Q&A: SHEA white paper identifies gaps in antibiotic stewardship research
Click Here to Manage Email Alerts
The ability of antibiotic stewardship programs to control and reduce the unnecessary use of antibiotics could be improved by addressing several research gaps, according to a Society for Healthcare Epidemiology of America white paper published in Infection Control & Hospital Epidemiology.
According to one estimate, infections caused by multidrug-resistant organisms could be the third-leading cause of death in the country, killing up to 162,000 people each year.
“Antibiotic stewardship is crucial to maintaining the effectiveness of life-saving treatments and preventing harm to patients and the wider community,” SHEA president Hilary Babcock, MD, MPH, professor of medicine at Washington University School of Medicine in St. Louis, said in a news release. “We developed this research agenda to draw attention to serious gaps in our knowledge for future investigators and funders.”
Infectious Disease News spoke with Andrew Morris, MD, medical director of the Sinai Health System-University Health Network Antimicrobial Stewardship Program and lead author of the white paper, about the gaps in research and what is needed going forward. – by Marley Ghizzone
Q: What inspired the white paper?
A: The white paper was inspired by a recognized gap in terms of directing research on an important topic: antibiotic stewardship. This is important for funders of epidemiology and research, such as the CDC and NIH, as they start to address the need to learn more and improve care. Additionally, this is important for researchers at all stages — to readily identify and seek to address the gaps in knowledge.
Q: How far has research into antibiotic stewardship come and what has it given us?
A: We have made tremendous progress in just the past few years in antibiotic stewardship. As little as 10 years ago, very little was known, with approximately 100 papers published on the topic. Since that time, we have learned more about the epidemiology of antibiotic use and resistance, and have started to see more papers using large data sets. Additionally, we are starting to learn which interventions work and which ones don’t to change prescribing (of antibiotics) behavior. Researchers are starting to recognize that behavior change requires new skill sets and disciplines that borrow from sociology, psychology, medical anthropology, behavioral economics and even game theory.
Q: What gaps still exist?
A: The gaps remain large. Some of the fundamental questions on antibiotic use remain unanswered: Why do patients who clearly do not have a bacterial infection continue to be treated inappropriately with antibiotics? How long should we treat common infections like pneumonia? Is one antibiotic better than another, or is one antibiotic better than two for common infections? To what extent do we need to reduce antibiotic use to make an impact on antibiotic resistance or Clostridioides difficile, etc.? What has been the effect of antibiotic use and antibiotic resistance to the U.S. population? To health care costs? To economic loss? Do patients with a weakened immune system from, say, cancer chemotherapy, or from medications to prevent organ transplant rejection, need a different approach to antibiotic treatment? How different? What are the best study designs for antibiotic stewardship studies? The list goes on.
Q: What types of studies are needed to fill these gaps, and for which infections?
A: A variety of study types are needed. We need good, prospective, longitudinal, population-based epidemiological studies to understand antibiotic use and resistance. Ideally, this comes from high-quality data systems that are linked with patient clinical information, outcomes and microbiology. We also need studies focused on common clinical conditions treated with antibiotics, such as pneumonia, skin and soft tissue infections, urinary tract infections, diabetic foot infections and intra-abdominal infections. We need studies that look at the comparative effectiveness of different strategies to treat infections. We need comparative effectiveness studies that help us understand how to use technology (eg, electronic health records and computerized decision support) to best to change behavior. We need studies to understand how to optimally get information to prescribers in a manner that will change their behaviors. We need implementation science studies to understand how to do antibiotic stewardship in long-term care and ambulatory care. We need epidemiological studies that look at various metrics and tie them to outcomes to see which metrics matter. Finally, we could use mathematical modeling studies to help us understand how many of these studies will make a difference in large populations over different time periods.
Q: How will this help providers and patients?
A: Providers and patients deserve the best, safest care. Currently, many people believe (often unconsciously) that antibiotic stewardship means increasing individual patient risk for the good of the population. We need to get better data to assure us that this notion is false and, if/where it isn’t false, what is the magnitude of increased risk. (For example, when a patient reports a penicillin allergy, doctors avoid prescribing any penicillin or similar drug. Often, they are trading off a very low likelihood of a severe adverse drug reaction with a higher likelihood of inadequate treatment because of using a drug that has lower efficacy or other safety risks.)
Reference:
Morris AM, et al. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.276.
Disclosure: Morris reports no relevant financial disclosures.