AAMC Reporter: April 2007

UCSF Medical Center Fights Back Against Resistant Bacteria

More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the antibiotics most commonly used to treat them. Source: Centers for Disease Control and Prevention

In the grand scheme of things, it was not so long ago that the health care community viewed antibiotics as a medical magic bullet. Today, however, that perception is radically different, as the overprescription of certain antibiotics (along with other factors) has led to resistant bacterial strains that do not respond to conventional medications, often resulting in more serious or hard-to-treat infections. This is particularly true in the hospital setting, where bacteria are rampant and infections can spread from a wide range of sources.

But hospitals are beginning to fight back. One facility at the forefront of this counterattack is the University of California, San Francisco (UCSF) Medical Center, where an antimicrobial drug management program is beginning to show real results.

In theory, the program is simple. A select multidisciplinary team—including infectious-diseases-trained pharmacists, physicians, fellows, and residents—overseen by the UCSF School of Pharmacy tours the medical center's approximately 100 adult ICU beds each morning, checking the dosage and selection of the antibiotics prescribed to each patient (the team also reviews prescriptions via a computer system). The team then evaluates each prescription based on previously defined criteria covering the specific type of antibiotic, relevant medical conditions, and the amount of time a patient has been receiving a certain medication. If the team discovers that a certain antibiotic treatment is incorrect or less appropriate or cost-effective than another, equally effective treatment, the team intervenes and recommends a new protocol, with the ultimate goal of using antibiotics more judiciously.

"When the team identifies inappropriate antibiotic therapy, as per previously defined criteria, the team recommends alternatives. In most instances, the primary team changes to the appropriate therapy. Ultimately, however, the multidisciplinary team has the authority to discontinue inappropriate therapy and adjust accordingly," said program creator B. Joseph Guglielmo, Jr., Pharm.D., who also chairs the UCSF School of Pharmacy Department of Clinical Pharmacy. "As is well established in the medical literature, there is a true shortage in the antibiotic pipeline, particularly for agents active against gram-negative bacteria. This fact, coupled with rising bacterial resistance, has resulted in a crisis in many medical centers. The main goal here is the prevention of bacterial resistance, but there's also a toxicity reduction component, and a cost-effectiveness component."

Based on the Infectious Diseases Society of America and the Society for Health Care Epidemiology of America's "Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship," released recently in the journal Clinical Infectious Diseases, programs similar to that at UCSF produced a decrease in antimicrobial use between 22 percent and 36 percent, with annual financial savings between $200,000 and $900,000.

A 2005 article in the Joint Commission Journal on Quality and Patient Safety showed that the UCSF, through the antimicrobial program, was able to reduce the prevalence of the vancomycin-resistant enterococci (VRE) bacteria, specifically in the critical care setting.

While it is hard to argue with the program's results, organizers originally feared that arguments would arise over the program and what could potentially be seen as unnecessary oversight. But recent scrutiny—by both the government and the general public—of the issues of bacterial resistance in particular and improving care quality in general has persuaded many to embrace the program.

"Physicians don't like anyone second-guessing what they do," said Michael Gropper, M.D., Ph.D., director of critical care medicine at the UCSF Medical Center. "But with issues surrounding public reporting, as well as intense media pressure, there really isn't any more room to argue with these kinds of measures."

Adding that the number of "ugly confrontations" over the program and the resulting interventions has been fewer than expected, Gropper said that busy physicians seem to welcome the helping hand.

"In today's teaching hospital environment, people are happy to get whatever help they can," he said. "If they get a call from [the antimicrobial team] saying they don't think you're prescribing the right antibiotic and that they can rewrite the prescription, people are grateful for the help.

"The entire system functions in an almost invisible way." That is not to say that confrontations do not happen. While rare, when a difference of opinion does arise, the parties consult with Richard Jacobs, M.D., Ph.D., who oversees the center's infectious-diseases management program.

"Most of the time, the problem is mitigated," Jacobs said. "But if it is not and someone is insistent, then they will get [another opinion]. This being a teaching institution, we don't do this in a punitive way. Our goal is to educate."

—By Scott Harris

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