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Clinical laboratories and microbiology tests provide key tools for physicians engaged in antibiotic stewardship programs

One important and continuing trend in healthcare is the need for hospitals, nursing homes, and other medical providers to introduce effective antibiotic stewardship programs (ASPs). The findings of a recent study on antibiotic stewardship emphasize the need for improvement and suggest guidelines that will involve and engage clinical laboratories.

Antibiotic-resistant infections kill at least 35,000 people in hospitals each year, according to the Centers for Disease Control and Prevention (CDC). And that, the CDC notes, is out of 2.8 million drug-resistant infections that occur annually.

In a recent brief of a study The Pew Charitable Trusts (Pew) conducted with the CDC and various public health and medical experts, Pew wrote, “Minimizing inappropriate antibiotic use in hospitals is a vital element in the fight against antibiotic resistance because more than half of patients admitted to hospitals will receive these drugs. Determining how much antibiotic prescribing is inappropriate and setting national targets to reduce such use are necessary steps for guiding clinical efforts and policies that promote improved antibiotic use.”

To do this, and Pew and the CDC are suggesting “widespread adoption of effective antibiotic stewardship programs, which promote responsible antibiotic prescribing, in order to minimize the harmful effects of inappropriate or unnecessary antibiotic use for patients and slow the spread of resistance.”

And because clinical laboratories perform all the in-hospital testing for ASPs, they will be big part of this effort.

Pew/CDC Set New National Targets for Antibiotic Use Improvement

The Pew brief states that in 2018 the researchers began “to evaluate antibiotic use in hospitals and set national targets to improve prescribing.” The brief adds that “Because of the complexity and diversity of illnesses among hospitalized patients, and the limitations on available clinical data for all antibiotic use in hospitals, the panel focused its analysis on four categories of prescribing that account for the most common antibiotic therapies in US hospitals. Using national prescribing data, the experts examined the use of two types of antibiotics—vancomycin and fluoroquinolones—and antibiotic treatments associated with two conditions: community-acquired pneumonia (CAP) and hospital-acquired urinary tract infection (UTI).”

It their paper published in JAMA Network Open, titled, “Assessment of the Appropriateness of Antimicrobial Use in US Hospitals,” the Pew/CDC researchers wrote, “In this cross-sectional study of 1,566 patients at 192 hospitals, antimicrobial use deviated from recommended practices for 55.9% of patients who received antimicrobials for community-acquired pneumonia or urinary tract infection present at admission or who received fluoroquinolone or intravenous vancomycin treatment.”

Infection Control Today reported that the CDC and Pew set the following goals for hospitals, but did not give a deadline for improvement:

  • Decrease antibiotic inappropriate prescribing in CAP and UTI cases by 90%.
  • Decrease overprescribing of fluoroquinolones and vancomycin by 95%.

“Meeting these national reduction targets will require widespread adoption of effective antibiotic stewardship programs, which promote responsible antibiotic prescribing in order to minimize the harmful effects of inappropriate or unnecessary antibiotic use for patients and slow the spread of resistance,” noted the Pew brief, which also pointed out that hospitals should provide incentives to report antibiotic use and impact of stewardship programs to the CDC’s National Healthcare Safety Network (NHSN).

‘Ample Room for Improvement’

The Pew/CDC panel of experts analyzed hospitalized patient data from August 2017 through May 2020. Of those patients, the researchers found that:

  • 219 had CAPs,
  • 452 had UTIs,
  • 550 had received fluoroquinolones, and
  • 403 had received vancomycin.

They also found that:

  • 56% of antibiotic prescriptions were wrong in the type of antibiotic, how long it was used, or why it was chosen.
  • 79% of antibiotic prescriptions for CAP were inappropriate.
  • 77% of antibiotic prescriptions did not suit UTI patients.
  • 47% of fluoroquinolone prescriptions were unsupported.
  • 27% of vancomycin prescriptions were amiss.

The researchers concluded that providers have “ample room for improvement,” the Pew brief notes.

“A substantial percentage of CAP, UTI, fluoroquinolone, and vancomycin treatment was unsupported by medical record data collected (55.9% overall and as high as 79.5% for CAP),” the researchers wrote in their published study. 

Pew/CDC Researchers Find Many Antibiotic Prescription Errors

According to the Pew/CDC researchers, missteps in antibiotic usage include:

  • Treating inpatients too long with antibiotics.
  • Selecting antimicrobials inconsistent with guidelines.
  • Absence of signs and symptoms of infection.
  • Lack of clinical laboratory tests or microbiologic evidence of infection.

The study revealed antibiotic duration errors were most prevalent in the CAP patients, some being treated with antibiotics for more than seven days.

“Almost 60% of the inappropriate prescribing is attributed to exceeding the recommended seven days of treatment, and the use of the wrong antibiotic accounts for most of the remaining inappropriate (CAP) cases,” the Pew brief explained.

Antibiotics Prescribed without Evidence of Infection

As medical laboratory professionals know, microbiology tests identify presence and type of bacteria in urine. But the Pew/CDC researchers reported they found UTI cases that lacked evidence of infection.  

“In most instances—where antibiotic use was not supported—the antibiotics were prescribed to patients who lacked symptoms or microbiology test results consistent with UTIs,” according to their report.

Antibiotics Overprescribed to COVID-19 Patients

Another study conducted by The Pew Charitable Trusts “assessed the frequency of bacterial infections and antibiotic prescribing patterns in hospitalized patients diagnosed with COVID-19 in the US.” The researchers, according to the Pew brief on that study, titled, “Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?” used “IBM Watson Health’s electronic health records [EHR] database to capture data about approximately 5,000 patients and nearly 6,000 hospital admissions from February through July 2020.”

The researchers of that study found potential antibiotic misuse among COVID-19 patients as well.

  • 52% received at least one antibiotic prescription.
  • 36% had multiple antibiotics.
  • 96% were treated with antibiotics within 48 hours of admission and likely before infection was confirmed. 
Rachel Zetts headshot in black sweater
“Our data shows that there was very likely a significant amount of unnecessary antibiotic prescribing among hospitalized COVID-19 patients,” Rachel Zetts, Officer, Antibiotic Resistance Project at The Pew Charitable Trusts, told Becker’s Hospital Review. “Overprescribing on this scale could negatively impact the progress we’ve made in the fight against antibiotic resistance over the years, so encouraging physicians to reduce inappropriate antibiotic use and equipping them with the tools needed to do so is critical.” Those tools include test results clinical laboratories produce in support of antibiotic stewardship programs. (Photo copyright: The Pew Charitable Trusts.)

Clinical Laboratories are Key Partners

Hospital-based clinical laboratory leaders may want to contact physicians and infection control colleagues and work toward correcting use of antibiotics in patient care. And microbiologists are advised to aggressively communicate available medical laboratory test data about UTI infections, which the Pew/CDC study suggests can be missed.

Medical laboratories provide testing to diagnose infections and to identify strains of infectious agents that may be antibiotic-resistant. Therefore, lab leaders will be key partners in hospitals’ efforts to reduce infections and prevent antibiotic resistance.

—Donna Marie Pocius

Related Information:

Health Experts Establish Targets to Improve Hospital Antibiotic Prescribing

Assessment of the Appropriateness of Antimicrobial Use in U.S. Hospitals

CDC Wants to Improve Antibiotic Overprescribing by Over 90%

National Healthcare Safety Network (NHSN)

Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?

Antibiotics Significantly Overprescribed During Early Months of Pandemic, Study Suggests