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Combating antibiotic resistance in Canada


Michael’s Story

Michael was a 75 year-old living in Canada’s Prairies. His wife recently spent five days in hospital for a scheduled hip replacement. At the time she was admitted to hospital, Michael was on a one-week course of Amoxicillin, an antibiotic medication to treat a sinus infection. Michael spent a great deal of time with his wife at the hospital, helping her to recover after surgery. A few days after his wife was discharged, Michael started to experience severe diarrhea, high fever and stomach cramps. He was eventually diagnosed with an infection from C. difficile bacteria, which is commonly found in Canada’s hospitals and health care institutions and is very dangerous for older people.

Michael was at additional risk because he was taking antibiotics, which killed off important bacteria-fighting organisms in his gut. Eventually, Michael needed to be hospitalized. The C. difficile strain that he was infected with causes severe disease and is difficult to treat. Sadly,  two weeks after he was admitted to hospital, Michael passed away.

Michael’s story is increasingly common in Canada;  deaths from C. difficile have increased fourfold in the last twenty years in Canada.

Antibiotic resistant organisms have been identified by Health Canada, the US Centre for Disease Control and the World Health Organization, as a major global public health threat.

Antibiotics are one of the major breakthroughs in modern medicine. However, their use has also led to the growth and global spread of antibiotic resistant organisms. Almost a century after we entered the antibiotic era, experts warn that without appropriate interventions and management of antibiotic use, we could enter a post-antibiotic era.

A brief history of antibiotics, and antibiotic resistance

The wide-spread introduction of antibiotics to treat bacterial infections in the early 20th century revolutionized not only medicine, but society.

The introduction of antibiotics led to plummeting death rates from newborn infections, and from common and now treatable bacterial illnesses – like pneumonia and strep throat. Many achievements in modern medicine – whose potential complications include infections – such as major surgery, organ transplantation and chemotherapy would not be possible without antibiotics.

Antibiotic medications are used to treat everything from skin acne to serious blood infections. The long list of uses of antibiotics has led to a tremendous amount of use, but misuse as well.

Antibiotics are often prescribed when they are not needed, such as treatments for the common cold or upper respiratory infections. Antibiotics are also prescribed as a precaution when doctors aren’t sure if an infection is viral or bacterial.

In Canada, approximately half of all prescriptions for antibiotics are unnecessary. Canada is not alone in this  – the United States Centre for Disease Control reports similar figures for antibiotic misuse.

There has also been widespread use of antibiotics beyond humans. For decades, it has been routine practice at many farms to give low doses of antibiotics to poultry, swine and cattle to promote growth and reduce infection. In Canada, 88% of total antibiotic use by volume is in animals. The more antibiotics are used, the more organisms emerge that are resistant. However, these pathways are difficult for scientific research to establish.

Scott McEwan, professor at the Ontario Veterinary College in Guelph says that the food system we have today is so complex that “its hard to measure whether drug use on a farm to treat a sick chicken really has an impact on people.” Because of the scientific uncertainty and debate McEwan says “it’s hard to get consensus on what to do next and progress in this area is painfully slow.”

Another important factor in trying to deal with antibiotic resistant organisms is the small number of new antibiotics being developed. In the last forty years only four new classes of antibiotics have been launched and most pharmaceutical companies have ceased research and development in antibiotics.

Kamran Khan, an infectious disease specialist and researcher at St. Michael’s Hospital in Toronto says “there is an imbalance between the pace of new organisms becoming resistant and the development of new antibiotics.”

John Conly, an infectious diseases specialist at the University of Calgary, says the fact that there are few new antibiotics coming down the pipeline is a “big gap in drug development” noting “there are no incentives for the pharmaceutical industry to develop antibiotics.”

Conly points to the high costs of research and development in bringing a new drug to market, and notes that there is little profit in developing antibiotics which are taken for a few days at a time, as compared to diabetes or HIV medications, which patients take for a lifetime.

Antibiotic resistance has been described as a global problem, with a need for global solutions. However, it affects each of us; we are part of the problem and part of the solution.

Click to expand the infographic  on antibiotic resistance, reprinted with permission from the World Health Organization.

What-you-need-to-know-about-antibiotic-resistance-Eng copy

What is Canada doing?

The front lines of the battle with antibiotic resistance are often fought in hospitals where there are high rates of antibiotic use. Hospitals are often the place where the most resistant strains of antibiotic resistant organisms – such as C. Difficile and Vancomycin-Resistant Enterococcus – are present.

Kamran Khan notes that it sometimes seems as though “we are back in the pre-antibiotic era when trying to treat these infections in hospitalized patients.” He says that doctors are increasingly trying to manage infections that just a decade ago were easily treated, but today are more often resistant to conventional antibiotic treatments.

