I’m Ghinwa Dumyati, M.D., professor of Infectious Diseases at the University of Rochester Medical Center (URMC) and director of the communicable diseases surveillance and prevention program at URMC’s Center for Community Health. For the past five years I’ve led the Rochester Patient Safety Collaborative, a citywide effort that has reduced Clostridium difficile (C. diff) infections at four local hospitals by more than 30 percent. An important part of reducing C. diff, which can cause life-threatening diarrhea and inflammation of the colon, is reducing the inappropriate use of antibiotics. We worked with physicians, nurses, pharmacists and others to improve how antibiotics are prescribed. With a grant from New York State, I’m also working to reduce the use of unnecessary antibiotics in nursing home patients, who are at high risk for C. diff. My next frontier, in collaboration with Erica Dobson, is curbing the overprescribing of antibiotics in the outpatient setting – doctor’s offices, dentist offices, emergency departments and urgent care clinics.
Hi Reddit! I’m Erica Dobson, Pharm.D., an Infectious Diseases Clinical Pharmacist at the University of Rochester Medical Center. I’m a board certified pharmacotherapy specialist (BCPS) and an American Academy of HIV Medicine HIV-certified pharmacist (AAHIVP). I work with health care providers to ensure patients get the most appropriate antibiotic for their condition and take the antibiotic for the right amount of time. I’m partnering with Dr. Dumyati to bring these efforts into the community. Antibiotics are lifesaving medications, but inappropriate use leads to antibiotic resistance, one of the world’s most pressing health threats. If we don’t address this problem now, we will face a future in which bacterial diseases are untreatable and can be fatal. We’re here to answer questions about antibiotics, including: why they are important; what they should and shouldn’t be used for; how we can curb the use of inappropriate antibiotics and why it’s important to curb the use; what the future looks like if we fail to use these medicines judiciously; and more.
We’ll start answering questions at 2 pm. Ask us anything!
Hi Professor Dumyati and Dr Dobson - thank you for spending time with us to carry out this AMA.
I applaud your efforts in reducing antibiotic use in primary care and other health settings. But unfortunately, there is a lack of control of such antibiotic usage in many third world countries where antibiotics can be bought over the counter. In addition, there is still rampant antibiotic use in livestock and farming around the world, contributing to the development of resistance.
What's your view on how these issues should be tackled?
In relation to new and emerging therapeutics, what's on the horizon from your point of view, that is most promising?
Lastly, are we really going to be faced with a post-apocalyptic future of people dying from sore throats and superficial cuts because nothing works in the future (okay, I'm sensationalising now, but there are doomsayers who fear this outcome) - your view?
Thanks in advance!
Thank you for starting with some of the greatest challenges that we face with global antibiotic stewardship implementation efforts. A detailed account of the challenges that must be overcome was recently published (http://journal.frontiersin.org/article/10.3389/fmicb.2016.01860/full). These challenges include limited resources in developing nations and underwhelming resources devoted to antibiotic resistance in high income nations. Surprisingly, there have also been news reports that “under-the-counter sales” of antibiotics are occurring in the United States. Given the spread of microorganisms has no border, an international coordinated approach to address this problem is necessary. The WHO is providing technical assistance to help countries develop their national action plans, and strengthen their health and surveillance systems so that they can prevent and manage antimicrobial resistance. WHO is also working closely with the Food and Agriculture Organization of the United Nations (FAO) and the World Organization for Animal Health (OIE) in a ‘One Health’ approach to promote best practices to avoid the emergence and spread of antibacterial resistance, including optimal use of antibiotics in both humans and animals.
Thank you for doing this AMA!
My understanding of the medical community's consensus on correct antibiotic use is that we should always finish the full course of antibiotics once they are prescribed. Occasionally, I see reports or reviews that argue these predetermined courses of antibiotics are sometimes longer than they need to be for efficacy, and that too-long courses of antibiotics may themselves create health issues.
Can you give some guidance on how substantiated these views are? If there is more nuance in correct antibiotic usage than is currently being communicated to the public, do you think it is possible to promote it without undermining present understanding of antibiotic resistance?
You are correct, the medical community’s consensus has long been (since the mid-1940’s) that patients should complete the full course of antibiotics that are prescribed by the provider even if they are feeling better. Continuing antibiotics beyond the resolution of symptoms for infections such as pneumonia had been justified for many years on the premise that doing so would prevent relapses and antibiotic resistance. However, we are learning that for some infections, such as uncomplicated pneumonia and urinary tract infections, acute bacterial sinusitis, and cellulitis, that shorter courses of therapy are equally effective to the traditional prolonged course. The best advice for the public at this time is to continue to take the antibiotic without skipping doses and to decide upon the best duration of treatment with the prescribing health care provider --- sometimes that duration may be short and sometimes it may be long, it depends on the infection type, severity, pathogen, bacterial burden and best-available evidence from clinical trials.
