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Annual Report Year 3
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University of Pennsylvania—
The Patient or the Community: Balancing Tensions Created by Antibiotic Resistance
The Penn CERTs hopes to optimize drug prescribing and improve the risk/benefit balance from drugs, particularly for anti-infectives. The Penn CERTs accomplishes this research and dissemination effort by linking the pharmacoepi-demiology skills of the Center for Clinical Epidemiology and Biostatistics with the pharmacoeconomics skills of the Leonard Davis Institute of Health Economics, the experience in patient-oriented research of the General Clinical Research Center, basic science laboratories interested in evaluating the molecular mechanisms of drug effects, and the social science skills of non-biomedical researchers at Penn.
Key projects:
- Development of computer simulations of various data analysis approaches to improve the methods and reporting of results from multi-center or multi-site analyses
- Evaluation of risk factors for antibiotic-resistant infection in liver transplant patients
- Development and management of a fellowship training program in pharmacoepidemiology, in keeping with the mission of educating professionals
The University of Pennsylvania is working to preserve drug safety and efficacy for future generations of patients. Their focus on the best use of anti-infectives has led to great insights on prescribing patterns and the tensions exerted on caregivers when weighing the threat of growing bacterial resistance to antibiotics and the immediate need of their patients for the most effective treatment. This knowledge is being applied at the Penn CERTs and around the country to safeguard the efficacy of antibiotics for all patients.
Increasingly, research is showing that the misuse and overuse of antibiotics is leading to the development of more resistant strains of bacteria. Treating infections caused by bacteria resistant to more than one antibiotic becomes difficult.
At first, most of the attention on drug resistance was directed towards hospitals. With very ill patients in such close proximity to one another and antibiotic use so heavy, many drug-resistant strains emerged in this setting.
One means of ensuring proper antibiotic use is a hospital-based antimicrobial management program developed by the Penn CERTs faculty. Selected antibiotics are available to patients in the hospital, but only to those who fit certain criteria. The goal of this program is protection against the development of resistance. Penn CERTs faculty have demonstrated this project to be effective in improving patient outcomes and in reducing hospital costs, and it is now being copied by hospitals around the country. Follow-up studies are underway to determine how to improve its function even further, such as by reducing miscommunication between the house staff treating the patients and those staffing the program.
“The Penn CERTs is addressing a problem of extreme public health importance. Too many interventions have consisted of simply distributing new guidelines. It is time we realize that this will not in and of itself change behavior.”
—Rich Besser, Centers for Disease Control and Prevention
But problems outside the hospital setting persist. Researchers are realizing that bacterial infections acquired in the community are showing resistance and putting otherwise healthy people at risk. Common infections such as pneumonia and ear infections are increasingly hard to treat with standard antibiotics.
With studies identifying misuse and overuse of antibiotics for predominately non-bacterial respiratory infections as the likely culprit, physicians are under pressure to withhold antibiotic prescriptions, particularly for new agents, in order to preserve their effectiveness for future patients. But when faced with the needs of their sick patient, doctors are reluctant to do so.
The tensions created between the danger to the community (resistant bacteria created by antibiotic misuse) and the danger to the individual patient (the need for the most effective medicines) can force a difficult choice on a physician.
To explore this conundrum, Dr. Joshua Metlay and colleagues from the Penn CERTs surveyed both generalist physicians and infectious disease specialists to gauge their attitudes towards antibiotic prescribing for patients with community-acquired (vs. in-hospital) pneumonia.
An anonymous survey to 400 general internists and family medicine doctors and 429 infectious disease specialists turned up a consensus from both groups. Both were more likely to prescribe newer, more broadly acting antibiotics than older medicines still recommended by national guidelines.
The older medicines were more susceptible to bacterial resistance, but using them prevented the overuse of these new, more powerful agents and thus delayed resistance to the newer drugs. The doctors overwhelmingly considered the individual health concern over the public health issue of future drug resistance.
The risk of contributing to antibiotic resistance ranked last among seven factors influencing the physicians' treatment choice. The efficacy of the chosen drug was far and away the most important among both groups of physicians.
The tension and confusion created by emerging antibiotic resistance showed in the doctors' other responses to the survey.
About 82% of generalists and 94% of infectious disease specialists believe that bacterial drug resistance is a growing and major public health problem. But just over half said they would consider the potential benefit for their patient against the potential harm to the community before prescribing an antibiotic.
While the vast majority of the polled physicians agreed that patient demand was a significant factor in over-prescribing of new antibiotics, only 36% of generalists and 22% of the specialists believed they prescribed antibiotics more than they should.
The overall message from the study was clear. Physicians' concern for their individual patients' health trumped any worries over public health issues in the arena of antibiotic resistance, despite guidelines to the contrary from such influential bodies as the Infectious Diseases Society of America and the American Thoracic Society.
Dr. Metlay and his team concluded that because of this ingrained attitude, educational programs and the issuance of guidelines would not be enough. The matter is further muddled by the presence of multiple, and often conflicting, guidelines.
Insights from these types of results have contributed to the development of several intervention programs that aim to improve the quality of antibiotic use in hospital and community-based settings. A central feature of the Penn CERTs programs to improve antibiotic use is the reliance on multidimensional interventions that incorporate patient, provider, and organizational components.
For example, a Penn CERTs study showed that outpatient use of academic detailing directed at physicians is effective in reducing the prescribing of antibiotics unnecessarily for upper respiratory infections. A follow-up study has added efforts to educate patients who had received antibiotics after the first intervention that such antibiotics are not necessary in the future. An evaluation of that program is underway.
The Penn CERTs continues not only to provide insight on the mechanics of antibiotic use, but also its implications on public health, policy, and economics. This multifaceted approach to improving a single but far-reaching therapy is fast becoming a hallmark of CERTs research. The Penn CERTs program to improve antibiotic prescribing reflects the core belief that maximizing the benefit and minimizing the risk of drugs requires educational efforts that involve not only physicians, but patients as well.