An international study found that about 70% of patients across 1,200 Intensive Care Units were receiving antibiotics, 30% of which were unnecessary. With increased, and often inappropriate use of antibiotics promoting the emergence of resistant organisms, there has been a focus on improving the use of antibiotics in hospitals through better education and monitoring.

Antimicrobial stewardship programs

This approach has been formalized into antimicrobial (or antibiotic) stewardship programs which are coordinated programs in hospitals that try to improve and measure the use of antibiotics.

Typical components of antimicrobial stewardship programs include education for staff around appropriate antibiotic use, computer-based monitoring of antibiotic use and resistance, and the use of audit and feedback to review antibiotic prescribing patterns. Generally, stewardship programs include the participation of a multidisciplinary group of staff – including infectious disease specialists, nurses, pharmacists and hospitalist physicians.

Research suggests that stewardship programs minimize unnecessary use of antibiotics, improve documentation of how antibiotics are being used and decrease overall costs associated with antibiotic treatment and infections. In terms of patient care, stewardship programs reduce the use and intensity of antibiotics, and are not associated with higher infection rates, longer patient length of stay or worse health outcomes.

Andrew Morris, an infectious disease specialist who leads the stewardship program at Mount Sinai and University Health Network says that the biggest barrier to adopting stewardship programs across Canadian hospitals is funding. He notes that hospitals have to find money within their budgets to pay for these programs.

Research suggests that antimicrobial stewardship programs can save hospitals money through reduced antibiotic costs and savings due to fewer cases of antibiotic resistant infections.

The stewardship program at Mount Sinai and University Health Network, which combined have over 1000 patient beds, runs on a budget of approximately $900,000 per year, according to Morris. He says “there are no mechanisms in place to properly fund this patient safety and quality intervention.”

However, hospitals are becoming increasingly interested in putting in place stewardship programs. This is in part due to the introduction of an Accreditation Canada requirement that all inpatient acute care hospitals establish stewardship programs.

Wendy Nicklin, CEO of Accreditation Canada notes that this is just the first year that this requirement has been in place, and there is much room for improvement. She says that only about 35% of inpatient acute care hospitals have a stewardship program in place.

“There is no one size fits all to antimicrobial stewardship programs” Nicklin says, noting that some organizations, especially non-academic or smaller hospitals do not feel that they have the expertise in infectious diseases to run stewardship programs. These hospitals often do not have infectious diseases specialists, who traditionally lead stewardship programs.

Morris suggests that the Accreditation Canada requirement has brought a great deal of awareness to the need for stewardship programs, but more needs to be done to build up capacity for hospitals to introduce and sustain these programs. “It is possible to bring people with little [infectious disease] training up to speed on how to do stewardship programs” he says.

Whats next in the fight against antibiotic resistance?

However, experts agree that hospital-based stewardship programs are just one piece of the complex approaches needed to deal with antibiotic resistance.

Kamran Khan says a paradigm shift is needed in how health care providers approach dealing with infections. He says “there is a tension between the individual patient and society, and health care providers wanting to do something for their patients” – which often means prescribing an antibiotic, even when this can do more harm than good.

Vanessa Allen, an infectious disease specialist and microbiologist at Public Health Ontario agrees, saying a change is needed in health care to deal with the challenge of antibiotic resistance.

“When penicillin was first introduced in the 1940s, all of sudden there was a magic bullet approach where infections like gonorrhea could just go away” Allen says, noting that many of today’s health care providers, and patients, still continue to believe antibiotics are a magic bullet solution.

“We don’t want to go back to the pre-antibiotic era, so we need to invest in more sophisticated and thoughtful interventions to manage infections” she says.

However, given the many different drivers of antibiotic resistance – including inappropriate use in farming and across various health care settings – it is clear that no one individual or group can solve this challenge alone. Scott McEwan notes that with antibiotic resistance “everyone has a piece of it, but at the end of the day it is hard to hold any one group accountable.” He says “there is also someone else to blame or point a finger at.”

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10 comments

  1. Rob Devitt & Jeff Powis M.D.

    Since 2010 Toronto East General Hospital has seen first-hand the value of a robust antimicrobial stewardship program. Our experience has shown that these programs can be cost neutral and indeed even cost positive through the savings achieved by reduced antibiotic use and lower rates of hospital acquired infections. We monitor savings, costs and quality metrics for our program quarterly to ensure sustainability and continuity of our successful program. Effective collaboration between IPAC, hospital programs and hospital leadership should allow for the maximization of cost recovery and thus ensure that stewardship helps the “bottom line”. Based on our experience, funding should never be seen as a barrier to implementation.
    Rob Devitt & Jeff Powis M.D.