Apart from prescribing antibiotics for C diff, fecal transplants and tinkering with the microbiome has had success for treating C dif infections too i believe.
This was some time ago though. My question is, what are your frank thoughts on microbiome related therapies? Will we see specific products coming out soon, or are we still going to be at the fecal transplant stage, where we know certain communities of bacteria are good but can't narrow it down to one good species or metabolite?
We are aware of a recent review (linked below) that summarizes progress that has been made with respect to antivirulence approaches (narrow-spectrum treatments that will limit the ability of a pathogen to cause disease without altering the normal ecology of the recipient), probiotics, fecal microbiota transplants, and phage therapy. There are also some investigational oral microbiome therapies that are being developed and studied. The bottom-line is that we need more research to better understand gut ecology and develop additional treatment strategies that treat bacterial illness and limit collateral damage to the microbiota. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831151/
How much does it take to mess up your gut flora?
What can be done to restore gut flora?
Should doctors prescribed antibiotics only after tests confirmed that they are necessary or is it okay to try them as long a patient hasn't taken any antibiotics recently?
You can negatively affect the balance between normal gut flora by using only one dose of an antibiotic. However, the time that it takes to recover from this imbalance is more prolonged (up to 12 weeks) if you are on a longer course of antibiotics.
It is controversial, but some suggestions to restore gut flora might include taking probiotics (you should check with your provider before doing so).
Antibiotics should only be used when the provider believes there is a bacterial infection, many times we start the antibiotics before test results are available and in the hospital-setting we will re-evaluate the need to continue or change these antibiotics once tests results are available. There is lots of work being done to develop more rapid and accurate diagnostics that can help physicians make the difficult decision of when antibiotics are needed.
As someone who has suffered from C. difficile and had an FMT because of it, I'd like to thank you for the work you both do for public health and prevention of this disease. As you know, the current medical plan for treating C. diff in the US involves a course of Flagyl (which, if you're intolerant to it, is almost as bad as the C. diff), or vancomycin. Failure to respond clinically, or relapsing, involves more of the same treatment. And even more if you relapse yet again (these aren't cheap drugs btw, and you could be on them for many months). It's not until a third relapse occurs that a fecal matter transplant (FMT) is warranted, yet these have a 90% cure rate, compared to something like 40% for antibiotics alone. Why is it that this is not the default treatment for a confirmed C. diff case? Why do we first subject people to months of expensive drugs, which so often fail for this particularly difficult disease? (And keep in mind when you have this disease you will very likely be unable to work or go about your daily life, so those are very tough months.)
We are sorry to hear about your experience with C. difficile. There is a lot of ongoing studies to better understand the best approach to treating this disease, by using FMT (fecal microbiota transplantation) and other new agents (yes, expensive) such as monoclonal antibodies.
As someone currently suffering from an illness for which antibiotics were prescribed but did NOT work .. and only led to suffering secondary issues caused by the antibiotics, this is a seriously timely AMA! Thank you, thank you, thank you!
I have two unrelated questions:
You mention prescribing the "right" antibiotics. What does this look like? Prescribing weaker ones for smaller infections, stronger ones for worse infections? Or are there -- not a doc here, so I'm kind of clueless -- more targeted ones that should be used but aren't, like certain kinds that are better for chest infections, whereas others work better for an infected injury?
Are people still looking into the influence on antibiotic resistance caused by the use of antibiotics for animals? Not just food animals, like cows and pigs, but I foster kittens and they're constantly getting infections and being prescribed clavamox / amoxicillin by the vet. Does this influence our own resistance? Is it being studied, or affecting what you're looking into?
The “right” antibiotic, at least the way that we use this term when we are talking about improving antibiotic use, is one that is used only when it is indicated based on the type of infection (i.e. infections caused by bacteria such as a symptomatic urinary tract infection need an antibiotic, but antibiotics will not work for a runny nose caused by viruses). The “right” antibiotic also refers to selecting one that is recommended as preferred in national guidelines for the type of infection that is being treated whenever it can be used.
The harm of the use of antibiotics in farm animals is when it is used for growth promotion and for prevention of infection (instead of treating infections when they are encountered) in feed and in water. Both in the U.S. and globally there is a plan to eliminate the use of medically important (those that are used in humans and food-producing animals) antibiotics as growth promoters. There is also a role for educating veterinarians on how to improve the use of antibiotics in treating infections in small animals.
Thank you for holding this AMA! Do you have any thoughts on the impact antibiotics have on gut flora?
