Cheryl Martin (Host): You've probably experienced your doctor giving you antibiotics to treat infections caused by bacteria. Now there's great concern about a trend of increasing resistance to antibiotics because of overuse. Here to talk about efforts to prevent this, is Dr. Ryan Dare. He's an Infectious Disease physician and an Associate Professor of Medicine at UAMS. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Cheryl Martin. Dr. Dare, thanks for coming on.

Ryan Dare, M.D.: Thank you for having me. I'm excited to be here.

Host: First, you are the Director of the Antimicrobial Stewardship Program here at UAMS. Talk about this work and what antibiotic stewardship is and why it's essential in healthcare settings.

Ryan Dare, M.D.: Well, there's probably not a better topic to ask me to talk about because this is my life. This is what I do, and, and I love it. And simply, germs are smart. Germs are very smart. When penicillin was discovered in the forties, we believed that the war on bacteria and germs was starting and we would cure the world of infections in no time.

But joke was on us. The germs are smarter than us and they figured out ways to get around not just penicillin, but every class of antibiotic developed since then. And unfortunately, all this exposure of antibiotics to germs makes the germs even smarter, and they become resistant with growing exposure to these treatments.

And so simply, antimicrobial stewardship or antibiotic stewardship is the concerted efforts of trying to use the most effective, appropriate drug for the shortest duration, for the right infections to minimize unnecessary exposure, which would breed ongoing resistance.

Host: How does antibiotic overuse contribute to antibiotic resistance?

Ryan Dare, M.D.: Well, like I said, the germs are just very smart. And this is actually what attracted me into microbiology when I was 18 in college. And I said, well, how in the world can something that's one cell be able to outsmart, outdo and sometimes even kill such a magnificent, being as a human?

And they're brilliant. Even only being one cell. They're brilliant. You expose a germ or a bacteria to an antibiotic, and it will have the memory, to say, you know what, let's create ways to not only make that drug less effective, but we could even create ways to destroy that medication. So the bacteria are pretty smart and we use them.We get exposed to them, and then the resistance develops.

Host: So, what are some of the key principles then of effective stewardship programs?

Ryan Dare, M.D.: It's kind of tough. You gotta balance a little bit of provider autonomy with education and not overstepping a police role. And so what you don't want to do is come in and say, well, this is how doctors have to practice. That doesn't sit well with a lot of people who've spent a lot of decades of their life fine tuning their craft. And so probably the key principle is to simply educate providers. Knowledge is power. And so, using evidence, using data that has been shown to improve antibiotic use or, show data that can show the providers what the best treatments are for certain conditions and then let them run with that.

So my approach to this is not to get in the weeds and micromanage providers. It's more to stand back and provide the physicians and providers with resources to where they can treat patients with infections in the most effective evidence-based way possible. And my way of doing that is just know the literature.

It's kind of goes on deaf ears if our approach in our program is to run around and say, well, this is what I think you should do, or I say you should do this, that just doesn't work. What works is evidence. And so I have to know the evidence. I spend a lot of my free time, learning about antibiotic practice and all kinds of aspects of medicine that I never get into, microdosing doxycycline in the subcutaneous tissue to prevent a surgical site infection.

I've read about it, it's kind of my hobby is to sit around and find the small niches of antibiotic practice to kind of be aware of what data's out there so I can share that with our surgeons and our medicine physicians and specialists and improve antibiotic use for the system.

Host: How can doctors educate patients about the appropriate use of antibiotics?

Ryan Dare, M.D.: Ooh, this is a tough one. Mostly because we're not very good at this. This is a new field too. Probably in the early two thousands with the increasing resistance, it became a mandate that stewardship programs had to exist for hospitals and hospital systems. And so we're in a relatively new field, probably 20 years in of practicing best antibiotic stewardship practice.

And so getting the providers to buy in first has been the biggest hurdle. And now the second would be, well, how do we educate patients? And, it's hard because patients, believe a lot of times that they just need an antibiotic. And so if they go to the doctor and say, Hey, I, just need an antibiotic.

It's a lot easier said than done to just say, no, no, no, you don't need an antibiotic. You're fine. What's hard is to look that patient in the face and have to say, no, no, no, you don't need that. And here's why. It's time consuming. It makes the patient sometimes feel not heard. A lot of these primary care providers are heavily judged on their patient satisfaction metrics.

And so there's a lot of strings being pulled different ways when it comes to educating patients. So, we have to get better at this. We have to put more effort into this, and there has been some research done on it, which has been very effective and pretty interesting. One thing is, simply just adding information into the clinic, infographics, when they're in the waiting room, having posters on the wall that highlight the negative outcomes of antibiotic exposure, unnecessary antibiotic exposure, the side effects of antibiotics, some education of when you need antibiotic, when you don't.

