Rationing of Antibiotics in the Critically Ill: Not if, but How?

Guest Post: Simon Oczkowski
Paper: Antimicrobial stewardship programmes: bedside rationing by another name? 

The threat posed by antimicrobial resistant organisms (AROs) has long been recognized by the medical community as an emerging problem in public health. Though slow and insidious changes in the ability of bacteria, fungi, parasites, and viruses have real and profound effects on patients around the world, it is often dramatic examples of patients dying from infections resistant to all antibiotics which receive the most attention.

What is the solution to this problem? Given its complexity it is unlikely to be a single, simple intervention. The development of new antimicrobials could promises to have a major impact on reducing the mortality, morbidity, and cost of ARO infections, developing new antimicrobials takes time and significant financial resources. The development of AROs resistant to almost all known antimicrobials only a century from their initial widespread use suggests that this is a biological arms race that we can not win.

A systematic reduction in antimicrobial use can actually prevent the development of AROs. In simplistic terms: when bacteria, fungi, parasites, and viruses are exposed to antimicrobials, the individuals which are susceptible to the antimicrobial die, leaving behind those who have some resistance to the organism to live and multiply and to spread their resistant genes on to the next generation, or to other nearby organisms. In short— the use of antimicrobials, over time, will result in the development of AROs. So how can we fairly reduce the use of antimicrobials?

It is well recognized that much antimicrobial use is unnecessary, such as antibiotics for the common cold.  Reducing the use of antimicrobials in patients with minor, non-life-threatening illnesses is a large-scale challenge, but poses little threat to individual patients. However the patients who are at most immediate risk of death from AROs— the critically ill patients in the intensive care unit (ICU) — are also tend to receive the most antibiotics. This is because it is delays in antibiotics during severe infections dramatically increases the patient’s chance of dying. The current strategy when patients are critically ill is to use heavy duty antibiotics early— to ‘shoot first and ask questions later.’ This is partly why critically ill patients have such high rates of AROs.

So, in these vulnerable ICU patients, how do we balance an individual’s immediate needs (use of heavy duty antibiotics) with those of the wider population (reduce use of antibiotics where possible)? Given the threats posed by AROs— the question is not about if we should ration antimicrobials in the ICU, but how? Like many questions in medical ethics, this is a conflict between individual benefits and harms, and the needs of the community.

One emerging strategy— antibiotic stewardship programs, ASPs for short— have become a prevalent feature in ICUs around the world. ASPs usually involve a combination of pre-approval by infections disease physicians prior to the administration of heavy duty antimicrobials, and joint decisions by infections disease doctors and ICU doctors about when to reduce antibiotics.

This makes some ICU doctors, such as myself, uncomfortable— reducing antibiotics when patients are at their sickest and most vulnerable feels like we are providing substandard care. Despite knowledge that it may improve rates of AROs, rationing of antibiotics feels like a betrayal of the patient in front of us.

In my recent article I use Peter Ubel’s definition of bedside rationing to demonstrate that ASPs do seem to be rationing. Though reductions of AROs are good for everyone— even the patient— this presumes the patient will survive in the first place to enjoy such benefits. Reducing antibiotics through use of an ASP may reduce that chance of survival.

In the article, I use Norman Daniels’ “Accountability for Reasonableness” framework to argue that if indeed ASPs are a form of rationing, they at least provide a fair process for setting these priorities. Thankfully studies of the overall effects of ASPs do not suggest a huge increase in the risk of death for patients, but there is also little evidence to suggest that they reduce AROs, likely in part because early studies have been designed to prove that careful reduction in antimicrobials does not result in significant increases in patient deaths. More work needs to be done to assess the impact of ASPs upon their long term effects upon both patient outcomes and AROs.

What is the take-away from all this? Firstly— that rationing antimicrobials is done every day in ICUs in the guise of ASPs. Secondly— that rationing antibiotics is not, in and of itself a bad thing and if carefully managed can balance the individual’s risk of harm with the needs of society. Thirdly— ASPs, with their judicious and rigorous approach to rationing antibiotics provide a model for how rationing patient care can be done fairly and safely.

In a health crisis like that posed by AROs— we need some good news.

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