Get Smart: Know When Antibiotics Work
Improving antibiotic use in U.S. ambulatory care
Lauri Hicks, DO
Director, Office of Antibiotic Stewardship
Medical Director, Get Smart: Know When Antibiotics Work
American Dental Association Meeting
November 07, 2015
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Disclosure
I have no actual or potential conflict of interest in relation to
this presentation.
Overview
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Discuss the problem of antibiotic resistance
Describe the Get Smart: Know When Antibiotics Work
program
Characterize the overall problem of inappropriate
antibiotic prescribing in the outpatient setting
Discuss antibiotic prescribing in dentistry and challenges
to improving use
Summarize national policy and initial steps to improve
antibiotic prescribing in dentistry
The Life-Saving Benefits of Antibiotic Use
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Once deadly infectious diseases treatable, substantially
reducing deaths compared to the pre-antibiotic era
Important adjunct to modern medical advances
 Surgeries
 Transplants
 Cancer therapies
Facing the End of the Antibiotic Era
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No new types of antibiotics developed in over 10 years
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More toxic antibiotics being used to treat common
infections
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Must treat antibiotics as precious and finite resource
Clin Infect Dis 2011 May; 52(suppl 5): S397-S428
Burden of Antibiotic Resistance, United States
Estimated cost of $30 billion annually
(range $20-$35 billion, 2008 dollars)
CDC. Antibiotic resistance threats in the United States, 2013.
www.cdc.gov/drugresistance/threat-report-2013/
Why Antibiotic-Resistant Infections
Cost Us All More
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Require prolonged and costlier treatments
Extend hospital stays
Necessitate additional provider visits and healthcare use
Result in greater disability and death compared to
infections that are easily treatable with antibiotics
Unintended Consequences of Antibiotic Use:
Antibiotic Resistance
CDC. Antibiotic resistance threats in the United States, 2013.
www.cdc.gov/drugresistance/threat-report-2013/
Actions to Address the Threat of Antibiotic Resistance
There’s More to the Story
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Antibiotics are responsible for almost 1 out of every 5
visits to emergency departments for drug-related
adverse events (142,000 visits annually).
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Antibiotics are the most common cause of drug-related
emergency department visits for children.
Shehab, et al. Clin Infect Dis. 2008 Sep 15;47(6):735-43
Unintended Consequences of Antibiotic Use:
Clostridium difficile
CDC. Antibiotic resistance threats in the United States, 2013.
www.cdc.gov/drugresistance/threat-report-2013/
A Primer on Appropriate Antibiotic Prescribing
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Practice guidelines from professional organizations and
CDC support more targeted antibiotic prescribing
Conditions for which antibiotics are not routinely
indicated
 Viral infections, including colds and bronchitis
 Includes some infections (e.g., otitis media) for which antibiotic
treatment had formerly been routine
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Use of diagnostic testing to guide prescribing
Choose recommended antibiotic, dose and duration
Challenge in dentistry with lack of specific guidelines for
treatment and changes in prophylaxis recommendations
Get Smart: Know When Antibiotics Work
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Launched the National Campaign for
Appropriate Antibiotic Use in the
Community in 1995, which was renamed
Get Smart: Know When Antibiotics Work in
2003
Work closely with a variety of partners to
reduce inappropriate antibiotic use in the
community
Focus on increasing awareness about
antibiotic resistance with an aim to improve
antibiotic prescribing and use
www.cdc.gov/getsmart
Get Smart: Know When Antibiotics Work, cont.
