If a person is in danger of drowning, offering a life preserver is appropriate. However, if a person is surrounded by flames in a burning house, the life preserver won't help any. It may even make the situation worse by providing more fuel to the fire or blocking the path to escape.

Antibiotics are the life preservers of health care. Without them, many more people would die from infections caused by injury, illness, exposure to infectious agents, or the effects of surgery. However, they are not appropriate for everything.

The Centers for Disease Control and Prevention (CDC) devotes substantial attention to antibiotic prescribing and use, reporting "about 30% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or suboptimal."

At Mayo Clinic, there is an entire group that focuses on antimicrobial stewardship, or the appropriate use of antibiotics, as well as antifungal and antiviral agents. The focus of the Enterprise Antimicrobial Stewardship Program is probably not the first thing most Mayo Clinic staff members think about when they start work each day. But Sara Ausman, Pharm.D., Mayo Clinic Health System — Northwest Wisconsin, and Sarah Lessard, Pharm.D., Mayo Clinic Health System — Southwest Wisconsin, two of the fewer than a dozen antimicrobial stewardship pharmacists at Mayo, might like that to be true.

"Bacteria and other infectious organisms are extremely smart and can quickly adapt and become resistant to the antibiotics we have” says Dr. Ausman. "Many of our efforts as antimicrobial stewards are focused on making sure we prevent as much development of resistance as we can."

Everyone has a role to play, she says.

Appropriate use of antibiotics

Providers and patients can both be involved in the decision making. This includes deciding when to prescribe antibiotics, and the type and duration of treatment.

"When antibiotics are used appropriately, they have a definite role and benefit for patients," continues Dr. Ausman. "Antimicrobial Stewardship practitioners across the Mayo Enterprise have implemented a series of rules, or flags, in Plummer Chart to identify hospitalized patients on antimicrobial therapy that may need to be adjusted to meet the needs of the patient’s situation."

Many of these system prompts rely on test results from bacteria cultures, the standard of care for inpatients. However, in the outpatient setting many antibiotics are prescribed without a lab culture to identify the exact infectious agent.

"In an outpatient setting, 30-50% of antibiotics are prescribed inappropriately," says Dr. Ausman, "either the wrong dosage or the wrong medication for the condition."

Historically, the Antimicrobial Stewardship team has seen patients prescribed antibiotics for bronchitis, gout and the common cold, among other conditions where an antibiotic will be no help.

Additionally, the team promotes use of the narrowest spectrum antibiotic appropriate to the diagnosis, and the shortest possible duration of treatment.

"Antibiotics are not benign," says Dr. Lessard. "They do have side effects, which can lead to significant problems which may lead to hospitalization. Their use can lead to antibiotic resistance in a patient. And, unnecessary use contributes in several ways to rising costs in health care."

Real-life cautionary tale

Dr. Lessard saw these dangers up close and personal a few months ago.

"A multi-drug resistant organism developed quickly in one of our patients being treated in the outpatient setting," says Dr. Lessard. "My job was to investigate the situation and determine if anything could have been done differently."

She tells this story:

The patient was a woman with a long history of urinary tract infections and numerous courses of antibiotics. She had a semi-permanent catheter inserted for bladder relief. After observing some inflammation in the area, her care team determined she had another UTI.

Because the patient and her long-term bladder concerns were well known by the doctors, she was prescribed a 10-day course of cefdinir, a cephalosporin antibiotic. The bacteria was cultured, and the lab returned back 'Enterobacter' as the suspected organism which had not been isolated in this patient before. The lab results showed that the Enterobacter, an organism known for its ability to acquire resistance during treatment with certain antibiotics, was initially responding to the cefdinir, and so the treatment continued as prescribed.

However, the patient developed a resistance to cefdinir shortly thereafter, and infection got worse. The organism also developed resistance to multiple other antibiotics, and a different course of treatment had to be determined. Fortunately, the patient survived without substantial adverse effects, but a mistake had been made.

"Actually catheter-associated UTIs are one of our focus areas in the Antimicrobial Stewardship Program at Mayo," says Dr. Lessard. "These are very common, and also commonly overtreated. A care process model in AskMayoExpert guides providers through options leading to more appropriate prescribing of a narrower spectrum antibiotic and shorter durations of treatment."

AskMayoExpert is an online point-of-care tool that gives health care providers access to Mayo-vetted information, including disease management protocols, care guidelines, treatment recommendations and reference materials.

Specific to this case, the AskMayoExpert algorithm guides providers to use antibiotics with the narrowest spectrum of activity to adequately treat the infection. This will lessen the impact on patients' normal bacterial flora. AskMayoExpert also recommends using the shortest effective treatment duration to prevent overexposure of the patient to antibiotics.

Enterobacter is a member of a group of bacteria collectively referred to as SPACE organisms (S: Serratia, P: Pseudomonas, A: Acinetobacter, C: Citrobacter, E: Enterobacter), which have very aggressive and inducible antibiotic resistance mechanisms.

"These are the bacteria that keep us up at night," says Dr. Ausman. "We are actively trying to prevent activation of their resistance mechanisms, because we know that exposure to certain cephalosporin antibiotics can lead to resistance not only to that original antibiotic, but others as well."

Education is key

Dr. Lessard believes that education is the key, and she wants all Mayo Clinic providers to use AskMayoExpert to guide decisions around antibiotic use.

"We need to think about antimicrobial stewardship every day," she says. "We have to tackle the idea that 'I have to give my patient something.'"

She and her colleagues have made strides in this area, especially related to the management of upper respiratory tract infections. They are working on a large project across Mayo Clinic to eliminate the use of antibiotics for select upper respiratory infections — another set of illnesses that are generally viral and will not respond to antibiotics.

As part of this project, the team created a tool in Plummer Chart — Mayo's name for electronic health records — to assist providers in the outpatient setting. This tool primarily provides recommendations on symptomatic management appropriate for an upper respiratory infection along with appropriate antibiotic selection —if antibiotic therapy is deemed necessary.

These efforts to reduce antibiotic resistance and prolong the usefulness of the currently available treatments are only one part of the Antimicrobial Stewardship Program. The multidisciplinary team also is responsible for heading off issues relating to the treatment of parasites, viruses and fungi.

The program's primary goals are to:

• Improve clinical outcomes while limiting unintended consequences such as prevent emergence of resistant microorganisms or pathogenic organisms, such as Clostridium difficile, carbapenem-resistant Enterobacterales or Vancomycin-resistant Staphylococcus aureus.
• Improve quality and safety of patient care and reduce toxicity and errors.
• Prevent readmissions.
• Decrease length of stay and mortality.

And when possible, at the same time, they will reduce health care costs — without adversely impacting quality of care.

It's a big job, and one that these pharmacists and their physician, nursing, and laboratory medicine colleagues and other members of the Antimicrobial Stewardship team take seriously.

For related information and guidance from the Centers for Disease Control and Prevention, visit the Healthcare-associated Infections website.

Media contact:

• Elizabeth Zimmermann, Mayo Clinic Public Affairs, newsbureau@mayo.edu

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