CDC officials want physicians to ‘Get Smart’ about antibiotic use

The CDC’s comprehensive program attacks resistance from all sides of health care.

With an empty antibiotic pipeline and the emergence of highly resistant bacteria, such as those containing the New Delhi metallo-beta-lactamase-1 gene, physicians are finding it increasingly difficult to treat even the most common infections.

“We have isolates coming out of India that are panresistant, so with respect to what is available, there are no antibiotics with which to treat these infections,” Timothy Walsh, PhD, of the University of Cardiff in Wales, said during a press conference at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy.

The CDC’s multifaceted Get Smart programs, however, advocate fighting resistance through judicious use of the existing antibiotic pipeline. The programs will conduct an observance, Get Smart About Antibiotics Week, from Nov. 15 to Nov. 21, during which health officials plan to introduce new promotional activities and increase communications strategies.

“What we [Get Smart] aim to do is educate health care providers, as well as parents of young children and the general public, about the importance of appropriate antibiotic use with the intention of decreasing the spread of antimicrobial resistance,” Lauri A. Hicks, DO, medical epidemiologist and medical director of the Get Smart: Know When Antibiotics Work program, which focuses on appropriate antibiotic use in the outpatient setting, told Infectious Diseases in Children.

“There is a lot of focus on development, but there is very little focus on improving antibiotic use,” Arjun Srinivasan, MD, medical director of Get Smart for Healthcare, a companion program of the Get Smart initiative, said in an interview. “We have to address both sides of the coin. Just addressing one issue, ultimately, isn’t going to be effective in solving the problem in the long haul.”

Providers, parents and the public

A major objective of the Get Smart program, which launched an initial media campaign in 2003, is reducing antimicrobial use in the community, by educating providers about proper prescribing practices, Hicks said.

“Our Get Smart provider education materials include treatment guidelines, especially for upper respiratory infections, and detailing sheets, which are available for download at our website,” she said. “We also are about to launch additional educational opportunities, including a continuing education course for pharmacists and medical school curricula.”

Hicks said there are various continuing medical education courses that are accessible online (See references below), including a program designed to enhance otitis media diagnosis and a Get Smart CME course for credit.

Get Smart officials are also partnering with state health departments to implement electronic medical record prompts that would improve physicians’ ability to accurately diagnose diseases and determine if antibiotic therapy is appropriate.

Physicians also contend with patients who visit their offices intent on obtaining antibiotics despite diagnoses. Therefore, tools to aid providers in addressing patients’ concerns are also key components of the Get Smart program. Hicks said, for example, that a video giving providers practical tips on how to discuss the issue of avoiding unnecessary prescriptions will soon be available on Medscape’s website (www.medscape.com/partners/cdc/public/cdc-commentary).

Another popular item already in use is the viral prescribing pad, which provides recommendations for symptomatic therapy.

Stressing adherence to antibiotic prescriptions is also important, and traditional methods of patient education, such as brochures, handouts, posters and fact sheets, may be useful in driving these points home, according to Darcia D. Johnson, program officer for Get Smart, who said physicians can distribute these materials or place them in their offices to increase awareness among patients.

Recent communications activities also involve disseminating messages using social media, including Facebook, Twitter and podcasts.

Appropriate inpatient use

Although the Get Smart programs address antimicrobial use in community and outpatient settings, inpatient facilities have received little attention. Therefore, in 2009, the CDC launched a companion program called Get Smart for Healthcare that focuses on appropriate antibiotic use in acute care facilities.

“We decided to build on the CDC’s experience with the Get Smart: Know When Antibiotics Work program in trying to improve antimicrobial use because health care is a continuum,” Srinivasan said. “People who are in outpatient clinics are the same people who get admitted to hospitals, and it’s the same people in hospitals who then go back and see doctors in clinics.”

The campaign advocates paying attention to certain prescribing practices, such as writing dose, duration and indication on antibiotic prescriptions.

“If you write the duration up front, you’re more likely to have the right duration of therapy than if you’re asking someone down the road to try to figure out what the duration should have been and stop it,” Srinivasan said.

He also said reassessing therapy and enhancing microbiology practices are important.