Antibiotics destroy or disrupt the protective bacteria (the good) in our gut (flora/microbiome: it is a community of natural occurring bacteria on our skin, mouth, gut, urinary tract, respiratory tract). With a disrupted microbiome bad bacteria in the gut, such as C. difficile can easily multiply.
C. difficile is a bacteria that causes inflammation in the large intestine leading to diarrhea and sometimes life-threatening illness.
Hi to both of you and thanks for doing this AMA.
As a soon-to-be graduate hoping to research antibiotics in the future, where would you recommend for finding out the latest information/news about resistance and how it's effecting people? Also, what can I do with people around me to help them understand the problem?
Resources that we find useful to keep up on antibiotic resistance are listed below:
This is a little bit older but you might find it useful: https://academic.oup.com/cid/article/43/5/630/506030/World-Wide-Web-Resources-on-Antimicrobial
It is very admirable that you would like to engage in efforts to help raise awareness of antibiotic resistance. It sounds like you are prepared for the first step, which is to continue to educate yourself regarding the problem and its negative impact on public health. There are multiple methods that can be used to help educate the public and overcome a widespread misunderstanding about antibiotic resistance. Some of the methods used by the CDC and WHO include the use of posters, infographics, public radio, lectures, television stories, and more. Some more powerful tools include real-life stories of how people around the globe have personally been impacted by antibiotic resistance, found in the links below.
How antibiotics work? How are antibiotic resistant strains different from the normal ones, which makes them difficult to kill?
This is a really good explanation of how antibiotics work: http://learn.genetics.utah.edu/content/microbiome/antibiotics/
The CDC has a detailed description of how antibiotic resistance happens here: https://www.cdc.gov/drugresistance/about.html
Thank you for taking your time to answer our questions!
Chronic Lyme Disease is highly controversial within the medical community. Many deny its existence, while others believe it is very real. For those in the latter group, the most common recommendation is a course of long-term antibiotics. It is known that this has harmful side effects, so it is often prescribed along with probiotics to replenish bacteria lost.
What are your views on Chronic Lyme Disease? What is your stance on long-term antibiotics for it? Are there alternative treatments which could potentially be effective?
We are not experts on the treatment of Lyme Disease.
Hello to you both... As a working nurse (med/surg) I just want to say that it seems like most of what I do involves pushing ABX... Cefepime, Vanco, Flagyl, Azith... You name it, day after day, shift after shift... Often multiples on the same pt... What's the solution? What's our future going to look like???
You are right, 50% of patients in the hospital in the U.S. are on antibiotics during any given day (http://jamanetwork.com/journals/jama/fullarticle/1911328). There is also evidence to suggest that there is ample opportunity to improve the use and reduce potential harms of antibiotics. The CDC has issued core elements for antibiotic stewardship programs in the hospital. Antibiotic stewardship refers to using antibiotics only when needed and using them responsibly by selecting/taking the right drug, right dose, at the right time, and using it for the right duration. You can learn more here: https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
It sounds like you are very interested in this, there is national movement to get nurses more involved in antibiotic stewardship. Locally, we are working very closely with nurses in our long-term care facilities. Nurses are often the ones there with the patient and their evaluation and communication with the provider helps to identify the need (or not) for antibiotics.
Thank you for the AmA.
My question relates to public health and the usage of antibiotics. I work in public health with infectious diseases and at times am frustrated with medications given to treat various infections. I understand that antibiotic resistant infections are a real threat to future healthcare providers and the public but cannot understand the following logic.
1.) Why when treating a probable STDs the provider often tends to give the lesser treatment of azithromycin rather than ceftriaxone and azith. I have seen many times the treatment for chlamydia (1 gm azith) as a presumptive treatment for symptoms associated with STDs. The patient then comes back as positive for Gonorrhea and was given only half the treatment. Why not treat for the greater and hope it's the lesser? Isn't there more of a chance for resistance by only giving half the treatment?
2.) What measures are being taken with federal government or what advancements have taken place to help introduce new drugs that will not have bacteria resistant to it.
The increasing frequency with which we are seeing antibiotic resistant pathogens in practice underscores the need to develop novel antibiotics. There is a long road to recovery for the antibiotic pipeline, but work in this space is already being done. Revitalization is nationally and internationally advocated (see links below) and requires a coordinated approach by scientists, drug developers, policymakers, and other key stakeholders. One example of collaboration in this area is the Combating Antibiotic-Resistant Bacteria Accelerator (CARB-X) Program that brings together global partners to promote innovation and accelerate the number of diverse antibiotics in the drug development pipeline.
