Infection Control & Hospital Epidemiology (2019), 40, 206–207 doi:10.1017/ice.2018.313


Commentary


It is time to define antimicrobial never events Jiajun Liu PharmD1,2, Keith S. Kaye MD, MPH3, Nicholas J. Mercuro PharmD4,5, Susan L. Davis PharmD4,5,


Twisha S. Patel PharmD6, Lindsay A. Petty MD6, Gwendolyn M. Pais PhD1 and Marc H. Scheetz PharmD, MSc1,2 1Pharmacometrics Center of Excellence, Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, 2Northwestern Memorial Hospital, Chicago, Illinois, 3University of Michigan Medical School, Ann Arbor, Michigan, 4Henry Ford Hospital, Detroit, Michigan, 5Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, Michigan and 6Michigan Medicine, University of Michigan, Ann Arbor, Michigan


Abstract


Inappropriate antibiotic use is associated with increased antimicrobial resistance and adverse events that can lead to further downstream patient harm. Preventative strategies must be employed to improve antibiotic use while reducing avoidable harm. We use the term “antibiotic never events” to globally recognize and define the most inappropriate antibiotic use.


(Received 30 October 2018; accepted 4 November 2018; electronically published 5 December 2018)


Antibiotic overuse directly fuels the development of multidrug- resistant pathogens and challenges public health efforts world- wide.1 Although resistance was initially confined to hospital infections, community settings are no longer a safe harbor from antibiotic resistance.1 Annually in the United States alone, more than 2 million people acquire antibiotic-resistant infections and at least 23,000 die.2 Aside from driving resistance, antibiotic overuse puts patients at risk for adverse drug events. Notably, antibiotic use in the outpatient settings contributes to approximately 20% of all drug-related emergency department visits in the United States, and 1 in 5 in patients receiving antibiotics experiences an adverse effect.3,4 We have collectively reached a societal tipping point in which inappropriate antibiotic use must be addressed. It is critical to establish tools to effectively identify, track, and compare antibiotic use and/or misuse and risks associated with inap- propriate use across multiple care environments. In this vein, we propose that a new framework for classification of antibiotic misuse should be created. In cases in which antibiotic use is expected to result in negligible benefit and risks substantially exceed potential gains, over-prescription must stop. Thus, we suggest adoption of the term “antibiotic never events” (ANEs), which we define as widely recognized clinical scenarios in which antibiotic use is convincingly inappropriate.


Never Events, a Brief History of the Term


Patient safety is a national focal point in the delivery of quality healthcare in the United States. In 2001, the term “never events” was introduced to describe particularly severe medical errors that should never occur.5 Subsequently, the National Quality Forum published a report on “serious reportable events” based on never


Author for correspondence: Marc H. Scheetz, PharmD, MSc, Professor of Pharmacy


Practice;Midwestern University, Chicago College of Pharmacy, Pharmacometrics Center of Excellence; 555 31st St, Downers Grove, IL 60515. E-mail: mschee@midwestern.edu Cite this article: Liu J, et al. (2019). It is time to define antimicrobial never events. Infection Control & Hospital Epidemiology 2019, 40, 206–207. doi: 10.1017/ice.2018.313


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


events.5 This seminal report defined and categorized medical errors to systematically investigate the most serious errors and to use this knowledge to improve patient safety outcomes.5 The measurable never events, though not comprehensive, were clearly regarded as unacceptable errors by the medical community and the public. The applications of the term “never events” is relevant to the field of infectious diseases. From the NQF report, the Centers for Medicare and Medicaid Services created a list of never events in 2008 that included catheter-associated urinary tract infections, vascular catheter-associated infections, and surgical site infections.6 The purpose of the list at that time was to limit payment for preventable infections.


Never Events, Contemporary Application to Antibiotics


Although the term “never events” applies to infections that should not be acquired in the hospital setting, the appropriateness of antibiotic prescribing has not been addressed. The literature documents that nearly 50% of antibiotic use is inappropriate.7 Any use that is not expected to result in abatement of illness contributes unnecessary and unacceptable risk and violates the well-known medical tenet of “first, do no harm,” and these instances should be termed “antibiotic never events” (ANEs). Risk is realized in direct patient harm (ie, adverse drug events), downstream antibiotic collateral damage (eg, C. difficile infection), and transfor- mation of susceptible organisms into untreatable drug-resistant pathogens. The current ANE framework can be used to capture the risks of antibiotic misuse in certain situations3 in which antibiotic use is not only clinically unsupported but carries a definable or measurable risk of serious harm. We are applying ANEs to the treatment of syndromes where little to negligible benefit of treatment with antibiotics exists. These include asymptomatic bacteriuria and viral upper respiratory tract infection. Asymptomatic bacteriuria is characterized by the presence of a specified quantity of bacteria in an appropriately collected urine culture from an individual without signs or symptoms of urinary tract infection. Past research clearly


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