“There are a lot of things we treat on the inpatient side where our therapy could be improved if we had culture results,” Srinivasan said. “A lot of times, antimicrobial therapy gets started, but then after 48 or 72 hours, there is usually a lot more information that helps you decide whether or not the patient still needs an antimicrobial or if the patient is on the right antimicrobial.”

To promote these messages and practices, program planners will launch a Get Smart for Healthcare website, along with other observance week activities.

Srinivasan also said the CDC is working with the Institute for Healthcare Improvement, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America to explore the best ways to disseminate information and apply knowledge about how to improve antibiotic use in inpatient facilities.

Clinical implications

Physicians working in acute care hospitals have hope for the Get Smart for Healthcare program, said Christopher Ohl, MD, associate professor of medicine at Wake Forest University School of Medicine.

“Guidelines for antimicrobial stewardship were published in 2007, but they weren’t widely accepted because we felt like they told us where we need to be, but they didn’t tell us how to get there,” Ohl said in an interview. “And they also didn’t reflect the reality of a lot of community hospitals, which don’t always have the infectious disease resources or the pharmacy resources required by guidelines.”

The Get Smart for Healthcare planners considered these concerns during development and now provide tool kits with more feasible guidance for physicians working in acute care settings.

Additionally, the campaign promotes looking beyond traditional ideas about how stewardship programs work. Ohl said hospitals without infectious disease specialists can have other physicians fill that role and help decrease antibiotic overuse.

“A hospitalist, internist or interventionist, for instance, may be able to fill that role, particularly if they have had some additional training in the topic of stewardship and infectious diseases therapy,” he said. “It’s the same in the PharmD realm.”

Currently, some academic institutions, state health departments and professional societies already offer this training, but a standardized certification program would be extremely beneficial, Ohl said, noting that campaigns such as Get Smart may help secure resources for these programs by advocating additional education.

Working with other tools, such as the National Healthcare Safety Network, also offers opportunities to monitor antimicrobial use and the efficacy of intervention programs, according to Srinivasan.

“This has historically been one of the major challenges in the effort to improve antibiotic use,” he said. “This system, which will allow people to track that use electronically, would not only allow you to assess how your interventions are working, but eventually, it would also allow you to compare yourself to other facilities that are similar to yours.”

This communication provides an important avenue to exploring how to tailor antimicrobial stewardship programs to each hospital so that they will be effective, Ohl said.

Antimicrobials in animals

In 2004, Get Smart also extended its reach to include veterinarians and others caring for animals.

“Get Smart: Know When Antibiotics Work on the Farm emerged due to the concern about antibiotic-resistant organisms in animal products,” Ezra J. Barzilay, MD, of the CDC’s National Surveillance Team for Enteric Diseases, said in an interview. “The program works to promote appropriate antibiotic use in veterinary medicine and animal agriculture.”

State-based programs are an important element of Get Smart on the Farm. They foster collaboration between state public health and veterinary communities and help implement community-based programs on appropriate antibiotic use in animals, according to Barzilay. These programs often include traditional campaign-like materials, such as brochures and posters.

The main focus of Get Smart on the Farm, however, is early education for veterinary students.

“We were approached by partners at veterinary schools because the people with whom we were working in academia were seeing a lack of effort in educating the veterinary community on the judicious use of these antibiotics,” said Tom Chiller, MD, MPH, associate director for epidemiological science in the CDC’s Division of Foodborne, Waterborne and Environmental Diseases.

“The program is focused on an educational curriculum for veterinary students in their first and second years,” Barzilay said. “By stressing the importance of proper prescribing practices during their formative years, the students will be more responsible and more aware of the issues of prescribing behaviors when they ultimately become clinicians.”

The veterinary curriculum is an interactive Web-based educational program with background and species-specific and case-based modules that cover microbiology, pharmacology, public health and infectious diseases.

Barzilay said the curriculum is designed to be more entertaining and engaging than typical classroom lessons. One module, for example, is a comic book space module called “Where in the World is Ella Salmonella?” Additionally, the website contains a video project of students filming themselves working with farmers and veterinarians.

