Dave Caron, Martha’s Vineyard Hospital’s director of pharmacy, is on a mission to educate the Vineyard on the consequences of antibiotic misuse through an antibiotics stewardship initiative program. Caron is also tasked with making sure hospital staffers refine their prescription practices to ensure antibiotics aren’t distributed for the wrong reasons.
“At least 80 million antibiotic prescriptions each year are unnecessary, which makes improving antibiotic prescribing and use a national priority,” according to the Centers for Disease Control. Caron and Dr. Alamjit Virk, director of emergency medicine and hospitalists services, explained the importance of the initiative in an era where antibiotic-resistant bacteria haunt an increasing number of hospitals.
“For a lot of people, through their own experiences, through marketing, the expectation is they’re going to get an antibiotic if they have a certain symptom,” Virk said. “And the confusion that I think comes into play is that these are habits that people have developed [due to] an incidental positive impact … if they have a cold that’s related to a virus and they’re prescribed an antibiotic and they get better, they equate getting better with the antibiotic, when in fact they would have gotten better regardless of the antibiotic.”
It becomes difficult to explain to patients the antibiotic probably didn’t have a role in their return to health, Virk said, especially when they have received antibiotics multiple times for nonbacterial infections and felt better after a few days.
Caron said many folks harbor these expectations of receiving an antibiotic for ear infections, sinus infections, bronchitis, and intestinal ailments, when very often these are viral infections — no bacteria is at play.
“We bear responsibility too, as practitioners,” Caron said. “Generations of pharmacists and physicians who had these tools to treat infections with … were liberal about it. You know, nobody ever thought about superbugs 25, 30 years ago. There was due diligence, but certainly not in what we’re thinking about now, because you gave someone an antibiotic and there weren’t consequences. There wasn’t resistance like there is now. That’s our biggest concern.”
Perhaps the most notorious antibiotic resistant pathogen in the U.S. is MRSA (Methicillin-Resistant Staphylococcus Aureus). The bacteria is often found in hospitals.
“It didn’t exist before antibiotics were used on a widespread basis,” Virk said. “If somebody came in with an abscess, a pus collection in their skin, the treatment was basically incision and drainage. You didn’t need antibiotics. Once you opened it up, exposed the pus, the abscess cavity, to air, people would get better. Over the course of the past 20 years, there’s been a huge ramp-up in MRSA infections.”
Virk went on to say abscess bacteria wasn’t cultured in the past because antibiotics weren’t going to be employed. But now, when someone comes in with an abscess, a culture must be done to rule out pathogens such as MRSA.
Superbugs like MRSA result from unbridled use of antibiotics, Virk said. “You’re basically promoting resistance within the bacteria that cause disease by overprescribing antibiotics, because you’re essentially selecting out bacteria that have resistance to these antibiotics and those selected-out bacteria will then come to dominate infections, which are much more difficult to treat, and you need stronger, more broad-spectrum antibiotics to treat those bacteria.”
Virk said MRSA has been encountered at the hospital.
But like E. coli and other hospital infections, Martha’s Vineyard Hospital has a low incidence of such pathogens compared with other institutions in the state, Caron said.
He described the antibiotic vancomycin as the “gold standard” for treating MRSA.
“We’re lucky here because we can still treat MRSA with vancomycin,” he said. “At other hospitals, that’s not always the case.”
Caron noted the hospital is actually able to employ bacterin, an early 20th century antibiotic, in some cases to combat MRSA, while many other hospitals cannot muster efficacy from the same drug against MRSA.
As daunting as MRSA can be, it’s vancomycin-resistant enterococci (VRE) that Caron finds fearful. The National Institute of Allergy and Infectious Disease website describes vancomycin as “the antibiotic of last resort for resistant infections.” Caron said VRE most often presents in wounds. He does not believe it has been diagnosed at the hospital so far.
Virk noted he wasn’t anti-antibiotics, however. “I just want to emphasize, antibiotics when they’re utilized in appropriate settings are a very effective tool in terms of our treatment options,” he said.
Virk agreed with Caron that it’s not just the expectations of patients that drive the overuse of antibiotics.