National Action Plan for Combating Antibiotic Resistant Bacteria: https://obamawhitehouse.archives.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf
WHO Global Action Plan on Antimicrobial Resistance: http://www.who.int/antimicrobial-resistance/global-action-plan/en/
Not really a question but more of a comment. I am also a pharmacist and it is so refreshing to see a fellow pharmacist doing an AMA and spreading the word about just how much we can offer outside of just filling prescriptions. So thank you for taking the time out and not only doing super important work, but also in helping spread the word of how much we can offer.
We are really excited that you are participating in this AMA today! In our next venture together we are hoping to start to close the gap in our community as it relates to antibiotic overuse. We plan to partner with our primary care providers and urgent care centers to implement antibiotic stewardship in the community. This will involve helping to develop local guidelines, tracking the use of our antibiotics locally, reporting the use of antibiotics back to the providers, and providing education. For example, we plan to target the overuse of antibiotics for acute bronchitis where the evidence demonstrates there is no benefit to antibiotic treatment.
As a fellow pharmacist I hope that you will get involved in antibiotic stewardship activities in your community (Erica).
How has research in tea-tree oil being used as a topical treatment for MRSA/VRSA going? Also, there's been research in using nanoparticles on surfaces to kill/prevent bacteria from growing, would this be more or less effective then coating common hospital surfaces with antimicrobial metals such as copper or silver?
Also, is the use of potent antibiotics in veterinarian medicine increase antibiotic resistance across the board in human cases? Should vets start using antibiotics contraindicated in human medicine on animals?
As someone who wants to go into ID and ID related public health what do you think would be more "exciting", I'm split between wanting to deal with emerging and zoonotic infectious diseases (I want to eventually work for the NCEZID) and going into the antibiotic resistance-related public health.
Your professional interests are not exclusive and could be complementary. I (Dr. Dumyati) am involved in both clinical infectious disease and surveillance for emerging infections such as, C. difficile and multi-drug resistant organisms. There is a benefit to having a clinical role where you see first-hand the impact of these infections on an individual level. The public health surveillance allows you to see the impact on a population level. Wearing both hats allows you to better understand the problems and come up with viable solutions. Both areas are extremely exciting.
To what extent do antibiotics in food (like meat) affect our resistance? Is this a huge contributing factor?
The use of antibiotics in agriculture does play a role in the spread of antibiotic resistance. The Food and Drug Administration (FDA) estimates that 80% of American antibiotic use (by weight) today takes place on farms. Antibiotic resistant bacteria can be transferred from animals to people after ingestion of contaminated food products, including meat, or more commonly through direct contact with the animal. For example, MRSA infection has been reported in pig farmers and quinolone (e.g., ciprofloxacin) resistant bacteria in poultry farmers. There is a plan to improve the transparency from food producers on the antibiotics used to raise the meat that is ingested to allow consumers to make informed purchasing decisions. There is great review on this topic here: https://www.ncbi.nlm.nih.gov/pubmed/?term=agricultural+application+for+antimicrobials++and+aiken+SL
In an in-patient, or out-patient setting, what can the average person do to prevent acquiring a superbug from a medical setting?
Also, how can you get a hospital to tell you their infection rates? I tried at our local hospital, but was stymied. They told me the rates were "good", and that is all the information they offered me.
I've had two relatives die of c-diff during extensive medical treatment. As a stage four breast cancer patient (five years now), I would prefer to have my ticket pulled by something other than an avoidable infection.
Thanks for your advice in advance. BTW: The University of Rochester rocks! I'm not biased at all :)
As a patient you can start to protect yourself from 'superbugs' by asking your providers to wash their hands. There is a nice infographic provided by the CDC here: http://www.cdc.gov/drugresistance/protecting_yourself_family.html
You are able to find some infection rates on the website provided by the U.S. Centers for Medicaid and Medicare Services called Hospital Compare: https://www.medicare.gov/hospitalcompare/search.html?
We also want to emphasize the role of vaccines in helping to limit the spread of antibiotic resistance. When people are vaccinated there is less infections requiring the use of antibiotics. See the question and answer from the WHO on this topic: http://www.who.int/features/qa/vaccination-antibiotic-resistance/en/
The problem of overuse of antibiotics has been known and publicized for years. Why are physicians still over-prescribing them?
There are a lot of factors that go into the decision to prescribe an antibiotic. Factors include not knowing the exact diagnosis (bacterial vs. viral), patient expectations (patients demanding an antibiotic for themselves or their children), prescriber time pressures (not having enough time to explain why antibiotics are not needed for viral infections), and patient satisfaction (the provider perception is that the patient may be happier with an antibiotic). To learn more about when antibiotics are needed (or not), check out the CDC Get Smart Campaign material: https://www.cdc.gov/getsmart/community/
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