Antibiotic Stewardship: Thinking Out of the Box

Our editor-in-chief highlights a community level drug issue that has a population consequence.

I remember when my kids had an ear infection that prescribing a broad-spectrum antibiotic was a routine practice. After all, the infection could be bacterial, so just treat it in case it is, right? The drugs were relatively inexpensive, and side effects were rare and not life-threating. My wife left the office happy, too.

Unfortunately, things haven’t changed much in the 30 years since my kids were little—but in my opinion they need to change. Based on some articles I’ve read recently, I can see that physicians are still prescribing too many antibiotics or are frequently prescribing the wrong ones. According to a study published online on July 25, 2013, in the Journal of Antimicrobial Chemotherapy, the author states, “For good reason, there has been a lot of messaging about how antibiotic overuse causes resistance, and this needs continued emphasis. In this discussion, we need to bring specific attention to the issue of the types of antibiotics that are prescribed, particularly the overuse of the broader spectrum classes. If we overuse antibiotics when they are not needed, then they won’t work in the future when they really are needed because of resistance. But we also need to make sure that everyone understands some of the other patient-level harms that antibiotics can cause, including serious allergic reactions, serious infections such as C difficile colitis, as well as longer-term implications from disturbing the normal ‘microbiome.’”

This problem is often addressed in health systems by the establishment of a multidisciplinary approach to antimicrobial stewardship. Such a program includes the establishment of criteria for appropriate antimicrobial use and monitoring antimicrobial usage patterns and length of therapy for the development of recommendations for antimicrobial therapy. Sometimes such programs restrict certain antibiotic usage to a consult from an infectious disease expert before using these medications. In reality, such programs may be easier to establish within a health system where everyone works for the same entity. But could this model work in a community setting, too? Even more important—has the overprescribing of antimicrobials reached a level where intervention is needed now before the consequences become significant?

I will leave that decision for others to make, but let me mention some possibilities. Could a pharmacy chain work with a state health department and the Centers for Disease Control and Prevention to implement a statewide antimicrobial stewardship program? Collecting data from the antimicrobial prescribing patterns using the prescription filled in that chain could identify potential problems. Could the pharmacists from that chain then be used to do physician detailing on appropriate usage of these agents? Then, based on these interventions, could pharmacists measure changes and refine or maintain the intervention?

Of course, this is an out-of-the box idea that may be rejected by most as impossible. And maybe it is. But if we want to begin positioning the pharmacist as the drug expert at the community level, we need to start addressing the community-level drug issues that have a population consequence. Antimicrobial overprescribing seems to be one of those issues.

Here’s another question that needs to be asked: Is this a role that pharmacists can and should play in a reformed health care system? Pharmacists, in fact, are part of such a system in the health-systems sector. Couldn’t they also be part of such a system in the community? I believe that they can, but it will take a different kind of thinking than the one we used to create the problem we face with the overutilization of antimicrobials in general and, even where usage is indicated, the wrong choice of antibiotic.

Mr. Eckel is a professor emeritus at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He is interim executive director of the North Carolina Association of Pharmacists.