MIAMI BEACH – In the 2 years since California mandated judicious antimicrobial use, more money has poured into antimicrobial stewardship programs to combat inappropriate use, increasing resistance, and the sometimes debilitating adverse effects of these agents.
It is unlikely that hospital administrators would have funded these initiatives to this extent, particularly during a time of constrained budgets, without the law, Dr. Kavita K. Trivedi said.
"California currently is the only state with legislation regarding antimicrobial use. We hope that other states will follow along, especially because we’ve had such a positive experience with our legislation," said Dr. Trivedi, public health medical officer for the California Department of Public Health in Richmond.
"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients."
Clinically speaking, the law could not have come at a more critical point, Dr. Trivedi said. "I personally hear about all the resistant organisms and infections we have in the State of California. And thus far, we have had about 15 infections where we had absolutely no antibiotics that we can treat these patients with. It’s very concerning."
Not only has inappropriate antimicrobial use caused the current problems, but "we don’t have any antibiotics coming down the line that will be able to help those 15 patients of mine in California," she said. There are only 15 or 16 antibiotics currently in development in the United States, and only 8 have any activity against gram-negative bacteria, where resistance patterns are particularly worrisome, she added.
"We are seeing and entering now that postantibiotic era where we don’t have the right antibiotics out there to treat our patients," Dr. Trivedi said at the symposium. "It’s very, very concerning."
The 425 general acute care hospitals in California had 2 years to comply with the law after Gov. Arnold Schwarzenegger signed Senate Bill 739 into law in January 2008. "In this very long Senate bill, there is one sentence that was snuck in at the last minute regarding antimicrobial use. I’m very happy that someone did this," Dr. Trivedi said. The law includes a requirement that "all general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which should be monitored jointly by appropriate representatives and committees involved in quality improvement activities."
"We, and by that I mean the California Department of Public Health, interpret this to mean each California acute care hospital should have an antimicrobial stewardship program," Dr. Trivedi said.
"If they do it appropriately, they are going to decrease health care costs, reduce resistance rates, and improve the number of resistant infections in patients, so overall it’s a ‘win-win.’ "
A meeting attendee questioned how the public health department can help hospitals develop effective programs and, at the same time, punish hospitals that do not comply. "Although this is punitive now, and we are citing hospitals for not having stewardship programs, it is really encouraging hospitals to do the right thing in terms of patient safety and quality. So we do believe in our legislation and are very proud of it," Dr. Trivedi said.
The director of the hospital medicine program at the University of Michigan, Ann Arbor, Dr. Scott A. Flanders, was not convinced about legislation. "I’m reluctant to say that states should mandate [these programs]," he asserted. More research is needed to define the most essential aspects of effective stewardship programs, he said when reached for comment.
"While I applaud efforts to improve antimicrobial use – it’s critically important and hospitals need to prioritize it – I don’t know that legislation is always the best way to do that," Dr. Flanders said. "Many hospitals are resource constrained and are struggling with numerous legislative and nationally imposed mandates. Adding yet another on top of it is a challenge."
Arizona and Minnesota are among other states considering legislation to bolster antimicrobial stewardship, Dr. Trivedi said, but the proposals so far are not as strict as the law in California.
Because of the legislation, California launched its Antimicrobial Stewardship Program Initiative in February 2010. To initially assess the status of stewardship statewide, the health department conducted a web-based survey from May 2010 to March 2011. Responses came from 220 acute care hospitals, for a response rate of 52%. Of these, 167 were community hospitals. Almost half of these community hospitals, 45%, had a stewardship program, and another 31% were planning such an initiative. "A good chunk of our community hospitals ... already had these programs, even before our initiative started to help them," Dr. Trivedi said.