Residents of the Glencroft Center for Modern Aging enjoy a variety of no-cost “perks” that come with living in the largest continuing care retirement community in Arizona. There’s indoor swimming, a modern performance (fitness) center, an amphitheater, miles of walking trails, and scrapbook-worthy events.
One of the behind-the-scenes perks is an onsite antibiotic stewardship program, something many “outsiders” may not have heard of before now.
The program strives to improve when and how antibiotics are prescribed by clinicians and used by patients. A primary goal is protecting patients from adverse side effects of unnecessary antibiotic use, including widespread antibiotic resistance, now a significant public health problem. Antibiotic Stewardship Program Director Dr. Pete Patterson runs this program at Glencroft.
“The main problem in infectious disease is people receiving antibiotics for infections they do not have,” explains Dr. Patterson, a third-generation physician. The Centers for Disease Control and Prevention (CDC) would agree, citing that nearly 30 percent of antibiotics prescribed annually in the U.S. are unnecessary.
Isn’t it better to take antibiotics, “just in case?”
While antibiotics can undoubtedly save lives, more than 35,000 Americans die annually from the effects of widespread antibiotic resistance. Resistance occurs when bacteria develop the ability to fight off drugs designed to kill them. Dr. Patterson further explains that intestinal bacterial flora is altered whenever antibiotics are introduced, killing off the “good bacteria” and allowing overgrowth of resistant bacteria. He said this could lead to antibiotic-related diarrhea, which may be severe, even fatal for seniors in poor health.
Other common adverse side effects include vomiting, indigestion, spontaneous Achilles tendon rupture, and undesirable changes in heart rhythm. Such undesired side effects demonstrate that antibiotics are not risk-free and can be detrimental and even deadly to aging adults.
But age alone isn’t a deciding factor. A healthy 80-year-old has a much greater chance of recovering from the effects of antibiotics than a person of any age with underlying health conditions.
Dr. Patterson says that antibiotics are often mistakenly given to prevent infection. For example, elderly adults with frequent urinary tract infections (UTIs) may be given antibiotics to avoid future infections. This antibiotic prophylaxis does not prevent a UTI. He says that antibiotics only prevent infection in specific cases. An example is surgical antibiotic prophylaxis, the practice of pre-treating just before surgery.
Dr. Patterson believes the issue boils down to education and changing behaviors dating back many decades. “Antibiotics are deeply embedded in our culture. When my father graduated from medical school in 1942, penicillin was just being introduced. If you were wounded during the American Civil War, you had a 30-40 percent chance of dying from infection. By contrast, in WWII, that rate dropped to two percent because of penicillin, which was available only to the military at that time. After the war, penicillin (and later antibiotics) became broadly available and overused.
Dr. Patterson explains that in an earlier time, the “mark of a good clinician was how fast you could recognize the earliest signs of infection and get that patient on an antibiotic. In today’s era of antibiotic overuse and widespread resistance, that quick-draw strategy is a prescription for trouble.” He describes what those in the medical profession call “the elevator ambush,” where the doctor gets off of the hospital elevator only to be surrounded by family members pressuring him or her to treat their loved one with antibiotics.
Based on Dr. Patterson’s experience and research, the people who get frequent courses of antibiotics are often the ones with frequent returns to the hospital. In the post-acute care community, an unscheduled return to acute care is a big issue, as skilled nursing facilities are penalized. He says the medical community needs to “unwind that” by training clinicians to meet clinical and laboratory criteria for an infection before prescribing antibiotics. “Then if the benefit outweighs the risk,” Dr. Patterson says, “you can safely give an antibiotic.”
Many clinicians have limited training when it comes to antibiotic stewardship. Dr. Patterson recognizes the challenge to train as a group in a setting such as Providence Place, which is Glencroft’s skilled nursing facility. Individual physicians see patients on different days, so it’s impossible to get them all in one room for the time it takes to cover the materials. Dr. Patterson’s program accommodates this challenge by including a 10-page tutorial with case studies that clinicians may read independently.
The trick, said Dr. Patterson, is to open their minds to a new approach. “I’m pretty good at inspiring people that this problem is worth taking on,” he insists. “First, I meet with the senior care team, including the medical director, the administrator, and the director of nursing. The medical director is, by federal regulation, accountable for the quality of care. Hence, I spend a lot of time making sure we are on the same page.”
The other side of the coin is data collection. Glencroft carefully tracks antibiotic use, results, and side effects, reporting quarterly, and using this surveillance data to drive a decrease in overuse. Dr. Patterson assures, “when clinicians can see their data, it’s like seeing yourself in the mirror. That’s what causes a shift in their perspective on overuse and a subsequent change in practice”.
Dr. Patterson credits the widespread overuse of antibiotics as one of the greatest health issues of our time. For those interested in learning more, he recommends “The Antibiotic Era: Reform, Resistance, and the Pursuit of a Rational Therapeutics,” by Scott Podolsky.
Dr. Patterson is also a member of the Glencroft Center for Modern Aging Board of Directors.