Are You an Antibiotics Steward or Deadbeat?

If your healthcare organization is weak on antibiotics stewardship, it's not meeting its most basic goal: Do no harm.

Antibiotic resistance is everyone's problem, and yet it's no one's.

It's impossible to tell with any degree of accuracy how any one physician's prescription activity is fouling the effectiveness of critical lifesaving drugs or contributing to the rapid development of antibiotic-resistant superbugs.

But on a grand scale, the problem of antibiotics overuse is plain: It's causing unnecessary suffering and death. For healing organizations then, it seems antibiotics stewardship should be a top priority for those in the c-suite who are in a position to do something about it.

Too frequently isn't.

"Frankly, this conversation is invisible in most corporate suites, but it's very important," says Cliff Deveny, MD, senior vice president of physician services and clinical integration at Englewood, Colorado-based Catholic Health Initiatives, which operates health systems in 19 states.

Deveny was speaking at the ABX Crossroads national symposium earlier this month in Nashville, which I attended. The conference was aimed at exploring the clinical, financial, and operational challenges facing healthcare providers in the "post-antibiotic era," and sought to define practical strategies to help clinicians elevate this issue to the forefront in the c-suite.

Deveny says that thanks to the global nature of the antibiotics resistance problem, it can be easy to push it to the back burner at individual organizations. It's up to pharmacists, hospitalists, infection control specialists, and healthcare administrators to educate boards and senior executives to the importance of addressing the problem on the organizational level.

This is not a problem to be blamed exclusively on the healthcare industry. To be sure, the livestock industry, a terrible abuser of antibiotics, is another culprit of the rapid development of antibiotic resistance. A paper published just this week in the journal Pediatrics says the livestock industry's use of antibiotics is affecting doctors' ability to treat life-threatening illnesses in children.

Still, hospitals and health systems are prime examples of an industry that's not doing enough.

Powerful Stories
"It's critical for you all to have the message, the examples, and the stories of why this is so important," Deveny told a roomful of about 200 attendees from across the country.

The data is powerful. The same Pediatrics paper says that more than two million Americans develop antibiotic resistant infections each year and more than 23,000 die from them. The results are harrowing. They're chronicled in the individual stories of pain, loss and even death that result from the superbugs that have developed much more quickly than they should due to antibiotics overuse.

Deveny mentioned Daniel Fells, once a starting tight end for the New York Giants, now likely never to play again thanks to a deadly MRSA infection he got from a cortisone shot. In fact, he's lucky to be alive. Here's another one about former Tampa Bay Buccaneers and New York Giants kicker Lawrence Tynes.

Yes, the investments in education and clinical standards to combat antibiotics overuse can be expensive and the return on those investments can be hard to impossible to quantify. But if antibiotic resistance is to become less of an issue, they must be made.

And for organizations that are busily trying to shift and mold incentives toward the idea of improving the health of entire populations, such investments are table stakes. You can't say you're improving the health of your community if you're not serious about attacking antibiotic resistance organizationally.

If you need any more convincing of how much suffering antibiotic resistance causes, look no further than here. Remember, these are the survivors.

A Cruel Outcome
Here's a personal story of one of my good friends from college who isn't. Albert is not his real name, but I'll use it here. Albert befriended me the first day I showed up at my freshman residence hall in college. He brought me home once or twice when he knew I was going to be alone for the weekend. I met his parents, his sister. I was a groomsman in his wedding. We kept in touch over the years. He called me this June to catch up and told me that after he experienced headaches and vision problems, his doctors discovered a mass in his brain.

They found out it was malignant after the surgery. But the cancer didn't kill him. Albert died this summer due to a preventable surgical site infection. He's a statistic now, but less than six months ago, he was a successful 45-year-old electrical engineer, with a wife and two kids to whom he was devoted.

Everyone understands that major brain surgery is highly risky. But the initial surgery was successful, which made what happened next especially cruel. I spoke to Albert the day following his first surgery. He was himself, he was feeling well, and he had just eaten a hamburger. He got to go home the next day.

The prognosis for him, at least in the short term, was excellent. Within a few days, however, he was back in the hospital with an abscess—an infection at the surgical site. He lasted two more days following emergency surgery to address that abscess. Then he was gone.

Granted, there's no guarantee my friend wouldn't have died eventually from the cancer. But we will never know. What we do know is that he certainly died sooner, and in more pain, than he would have had he simply elected not to have the surgery. Is that a choice people should have to make in 2015? A roll of the dice on whether to suffer with operable brain cancer rather than subject yourself to the not unlikely chance that you will contract a deadly infection from a surgery meant to heal?

If you're running a hospital or health system, your challenges are real and significant. Healthcare is being disrupted on all levels, and your top goal is keeping your organization healthy financially and strategizing a way forward to ensure its continued existence. You can't help the community if you can't keep your doors open.

All that makes it easier to shift this problem to the back burner and pay more attention to problems and challenges that may directly affect your health system's revenue, yet perhaps nothing else is such a chronic public health issue, and potentially involves your organization so directly.

So let's just state this plainly. If you're not paying attention to antibiotic stewardship, and actually doing something about it clinically, your promises that your health system is committed to improving the health of the community ring hollow.

Senior executives frequently tout improving the health of the community as one of their highest and most sacred goals—in fact the reason for their organization's existence. Yet evidence is overwhelming that overuse of antibiotics by physicians may be among the top threats to public health now and into the future.

And hospitals and health systems aren't doing enough about it.

Hospitals, as they develop closer partnerships with post-acute care providers, are positioned to make key strides in antibiotic stewardship, says Kavita Trivedi MD, a consultant and former adjunct clinical professor of medicine at Stanford University School of Medicine.

"Focus on long-term care settings," she says. "It's an egregious situation happening in many nursing homes. On any one day, up to 8% of patients will be on antibiotics and patients have a 50% chance of being on them during a year."

She relates an example of a nursing home she recently worked with at which 104 patients were being treated with antibiotics for urinary tract infections even though only 8% of them met the clinical criteria for prescribing such drugs. That could be changed if nurses trained on antibiotic appropriateness were frequently monitoring the use of antibiotics at partner nursing homes, she adds.

"We are all at risk," Deveny says. "New levels of urgency, discipline, and rigor are required. Do we have the same ability as the bugs to adapt based on our environment?"

Unlike superbugs, healthcare is resistant to change.

"Clinicians are all very comfortable within our own silos and are well-intentioned, but we don't communicate and work together very well," he says. "As a physician, I was trained not to be accountable. If I screw up, I bring you back and I charge you again. How screwed up is that?"

You can access all the material from the speakers at the conference right here. It's worth your time, and your patients' health, to spend a little time on what they have to say about strategies to put to work in your organization right now.

"We're putting more and more people in danger and increasing costs," says Deveny. "Our promise to take care of you and not let you down is starting to fail."