Using Antibiotics Safely in Hospitals: Then, Now, and Beyond

Penicillin was discovered in 1928 and first used with human patients in 1941. Since then, penicillin and other antibiotics have revolutionized Western medicine. The number of lives saved counts in the millions.

But serious observers were cautious even in the antibiotic’s earliest days. Alexander Fleming, the Scottish scientist who identified the drug, noted the danger of inappropriate use (PDF) in 1945, when he was awarded a share of the Nobel Prize in Physiology or Medicine for the discovery. In his Nobel Lecture, Dr. Fleming described the ability of bacteria to develop resistance to penicillin and warned of the need for appropriate use.

Dr. Fleming’s early warning was prescient. Antibiotics alleviate immeasurable suffering. But when exposed to an antibiotic, bacteria can become resistant, making them harder to kill. This can make infections harder to treat and lead to deadly consequences for patients; each year 2.8 million people in the United States get an antibiotic-resistant infection, and at least 35,000 people die, according to the most recent statistics. If antibiotic resistance is not successfully combated, a simple sore throat could again become life-threatening. 

That’s why U.S. Antibiotic Awareness Week, which begins next Monday, is so important. This annual observance raises awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic use.

Understanding the need for appropriate antibiotic use is a critical first step in using them safely. The next step is applying that knowledge during care itself. That’s where AHRQ comes in. AHRQ has long funded research to help prevent healthcare-associated infections by improving how care is actually delivered. This includes developing practical tools to help clinicians use antibiotics appropriately.

The latest of these is the new Acute Care Hospital Toolkit, which we released earlier this week. More than 400 hospitals contributed to the development of this toolkit through their participation in our AHRQ Safety Program for Improving Antibiotic Use. The toolkit helps hospitals develop or improve antibiotic stewardship programs (ASPs), which are evidence-based programs that encourage appropriate use of antibiotics.

ASPs ensure that patients get the right antibiotics when they need them, and only when they need them—lessening the potential for antibiotic resistance. The toolkit takes antibiotic stewardship a step further, engaging prescribers at the bedside using the "Four Moments of Antibiotic Decision Making" to help improve antibiotic prescribing. The four moments are:

1. Make the Diagnosis. This occurs when initiation of antibiotic therapy is being considered. Ask, “Does my patient have an infection that requires antibiotics?”
2. Cultures and Empiric Therapy. This occurs when the decision has been made to start antibiotics. Ask, “Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate?”
3. Stop, Narrow, Change to Oral. This occurs on every subsequent day of antibiotic therapy. Ask, “Can I stop antibiotics? Can I narrow therapy? Can I change from intravenous to oral therapy?”
4. Duration. This should occur when it’s clear what infectious process is being treated and the patient is responding to therapy. Ask, “What duration of antibiotic therapy is needed for my patient’s diagnosis?”

The toolkit also includes best practices for diagnosis and treatment of infections, approaches to improve safety culture, and tactical recommendations to demonstrate the value of an ASP to administrators and prescribers.

U.S. Antibiotic Awareness Week is an ideal occasion to revisit Alexander Fleming’s warning from 1945: to rethink how we use antibiotics to ensure that they remain a viable treatment option for generations to come.  

Dr. Miller is a Medical Officer for AHRQ’s Healthcare-Associated Infections Program.

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