Just by simply putting that material in clinics has shown a decrease in antibiotic prescribing in those clinics and good randomized controlled trials. Also, adding a kind of a letter of commitment from the clinic with a signature from the physicians in the clinic that says we prioritize safe antibiotic practice and antibiotic exposure to the patients such that, we don't want to hurt you.

That's been shown to be effective. It would be helpful to educate patients outside of that, driving down the 630 Corridor, you see opiate stewardship billboards. We don't really see that yet with public service announcements or public awareness of the downsides of antibiotics.

And there's just a lot of misconceptions that the populace have that antibiotics do what they actually don't or can fix what they actually aren't built to fix, or that they have to be used in certain ways or certain times that they don't need to be. So probably educating patients and giving resources to providers to help with those discussions, to make sure that everybody's on the same page. There's an interesting study, published about eight years ago that it was all about expectation. And so they had patients who went into a walk-in clinic or to a primary care with a acute infection of some type and a lot of times there was the discussion of should you have antibiotics or not. And so the research study was to ask the patients, before going in, what is your expectation? And then coming out, what was your expectation? And same thing with the physicians. And a lot of times the conversation, I need an antibiotic or here taking antibiotic.

And what was very interesting is that the patients actually didn't say, all I wanted was an antibiotic. They said, if not given an antibiotic, what would have been the outcome here? And it was simply, they just wanted to be heard. If a provider said, you know what, you don't need an antibiotic, but I do think you would benefit from Flonase twice a day, some guafenesin before you go to bed, Tylenol every eight hours. If they didn't get an antibiotic, that would've been completely fine with them. However, if they asked the physicians, they said, no, I was stuck. The patient said they had to get an antibiotic and if they didn't get an antibiotic, they were going to be very upset with me. And so there is this a little bit of misconception that patients, while asking for an antibiotic are truly also just asking for the provider's expertise.

And if we spend the time as physicians to teach and share education material information with our patients; they will be very happy with our service. And so, that was kind of an interesting study to me that we believe that they're asking for antibiotics and in fact they're just asking to be heard.

Host: You know what, Dr. Dare, I'm glad you brought up common misconceptions. Give me a couple of examples of where a person may think they need an antibiotic for a particular situation, but that's not really what they need.

Ryan Dare, M.D.: That's a great question. And I think this maybe even got a little bit better. I don't know if we see that in the data or utilization rates, but I think with COVID it was very clear that you have a virus. There's not much to do about it outside of antivirals or wait it out. But prior to COVID, it was very common that people get colds and they just go to the doctor.

 So the number one misconception is that patients with acute respiratory infections need an antibiotic. That's just not true. In fact, 85 to 90% of all patients with upper respiratory tract infection do not benefit from an antibiotic. And we haven't talked about this yet, but every day of antibiotic exposure leads to a increased 5% rate of a adverse event.

And these adverse events can go on and on and on for antibiotic we're discussing or, what the patient's background is, young or old or immune suppressed or not, but antibiotics do not help colds or respiratory infections. Very rarely, you'll have bacterial causes that antibiotics can help with.

And a lot of our upper respiratory infections that do require antibiotics start with a cold, after 10 days of a viral infection, then a secondary bacterial infection might set in. So it's those key times and red flags that physicians are aware of that it's time to give an antibiotic.

And just because you don't feel well for four or five days with the respiratory tract infection, doesn't mean that you need an antibiotic. That's probably the first misconception that antibiotics are required for respiratory tract infections. A second one kind of interesting is actually not a misconception on the patient's perspective, but probably the providers mess it up.

It's that you have to finish every dose of antibiotic that your doctor gives you. That is true. So that's not a misconception, but the misconception, is probably that the doctors are giving way too much. We have learned, there's a slogan in the antimicrobial stewardship world called shorter is better, and that's essentially because every study in the last 20 years of almost any infection that has looked at a shorter versus longer duration; the shorter is better. And so we've gone from comparing for certain infections 14 days to 10 days, and they go, well, ten's better, then 10 to eight and eight is better, then eight to five and five is better. And now we're down to five to three. So 10 years ago we were treating certain conditions for 14 days, and now we're doing it for three.

So you can imagine if the doctor gives you 14 days of antibiotics and they say, oh, you gotta take all of it; yes, you should listen to your physician if they're giving you three days, but if they're giving you 14, it's way too much. So that's a misconception in a reverse way that we have to get the providers to do the right thing.

So, I think allergy and intolerance is a big misconception. 10% of the, United States will, report that they have a penicillin allergy. When looked into that by allergists, probably 80% do not have a true allergy. Now, that doesn't mean that 10% of the pop or 8% of the population is lying about it.

