CDC officials want physicians to ‘Get Smart’ about antibiotic use

The CDC’s comprehensive program attacks resistance from all sides of health care.

With an empty antibiotic pipeline and the emergence of highly resistant bacteria, such as those containing the New Delhi metallo-beta-lactamase-1 gene, physicians are finding it increasingly difficult to treat even the most common infections.

“We have isolates coming out of India that are panresistant, so with respect to what is available, there are no antibiotics with which to treat these infections,” Timothy Walsh, PhD, of the University of Cardiff in Wales, said during a press conference at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy.

The CDC’s multifaceted Get Smart programs, however, advocate fighting resistance through judicious use of the existing antibiotic pipeline.

Arjun Srinivasan, MD
Arjun Srinivasan, MD, said a comprehensive approach is needed to combat antibiotic resistance.
Photo by Srinivasan A

“There is a lot of focus on development, but there is very little focus on improving antibiotic use,” Arjun Srinivasan, MD, medical director of Get Smart for Healthcare, said in an interview with Infectious Disease News. “We have to address both sides of the coin. Just addressing one issue, ultimately, isn’t going to be effective in solving the problem in the long haul.”

A major objective of the Get Smart program, which launched an initial media campaign in 2003, is reducing antimicrobial use in the community by educating providers about proper prescribing practices, Lauri A. Hicks, DO, medical epidemiologist and medical director of the Get Smart: Know When Antibiotics Work program, which focuses on appropriate antibiotic use in the outpatient setting, told Infectious Disease News.

“Our Get Smart provider education materials include treatment guidelines for upper respiratory infections and detailing sheets, which are available for download at our website,” she said. “We also are about to launch additional educational opportunities, including a continuing education course for pharmacists and medical school curricula.”

Hicks said there are various continuing medical education courses that are accessible online, including a program designed to enhance otitis media diagnosis and a Get Smart CME course for credit.

Get Smart officials are also partnering with state health departments to implement electronic medical record prompts that would improve physicians’ ability to accurately diagnose diseases and determine if antibiotic therapy is appropriate, according to Hicks.

Physicians also contend with patients who visit their offices intent on obtaining antibiotics despite diagnoses. Therefore, tools to aid providers in addressing patients’ concerns are also key components of the Get Smart program. Hicks said, for example, that a video giving providers practical tips on how to discuss the issue of avoiding unnecessary prescriptions will soon be available on Medscape’s website (www.medscape.com/partners/cdc/public/cdc-commentary).

Another popular item already in use is the viral prescribing pad, which provides recommendations for symptomatic therapy.

Stressing adherence to antibiotic prescriptions is also important, and traditional methods of patient education, such as brochures, handouts, posters and fact sheets, may be useful in driving these points home, according to Darcia D. Johnson, program officer for Get Smart, who said physicians can distribute these materials or place them in their offices to increase awareness among patients.

Recent communications activities also involve disseminating messages using social media, including Facebook, Twitter and podcasts.

Appropriate inpatient use

Although the Get Smart programs address antimicrobial use in community and outpatient settings, inpatient facilities have received little attention. Therefore, in 2009, the CDC launched a companion program called Get Smart for Healthcare that focuses on appropriate antibiotic use in acute care facilities.

“We decided to build on the CDC’s experience with the Get Smart: Know When Antibiotics Work program in trying to improve antimicrobial use because health care is a continuum,” Srinivasan said. “People who are in outpatient clinics are the same people who get admitted to hospitals, and it’s the same people in hospitals who then go back and see doctors in clinics.”

The campaign advocates paying attention to certain prescribing practices, such as writing dose, duration and indication on antibiotic prescriptions.

“If you write the duration up front, you’re more likely to have the right duration of therapy than if you’re asking someone down the road to try to figure out what the duration should have been and stop it,” he said.

Srinivasan also said reassessing therapy and enhancing microbiology practices are important.