“It’s kind of a co-dependency,” he said. “I don’t want to blame it just on the patients. It’s the providers. The easiest thing for you to do when somebody comes into your office or the emergency department is to say, Hey listen, you have a bronchitis, we’re going to treat you with an antibiotic. And the patient feels like they got something. It’s easier for me to write an antibiotic [prescription] than it is to explain to a patient that you probably have a viral infection. This is probably not bacterial. To lecture somebody and to not meet their expectations is a harder thing to do than just write a script and say you’ll be better in three days.”
Caron said one provider who was notified by the hospital that they appeared to have dispensed an antibiotic incorrectly admitted the patient essentially ground them into submission.
“Listen, I went over this three and four times with the patient,” Caron recalled the provider saying, “and they weren’t buying it, so I finally relented and gave them an antibiotic.”
On the personal level, “antibiotics are not innocuous,” Virk said. He pointed out they can create disease.
“[It] can lead to colitis,” he said, “which is difficult to treat. You can wind up with allergic reactions. You can wind up with yeast infections. You can wind up on a personal level with multiple complications from antibiotics.”
Oddly enough, Virk said, in the intestines antibiotics can trigger a surge in bacteria: “What you wind up doing with antibiotics is you disrupt the gut flora, where you get certain bacteria that are part of that flora that get killed off with antibiotics, which leads to overgrowth. And the most common overgrowth is with Clostridium difficile, which within that environment, within the gut, [can] lead to a colitis, which is a real challenging problem for us to treat if it develops.”
“The communities of microbes that normally live in the gut, called the microbiota or microbiome, usually prevent (Clostridium) difficile colonization and suppress (Clostridium) difficile-associated disease,” according to the National Institute of Allergy and Infectious Disease website. “Antibiotic treatment can alter the microbiota in such a way that allows (Clostridium) difficile, a bacterium that is naturally resistant to many common antibiotics, to grow and cause inflammation in the colon.”
Caron and his peers have Clostridium difficile on their radar. “We have an organization in the hospital called the pharmacy and therapeutics committee, and we look at every Clostridium difficile case diagnosed in the hospital to see if in fact we are using the right treatment methodologies — where the source of it was,” Caron said. “Was it from our prescription of antibiotics?”
The analysis isn’t intended to cast blame but to further education, he said. “If we find out, for instance, that there’s a pattern associated with a particular practitioner who prescribes antibiotics and a percentage end up with Clostridium difficile,” he said, “we can then circle back and say, Hey, here’s this piece of information …”
Concerning the hospital’s pediatricians, he said, they’ve been good at adopting a wait-and-see approach with ear infections, instead of dispensing antibiotics right off the bat. Not an easy task when a parent is dealing with a miserable child.
“There’s literature coming out — an ear infection in kids may not need antibiotics, that it’s OK to take a wait-and-see approach to it,” Virk said. “A lot of these resolve on their own without the need for antibiotics.”
Caron and Virk both noted the pharmaceutical industry played a key role in the uptick in antibiotics use.
“In the late ’80s, early ’90s, when I was doing my training, ciprofloxacin was a relatively new antibiotic,” Virk said. “The only indication for ciprofloxacin in terms of the infectious disease recommendations was for the treatment of urinary tract infections resistant to bacteria …”
The drug manufacturer opted to market it for everything from bronchitis to skin infection to boost sales, he said. They ramped up sales calls and drug lunches at hospitals. “Within a year it was the No. 1 prescribed antibiotic in the county,” he said.
Partners Healthcare, which is the parent company of Martha’s Vineyard Hospital, now bans drug marketers from their facilities, and staff are not allowed to take things like pens, samples, pads, or other material distributed to market drugs, he said.
“Every doctor’s office had Cipro samples that they would give to patients,” he said.
“And not only that, but the tactic was the salesperson would come in and rearrange the doctor’s sample shelves so the Cipro samples would be the first line on the shelf, so those are the ones you would pull …” Caron said.
The hospital is rife with posters and pamphlets about antibiotic overuse, he said and as part of a public education drive, Caron said he has visited senior centers to spread the word.
All new hires at the hospital must engage with an online educational tool on the subject as part of the orientation process at the hospital, he said.
Caron will give a talk on the hospital’s antibiotics initiative on Sept. 11 at the Edgartown Council on Aging.