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Volume: 23S7 - November 1997 CONTROLLING ANTIMICROBIAL RESISTANCE CONFERENCE OBJECTIVES AND RECOMMENDATIONS WORKING GROUP ISSUES1. Antimicrobial Use Selective pressure exerted by widespread antimicrobial use is considered to be a major factor in the emergence of resistance. In some countries, antimicrobial drugs are available over the counter and are present in folk remedies; in others, their abuse in prophylactic and empiric therapy and the indiscriminate use of broad-spectrum antimicrobial drugs in the community have been major contributors. The association between increased rates of antimicrobial use and resistance has now been documented for nosocomial infections in hospitals(17), community-acquired infections(18) and in case-control studies showing recent antimicrobial use as a significant risk factor for infection with a resistant pathogen(19), probably because of the selective advantage to resistant strains conferred by use of the antimicrobial agent. Resistance factors can spread rapidly, not only locally but also, with greater movement of people around the world, globally. Microorganisms and their resistance factors may also be transferred from country to country in animals and commercially produced fruits and vegetables. In the community General practitioners and family medicine practitioners were responsible for over 21 million oral antimicrobial prescriptions during 1996 out of a total number of just over 26.25 million (data supplied by IMS Canada, see Figure 3, Appendix IV). Ideally, physicians should know the specific organism that is causing infection before they choose an antimicrobial agent for their patient. Usually, however, there is delay before the laboratory results are available, and the prescription is made for an agent that provides effective treatment against the most common organism(s) likely to be causing the patient's symptoms. At present, comprehensive data on patterns of resistance in the local community are not available as a basis for the choice of an antimicrobial drug. Physicians concerned about the possibility of a highly resistant pathogen may prescribe a broad-spectrum antimicrobial drug in order to cover all eventualities. This drug will likely not be changed to one with a narrower range even if the laboratory results eventually indicate such a change, because the patient will have paid for and started the course of treatment prescribed. As well, physicians often prescribe antimicrobial agents for conditions that do not warrant such therapy - for instance, colds and other infections caused by viruses. There may be several reasons for this, including inadequate knowledge of the proper indications for some drugs; lack of awareness of guidelines; pressure from patients and physicians' own desire for immediate results; lack of time to explain that antimicrobial drugs are not indicated (a Gallup poll found that about 50% of Canadians believe that antibiotic drugs are active against viral infections); and the fear that physicians themselves will suffer financially if patients go elsewhere for the treatment they want. In fact, one study(20) has challenged the idea that patients exert pressure for antimicrobial therapy. Instead, their satisfaction in this study correlated with the amount of time spent with the physician and an improved understanding of the disease. Recommendation 1 To reduce overall antimicrobial usage (prescriptions) by 25% within 3 years by focusing on community-acquired respiratory infection. Participants discussed several ways of achieving this goal. Changing physician behaviour
Changing patient behaviour
Vaccines
Canadian data
In acute care institutional health settings Antimicrobial resistance in the community and in hospitals has certain contributing factors in common: inappropriate physician prescribing practices, and the amplification of the spread of resistance by person-to-person transmission of resistant microorganisms in crowded institutional settings. In the hospital, antimicrobial drugs are used to treat infection and also for prophylaxis. In one Canadian study it was estimated that only 52% of hospital prescriptions for antimicrobial drugs were appropriate; an estimated $300 to $850 million yearly is spent in Canadian hospitals on inappropriate prescriptions (data presented by Dr. Robert Coambs). By adapting the model of quality improvement of Langley, Nolan and Nolan(21), one Canadian hospital has been able to focus on the processes that needed improvement in order to achieve optimal use of antimicrobial drugs and a high quality of infection control. Working with other hospital committees, a multidisciplinary Antimicrobial Use Committee put into practice a number of changes, including the following: a handbook on antimicrobial usage that is updated annually; an automatic 3-day stop order for antimicrobial drugs; regularly updated surgical prophylaxis guidelines; mandatory medical consultations for use of specific broad-spectrum antimicrobial agents; an on-line infection control manual; and revised infection control srategies to meet the needs of the changing profile of hospital patients (i.e., more acute illnesses). An analysis of trends in antimicrobial resistance over the period of change showed that the susceptibility of four commonly encountered gram-negative organisms to cephalosporins did not change over 6 years; and that despite an "outbreak" of VRE in 1995, transmission since then from patients with VRE has been limited. Furthermore, there was a reduction in the use of antimicrobial agents and in antimicrobial expenditures, from $3.0 million in 1991-92 to $1.8 million in 1995-96 (data presented by Dr. John Conly). Working group participants felt that protocols for the proper use of antimicrobial agents would be extremely important in reducing the amount of inappropriate prescribing. Recommendation 2 To improve funding and access to expert resources on antibiotic use in all Canadian health care settings. This will be accomplished by the creation of expert panels to promote local antibiotic use protocols and to provide case consultations as an adjunct to existing provincial or regional public health networks. Recommendation 3 To establish antibiotic stewardship and antibiotic use teams in all Canadian hospitals by a) incorporating them into accreditation standards; b) obtaining support from the medical and administrative leadership. In chronic care settings Because no data were available on correctional facilities or the armed forces, discussion was limited to nursing homes and long-term care facilities. It was noted that the presence or absence of infection in long-term care facilities is often not clear, and that even when a diagnosis is made on the basis of clinical features, the specific etiology is not determined. Because physicians are present in the institutions only at certain times, there is pressure on them from other health care workers and from residents' families to prescribe antimicrobial drugs to prevent potential infections from occurring. Recommendation 4 To establish antimicrobial usage, monitoring, and intervention programs at the long-term care institutional level. Short-term: monitoring of antimicrobial usage Intermediate term: monitoring of antimicrobial appropriateness Long-term: optimizing antimicrobial use To achieve this goal, an antimicrobial use program similar to the one recommended for acute care facilities should be developed. Guidelines for the clinical diagnosis of specific infections commonly found in long-term care facilities are also necessary. Perceptions of antimicrobial use The use of focus groups of physicians and patients by the CDC, Atlanta, to investigate attitudes has shown that even though physicians are aware of the harmful effects of over-prescribing antimicrobial agents and of their own role in this practice, still they continue to over-prescribe. In part this may be to ensure patient satisfaction - to provide a "quick fix" - or to avoid the need for explanations about why a prescription is not in the patient's best interest. Parents deny demanding that their child's physician prescribe these agents, and say that it is up to physicians themselves to decide on the course of treatment. About 90% of parents surveyed were aware of antimicrobial resistance, and many parents voiced concern about it (data presented by Dr. Ben Schwarz). Recommendation 5 To improve the public's perception about the risks/benefits of microorganisms and the risk/benefits of antimicrobial therapy. Suggested ways of accomplishing this recommendation included targeting parents of small children by media campaigns and educational programs; establishing a baseline inventory of health promotion projects across the country with regular evaluation of their effects; establishing a clearinghouse of information; and addressing the impact of employee absenteeism policies and day-care attendance policies on the use of antibiotics in children. Recommendation 6 To improve physicians' perceptions about the risk/benefits of microorganisms and the risk/benefits of antimicrobial therapy. Guidelines were considered to be useful for the clinical diagnosis of infection and the indications for treatment; as well, it was felt that to change perceptions, feedback should be given to physicians about their prescribing behaviour while at the same time a support system would be in place to make expertise available to individual practitioners and small hospitals.
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