“There are a lot of things we treat on the inpatient side where our therapy could be improved if we had culture results,” he said. “A lot of times, antimicrobial therapy gets started, but then after 48 or 72 hours, there is usually a lot more information that helps you decide whether or not the patient still needs an antimicrobial or if the patient is on the right antimicrobial.”

Srinivasan also said the CDC is working with the Institute for Healthcare Improvement, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America to explore the best ways to disseminate information and apply knowledge about how to improve antibiotic use in inpatient facilities.

Clinical implications

Physicians working in acute care hospitals have hope for the Get Smart for Healthcare program, said Christopher Ohl, MD, associate professor of medicine at Wake Forest University School of Medicine.

“Guidelines for antimicrobial stewardship were published in 2007, but they weren’t widely accepted because we felt like they told us where we need to be, but they didn’t tell us how to get there,” Ohl said in an interview. “They also didn’t reflect the reality of a lot of community hospitals, which don’t always have the infectious disease resources or the pharmacy resources required by guidelines.”

The Get Smart for Healthcare planners considered these concerns during development and now provide toolkits with more feasible guidance for physicians working in acute care settings.

Additionally, the campaign promotes looking beyond traditional ideas about how stewardship programs work. Ohl said hospitals without infectious disease specialists can have other physicians fill that role and help decrease antibiotic overuse.

“A hospitalist, internist or interventionist, for instance, may be able to fill that role, particularly if they have had some additional training in the topic of stewardship and infectious diseases therapy,” he said. “It’s the same in the PharmD realm.”

Currently, some academic institutions, state health departments and professional societies already offer this training, but a standardized certification program would be extremely beneficial, Ohl said, noting that campaigns such as Get Smart may help secure resources for these programs by advocating additional education.

Esra Barzilay
Ezra J. Barzilay

Working with other tools, such as the National Healthcare Safety Network, also offers opportunities to monitor antimicrobial use and the efficacy of intervention programs, according to Srinivasan.

“This has historically been one of the major challenges in the effort to improve antibiotic use,” he said. “This system, which will allow people to track the use electronically, would not only allow you to assess how your interventions are working, but eventually, it would also allow you to compare yourself to other facilities that are similar to yours.”

This communication provides an important avenue to exploring how to tailor antimicrobial stewardship programs to each hospital so that they will be effective, Ohl said.

Get Smart on the Farm

In 2004, Get Smart also extended its reach to include veterinarians and others caring for animals.

“Get Smart: Know When Antibiotics Work on the Farm emerged due to the concern about antibiotic-resistant organisms in animal products,” Ezra J. Barzilay, MD, of the CDC’s National Surveillance Team for Enteric Diseases, said in an interview. “The program works to promote appropriate antibiotic use in veterinary medicine and animal agriculture.”

State-based programs are an important element of Get Smart on the Farm. They foster collaboration between state public health and veterinary communities and help implement community-based programs on appropriate antibiotic use in animals, according to Barzilay. These programs often include traditional campaign-like materials, such as brochures and posters.

The main focus of Get Smart on the Farm, however, is early education for veterinary students.

“We were approached by partners at veterinary schools because the people with whom we were working in academia were seeing a lack of effort in educating the veterinary community on the judicious use of these antibiotics,” said Tom Chiller, MD, MPH, associate director for epidemiological science in the CDC’s Division of Foodborne, Waterborne and Environmental Diseases.

“The program is focused on an educational curriculum for veterinary students in their first and second years,” Barzilay said. “By stressing the importance of proper prescribing practices during their formative years, the students will be more responsible and more aware of the issues of prescribing behaviors when they ultimately become clinicians.”

The veterinary curriculum is an interactive Web-based educational program with background and species-specific and case-based modules that cover microbiology, pharmacology, public health and infectious diseases.

