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SALT LAKE CITY — Antibiotics can be extremely helpful for treating infections, but overuse and overprescription are quickly lowering their efficiency and requiring physicians to prescribe stronger antibiotics to treat the same conditions.

Dr. Eddie Stenehjem, medical director of antibiotic stewardship at Intermountain Healthcare, said because Intermountain Healthcare values antibiotic stewardship, having an effective unified system has become normal for them but it is not something that a majority of health systems across the country have.

A recent study led by Intermountain analyzed antimicrobial stewardship programs in 20 different health care systems. These programs help hospitals and systems ensure that antibiotics are being used appropriately and try to reduce their use to prevent the development of resistance in bacteria.

Stenehjem said the purpose of the study was to raise awareness of what a successful antimicrobial stewardship program looks like, a step towards better stewardship across the country.

It is a starting point to be able to analyze the effectiveness of each model, and find what works best to address patient care for each organization, while reducing the development of bacteria that are resistant to antibiotics.

Antimicrobial stewardship programs

Throughout the study, Intermountain Healthcare researchers found that antimicrobial stewardship programs vary significantly.

The completed study, which was published in June in a journal called Clinical Infectious Diseases split the programs into four categories:

• Collaborative, which developed organically and are run by committees and don’t have a formal structure.
• Centrally coordinated, which have a formal structure and a committee with accountability. They often form organically as well, but are used throughout a health care system.
• Centrally led, which have a formal system with leaders, accountability, resources and goals. Here, tools and technology changes are universal throughout the system and participation is required.
• Collaborative, consultative network, which has leaders outside the organization participate as consultants and sites receive support from the broader company.

Intermountain Healthcare most closely resembles the centrally led model.

Stenehjem said once stewardship practices were implemented at Intermountain Healthcare’s 39 urgent care centers in Utah, there was a 50% reduction in antibiotic use for respiratory issues.

“That just shows (the impact) a centrally led program with collaboration and partnership with the urgent care service line … can have because we’re talking about, you know, hundreds of thousands of antibiotic prescriptions not given because of these practices,” Stenehjem said.

Whitney Buckel, antimicrobial stewardship pharmacist manager at Intermountain Healthcare, said she often gets questions about Intermountain’s antimicrobial stewardship program from other health systems, and this study allows for a better characterization of their program to help them, and the ability for Intermountain to learn from other programs.

As different methods are determined to be more effective, models can be developed for more health care systems.

“We want to push stewardship forward everywhere and this is a way to push the envelope and improve antibiotic stewardship nationally,” Buckel said.

In her role with the stewardship program, Buckel makes interventions for individual patients who have an infection and were prescribed antibiotics, suggesting a better antibiotic for a specific culture, no antibiotics or a shorter duration.

Buckel explained that they are not trying to find the best system, and recognizes the ideal system for antimicrobial stewardship can vary based on the health care system or hospital. However, more information about effective methods and more systems putting resources into making sure antibiotics are used appropriately can have a large impact on antibiotic effectiveness.

Superbugs?

As diseases evolve to fight antibiotics, antibiotic-resistant superbugs are formed, which cannot be treated with current antibiotics.

Because bacteria don’t spread through the air like viruses, diseases that are resistant to antibiotics won’t bring another pandemic like COVID-19, but superbugs still have serious consequences as it becomes harder and harder to treat them.

Buckel explained that the U.S. population used to use a lot of “Z-packs,” a standard course of azithromycin antibiotics, but because of how often they were used, Z-packs now don’t work as well for everyone, not just the people who used them, but because the bacteria have developed a resistance.

She also said some sexually transmitted diseases that used to be treated with a pill now need an injection because the pills are no longer effective.

“It’s kind of escalating,” Buckel said.

Stenehjem said the types of infections that are at risk of not being able to be treated by drugs are urinary tract infections, pneumonia and other infections that are not very transmissible but can be very serious.

During the COVID-19 pandemic, there was more data about multi drug-resistant organisms increasing, and new antibiotics are not being created fast enough to match the rate of drug resistance.

“We’ll continue to see more patients develop infections with completely drug-resistant pathogens, which we don’t have antibiotics to treat,” Stenehjem said.

What’s next for the research?

Buckel said each health care system is currently required to have an antibiotic stewardship program, so many have implemented a minimal program and electronic health records have also made it easier for health systems to do something. However, there is still a lot more to be done with improving the programs and helping them become effective at reducing antibiotic use.

Through the network of experienced people working on this study, she said they were able to talk about how to start an antimicrobial stewardship program at a new organization, and what positions are needed for an organization that is just beginning.

Stenehjem said many organizations consider antibiotic stewardship in a hospital, but not throughout the health care system. He said a majority of anitibiotics are used in an outpatient setting, in clinics or doctors’ offices, and including outpatient services in a stewardship program allows the program to actually affect community antibiotic consumption.

“(Including outpatient systems) really is going to influence population health, and it’s a public health matter because of the development of drug resistance and superbugs,” Stenehjem said.

This study focused primarily on inpatient care and further research could expand into antibiotic prescriptions in outpatient settings, including doctors’ offices and clinics.

Research in this area will continue, although it may be led by other organizations. The Pew Charitable Trusts, which helped with this study, organized a meeting in Utah with stewardship experts in September to specifically discuss antimicrobial stewardship in outpatient settings.

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