  2. Steve Buick, Institute of Health Economics, Edmonton

    Should hospitals screen for antibiotic-resistant organisms (AROs)? Should they screen for specific ones or a range, or rely on general infection-control measures? How should we decide? – how do we know if screening is worth doing? A 3-day “Consensus Development Conference” on ARO screening and surveillance in Calgary in June 2014 will look at these and related questions, including stewardship of antimicrobials. For information email AROs@ihe.ca

  3. Chris Paterson, CAHO

    Kudos to Dr. Andrew Morris and his team at Mount Sinai Hospital/University Health Network (UHN) for their leadership in antimicrobial stewardship. Having made an impact in MSH-UHN hospitals , Dr. Morris and team are leading the implementation of the CAHO Antimicrobial Stewardship Program in ICUs. This is a great example of collaboration for the successful implementation of research evidence to address a critical challenge in health care. CAHO is pleased to support the project through the Adopting Research to Improve Care (ARTIC) Program. The need is great: Patients in ICUs are the sickest and most vulnerable in the hospital. Over 70% of these patients are on antimicrobials, an agent that kills microorganisms or inhibits their growth. Antimicrobials are used to treat serious infections, but unnecessary exposure to antimicrobials puts patients at risk for adverse drug events and drug-resistant inflections, such as C. difficile. The ASP optimized the use of antimicrobials and developed a system for hospitals to compare their results, so that best practices can be shared across the entire health care system. It is anticipated that this will reduce intensive care units (ICUs) antimicrobial use by 12 to 25% and reduce ICU antimicrobial costs by 23 to 41%. Importantly, this program is better for patients by reducing unnecessary exposure to antimicrobials, often a significant risk for ICU patients. CAHO is most proud of the fact that our investment has helped spread the implementation of this impactful and innovative program across nine Ontario hospitals to date. We also want to find ways to work with more provincial partners to accelerate this type of evidence-informed quality improvement right across the province.

  4. Elizabeth Rankin BScN

    Your points on antibiotic resistance are not new but should be kept in mind. The case cited about the man who died from C. Diff who was on antibiotics at the time for a sinus infection, not uncommon and often needed, is not the culprit although since it was mentioned it lead me to consider “what else” might have pre-disposed this man to C. diff? Yes, he was a visitor to the hospital so this suggests he had an opportunity to “pick up” the organism. But taking the antibiotic he was on is not necessarily what pre-disposed him to either picking it up or succumbing to the organism. A man of 75 could have been on other drugs such as proton pump inhibitors, a very common drug that those over 50 years of age take, and this drug is “notorious” for pre-disposing people to C. diff, along with other bad side-effects such as osteoporosis.
    The other point that was overlooked is very important and this is having a patient safety system in place where all staff, [all employees] and hospital visitors understand the protocol for preventing infections. Infection control reconciliation programs are needed everywhere. Places like Johns Hopkins have implemented The Science of Patient Safety program and have seen their infections rates significantly decline but it requires buy in of the entire staff at the hospital.

    Elizabeth Rankin BScN

  5. JP Graba

    I can understand that in the community this can be attributed to the habit of the ‘art’ of medicine prescribing instead of the science of medicine (and the lack instant lab results to best treat that individual during the walk-in or office visit).%featured% But with 2013 technology (ie EMRs/HIS, POE algorithms) how is it an antibiotic can be ordered inside a Canadian hospital (ICU or otherwise) against an organism of which it has no effect ? Why is it perpetuated on the wards (my assumption though, as I don’t know the literature on this) ? Are we ‘training’ our med students and PGYs to continue doing the same-old same-old ?%featured%

    • A Morris

      I agree, it seems mind-boggling. %featured%But it is the reality: our currently employed technology is woefully behind its theoretical abilities. For reasons of cost, primarily. Additionally, we don’t usually know what infection the patient has when we start treatment.%featured% Despite these caveats, there is still tremendous room for improvement–which is why antimicrobial stewardship programs are so important.

  6. Dr.Rimma MZ, SMH

    Thank you for bringing this up. I think it is a Global problem, not just Canadian.There are another aspects. If you look around the most European countries you can find that everyone can buy almost any antibiotics from the pharmacy without doctor’s prescription, only under the pharmacist consult. Of course no further monitoring from the GP. Many people are not relay on GP any more and go for advise to the internet sources in some cases. Considering the world as place with easy travel, it does not take long to bring untreated/over-treated/resistant bacteria to any part of the globe. Another aspect is the duration of the antibiotics treatment. In the recent study we found out that the short vs. long duration is actually has the same outcomes! The treatment works in 3 days too. So, it is about What, who, what diagnosis, what antibiotic, what duration? You can find a great video on the WHO website” The 5 things everyone needs to know about the antibiotics.” http://preview.tinyurl.com/m4ljemu

  7. Dr. Ploguraz

    The biggest issue, and one that is briefly mentioned in the article, is that of antibiotic use on livestock. Before we tackle human antibiotic overuse, this should be addressed and optimized.

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