Safely reducing antibiotic use in the acutely ill: but at the cost of more admissions?

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Can we reduce antibiotic use in hospitals?  And can it be done safely? This is the question that Modernising Medical Microbiology Researcher Dr Nicola Fawcett wanted to investigate in research published in the BMJOpen today.

We know from many previous studies that when people are ill and come to hospital, antibiotics are often given out when they’re not needed, for many different reasons – uncertainty, the wish ‘not to miss’ something important, reassurance, patient demands…  Whilst it’s important to reduce antibiotic use to prevent difficult-to-treat infections in the future, it’s also very important that pushing Doctors to reduce antibiotic use doesn’t put patients at risk.

Modernising Medical Microbiology Researchers wanted to see if there was any evidence that a Doctor that was a specialist in Infection management (an ‘Infectious Diseases Physician’) could use significantly less antibiotics that other Doctors in ill patients. Previous studies have suggested this was possible, but few had looked at how patients fared. So our researchers also asked – were patients doing worse when antibiotics were used more sparingly?

They looked at everyone who was admitted to the acute medicine service at the John Radcliffe Hospital over a week (297 patients). Acute medicine looks after people with pneumonia, urine infections, sepsis, chest pain, headaches – pretty much everything that does need hospital care, but doesn’t need a surgeon or a specialist. It also deals with a lot of the uncertainty. For instance, an elderly person may have become confused and weaker. Sometimes this is because of an infection requiring antibiotics, other times it may be due to a virus, a salt imbalance, or a change in medication, and often, despite tests, it can remain unclear exactly what has caused the problem.

The researchers found that the medical team led by the Consultant specialising in infections used about 30% less antibiotics per patient than other teams in total during that week. There was no suggestion that the patients did any better or worse, and there were no delays in treatment of sick patients with sepsis with this more ‘cautious’ antibiotic strategy.

As the size of this group wasn’t enough to really answer the question about how patients did, so the researchers also looked at a large hospital database over a 3 year period (over 47,000 patients). They looked to see if there were any excess deaths in patients treated by the infections specialist (who we found used less antibiotics), and found that patients did just as well.  In all these comparisons, the researchers checked that these results weren’t just the result of sicker (or more well) patients being treated by the infection specialist, and even when taking into account things like age and other medical conditions, the difference remained.

They also found something interesting – patients managed by this ‘antibiotic sparing’ Consultant seemed to stay in hospital longer, and were more likely to be admitted to hospital overnight, rather than being sent home the same day.  When they looked back at the week of admissions, the patients being ‘kept in’ more often by the Infection specialist were the patients where the diagnosis was unclear, but might be an infection (and they were not in need of urgent antibiotics).  In patients where there was clearly an infection, or clearly no infection  – like patients with a possible heart attack – the same percentage of patients were admitted.

It appeared that for these ‘uncertain’ patients, the Infection specialist employed a strategy of ‘hold antibiotics and observe the patient overnight’, where other Doctors were more likely to ‘prescribe antibiotics just in case it’s an infection, and let the patient go home’.  This was backed up by the opinions of other doctors who noted that when you didn’t know exactly what was going on,  antibiotics were often seen as a ‘safety net’.  Alternatively the ‘safety net’ was admitting the patient to hospital, and getting more information.

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Whilst reducing antibiotic use is important, the researchers noted that if this came at the cost of more people being admitted to hospital (and coming into contact with more resistant, difficult-to-treat bacteria) – efforts to reduce antibiotic use may actually be counterproductive, and encourage the spread of these resistant infections.  It may also risk increasing the burden on already over-stretched hospitals and emergency departments.

The researchers noted the study was a relatively small one,  and only looked at one Infection specialist  – to find out whether this ‘hold antibiotics and observe’ vs ‘prescribe and discharge’ was more widespread, a larger group of doctors and patients in different hospitals would have to be looked at. Other studies looking at antibiotic use hadn’t seen this effect before. Hopefully as more hospitals switch to computer-based systems, this will be possible, rather than being limited by the time required to look through stacks of paper notes.

Better diagnostic tests are being developed – certainly these will help pinpoint those needing treatment. Whilst we wait for these, we can prescribe antibiotics in uncertain cases, but make sure all prescriptions are reviewed and stopped if it’s clear they’re no longer needed. (This approach will be a major focus for the NHS  and will be investigated by MMM’s ARK Programme).

Ultimately this study suggests that antibiotic use can be reduced quite significantly in ill patients admitted to hospital. But whilst it’s easy to say to Doctors, and patients, “Don’t use antibiotics if they’re not needed” – often it isn’t clear whether they’re needed or not. Doctors and patients need more support to enable use to make safe decisions together, to choose the best option for the patient.

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The research paper by Fawcett et al is available free online at BMJOpen http://bmjopen.bmj.com/content/6/8/e010969.full.

The work was supported by funding from the National Institute for Health Research via the Oxford Biomedical Research Centre, and the Health Protection Research Unit. Fawcett is supported by an MRC UK Clinical Research Training Fellowship 

 

 

 

 

 

 

 

 

 

 

 

 

 

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