After reports that a dangerous drug-resistant bacterium, carbapenem-resistant Klebsiella pneumoniae, or CRKP, had spread to at least 356 patients in Southern California last year, Times staff writer Molly Hennessy-Fiske spoke with Dr. Kavita Trivedi, medical epidemiologist with the California Department of Public Health's Antimicrobial Stewardship Program Initiative, about what can be done to reduce the spread of such drug-resistant "superbugs."
What can healthcare officials do to stop the spread of drug-resistant "superbugs"?
One of the main ways of dealing with antimicrobial organisms in hospitals is to develop an antimicrobial stewardship program. These are programs that promote the appropriate use of antibiotics. That ensures that a patient receives the appropriate agent, or antibiotic, the right dose and the correct route of administration.
What does that mean?
When patients come in to the hospital and we know they have an infection, the first day or two we don't know what the causative agent is, but we have to give them an antibiotic. This program helps ensure that the patient then gets the appropriate antibiotic.
What is the danger of giving someone an antibiotic that's too strong?
If you have a certain organism and I give you a broad-spectrum antibiotic like a carbapenem that covers that organism and 10 others, that organism learns how to fight off that antibiotic. So it's much better if I give you an antibiotic that is specific to the pathogen you have.
But what if a patient shows up with a severe infection?
It may be appropriate to give a patient a carbapenem, but then maybe when you get the lab results back, you can switch to something more specific. As a clinician, it's really hard to answer that question, because when a patient comes in, you want to give them the best option you have, and a lot of times that's a broad-spectrum antibiotic. It's not that doctors are doing anything wrong. They're in this healthcare environment where you have to see patients quickly and things get missed.
What can officials at healthcare facilities do?
For example, the lab looks at how much E. coli has been isolated in patients at your facility in a given year. They can look at how many of those specimens were susceptible to a given antibiotic. You really should use that susceptibility guide to decide what will work. We want to save these broad-spectrum antibiotics that we have in our arsenal for the really, really bad infections. It is not appropriate to use antibiotics without thinking about the repercussions. What's happening is there are a lot of places where they don't pay attention as much and they just give a broad-spectrum (antibiotic) that may not be appropriate.
What can patients do?
It's not right to pressure your doctor to give you antibiotics for a viral infection. We need to be cognizant about limiting the use of antibiotics, period, because we really are going to have problems. CRKP and MRSA (Methicillin-resistant Staphylococcus aureus) are the end result of us using antibiotics perhaps not as well as we should be using them. We have now developed these organisms that know how to combat even our biggest and baddest antibiotics. We cannot have these multi-drug resistant organisms running rampant. It's a good reminder to everyone, patients and providers, that we need to be really prudent when we give antibiotics to everyone, in-patient and outpatient.
What should patients ask their doctors?
Unfortunately, the culture now in these doctors' offices is you go in and say, 'I have bronchitis' and demand antibiotics. Let's say you have bronchitis and you take [azithromycin]. Most cases are viral. If you had bacteria in your respiratory tract, they may have developed resistance. If you develop bronchitis that is bacterial, the next time you're treated the [azithromycin] might not work. The public needs to give doctors that option to say that it's a virus instead of demanding antibiotics. We can also help doctors understand that it's OK to tell a patient to go home and rest and you don't have to give them something to make them feel like they got something out of the appointment. That is the culture. What we're trying to do with this initiative is to swing it the other way.
So patients should ask about the tradeoffs of antibiotics?
Exactly. If you initiate that conversation, that opens the door for the physician to have that conversation with you and you can develop a plan — if I don't get better in five days, say, then I can come back and try something else.
So what does your initiative do?
California is the only state that has any legislatively mandated wording concerning using antibiotics in hospitals. Hospitals are required to have oversight of the judicious use of antibiotics. It has translated into giving many hospitals the backing that they needed to develop these programs.... It's the lab that's running the susceptibilities, the pharmacists who really understand the pharmacology of the antibiotics, it's the physician, the infection control officer for the building — it's multidisciplinary. There are many programs already in place that are very successful that have helped improve the use of antibiotics and have shown some good effects.