In classic form, we have a public health threat reported without effective means and empowerment of front line physicians to anticipate, track, and respond to the problem. Of course, this predisposes you have a healthcare community receptive to the threat assessment in the first place.
Here's Ground Truth, from those of us practicing daily clinical medicine:
- There is no place a physican can go to see regularly updated (at least once a business quarter would be nice) statistics for antibiotic resistance, by pathogen, by patient age, and by sample site for their community. What the medical community needs is access to everything they see: from Staph aureaus to Pseudomonas. From Enterococccus to anaerobes.
- If the physician has hospital admitting privleges, they may have access to a report from the hospital's clinical laboratory called an antibiogram. Most antibiograms are updated quarterly, twice a year, or yearly.
- The reality is most physicians pay little attention to their local antibiograms unless they are infectious disease specialists or were "burned" in the past through direct experience treating a patient with a drug resistant organism.
- Pertinent to the above point, there are no mandatory requirements to report this information to officials, and your local public health officer has no bandwidth to even deal with this information if it were offered.
- CDC is paid to forensically evaluate this kind of data, but there is no support for frontline healthcare providers beyond the threat assessment and peer-reviewed academic reports they have been publishing.
- Those of us on the frontline struggle to have an understanding around the concept of proper antbiotic stewardship. Particularly when the agriculture industry runs amok and without regulation of their antibiotic use. Particularly when Americans flush antibiotics down the toilet... antibiotics that influence the endemic milieu of resistance in our ecosystem. Particularly when emergency physicians find themselves constantly pushed to give antibiotics to a general public on Medicaid abusing the emergency healthcare system with no pushback from the system. Particularly when the rest of the world we are connected to abuse antibiotics with abandon. Particularly when our hospitals are colonized and there is unclear guidance regarding what to do about it.... Thank God the public has come around to an understanding that they are unlikely to get an antibiotic every time they are ill with what looks like viral disease.
- Even if we could control the above uncontrollable factors, most physicians would ask the logical question, "How do I manage the process of what antibiotic to use?" We'll come back to that question later...
- We have hospital clients who have given us antibiograms for forecast processing. So far as we have seen, it works. But we've noted a few problems rolling this product out:
- Physicians rarely paid attention to the antibiograms in the first place.
- Now you're telling them you can forecast shifts in antibiotic resistance, by pathogen, by age group, and by sample site... but how do you use that information in context with "proper" antibiotic stewardship?
We have found physicians learn through patient mishaps and within a few months of producing the first forecast noted the first such mishap that could have been averted had they paid attention to the forecast. Common to any technology roll-out, you have early adopters and those who stick to the "tried and true". We of course have a few physicians in our mix of clientele who believe their personal method is the best option and ignore the forecasts- we have seen this social behavior during tech roll-outs so often that we have come to expect it.
One of these physicians had an elderly patient come in with a urinary tract infection. He fell back on the same standard antibiotic he's always used for years to treat urinary tract infection. The forecasts for that antibiotic-disease combination clearly indicated that not only was the antibiotic close to the threshold of 80% efficacy but projections indicated efficacy would drop another 10-15% in the next 2 years. The physician ignored the forecast, and the patient was admitted for pyelonephritis. About the same time the original urine cultures came back with an antibiotic resistance profile that was consistent with the forecast: that it was no longer considered effective. The patient was admitted for several days on IV antibiotics and was seriously ill. Nevermind the cost implications of the avoidable outcome...
We have observed that public health and your average healthcare provider tends to ignore operational forecasts of infectious disease. The common statement we hear is "I already knew that". Yet, no such forecast was conveyed to the public. We have come to realize the real power of change resides in the public themselves: to educate them about the threat and then give them direct access to their own local forecasts of antibiotic resistance. We consider this a patient safety issue, where in the case of the true-story elderly patient described above, she (or her family members) should have known the antibiotic prescribed was probably inappropriate and set her up for serious illness and a hospitalization. Perhaps the only way of ensuring this is to make such information publicly available. This would ensure a "check and balance" for those healthcare providers who resist change.
To play Devil's Advocate, one might say, "If you have a trustworthy forecast, what would you do with the information?" Again we come back to proper guidance regarding how best to manage antibiotic use. Most healthcare providers understand you should not prescribe antibiotics unless you have indication of a bacterial etiology. But once you tell people you are able to anticipate shift in antibiotic resistance, the tougher questions come:
- Which antibiotic do I stick with? The one that is 100% effective or the one that is 90% effective?
- How long do I continue to use this currently-effective antibiotic? Should I rotate it out for other similarly effective antibiotics? Is it better to keep the organism in question constantly on its toes or allow it to adapt to one antibiotic at a time?
- If I rotate an antibiotic out of my repertoire of antibiotics, when can I bring it back into use? How do I verify this antibiotic is ok to use once again?
- ... And more...
So again we'll ask CDC to step up to the plate with more than telling us what we already know. It is time to empower the local provider and the public with not just with the local-specific surveillance data, but answers to the above questions. To HHS, we would point out that we expect CDC to say they are not authorized to share such data due to confidentiality concerns with the involved medical centers that provided the data. Yet, most of America's hospitals take billions in Medicare and Medicaid payments- American taxes pay for this- and it should become manditory such information be shared publicly to empower communities to properly address the problem.