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Historically the program has focused on the
upper respiratory infections most
commonly caused by viruses yet often
prescribed antibiotics and primary care
providers
This focus is expanding to include other
specialties and conditions and all
healthcare settings
www.cdc.gov/getsmart
Get Smart Activities to Improve Antibiotic Use
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Educate general public and providers about antibiotic
resistance and appropriate antibiotic use
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Get Smart About Antibiotics Week
Detailing sheets
Tools (viral prescribing pad)
Curricula and continuing education
Measure and characterize prescribing
practices
Develop policy (e.g. guidelines)
Evaluate interventions
Foster partnerships
Efforts to Improve Antibiotic Use:
Get Smart About Antibiotics Week
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This year: November 16-22, 2015
Increase awareness of antibiotic resistance and the
importance of appropriate use of antibiotics in all
healthcare settings
Partner with a variety of organizations, including health
agencies in more than 40 countries
Engage the media to disseminate messages on the
radio, in print, on television and in social media
“Preserve the Power of Antibiotics”
Antibiotic Prescription Costs in Billions ($US),
by Treatment Setting, United States
For 2009, total costs $10.7 billion
0.5
3.6
6.5
Suda et al. J Antimicrob Chemother 2013; 68: 715–718
Community
Hospitals
Nursing homes
Community Antibiotic Prescribing Practices
United States, 2010
Prescriptions per 1000 persons
1600
Providers prescribed 833 prescriptions per
1000 persons in the community setting in 2010
1400
1200
1000
800
600
400
200
0
0-2
3-9
10-19
20-39
Age group (years)
Hicks LA et al. N Engl J Med 2013;368:1461-1462
40-64
≥ 65
What Are We Prescribing?
Antibiotic agent (top 5)
Number of
Prescriptions per
prescriptions in
1,000 persons
millions (%)
Azithromycin
51.5
166
Amoxicillin
51.4
166
Amoxicillin/clavulanate
21.5
70
Ciprofloxacin
20.4
66
Cephalexin
20.1
65
Top Prescribers by Provider Specialty, 2010
Number of
prescriptions in
millions (%)
Prescriptions per
provider
Family Practice
64.6 (25)
672
Pediatrics
33.2 (13)
612
Internal Medicine
32.5 (13)
388
Dentistry
25.7 (10)
209
Nurse Practitioner
16.9 (7)
154
Provider Specialty (top 5)
Antibiotic Prescriptions per 1000 Persons
of All Ages By State, 2010
Highest
prescribing
rate
(1237/1000)
Lowest
prescribing
rate
(529/1000)
Hicks LA et al. N Engl J Med 2013;368:1461-1462
Provider Prescribing Practices
for Adults in the Community
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Acute respiratory infection most common reason adults
receive an antibiotic
 More than one out of four antibiotic prescriptions for adult
outpatients are for conditions for which antibiotics are
not needed
 Providers often choose a broad-spectrum drug for conditions for
which antibiotics are rarely indicated
 Macrolides and fluoroquinolones are often prescribed when
amoxicillin is the recommended first-line therapy
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Providers in the South more likely to prescribe
for conditions that do not warrant antibiotic use
Prescribing by dentists was not captured in this study
Shapiro et al. J Antimicrob Chemother 2013 Jul 25
What Antibiotic Classes are Being Prescribed
by Dentists?
Antibiotic Class
Number
(millions)
%
Per 1,000
persons
Penicillin
17.07
69.6
53.9
Lincosamides
3.57
14.6
11.3
Macrolides
1.33
5.4
4.2
Cephalosporins and
related
1.24
5.1
3.9
B-Lactam, increased
activity
0.56
2.3
1.8
Tetracycline
0.47
1.9
1.5
Quinolones, systemic
0.21
0.8
0.6
Trimethoprim/
Sulfamethoxazole
0.05
0.2
0.2
Urinary anti-infectives
0.02
0.1
0.1
What Antibiotics are Being Prescribed by
Dentists?
Antibiotic Agent
Number
(millions)
%
Per 1,000
persons
Amoxicillin
13.80
56.3
43.6
Clindamycin Hcl
3.53
14.4
11.2
Penicillin Vk
3.24
13.2
10.2
Cephalexin
1.19
4.9
3.8
Azithromycin
1.14
4.7
3.6
Amox Tr/Pot Clavul
0.56
2.3
1.8
Doxycycline Hyclat
0.43
1.7
1.4
Ciprofloxacin Hcl
0.16
0.6
0.5
Erythromycin
0.09
0.4
0.3
Trimethoprim/sulfa.
0.05
0.2
0.2
Characteristics of Patients
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Females are prescribed antibiotics more often than
males
 Females 56.1% (13.7 million prescriptions, 85.2 per 1,000
females)
 Males 43.9% (10.73 million prescriptions, 68.9 per 1,000 males)
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Adults between 40-64 are prescribed the most antibiotics
by dentists (44.8%); followed by those aged 20-39
(23.9%) and 65+ (23.4%)
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Children 19 and under account for less than 10% of all
antibiotics prescribed by dentists
Is There Geographic Variability in Dentist
Prescribing?
