Doctors advised to curtail antibiotic dosages

The harried doctor scribbles a prescription for an antibiotic -- even though she knows it does no good in many cases and could be harmful in the long run for both patient and society.

Now, a team of University of Miami-Jackson Memorial researchers is working to control the use of antibiotics _ improving the quality of care and cutting costs, which are central issues in the health care reform debate reverberating in the Senate as advocates seek ways to find funding to help the uninsured.

"We need to get the message out," said Lilian Abbo, a UM doctor specializing in infectious diseases. "Antibiotics are great drugs if we are cautious and smart in how we use them. They are not the solution for viral infections" such as the common cold or the flu.

Abbo and pharmacist Laura Smith lead a program that started at Jackson Memorial in 2003. The program serves as a small example of how such evidence-based medicine can provide good care without increasing health care costs, which have been going up far faster than the rate of inflation.

Though their message is well known to experts, many doctors and nurses often use antibiotics out of habit. That's why the program is building awareness among hospital employees by handing out pocket cards and pushing information on an internal Web site.

For fiscal 2009, the program saved Jackson $163,276 -- about 2 percent of its $8.3 million budget. But considering that prices of antibiotics have been increasing about 7 percent annually, the true savings is about $840,000 -- 10 percent of the budget.

"This is a phenomenal program," said Pascal Goldschmidt, dean of the University of Miami medical school, because it concentrates on getting antibiotics "only to those who truly need it."

Though proper use can mean cost savings, "the key factor for this program is patient safety," said Thomas Hooton, a University of Miami professor who was once head of the antimicrobial program for the Infectious Diseases Society of America. "And there is a cost to society."

Microorganisms are constantly becoming resistant to antibiotics, which are everywhere these days. A patient flushes them out of their body and into the sewer system. Livestock get fed them by the ton.

As bugs become resistant to the older drugs, doctors have to use newer, often more expensive alternatives. That's why institutions around the world have developed antimicrobial programs.

"The problem is there are no new antibiotics in the pipeline" of pharmaceutical companies' research, "so we must protect the drugs we have," Smith said.

Among those who need antibiotics are patients undergoing open-heart or orthopedic-implant surgeries, as a preventive measure to avoid operating room infections.

As Goldschmidt points out, preventing hospital infections can mean huge savings in health care costs. Recent congressional testimony revealed that more Americans die of these infections each year than from car accidents, breast cancer or AIDS. Goldschmidt said UM has been able to get its surgical site infections down to 1 percent -- a third of the national average.

Just as important is not giving the patient too much of an antibiotic. Medicare data show that Jackson appropriately stops preventive antibiotics within 24 hours of surgery in 80 percent of cases _ slightly below the national average of 82.

UM's Hooton believes antibiotics are often used for much longer than they need be, although it varies depending on patient and condition.

The program also controls the types of antibiotics administered by having a list of those needing prior approval, based on cost, toxicity or effectiveness. The costs can vary widely -- from $4 daily to up to $600 for an intravenous antibiotic or $140 for one administered orally.

It's much easier to control antibiotic usage in a hospital than it is in the larger community. A national study by the Commonwealth Fund found that 43 percent of children have received "potentially inappropriate antibiotic prescription."

Some primary care doctors in South Florida have told The Miami Herald they sometimes find it easier to write a requested antibiotic prescription than to take the time to explain why it won't do anything. Many blame insurers for having such low rates for primary care that they can't afford to spend a lot of time with patients.

"There is a major problem with inappropriate indications," UM's Abbo said. She's especially concerned about pharmacies that offer cheap or free antibiotics. Publix, for one, publicizes free 14-day supplies of seven common antibiotics, if the patient has a prescription. It shouldn't be too easy to use antibiotics, the researchers believe.

Goldschmidt, the UM dean, said the University of Miami and Jackson are working together to establish an evidence-based system that can serve as a blueprint for efficient, effective care by using computerized physician order entry, in which doctors work from a template for specific conditions, in ordering tests, prescribing drugs and such.

Goldschmidt said that moving to such a system should improve care and reduce costs, but will require the medical school and Jackson to switch to electronic record systems _ a change that is expected to be completed within a year.
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