National Academies Report: Antimicrobial Resistance Considers Challenges to Stewardship

Stewardship of antimicrobials is as inconsistent across the US as the access to requisite timely and accurate diagnostics, and is further hindered by incomplete application of regulatory and practice standards, in the assessment of the Committee on Examining the Long-Term Health and Economic Effects of Antimicrobial Resistance in the United States.

The committee of the National Academies of Sciences, Engineering, Medicine recently released the report, Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine." The study was sponsored by the National Institute of Allergy and Infectious Diseases.

In the section, Stewardship and Infection Prevention, the Report implicates limited local laboratory capacity as a significant factor underlying use, or prolonged courses of empiric antimicrobial treatment.

"In this regard, the overuse of these medicines is in many ways a proxy indicator of other gaps in the health system, such as problems with infection control and uneven access to medicines, preventative services or primary care," the Committee observes.

Committee member Preeti Malani, MD, MSJ, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, considered the varying levels of access to testing and clinical expertise available at different health care settings, in discussion with Contagion.

"Yet, there is room for improvement in all settings, and that is the goal: finding ways to improve stewardship efforts based on local needs and resources," Malani said."Not every lab will have immediate access to rapid diagnostics, but creativity and technology may bring clinical expertise to places that may not have infectious disease consultation."

The committee affirmed that rapid diagnostic tests can reduce unnecessary reliance on antimicrobials, while acknowledging that their availability and adoption have been slow and uneven.The committee advocates for wider availability of point-of-care (POC) tests to distinguish viral from bacterial infection. It found evidence in one study that introducing testing which yields results within 12 hours ("rapid" relative to traditional culture and disk susceptibility testing) could reduce antimicrobial use by 14%.

The committee also distinguished between a lack of tests, and the disregard of test results."Sometimes tests are available and not used," the committee observed. "The clinical decision to prescribe an antimicrobial is influenced by the test performance and indication, reimbursement for it, and provider attitudes."

In considering approaches for improving antimicrobial prescribing, the committee emphasized the importance of policy development and regulatory enforcement, and their potential effectiveness relative to educational efforts, albeit also important.

"...knowledge of correct stewardship practices is rarely enough to alter providers' behavior, Qualitative research across six low- and middle-income countries found awareness of antimicrobial resistance and knowledge of the role of providers to combat it consistently very high," the Committee indicated."This does not necessarily translate into changes in prescribing patterns, however, as such decisions are influenced by larger social and economic factors."

Several health care settings are identified for having suboptimal antimicrobial use and infection control procedures for high-risk patient populations, which could substantially improve with greater application of well considered policy, according to the committee. Of particular concern are nursing homes, long-term acute care hospitals and dialysis centers.

The committee found that only one-third of nursing homes have comprehensive antimicrobial stewardship programs, despite an estimated 70 percent of nursing home residents receiving antimicrobials in an year.It points out that Clostridioides difficile infection, often attributed to inappropriate or excessive use of antimicrobials, is endemic in nursing homes; with one study finding 10 percent of patients who acquire C difficile in nursing homes die within 30 days.

As these settings have a financial relationship with CMS (Centers for Medicare and Medicaid Services), however, there is also opportunity for improving antimicrobial stewardship through rule and regulation, and financial incentives for adherence.

"Progress will require working together with public policy experts to determine whether there are levers that CMS can use to inform and incentivize these efforts," Malani commented. "Medicare is the primary payer for... these clinical settings, which are sites of extensive antibiotic use."

This is the first in a series of articles on the report. Check back on Contagion's site to view follow-up pieces.