Recent Study on Dental Prescribing Presented
at IDWeek
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Analysis of outpatient prescriptions 1996-2013 in the
British Columbia Pharmanet database
Overall community antibiotic use declined and physician
prescribing declined by 18%, but dental prescribing
increased by 62% during this time period
Rate of prescribing increased most for patients over 60
years of age
Webinar held by Canadian Dental Association informally
assessed reasons for increase
 Unnecessary prescription for periapical abscess and irreversible
pulpitis
 Slow uptake of guidelines recommending less prophylactic
antibiotic use for valvular heart disease and prosthetic joints
Patrick, D, et al. What Accounts for a Large Increase in Antibiotic Prescribing by Dentists? IDWeek Poster Presentation, 2015.
Study of Dental Prescribing for Adults in the
UK
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Cross-sectional study of management of adult patients
for acute dental conditions by general dentists in Wales
Antibiotics were prescribed to 57% of patients
Over half were prescribed in situations where there was
no evidence of spreading infections, and 71% were used
without a surgical intervention
Only 19% of antibiotics prescribed were indicated
according to guidelines
Factors associated with inappropriate antibiotic
prescription were patients who were unable or unwilling
to accept operative treatment, patient requests for
antibiotics, among others
Cope et al. Antibiotic prescribing in UK general dental practice: a cross-sectional study. Community Dent Oral Epidemiol. 2015.
Interventions to Improve Outpatient
Prescribing
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Print materials alone have little impact on prescribing
Audit and feedback of current practice has been
successful
Academic detailing, opinion leader education effective
Clinical decision support promising
Other options:
 Delayed prescribing practices
 Poster interventions involving public commitment to prescribe
judiciously
But all of these interventions rely upon having access to
data to identify problem areas and specific clinical practice
Arnold et al. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003539.
guidelines
Forrest et al. Pediatrics 2013 Apr;131(4):e1071-81.
Little et al. Lancet 2013 Oct 5;382(9899):1175-82.
Meeker et al. JAMA Intern Med. 2014;174(3):425-31.
Looking Closer at Dental Prescribing –
What Do We Know?
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Dentists prescribe approximately 10% of all antibiotic
prescriptions in the United States
Lack of evidence/data on actual prescribing behavior of
dentists for both antibiotic prophylaxis and therapeutic
treatment in the United States
Current American Heart Association Guidelines
recommend prophylaxis for patients meeting certain
criteria with amoxicillin as first line therapy
Unclear if guidelines focused on the therapeutic use of
antibiotics are followed
What About the Guidelines?
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Prevention of infective endocarditis: Guidelines from the
American Heart Association (2007)
 Update of recommendations from 1997
 Changes recommend prophylaxis for only those at highest risk of
an adverse outcome from infective endocarditis
 Amoxicillin recommended first line agent (if penicillin allergy:
cephalexin or clindamycin or azithromycin or clarithromycin)
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Survey of dentists in 2010 to explore the acceptance of
and impact of the revised guidelines on dental
practitioners and patients
 95% of responding dentists indicated they saw patients that
received antibiotic prophylaxis
 70% had patients that still received antibiotics before a dental
procedure even though it was not recommended by the
guidelines
Acceptance among and impact on dental practitioners of American Heart Association recommendations for antibiotic prophylaxis,
JADA, 2013; Prevention of infective endocarditis: Guidelines from AHA, JADA; January 2008
Guidelines for Prophylactic Antibiotics Prior to
Dental Procedures in Patients with Prosthetic
Joints
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2014 update of 2012 recommendations based on many
questions from the dental community after the 2012
release
The 2014 panel judged that the current best evidence
failed to demonstrate an association between dental
procedures and prosthetic joint infection
In general, for patients with prosthetic joint implants,
prophylactic antibiotics are not recommended prior to
dental procedures
The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints, JADA, January 2015
Therapeutic Guidelines for Prescribing
Antibiotics
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2004 ADA report on antibiotic resistance and prescribing
antibiotics
General guidelines:
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Make an accurate diagnosis
Use appropriate antibiotics and dosing schedules
Use narrow-spectrum antibiotics when possible
Avoid unnecessary use for viral infections
If treating empirically, revise treatment based on progress or test
results
 Obtain knowledge of side effect risk and drug interactions before
prescribing it
 Educate patient regarding proper use of the drug
Combating antibiotic resistance, JADA, 2004
Why are Dentists Important Antibiotic Stewards
and How Can You be Involved?
