The CDC is devoting funding to dozens of local health departments for programs to stop improper antibiotic prescribing following the rise in deadly bacterial and fungal infections during the Covid-19 pandemic.
The agency has already issued $120 million to departments in New York City, Los Angeles County, and more than 60 other jurisdictions to expand programs to improve antibiotic and antifungal prescribing within health-care settings.
Lauri Hicks, director of the Centers for Disease Control and Prevention’s office of antibiotic stewardship, said the agency has provided feedback on the work plans for each jurisdiction, and will grant additional funding through 2024.
Antibiotic-resistant infections and deaths increased during the first year of the pandemic, in part because a lack of knowledge on how to treat Covid-19 led medical professionals to turn to antibiotics. Infectious disease officials say the lessons here underpin the need for better antibiotic prescribing education.
“We have an opportunity right now to leverage what we have learned from this pandemic and apply it going forward,” Hicks told Bloomberg Law.
“If you take an antibiotic when it’s not needed, not only do you increase your own risk of a subsequent infection, but you also open yourself up to potential side effects and adverse events,” she said.
Measure, Track, Benchmark
Antimicrobial stewardship encompasses practices to measure and improve how antibiotics and antifungals are prescribed so that they’re effectively treating patients. Hospitals and long-term care facilities receiving federal funding, like Medicare, must have stewardship programs in place, including systems to track antibiotic use data and benchmarks to help reduce the number of resistant infections.
Before the pandemic, many hospitals saw successes in implementing these programs. But from March 2020 to October 2020, almost 80% of patients hospitalized with Covid-19 received an antibiotic, even though less than 3% had any indication they also had a bacterial infection, according to a CDC special report.
The agency found that hospital-onset resistant infections and deaths both increased by roughly 15% from 2019 to 2020, according to the CDC. This marked a shift from 2012 to 2017, when deaths from antimicrobial resistance decreased by 18% overall and nearly 30% in hospital settings.
“We’re starting to see increasing numbers of antibiotic resistant bacteria causing infections in otherwise healthy people in the community,” said David Hyun, director of the Antibiotic Resistance Project at Pew Charitable Trusts. He said it’s likely to get worse, with projections estimating that the annual number of deaths due to highly resistant infections will reach 10 million globally by 2050.
The CDC’s Core Elements of Antibiotic Stewardship lay out key principles for hospitals, outpatient settings, and nursing homes on tracking antibiotic use and carrying out prescriber education campaigns. More than 90% of US hospitals had a stewardship program aligned with these core elements before the pandemic, according to the CDC.
But with hospital resources diverted to the Covid-19 response, the early months of the pandemic saw “a lot of hospitals and health systems struggle to sustain or maintain their existing quality and safety programs,” Hyun said.
“When patients were arriving in the emergency department with a syndrome that looked a lot like community-acquired pneumonia, they were receiving antibiotics for Covid-19, " Hicks said.
Antibiotic overuse also opened up patients to increased risk of antifungal-resistant infections. Hospital-acquired infections from a highly antifungal-resistant strain—Candida auris—shot up 60% from 2019 to 2020, according to the CDC special report.
When patients are prescribed antibiotics for bacterial infections, “the fungi then have sort of a niche because there’s no competition,” said Tom Chiller, chief of the CDC’s Mycotic Disease Branch, which aims to prevent illness and death from fungal diseases.
Intermountain Healthcare, a Utah-based, nonprofit system of 33 hospitals, has a centralized, health care network-based stewardship program that’s focused on antibiotic prescribing across all areas of care, said Eddie Stenehjem, an infectious disease doctor and Intermountain’s medical director of antibiotic stewardship.
During the pandemic, Intermountain had pharmacists and physicians dedicated to stewardship in each network hospital. The health system did “incredibly well” to “ensure that our patients got treated appropriately for Covid-19, and that included not prescribing antibiotics,” Stenehjem said.
But not all stewardship programs had the necessary resources to withstand pandemic challenges, Stenehjem said.
A study published in June by Pew Charitable Trusts, Intermountain Healthcare, and the University of Utah found that all 20 health systems and network-based antimicrobial stewardship programs surveyed said the pandemic posed particular challenges for their stewardship activities, including “strains on staffing, a need to pause system-level stewardship goals and expansion activities, and an inability to conduct site-visits.”
Antibiotic stewardship leaders say improving tracking of antibiotic prescribing in outpatient settings and long-term care facilities will be essential in fighting resistant infections in the coming years.
The CDC estimates that roughly 80% to 90% of antibiotic prescribing in the US occurs in outpatient settings. The study from Pew, Intermountain, and the University of Utah found that among 20 health care organizations with active stewardship programs, only two had hired staff dedicated to antimicrobial prescribing in outpatient care.
A new health tool from athenahealth’s app epocrates is designed to offer guidance to health providers in outpatient settings on the best antibiotics to prescribe based on resistant infection data. The tool—Bugs + Drugs— incorporates data from athenahealth’s electronic records and organizes it by ZIP code, said Anne Meneghetti, an internal medicine physician and the executive director of medical information at epocrates.
Larger hospitals and health systems typically have centralized data infrastructure that can help prescribers track resistant infections to inform antibiotic use. Meneghetti said the goal of Bugs + Drugs is to offer a similar system to health-care professionals in outpatient settings.
“Let’s say in Florida, a pregnant woman has a urinary tract infection,” she said. “The app can say, ‘well in that ZIP code and surrounding areas, this is the likely bacteria that are detected, and here’s the susceptibility patterns,’ and that can help influence their decision making about which antibiotic they’re going to prescribe.”
Federal policies shouldn’t “merely require stewardship activities, but make sure that the providers and the practices have access to the necessary resources to conduct it,” Hyun said.
He said this support can come in the form of additional federal, state, or local funding to hire more stewardship professionals, and partnerships with larger health networks like Intermountain to learn how to integrate successful stewardship practices beyond hospitals into nursing homes, long-term care facilities, and outpatient settings.
President Joe Biden’s fiscal 2023 budget request from March included $28 billion for the CDC to boost “domestic and global threat surveillance, public health workforce development, public health laboratory capacity, and global health security.” Part of this funding would go toward supporting “state-based and international efforts to control antibiotic resistance.”
Hicks said improving antibiotic and antifungal prescribing starts with changing longstanding notions among both medical professionals and the general public of how these treatments should be used.
“Taking an antibiotic is not harmless,” she said.