Infection Control & Hospital Epidemiology
Table 1. Examples of Potential Antibiotic Never Events Antibiotic Never Events
Antibiotic use for a nonsusceptible organism after identification and susceptibility
Antibiotic use that exceeds 2 days after causative organism identified and susceptibility results available when de-escalation is possible (can safely be treated by a narrower agent)
Postsurgical antibiotic prophylaxis exceeds national guidelines Antibiotic use for viral upper respiratory tract infections Antibiotic use for asymptomatic bacteriuria
demonstrates that antibiotics do not confer clinical benefit and only impart adverse events.8 Similarly, viral upper respiratory tract infections without bacterial coinfection comprise another syndrome in which antibiotic use provides negligible benefit because anti- bacterial agents are not active against viruses. In patients with viral upper respiratory tract infections, those who received antibiotics had significantly longer hospital stay, higher in hospital all-cause infec- tions, and higher frequency of C. difficile infections compared to those who did not receive antibiotics.9 With these examples, we suggest defining the bounds of themost inappropriate and egregious use (ie, ANEs) to provide events that can be converted into a metric that can be easily followed. For certain inappropriate antibiotic use measures, the acceptable target event rate is probably a nonzero number or percentage of use, and the beauty of defining true ANEs is that the target level is actually zero. Temporal trendmeasurements of ANEs represent the perceptible “tip of an iceberg” of inap- propriate antibiotic usage. We further suggest several other syn- dromes that meet the criteria for low clinical benefit and high adverse event potential (Table 1). Defining the most egregious antibiotic use scenarios as ANEs
has the advantage of utilizing a framework that is already deeply rooted in medical culture. Patient safety literature, especially in surgery discipline, has employed the term never events to convey and quantify medical errors or adverse consequences.10 Khane- man and Tversky’s Nobel Prize–winning research on “negative framing” suggests that humans are more strongly inclined to take action when the actions in question are labeled to convey the loss avoided (rather than benefit gained) and when the consequences of failing to act are mentally vivid.11 Furthermore, this common language has facilitated a framework to identify and mitigate the causes of never events.10 It is time to take a similar approach in the classification of antibiotic use, implementation of a term that is clinically measurable and readily understood. Classifying
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inappropriate antibiotic use with an encompassing term allows these questionable antibiotic prescribing practices, facilitates measurement to be identified and ultimately allows for preven- tion. By defining ANEs, tracking and prevention efforts will ultimately facilitate behavior change in prescribing practices and minimize avoidable patient harm.
Financial support. S.D. receives grant support from Merck to her institu- tion. N.M. reports that he receives grant support from Merck to his institution. T.P. reports that she receives grant support from Merck to her institution. M.S. received honoraria from multiple nonprofit organizations; received an edu- cation grant from Allergan; and receives speaker fee from Premier Inc.
Conflicts of interest. S.D. reports that she has been a consultant for Achaogen, Nabriva, and Melinta. M.S. reports that he has been a consultant for Achaogen, SIGA technologies, Bayer and is on advisory board for Paratek. All other authors declare no potential conflict of interest.
References
1. Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:229–241.
2. Antibiotic/Antimicrobial resistance (AR/AMR). Centers for Disease Control and Prevention website.
https://www.cdc.gov/drugresistance/ index.html. Published 2017. Accessed October 7, 2018.
3. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017;177:1308–1315.
4. Lode H. Safety and tolerability of commonly prescribed oral antibiotics for the treatment of respiratory tract infections. Am J Med 2010; 123(4 Suppl):S26–S38.
5. Agency for Health Care Quality and Research. Patient Safety Primer: Never events. Patient Safety Network website.
https://psnet.ahrq.gov/ primers/primer/3/Never-Events. Updated August 2018. Accessed November 15, 2018.
6. Brown J, Doloresco F III, Mylotte JM. “Never events”: not every hospital- acquired infection is preventable. Clin Infect Dis 2009;49:743–746.
7. Glowacki RC, Schwartz DN, Itokazu GS, Wisniewski MF, Kieszkowski P, Weinstein RA. Antibiotic combinations with redundant antimicrobial spectra: clinical epidemiology and pilot intervention of computer-assisted surveillance. Clin Infect Dis 2003;37:59–64.
8. Zalmanovici Trestioreanu A1, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev 2015;4:CD009534.
9. Shiley KT,LautenbachE,Lee I. Theuse of antimicrobialagentsafter diagnosis of viral respiratory tract infections in hospitalized adults: antibiotics or anxiolytics? Infect Control Hosp Epidemiol 2010;31:1177–1183.
10. Berger ER, Greenberg CC, Bilimoria KY. Challenges in reducing surgical “never events.” JAMA 2015;314:1386–1387.
11. Milstein A. Ending extra payment for “never events”—stronger incentives for patients’ safety. N Engl J Med 2009;360:2388–2390.
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