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Dentists prescribe 10% of all antibiotic prescriptions, for
24.5 million prescriptions in 2013
Guidelines are in place but may not be well promoted,
understood or followed – review current guidelines for
prophylaxis as well as treatment of oral infections to
ensure antibiotics are used only when recommended,
and when they are needed the first line agent is used
Unnecessary antibiotic use in dental settings may lead to
unintended consequences for the patient – communicate
with patients about why an antibiotic may not be
necessary and is in their best interest
Peggy’s Story
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On Tuesday, April 13, my mom had a root canal, and the
dentist prescribed the antibiotic Clindamycin to treat an
abscess. The next day, she felt fine. On Thursday, mom
came home from work and said she didn’t feel well.
On Tuesday, April 20th, my brother came over to take my
mom to her doctor’s appointment. But she was very pale,
somewhat weak and dizzy. Worried about dehydration,
we decided that she should be taken to the hospital
instead, and we called 911.
Physicians determined that my mom had a massive
infection, later determined to be caused by Clostridium
difficile, which was brought on by antibiotic use.
http://peggyfoundation.org/
Peggy’s Story
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The doctors continued treating my mom with IV
antibiotics and other drugs, and told us that if she didn’t
respond by morning they would do surgery to remove
her colon “in an attempt to save her life”.
At 6:00 the next morning, the doctor called…My mom
had not improved overnight and surgery was necessary.
..We consented to the surgery.
…around 4 pm, her vital signs started to deteriorate. The
doctors put her on 100% oxygen and provided additional
drugs to support her blood pressure.
At 7:20 pm, the ICU doctor informed us that my mom
had passed. She had gone into cardiac arrest.
http://peggyfoundation.org/
National Momentum on Antibiotic Resistance
AR Threat Report
FY 15 Detect and Protect Initative
National Strategy & PCAST Report
FY 16 AR Solutions Initiative
National Action Plan
WH Antibiotic
Stewardship Forum
38
White House Forum
on Antibiotic Stewardship
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Over 150 organizations across human and animal
health:
 ~roughly 2/3 human health representing inpatient settings
(hospitals, long-term care), outpatient settings, patient
advocates, diagnostic & pharmaceutical manufacturers (CDC
lead)
 ~roughly 1/3 animal health partners representing food producers,
retailers, veterinary societies and organizations, animal
pharmaceuticals (USDA lead, FDA/CDC support)
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Government-wide collaboration (CDC, AHRQ, CMS,
FDA, USDA, DOD, VA) to support implementation and
acceleration of CARB Action Plan
39
American Dental Association
White House Forum Commitments
The ADA will provide appropriate scientific and clinical
expertise to fully assess and respond to antibiotic
healthcare issues, offer continuing education courses at
professional meetings, and provide systematic reviews and
current scientific information on the proper use of
antibiotics in online resources.
Challenges
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Dentists may be subject to pressure from other clinicians
to prescribe when not necessary
Unclear uptake of de-escalation of prophylaxis
recommendations and limited guidance for treatment of
infections
Prescribing data for physicians, nurse practitioners and
physician assistants are associated with diagnostic
codes, but that is not the case for dentists
Most studies assessing community antibiotic prescribing
have not included prescribing by dentists
Next Steps for Better Understanding Antibiotic
Prescribing by Dentists
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CDC exploring opportunities to measure and
characterize antibiotic prescribing by dentists
Pursuing partnerships with dental professional societies
Encouraging development of guidelines with more
specific recommendations for treatment of dental
infections in collaboration with professional societies
Considering needs assessment to determine what
information/tools would be most useful to dentists and
dental patients related to antibiotic stewardship and how
dentists can play a role
Questions?
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion