critical antibiotic-resistant genes, including training laboratory personnel in sentinel hospitals in standardized methodologies.
Attitude and behavior issues: There is a need to modify attitudes and behaviors among providers, patients, parents, managed care organizations, and the pharmaceutical industry. The IOM cited the following factors in each group that contribute to antibiotic misuse and rising resistance:
· Patient/parent factors: Anxiety; misconceptions about what antimicrobials do and/or that fever requires antibiotics; belief in healing power of physician; return-to-work needs; day-care requirements.
· Physician/provider factors: Real or perceived patient-parent pressure; economic concern for self (e.g., loss of clientele) and for patients (missing work); litigation concerns; inadequate knowledge; cognitive dissonance (i.e., knowledge but failure to act on it).
· Managed care factors: Cost-saving pressures to substitute therapy for diagnostic tests; productivity incentives; increased patient load; reduced appointment time and less explanation time per patient; responsiveness to patient complaints about "inadequate antibiotic use."
· Industry factors: Misleading or erroneous advertising; promotion by retailers.
Attitude and behavior options: Pursuing the following interventions and strategies could modify attitudes, behaviors, and policies on antibiotic use among the groups:
· Patient/parent behaviors: Education, physician explanation of prescriptions to patients in terms of implications of unnecessary use; educational materials at point of care and pharmacies; information to popular media for public education; economic incentives and disincentives (e.g., lower insurance fees for waiving drug coverage, medication copayments, formulary controls); knowledge-based day-care policies (e.g., no requirement of antibiotic therapy for readmission).
· Physician/provider behaviors: Alter patient expectations; education; use of opinion leaders to educate providers; information support systems; feedback to clinicians on local resistance trends; journals, conferences, symposia; emphasis on critical role of hand washing; develop clinical practice protocols; literature-based guidelines; local review and consensus integrated into guideline development; analyze practice patterns; audits of their antibiotic use compared to protocol and to peers; outcome analysis; peer feedback and discussion of outcomes; regularly provide drug prescribing reminders; incentives based on practice patterns and outcomes; reduce litigation concerns; develop faster, cheaper diagnostics for point-of-care testing (especially tests discriminating between bacterial and viral infections).
· Managed care policies: Demonstrate economic advantages of judicious antibiotic use; provide guidance about proper antibiotic use via Health Plan Employer Data and Information Set (HEDIS); provide industry access to local or regional infectious disease consultants; explanations of clinical practice protocols; feedback from patients, parents, providers regarding new practices and outcomes.
· Industry policies: Demonstrate economic advantage (e.g., longer duration of efficacy); promote responsible marketing and counter irresponsible marketing (opinion leaders); facilitate antibiotic research and development; tax incentives; extended patent life for antibiotics.
Reference
1. Institute of Medicine. Antimicrobial Resistance: Issues and Options. Washington, DC: National Academy Press; 1998.
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