They obviously had something happen with penicillin or a penicillin derivative at some point in their lifetime. However, intolerance and allergy are very different. If you took a high dose of amoxicillin with nothing on your stomach, it's going to irritate your stomach. And you may even throw up if you're in the wrong day of of the year.

And so, just because you didn't tolerate it does not mean, oh, I can never take that. Because we have a problem in the medical system of saying, well, if a patient says that they can't take amoxicillin, then it goes in their chart. And then if they come in the hospital septic, any derivative of that antibiotic class is now avoided.

And unfortunately, that leads to providing patients with less effective treatments, more toxic treatments, and we have great data to show that they have worse outcomes. Simply having a penicillin allergy in your chart leads to worse outcomes. And so I think a big misconception is that just because my stomach hurt when I took augmentin, that does not mean that I should never get ceftriaxone if I come in the hospital septic, and I don't think patients want that or think that, but they may not know that there's a big difference between, well, I didn't really like the way that made my stomach feel versus I had a true allergy where my throat swelled up and I couldn't breathe and have go to the hospital and have lifesaving measures done.

Probably, being a little more critical of what we are allergic to versus intolerant to would be helpful with providing the best antibiotics.

Host: So what should the patient do if indeed they had a reaction, let's say, to taking penicillin the first time? What can be done to ascertain if you're really allergic to it. If that was just a one time occurrence and it won't happen again.

Ryan Dare, M.D.: 80%, so similar number here, 80% of patients who have a true penicillin allergy will grow out of that in 10 years. And so if you had a penicillin allergy when you were a kid at eight years old, every 10 years, that rate of staying truly allergic goes down by 80%. So you can imagine a 60-year-old which is now five decades later, the chance of still being allergic is actually very small.

So what do you do about it? Well, you don't just cross your fingers. I mean, you could, depending on the severity of the situation, but the better way of doing this is there are allergy immunologists that you can see and be tested for penicillin allergy, true penicillin allergy. And we refer patients a lot to our allergists.

We also have a penicillin allergy kind of consultation in some of the hospitals that we work in where we can go through the history and sometimes even just asking the right questions, can take the penicillin allergy out of the picture. While sometimes you're like, well, this seems very low risk.

We could give you a small monitored test dose. Like, oh, this sounds high risk. We have to do a penicillin allergy test. So there's a lot that can be done, but number one is truly knowing what happened and, being open to the discussion. This may be being something that you've grown out of or maybe an intolerance rather than a allergy.

One thing we hear a lot from patients is, well, my mom was allergic to penicillin, so she told me never to take it. And there's no evidence that I'm aware of that penicillin allergies are a genetic predisposition that you do get passed down. So, that's one that we try to avoid, giving toxic, less effective medicines to, and talk to the patient about what the safe, options are.

Host: Thank you. That's great information. Now, in closing, how can hospitals monitor the effectiveness of their stewardship programs? Any suggestions there?

Ryan Dare, M.D.: Yeah. I've been doing this for over a decade for multiple hospitals and hospital systems, and I've seen it done in ways that are better than others. And there's easy ways and usually the easy way to monitor the effectiveness are not probably the best, and some of those are cost.

You could look at cost of antibiotic expenditures and say, well, that's a mechanism, if we're decreasing our costs. We're probably doing a good job. And I really just don't agree with that. Not that I'm an anti cost saving physician, but what that does to a program is promote them to focus on only expensive drugs, and that's not really an effective way.

A lot of times the expensive drugs are the newer ones, the more broad ones. Perhaps they are ones that shouldn't be overused, but using cost as a metric is typically not the best way to do it. A better way to do it is look at your utilization, your rates. If it's felt that your system is over-prescribing in the inpatient or outpatient, you can have, very clear rates of use of either all antibiotics, classes of antibiotics or individual antibiotics. And that could be per, a hundred patient days in a hospital or per 100 visits in the outpatient setting. But that comes with a little bit of gray measurement as well, because utilization, you don't want to just drive it down to where patients aren't being prescribed antibiotics. You want patients to have antibiotics when they need them. So the best mechanism is also the hardest to measure is appropriateness. If a system can have in place a way to measure appropriateness of antibiotic prescribing habits; that will decrease cost, it'll decrease utilization, it'll decrease side effects and readmissions and increase length of stay from their inpatients.

And most importantly, it will decrease multi-drug resistant development. And so tho that's just a harder thing to measure, but we have systems in place to measure it for certain groups and it works. And so that's kind of the holy grail is if, a system can measure the appropriateness of antibiotic prescribing practice in their system, inpatient and or outpatient; that's the best way to know if your program is working or not.

Host: Dr. Ryan Dare, thanks for sharing your expertise on antibiotic stewardship. It's obvious this is your passion. Very enlightening. Great information.

Ryan Dare, M.D.: Well, thanks for having me and giving me the opportunity to talk about it. So have a great day.

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