“We didn’t want to add more dry, lecture-type materials,” he said. “The curriculum is meant to be interesting, easy-to-understand and adoptable.”

The Michigan State University College of Veterinary Medicine and the University of Minnesota College of Veterinary Medicine have already incorporated Get Smart on the Farm’s educational program into their curricula. Barzilay said he hopes that the curriculum will be adopted by more veterinary schools as it evolves.

Communication is essential, and notifying deans of other veterinary schools will publicize the program and help create more educational opportunities. “We’re inviting people to help us develop even more modules in this curriculum so we can really round it out and make it a 4-year program,” he said.

Global efforts

As antimicrobial resistance surfaces worldwide, other countries are now also taking action and some are even coordinating their efforts with the United States.

“One of the exciting things this year is that we are partnering with the European Centre for Disease Prevention and Control (ECDC) to increase global awareness about appropriate antibiotic use,” Hicks said. “We also recently heard from health officials in Canada that they are going to join the effort.”

The ECDC’s Antibiotic Awareness Day will occur on Nov. 18 and coincides with Get Smart About Antibiotics Week. The event, however, differs from the CDC’s Get Smart observance, according to Sarah Earnshaw, project manager for the event, as countries across the European Union vary in cultures, needs and resources for establishing campaigns against antimicrobial resistance.

“European Antibiotic Awareness Day is not actually a campaign,” Earnshaw said at the 2010 International Conference on Emerging Infectious Diseases. “It’s a European public health initiative that aims to provide a platform and support for national campaigns about prudent antibiotic use.”

The ECDC produces tool kits of educational and information materials to countries a few months before European Antibiotic Awareness Day, and each year, the materials target a different group. They were geared toward the general public in 2008, primary care prescribers in 2009 and will be aimed at hospital prescribers in 2010, Earnshaw said.

Educational and information items include fact sheets, posters, brochures and videos about antimicrobial resistance and how to deal with patients who demand antibiotics. They are available in multiple European Union languages, according to Earnshaw, and are adaptable to different countries’ needs.

Partnerships with professional associations and governments are significant aspects of the initiative. “We’ve been working with them to get feedback on the materials we’ve been developing and also to use them as channels to amplify our messages,” Earnshaw said. “Political support is also something which we value very highly, so we’ve placed a lot of emphasis on advocacy.”

Europe and the United States are not alone in their efforts. Donna Kusemererwa, PharmD, executive director of the Ecumenical Pharmaceutical Network (EPN) in Nairobi, Kenya, also outlined the work being done in developing countries at the 2010 International Conference on Emerging Infectious Diseases.

Because churches and church-owned organizations provide up to 40% of health care services in Africa, EPN concentrates on the provision of quality pharmaceutical services in this sector, Kusemererwa said. It currently has more than 70 members from 31 countries in Africa, Asia, Europe and the Americas.

Its focus on antimicrobial resistance dates back to 2007. “The members agreed that, because of the high burden of disease in our countries and because of resource limitations, it was particularly important for us to take up antimicrobial resistance as an issue and start working,” Kusemererwa said.

To address the problem, the EPN developed “Fight AMR! Save medicines for our children.” The campaign’s centerpiece is a call-to-action document detailing the issue of antimicrobial resistance and delineating the roles that health care workers, government officials and the general public can play. They also created a few structured campaign activities that were launched at the World Health Assembly in 2009.

Kusemererwa noted, however, that one of the major hurdles with campaigns in these countries is convincing people that antimicrobial resistance is a real threat because other health issues often take precedence. But an effective point of entry has been infection control prevention.

“Infection control within these settings is more organizable and an easier intervention for us to target because people understand infection control better than they understand resistance,” she said.

Funding, however, is the biggest obstacle for antimicrobial campaigns in every country. These programs will only survive if the government and other organizations are willing to support and provide the resources necessary to keep these programs afloat, Hicks said. – by Melissa Foster

For more information:

• Earnshaw S. European Antibiotic Awareness Day: A single campaign across 32 countries. M1. Presented at: 2010 International Conference on Emerging Infectious Diseases; July 11-14, 2010; Atlanta.
• Hicks L. Get Smart about Antibiotics: U.S. efforts to address inappropriate antibiotic use. M1. Presented at: 2010 International Conference on Emerging Infectious Diseases; July 11-14, 2010; Atlanta.
• Kusemererwa D. Campaigns tackling antimicrobial overuse in the developing world. M1. Presented at: 2010 International Conference on Emerging Infectious Diseases; July 11-14, 2010; Atlanta.
• www.cdc.gov/getsmart/
• www.cdc.gov/getsmart/specific-groups/healthcare-providers.html
• www.cdc.gov/narms/get_smart.htm

Will Get Smart be effective in improving antibiotic overuse?

The program has the potential to be extremely beneficial in educating parents, patients and providers about the threat of antimicrobial resistance and why judicious use of antibiotics is so important.

Many of the bacteria that cause common infections in children, such as those that give rise to ear infections, pneumonia and skin infections, have become resistant to several of the antibiotics we have routinely used, which has significantly limited our choices for appropriate treatment.

Resistance can develop in multiple ways. Some bacteria, for example, have genetic mutations which confer resistance by preventing an antibiotic from entering the bacteria; others produce an enzyme that destroys an antibiotic’s function. Bacteria can exchange extra-chromosomal DNA which contains antibiotic resistance genes. When you expose bacteria to an antibiotic, the treatment will leave only those that are resistant.

Over time, as we use antibiotics, the resistant organism will eventually emerge as the common strain. In many communities across the country, for instance, 50% to 60% of the staph infections that occur in children are now due to methicillin-resistant strains of Staphylococcus aureus — a bacteria that we rarely saw outside of the hospital before 10 to 15 years ago. Furthermore, these strains differ from those seen in inpatient settings, indicating that the resistant strains have developed in the community.

To decrease antibiotic exposure and, therefore, pressure placed on bacteria to become resistant, understanding judicious use of antibiotics is essential. Because of the way antibiotics were used in the past, many parents and patients have felt that any kind of infection, even those that are viral in nature, needs to be treated with these medications. However, this sentiment is changing.

Recent data from the CDC suggest that the use of antibiotics to treat respiratory tract infections in children has declined, and other studies demonstrate similar decreases for other common illnesses caused by viruses, such as rhinitis, sore throats and colds, for which antimicrobial therapy is not indicated.

Providers’ willingness to discuss proper antibiotic use with parents and patients may be responsible for these marked reductions in use, suggesting that the public is willing to be educated and that physicians can increase public awareness of which infections require antibiotic therapy and which do not.

In the past, some physicians were concerned that it took so long to educate a parent about whether an antibiotic was necessary that, in many cases, it was simpler and more efficient to just give the treatment that they wanted. Many parents now understand, however, that decreasing inappropriate antibiotic use is crucial. Additionally, it is now known that educating parents, making them aware of proper antibiotic use and explaining why their child does not have an infection that requires antibiotic treatment is not that time-consuming. The current American Academy of Pediatric Guidelines for Health Supervision now include counseling on antibiotic use as a part of well-child care.

The Get Smart campaign can help deliver these messages and further facilitate communication between providers and parents. The program will provide a toolkit that pediatricians can adapt to their own practices and give insight into the best and least time-consuming way to disseminate information to parents. For some physicians, direct communication may be best, for others, it may include having brochures available and putting up posters in their offices. For others, utilizing social networking or playing videos in their offices may be more effective. Physicians will need to individualize their approaches and use the tools that they think will be most beneficial, which will be based on their style of practice and the patient population that they serve.

An important key to Get Smart’s success, however, is awareness. Physicians need to know that the program exists and become familiar with its information, messages, activities and modes of communication.

The education that Get Smart offers providers is also valuable. Part of the reason that antibiotics are overused is that, in some cases, providers have used them inappropriately for diagnoses that did not require antibiotic therapy. Some providers may need to be more aware of the cause of various common infections and the need for judicious use of antibiotics.

Joseph Bocchini Jr., MD, is Chairman of the Department of Pediatrics at Louisiana State University Health Sciences Center in Shreveport. He is also an Infectious Diseases in Children editorial board member.