Barzilay said the curriculum is designed to be more entertaining and engaging than typical classroom lessons. One module, for example, is a comic book space module called “Where in the World is Ella Salmonella?” Additionally, the website contains a video project of students filming themselves working with farmers and veterinarians.

“We didn’t want to add more dry, lecture-type materials,” he said. “The curriculum is meant to be interesting, easy-to-understand and adoptable.”

The Michigan State University College of Veterinary Medicine and the University of Minnesota College of Veterinary Medicine have already incorporated Get Smart on the Farm’s educational program into their curricula. Barzilay said he hopes that the curriculum will be adopted by more veterinary schools as it evolves.

Communication is essential, and notifying deans of other veterinary schools will publicize the program and help create more educational opportunities. “We’re inviting people to help us develop even more modules in this curriculum so we can really round it out and make it a 4-year program,” he said.

Global efforts

As antimicrobial resistance surfaces worldwide, other countries are now also taking action, and some are even coordinating their efforts with the United States.

“One of the exciting things this year is that we are partnering with the European Centre for Disease Prevention and Control (ECDC) to increase global awareness about appropriate antibiotic use,” Hicks said. “We also recently heard from health officials in Canada that they are going to join the effort.”

Europe and the United States are not alone in their efforts. Donna Kusemererwa, PharmD, executive director of the Ecumenical Pharmaceutical Network (EPN) in Nairobi, Kenya, also outlined the work being done in developing countries at the 2010 International Conference on Emerging Infectious Diseases.

Because churches and church-owned organizations provide up to 40% of health care services in Africa, EPN concentrates on the provision of quality pharmaceutical services in this sector, Kusemererwa said.

Funding, however, is the biggest obstacle for antimicrobial campaigns in every country. These programs will only survive if the government and other organizations are willing to support and provide the resources necessary to keep these programs afloat, Hicks said. – by Melissa Foster


POINT/COUNTER
Will Get Smart be effective in improving antibiotic overuse?

POINT

The program has the potential to be extremely beneficial in educating patients and providers about the threat of antimicrobial resistance and why judicious use of antibiotics is so important.

Resistance can develop in multiple ways. Some bacteria, for example, have genetic mutations which confer resistance by preventing an antibiotic from entering the bacteria; others produce an enzyme that destroys an antibiotic’s function. Bacteria can exchange extra-chromosomal DNA which contains antibiotic resistance genes. When you expose bacteria to an antibiotic, the treatment will leave only those that are resistant.

Over time, as we use antibiotics, the resistant organism will eventually emerge as the common strain. These strains differ from those seen in inpatient settings, indicating that the resistant strains have developed in the community.

Joseph Bocchini
Joseph Bocchini

To decrease antibiotic exposure and therefore pressure placed on bacteria to become resistant, understanding judicious use of antibiotics is essential. Because of the way antibiotics were used in the past, many patients have felt that any kind of infection, even those that are viral in nature, needs to be treated with these medications. However, this sentiment is changing.

Providers’ willingness to discuss proper antibiotic use with patients may be responsible for these marked reductions in use, suggesting that the public is willing to be educated and that physicians can increase public awareness of which infections require antibiotic therapy and which do not.

The Get Smart campaign can help deliver these messages and further facilitate communication between providers and patients. Physicians will need to individualize their approaches and use the tools that they think will be most beneficial, which will be based on their style of practice and the patient population that they serve.

Joseph Bocchini, Jr., MD, is chairman of the department of pediatrics at Louisiana State University Health Sciences Center in Shreveport.

COUNTER

The multifaceted Get Smart program is a logical approach to a major issue facing mankind. Infectious disease physicians have been preaching for decades that the overuse and inappropriate use of antimicrobials would eventually create a disastrous situation. We may be close to seeing physicians having few effective agents to prescribe. This makes it essential that the Get Smart program be successful in promoting changes in the use of available antimicrobials.

