{"id":3137,"date":"2017-03-16T12:43:08","date_gmt":"2017-03-16T11:43:08","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3137"},"modified":"2017-03-24T05:02:33","modified_gmt":"2017-03-24T04:02:33","slug":"rationing-of-antibiotics-in-the-critically-ill-not-if-but-how","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/03\/16\/rationing-of-antibiotics-in-the-critically-ill-not-if-but-how\/","title":{"rendered":"Rationing of Antibiotics in the Critically Ill: Not if, but How?"},"content":{"rendered":"<p><em><strong>Guest Post:\u00a0Simon\u00a0Oczkowski<br \/>\n<\/strong><\/em><em><strong>Paper:<\/strong>\u00a0<a href=\"http:\/\/jme.bmj.com\/content\/early\/2017\/03\/15\/medethics-2015-102785?papetoc\"><strong>Antimicrobial stewardship programmes: bedside rationing by another name?<\/strong><\/a>\u00a0<\/em><\/p>\n<p>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 <a href=\"https:\/\/amr-review.org\/sites\/default\/files\/160525_Final%20paper_with%20cover.pdf\">real and profound effects on patients around the world<\/a>, it is often dramatic examples of patients <a href=\"https:\/\/www.forbes.com\/sites\/brucelee\/2017\/01\/15\/woman-dies-from-bacteria-resistant-to-all-antibiotics-why-dont-more-people-care\/#25866cfe1648\">dying from infections resistant to all antibiotics<\/a> which receive the most attention.<\/p>\n<p>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, <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4486734\/\">developing new antimicrobials takes time and significant financial resources<\/a>. 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.<\/p>\n<p>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, <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4888801\/\">leaving behind those who have some resistance to the organism<\/a> to live and multiply and to spread their resistant genes on to the next generation, or to other nearby organisms. In short\u2014 the use of antimicrobials, over time, will result in the development of AROs. So how can we fairly reduce the use of antimicrobials?<\/p>\n<p><!--more--><\/p>\n<p>It is well recognized that <a href=\"https:\/\/www.cdc.gov\/media\/releases\/2016\/p0503-unnecessary-prescriptions.html\">much antimicrobial use is unnecessary<\/a>, such as antibiotics for the common cold.\u00a0 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\u2014 the critically ill patients in the intensive care unit (ICU) \u2014 are also tend to receive the most antibiotics. This is because it is <a href=\"http:\/\/www.ccmpitt.com\/ebm\/sepsis\/Kumar%20A,%20et%20al.%20%20Duration%20of%20hypotension%20before%20initiation%20o.pdf\">delays in antibiotics during severe infections dramatically increases the patient\u2019s chance of dying<\/a>. The current strategy when patients are critically ill is to use heavy duty antibiotics early\u2014 to \u2018shoot first and ask questions later.\u2019 This is partly why critically ill patients have such <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3231873\/\">high rates of AROs<\/a>.<\/p>\n<p>So, in these vulnerable ICU patients, how do we balance an individual\u2019s 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\u2014 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.<\/p>\n<p>One emerging strategy\u2014 antibiotic stewardship programs, ASPs for short\u2014 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.<\/p>\n<p>This makes some ICU doctors, such as myself, uncomfortable\u2014 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.<\/p>\n<p>In my recent article I use Peter Ubel\u2019s definition of bedside rationing to demonstrate that ASPs do seem to be rationing. Though reductions of AROs are good for everyone\u2014 even the patient\u2014 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.<\/p>\n<p>In the article, I use Norman Daniels\u2019 \u201cAccountability for Reasonableness\u201d 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 <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed?cmd=Search&amp;doptcmdl=Citation&amp;defaultField=Title%20Word&amp;term=Tabah%5Bauthor%5D%20AND%20A%20systematic%20review%20of%20the%20definitions%2C%20determinants%20and%20clinical%20outcomes%20of%20antimicrobial%20de-escalation%20in%20the%20intensive%20care%20unit\">do not suggest a huge increase in the risk of death for patients<\/a>, <a href=\"http:\/\/journals.plos.org\/plosone\/article?id=10.1371\/journal.pone.0171218#pone.0171218.ref003\">but there is also little evidence to suggest that they reduce AROs<\/a>, likely in part because early studies have been designed to prove that <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed?cmd=Search&amp;doptcmdl=Citation&amp;defaultField=Title%20Word&amp;term=Leone%5Bauthor%5D%20AND%20De-escalation%20versus%20continuation%20of%20empirical%20antimicrobial%20treatment%20in%20severe%20sepsis%3A%20a%20multicenter%20non-blinded%20randomized%20noninferiority%20trial\">careful reduction in antimicrobials does not result in significant increases in patient deaths<\/a>. More work needs to be done to assess the impact of ASPs upon their long term effects upon both patient outcomes and AROs.<\/p>\n<p>What is the take-away from all this? Firstly\u2014 that rationing antimicrobials is done every day in ICUs in the guise of ASPs. Secondly\u2014 that rationing antibiotics is not, in and of itself a bad thing and if carefully managed can balance the individual\u2019s risk of harm with the needs of society. Thirdly\u2014 ASPs, with their judicious and rigorous approach to rationing antibiotics provide a model for how rationing patient care can be done fairly and safely.<\/p>\n<p>In a health crisis like that posed by AROs\u2014 we need some good news.<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Guest Post:\u00a0Simon\u00a0Oczkowski Paper:\u00a0Antimicrobial stewardship programmes: bedside rationing by another name?\u00a0 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 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/03\/16\/rationing-of-antibiotics-in-the-critically-ill-not-if-but-how\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2153,577],"tags":[],"class_list":["post-3137","post","type-post","status-publish","format-standard","hentry","category-guest-post","category-resource"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Rationing of Antibiotics in the Critically Ill: Not if, but How? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/03\/16\/rationing-of-antibiotics-in-the-critically-ill-not-if-but-how\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Rationing of Antibiotics in the Critically Ill: Not if, but How? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"Guest Post:\u00a0Simon\u00a0Oczkowski Paper:\u00a0Antimicrobial stewardship programmes: bedside rationing by another name?\u00a0 The threat posed by antimicrobial resistant organisms (AROs) has long been recognized by the medical community as an emerging problem in public health. 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