Since their early use, antibiotics have transformed medical care by fighting infectious bacteria. Before antibiotics, infections were a major cause of death.
Earlier Initiative Paved the Way
DASON grew from an earlier initiative that the Duke University School of Medicine launched in 1997. Called DICON, the Duke Infection Control Outreach Network collaborates with rural hospitals to use evidence-based approaches to prevent infection. The goal is to improve outcomes for patients by reducing the rate of health care-associated infections.
But even back in 1945 when Alexander Fleming accepted a Nobel Prize for discovering a wonder drug called penicillin, he sounded a “note of warning” about over-prescribing antibiotics and misusing them. When physicians try to kill bacteria that cause infections, bacteria will try to evolve and adapt to survive. As those organisms work harder to adapt, the drugs used to fight them become less effective. And as the drugs become less effective, infections become harder to control.
Without changes in how we produce, prescribe and use antibiotics, experts at the World Health Organization say we’re heading into a “post-antibiotic era” with “devastating” implications for public health.
That’s the challenge behind a new initiative launched at Duke University School of Medicine. Supported by a three-year, $385,000 grant from The Duke Endowment, the aim is to help rural hospitals in the Carolinas use antibiotics more effectively in patient care.
“Physicians in difficult clinical situations have to make decisions about whether antimicrobial drugs are right for their patients, and then determine the correct dose, the timing and the duration,” says Dr. Rebekah Moehring, co-medical director of the Duke Medicine team. “This program is developing a support system for the people who are making these tough choices.”
A Serious Threat
Officials at the Centers for Disease Control say that antibiotics have been used “so widely and for so long,” antimicrobial-resistant germs are now a serious, worldwide threat. People infected with resistant organisms are more likely to have longer, more expensive hospital stays, CDC experts say, and may be more likely to die as a result of the infection.
At Duke University School of Medicine, Dr. Daniel Sexton calls it a perfect storm. About half of the people admitted to American hospitals receive antibiotics, he says, and an estimated 30 to 50 percent of those prescriptions are considered inappropriate.
“The motivation for prescribing antimicrobials may be convention, risk aversion, liability concerns or misinformation,” says Sexton, an epidemiologist. “Doctors might be playing it safe saying, ‘I know it’s probably a virus, but let’s cover it anyway.’ Regardless, we’re talking about an enormous percentage of people who receive antibiotics without any real indication. It has become a wave that’s flooding the place.”
To make matters more pressing, he says, the antimicrobial drug development pipeline is running dry.
With Dr. Moehring, Sexton is leading the Duke Antimicrobial Stewardship Outreach Network - called DASON for short. Designed to enhance clinician education and help hospitals develop formal policies to minimize the unintended consequences of antimicrobial use, DASON has created a network of hospitals that are benefiting from shared data and expertise. The focus is on rural hospitals because many do not have the resources to tackle this challenge on their own.
“The majority of Americans don’t get their care at Duke or Cleveland Clinic or Harvard, but in small community hospitals,” Sexton says. “But at those hospitals, time and people can be at a premium. By developing this network, we can provide expert functions onsite. When they say, ‘How are we supposed to fix this problem?’ we can say, ‘You could consider doing x, y and z.’”
In the Carolinas, 14 hospitals have joined the network. Since antibiotic stewardship is an emerging science, Sexton expects that DASON will lead to research and performance improvements that will benefit hospitals and patients across the country.
Reaping the Benefits
Myra Hawkins, DASON’s clinical pharmacist, works in the field, conducting need assessment surveys for hospitals, and then helping them form action plans. Key to the initiative is gathering data on antibiotic use.
“Because this is a network of hospitals, we can show what hospital x is using compared with the rest of the hospitals,” Hawkins says. “If hospital x is using a lot more of a certain class of antibiotics than the mean, we can share options that have worked in other locations.”
Nash General Hospital in Rocky Mount, North Carolina, has already reaped benefits from joining the DASON network. Early on, DASON helped Nash see that clinicians were often prescribing the antibiotic Tygacil for a wide range of patients, even though it’s ideally reserved for patients who have multiple drug allergies or very resistant bacteria.
“Tygacil is attractive because it theoretically covers a lot of different things, but it’s expensive and there are side effects,” says Luke Heuts, Nash’s clinical coordinator in pharmacy services.
Officials at Nash developed a plan for reserving Tygacil for certain patients, and then launched an educational campaign to spread the word. They also changed the electronic ordering system to include a popup alert when providers select Tygacil.
“The alert leads them through the appropriate patient criteria,” Heuts says. “Just by doing that, we’ve made a huge impact on how much Tygacil is being used.”
Being involved in DASON has been a huge educational undertaking, Heuts says. “It’s a change for the pharmacist; it’s a change for the nurses. But everyone wants to do the best thing for the patient. And as DASON helps us identify more initiatives to work on, it’s clear we’ll see better outcomes for the people we’re serving.”
Learn more about DASON.
Lin B. Hollowell III
Director of Health Care