One only has to look at the history of Staphylococcus aureus. We have gone from penicillin resistance to MRSA in hospitals and now a different strain of MRSA in the community. The spread of vancomycin-resistant staph would be devastating. The panresistant organisms from India have to be contained and underscore the need for Get Smart to succeed. The myth that every illness mandates a drug must be put to rest. CME programs for years have emphasized appropriate use. Practice guidelines have been widely available. Hand washing has been promoted. Unfortunately, many prescribers still take the easy way out by writing prescriptions rather than taking time to educate patients.

R. Brooks Gainer II, MD
R. Brooks Gainer

There is still tremendous pressure on health care providers to give patients what they want. There have been physicians penalized or even terminated by HMO’s because of complaints about not prescribing antibiotics.

The issue of antibiotics in the veterinary arenas poses many problems as well. The lack of available microbiologic support in the nonacademic world encourages overuse. The veterinarians also face a lot of client pressure to prescribe. Many antibiotics are available over the counter to breeders of both large and small animals. In their defense, the use is essential for disease prevention in many situations. The issue of antibiotics being present in the human food chain creates yet another problem. Also, some veterinary agents are often used by the breeders on themselves or the family members. I hope that the growing resistance will be a wake-up call to health care providers, the public and governments. In 1966, Professor Fred Whittelsey, a retired internist who had practiced in the pre-antibiotic era, stated, “If physicians don’t change how they use antibiotics sometime in the future, they may find themselves in situations that I faced in the 1930s — that is, having only kind words and pain control to offer my dying infected patients.”

Hopefully, society will provide Get Smart with the resources to help the program succeed.

R. Brooks Gainer II, MD, the Morgantown Internal Medicine Group, West Virginia.

With an empty antibiotic pipeline and the emergence of highly resistant bacteria, such as those containing the New Delhi metallo-beta-lactamase-1 gene, physicians are finding it increasingly difficult to treat even the most common infections.

“We have isolates coming out of India that are panresistant, so with respect to what is available, there are no antibiotics with which to treat these infections,” Timothy Walsh, PhD, of the University of Cardiff in Wales, said during a press conference at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy.

The CDC’s multifaceted Get Smart programs, however, advocate fighting resistance through judicious use of the existing antibiotic pipeline.

Arjun Srinivasan, MD
Arjun Srinivasan, MD, said a comprehensive approach is needed to combat antibiotic resistance.
Photo by Srinivasan A

“There is a lot of focus on development, but there is very little focus on improving antibiotic use,” Arjun Srinivasan, MD, medical director of Get Smart for Healthcare, said in an interview with Infectious Disease News. “We have to address both sides of the coin. Just addressing one issue, ultimately, isn’t going to be effective in solving the problem in the long haul.”

A major objective of the Get Smart program, which launched an initial media campaign in 2003, is reducing antimicrobial use in the community by educating providers about proper prescribing practices, Lauri A. Hicks, DO, medical epidemiologist and medical director of the Get Smart: Know When Antibiotics Work program, which focuses on appropriate antibiotic use in the outpatient setting, told Infectious Disease News.

“Our Get Smart provider education materials include treatment guidelines for upper respiratory infections and detailing sheets, which are available for download at our website,” she said. “We also are about to launch additional educational opportunities, including a continuing education course for pharmacists and medical school curricula.”

Hicks said there are various continuing medical education courses that are accessible online, including a program designed to enhance otitis media diagnosis and a Get Smart CME course for credit.

Get Smart officials are also partnering with state health departments to implement electronic medical record prompts that would improve physicians’ ability to accurately diagnose diseases and determine if antibiotic therapy is appropriate, according to Hicks.

Physicians also contend with patients who visit their offices intent on obtaining antibiotics despite diagnoses. Therefore, tools to aid providers in addressing patients’ concerns are also key components of the Get Smart program. Hicks said, for example, that a video giving providers practical tips on how to discuss the issue of avoiding unnecessary prescriptions will soon be available on Medscape’s website (www.medscape.com/partners/cdc/public/cdc-commentary).

