Antibiotic Stewardship and the C. Difficile Infection

JUNE 14, 2018
MD Magazine Staff

Peter Salgo, MD: Let’s turn to the 800-pound gorilla in the room: the inappropriate use of antibiotics, whether out in the real world or in the hospital setting. From personal experience, I can tell you that doctors are pushing antibiotics as if they are Teflon. I hate to say that. I love my colleagues, but this is nuts. How do you do that?

Darrell S. Pardi, MD: I think that’s another systematic problem. It’s easier to write a prescription than it is to take the time to explain to a patient why they don’t need an antibiotic. You get the patient in and out quickly and move on to your next patient. It’s a huge problem. I think we should treat it like the opioid epidemic. We need to treat it as a public health threat and provide better education.

Peter Salgo, MD: I don’t mean to denigrate the primary care physicians, as I don’t understand how anybody can do that job. I couldn’t do it. Everybody comes in your office and you’ve got to make real decisions, in real time, as to what to do. And you’ve got to make sure that your patients come back and see you. Sometimes, patients really want antibiotics. But at the same time, if you’re promoting the overgrowth of resistant bacteria and the growth of Clostridium difficile [C. diff] in the community and in the hospital, that’s got to be taken into consideration. I don’t know how you incentivize that.

Yoav Golan, MD: More and more research shows that as a clinician, particularly a primary care provider, if you spend time with your patient and tell them about the option of antibiotics and the harms, not just the potential benefits, patients understand that if antibiotics are not going to benefit them, they should not be prescribed.

Peter Salgo, MD: I’m going to stop you right there. You used the word “time.”

Yoav Golan, MD: Right.

Peter Salgo, MD: The average primary care physician, I’m told, who is out there in the real world, has about 7 minutes. If you’re going to take the time to discuss the granular structure of antibiotics in that setting, there goes your 7 minutes. You’ve got nothing.

Yoav Golan, MD: Well, I think changing antibiotic prescription habits entails a big discussion. But I think that when you talk about antibiotics within the context of C. diff, it’s important for clinicians to understand that antibiotics drive C. diff. Without antibiotics, we probably will see far less, if at all. Sometimes you have to use antibiotics, because antibiotics are like a hammer. You can build with them. You can destroy with them. They’re in your hand. You have to ask yourself, “Is the patient going to be benefitting or not?” At the end of the day, most antibiotic use is inappropriate and most antibiotic courses are too long.

So, clinicians have to ask themselves, “Does the patient absolutely need antibiotics? Can a patient call me back in 2 or 3 days? I think this is a virus that will go away.” And when you use antibiotics, you have to use them for the minimal amount of time and use them adequately. At the end of the day, it’s going to be all about antibiotic stewardship. Part of that will come from the clinician and part of that will be a pathway. That will be good for the clinicians, and the clinicians will have to follow up.

Darrell S. Pardi, MD: I actually empower my patients. When I see a patient with C. diff, I tell him/her that one of the biggest risk factors for recurrence is more antibiotic exposure. So, if any doctor or provider wants to give you an antibiotic, make sure you tell them, “I just got over C. diff. Do I really need this antibiotic?”

Peter Salgo, MD: OK, does that work?

Darrell S. Pardi, MD: I don’t know. I don’t think it hurts.

Dale N. Gerding, MD: It does, in the patients who I’ve encountered, who have had multiple episodes of C. diff. They are deadly afraid of getting another antibiotic, and they should be. It’s really devastating. But the antimicrobial stewardship movement, which actually didn’t even exist until the early to mid-90s, has really taken off. Now, we really are seeing much more thoughtfulness, at least in the institutional setting, about the use of antimicrobials. As we try to prevent the disease, as Yoav said, there are 2 ways to do it. First, we use barrier precautions. And the other is, don’t make the patients susceptible by not giving them unnecessary antibiotics. So, there are 2 methods for trying to control this disease.

Peter Salgo, MD: The best we can say at this point is: It’s a work in progress.

Transcript edited for clarity.
 

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