Although the Get Smart campaign has potential, a few clarifications are required.

The program implies that there are no treatments for viral infections, which is not accurate because antivirals are antibiotics in the truest sense of the word. This idea that viral infections do not have treatments neglects the fact that, for instance, if a child has a fever during flu season, oseltamivir and zanamivir are available and worthwhile treatments, especially for sicker children or children who have high risk factors. Additionally, several infections, including herpes simplex or herpes zoster, should be treated with these medications. One key way to avoid confusion is by referring to those antibiotics that lead to resistance as antibacterials.

Another important point is parent education. While the CDC and Get Smart concentrate on making sure parents understand antimicrobial resistance and prudent antibiotic use, they should also encourage parents to question a physician’s diagnosis in a respectful manner if he or she seems uncertain. A common scenario, for instance, involves a parent whose child has a cold or viral syndrome, and instead of following their pediatrician’s recommendations, they visit an urgent care center where the child is characterized as having some sort of diagnosed bacterial infection. Then, the child receives an unnecessary antibiotic prescription. The parents must understand, however, that these physicians do not deal with children every day, and therefore may be uncomfortable, less well-versed or less skilled in the subtleties of diagnosing diseases such as acute otitis media in pediatric patients. It is also important to note that these difficulties extend beyond urgent care centers and affect mid-level practitioners as well as less experienced pediatricians. However, physicians should be prepared to deny requests for antibiotics if they feel the prescription is unwarranted.

Additionally, although Get Smart’s circulation of detailed guidelines for diagnosing certain infections is helpful in re-emphasizing their importance, other factors complicate the issue of diagnosis. The guidelines have been around for about 10 years, and some physicians feel they are too stringent, especially for diagnosis of sinusitis and persistent rhinorrhea. Increased experience in examining these types of infections in children may be the best way to improve a provider’s ability to diagnose, although updated and more practical guidelines could be beneficial.

Overall, antibiotic overuse is slowly declining, and newer infant vaccines and programs, like Get Smart, that offer patient and provider education, have played a major role in this decline. But there is still room for improvement in prescribing unnecessary antibiotics for outpatient diagnoses such as pharyngitis, acute otitis media, rhinorrhea and cough syndromes. This problem in pediatric patients is accentuated among physicians who do not deal with children every day, mid-level practitioners and urgent care centers. For any provider, the tradeoff is terribly difficult between saying “no antibiotics” to an upset parent versus keeping them all seemingly happy with an antibiotic prescription and reduced “bounce-backs.” One way to avoid this issue with the especially common presentation of green rhinorrhea in children may be by bargaining with a parent. A physician can tell parents that he or she will save them another visit to the office and another copay by phoning in a prescription after the rhinorrhea has persisted beyond a 9- to 10-day window. Sinusitis is diagnosed strictly by history anyway, and this strategy may allay much of parents’ frustration.

Get Smart’s patient education materials are definitely useful for pediatricians. We like to have the brochures, packets and posters available for our office waiting rooms and our office rooms. Having this information on hand can aid a physician in explaining antimicrobial resistance, judicious use of antibiotics, the potential negative side effects of antibiotics and the unnecessary cost of prescribing antibiotics without indication. The materials can further help us persuade parents whose children have colds and purulent upper respiratory infections that the wait-and-see approach mentioned above is effective and beneficial.

One major problem, however, is parental lack of knowledge about the CDC. Depending on their age and education level, parents are not always aware of what type of organization the CDC is, its importance to the medical community and the expertise behind their decisions and recommendations. Providers often need to educate families about the CDC and why it is so important to follow the agency’s recommendations not only about antibiotics but also vaccines. Thus, Get Smart should also try to increase the public’s general awareness of the CDC.

The Get Smart campaign should also make one particular clarification. The program alleges that no treatment is available for viral infections. This could be somewhat detrimental, as we frequently treat influenza and herpes infections with specific antivirals. To avoid this confusion, they should probably say antibacterials (antibiotics) instead.

Stan L. Block, MD, is Professor of Clinical Pediatrics at the University of Louisville and the University of Kentucky. He is also an Infectious Diseases in Children editorial board member.