Antibiotics, Resistance, and Learning From Ebola

An Interview With CDC Director Tom Frieden

Hansa Bhargava, MD, Tom Frieden, MD, MPH

September 18, 2014

Antibiotic Prescribing

Hansa Bhargava, MD: I'm Dr. Hansa Bhargava from WebMD/Medscape, and today I am joined by Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention (CDC). We will be speaking about antibiotic resistance and other infectious disease issues.

In our survey about antibiotic resistance, clinicians indicated that almost one fourth of their antibiotic prescriptions are written when they are not absolutely sure that antibiotics are necessary. How does this figure compare with other sources, and is it consistent with your own experience?

Tom Frieden, MD, MPH: We have seen that about one third, and maybe as much as one half, of all antibiotic prescriptions in this country are either unnecessary or are inappropriately broad-spectrum. It's very important that we all keep in mind that every medication, including antibiotics, has risks and benefits. The risks include resistant infections, Clostridium difficile, adverse events, and allergic reactions. These are significant risks. There is, quite frankly, far too much antibiotic use in this country today. At the same time, if patients have bacterial infections, it's important to treat them quickly and completely.

Dr. Bhargava: Delayed antibiotic prescribing is one of the few strategies that has been proven to reduce antibiotic overuse. Yet, only 49% of the clinicians in our survey reported that they use this method. Why do you think this hasn't caught on?

Dr. Frieden: "Tincture of time" often works, but doctors are busy and patients sometimes demand treatment. It's important to step back, and if a patient says, "I want an antibiotic," to understand that more fully. What patients want is to get better. We can work with them on the best way to do this and say, "Let's give it a day or two and see how you feel," because most illnesses do get better.

Clinicians may not realize that there has been a big change in the causes of infection. Vaccines have been so effective that rates of Haemophilus influenzae and pneumococcal disease have plummeted. They are so much less common that such illnesses as ear infections and bronchitis, which before might have been somewhat more likely to be caused by bacteria, are now much less likely to be caused by bacteria.

Dr. Bhargava: The clinical impression -- what doctors see in their offices -- also makes a difference in whether a patient is likely to have a bacterial vs a viral infection.

Dr. Frieden: It's also important that doctors be engaged with their local health departments. The health department may know what is going around in the community, and that information can help clinicians provide tailored treatment for their patients.

Dr. Bhargava: Only half of all patients in our survey said they have talked with their healthcare providers about antibiotic resistance. Clinicians told us they wanted more and better educational materials for their patients. Do you think that patient education can make the difference in changing behavior?

Dr. Frieden: We all have a role to play -- clinicians, patients, health services, and public health. We have to emphasize that drug resistance is an enormous problem. We talk about the "pre-antibiotic era" and the "antibiotic era," and if we are not careful, we will be in a "post-antibiotic era." We have to understand that these medicines have risks as well as benefits, and that part of what we have to do is be good stewards of antibiotics so that they will be there when we need them later on, and when our children and grandchildren need them.

Ebola Lessons

Dr. Bhargava: Let's talk about Ebola. Although a widespread Ebola outbreak in the United States is very unlikely, the past few weeks have provided clinicians here with a crash refresher course on how to respond to these infections. Are there lessons learned from the CDC response that healthcare professionals can apply in the event of a serious outbreak?

Dr. Frieden: We are all connected by the air we breathe, the water we drink, the food we eat, and the planes we travel in. A disease threat anywhere is a threat everywhere. Our most important way of protecting people in this country against Ebola and many other threats is to stop them at the source, and that is what we are doing -- surging and putting more than 50 people on the ground in less than 2 weeks in the affected countries.

But for physicians and other clinicians in this country, it's a reminder to take a travel history. Many people go to places around the world where they are exposed to malaria, but they aren't diagnosed properly because a travel history isn't taken. In the case of Ebola, it's pretty straightforward: In the past 21 days, have you been in Liberia, Sierra Leone, Guinea, or Lagos? If not, there is no risk for Ebola. But if they have been to any of those countries, Ebola must be considered.

Antimicrobial Use and Resistance Patterns

Dr. Bhargava: Methicillin-resistant Staphylococcus aureus (MRSA) and other resistant organisms are increasingly prevalent, and therefore the appropriate choice of therapy for many common infections must change frequently. Are there resources available for our colleagues to have the most current prevalence and antibiotic resistance patterns based on geography?

Dr. Frieden: CDC, along with our state health departments and many health systems, is working to improve the amount of information that is available. We just launched an antimicrobial use and resistance module of the National Healthcare Safety Network that is used in virtually every hospital in the country. It is an automated way of providing information and getting information out so that you know the antibiotic use and the antibiotic resistance patterns. We encourage hospitals to participate.

Dr. Bhargava: Is that new program interfaced with electronic health records? Is that how hospitals use it?

Dr. Frieden: Yes. That program is entirely electronically driven. It requires no manual upload once you have the system working. It's an automated data transfer to provide information to clinicians at the time of prescribing.

Dr. Bhargava: That's wonderful. Dr. Frieden, thank you very much for your time today. It's a pleasure having you here.

Dr. Frieden: Thanks very much.