Another popular item already in use is the viral prescribing pad, which provides recommendations for symptomatic therapy.

Stressing adherence to antibiotic prescriptions is also important, and traditional methods of patient education, such as brochures, handouts, posters and fact sheets, may be useful in driving these points home, according to Darcia D. Johnson, program officer for Get Smart, who said physicians can distribute these materials or place them in their offices to increase awareness among patients.

Recent communications activities also involve disseminating messages using social media, including Facebook, Twitter and podcasts.

Appropriate inpatient use

Although the Get Smart programs address antimicrobial use in community and outpatient settings, inpatient facilities have received little attention. Therefore, in 2009, the CDC launched a companion program called Get Smart for Healthcare that focuses on appropriate antibiotic use in acute care facilities.

“We decided to build on the CDC’s experience with the Get Smart: Know When Antibiotics Work program in trying to improve antimicrobial use because health care is a continuum,” Srinivasan said. “People who are in outpatient clinics are the same people who get admitted to hospitals, and it’s the same people in hospitals who then go back and see doctors in clinics.”

The campaign advocates paying attention to certain prescribing practices, such as writing dose, duration and indication on antibiotic prescriptions.

“If you write the duration up front, you’re more likely to have the right duration of therapy than if you’re asking someone down the road to try to figure out what the duration should have been and stop it,” he said.

Srinivasan also said reassessing therapy and enhancing microbiology practices are important.

“There are a lot of things we treat on the inpatient side where our therapy could be improved if we had culture results,” he said. “A lot of times, antimicrobial therapy gets started, but then after 48 or 72 hours, there is usually a lot more information that helps you decide whether or not the patient still needs an antimicrobial or if the patient is on the right antimicrobial.”

Srinivasan also said the CDC is working with the Institute for Healthcare Improvement, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America to explore the best ways to disseminate information and apply knowledge about how to improve antibiotic use in inpatient facilities.

Clinical implications

Physicians working in acute care hospitals have hope for the Get Smart for Healthcare program, said Christopher Ohl, MD, associate professor of medicine at Wake Forest University School of Medicine.

“Guidelines for antimicrobial stewardship were published in 2007, but they weren’t widely accepted because we felt like they told us where we need to be, but they didn’t tell us how to get there,” Ohl said in an interview. “They also didn’t reflect the reality of a lot of community hospitals, which don’t always have the infectious disease resources or the pharmacy resources required by guidelines.”

The Get Smart for Healthcare planners considered these concerns during development and now provide toolkits with more feasible guidance for physicians working in acute care settings.

Additionally, the campaign promotes looking beyond traditional ideas about how stewardship programs work. Ohl said hospitals without infectious disease specialists can have other physicians fill that role and help decrease antibiotic overuse.

“A hospitalist, internist or interventionist, for instance, may be able to fill that role, particularly if they have had some additional training in the topic of stewardship and infectious diseases therapy,” he said. “It’s the same in the PharmD realm.”

Currently, some academic institutions, state health departments and professional societies already offer this training, but a standardized certification program would be extremely beneficial, Ohl said, noting that campaigns such as Get Smart may help secure resources for these programs by advocating additional education.

Esra Barzilay
Ezra J. Barzilay

Working with other tools, such as the National Healthcare Safety Network, also offers opportunities to monitor antimicrobial use and the efficacy of intervention programs, according to Srinivasan.

“This has historically been one of the major challenges in the effort to improve antibiotic use,” he said. “This system, which will allow people to track the use electronically, would not only allow you to assess how your interventions are working, but eventually, it would also allow you to compare yourself to other facilities that are similar to yours.”

This communication provides an important avenue to exploring how to tailor antimicrobial stewardship programs to each hospital so that they will be effective, Ohl said.

Get Smart on the Farm

In 2004, Get Smart also extended its reach to include veterinarians and others caring for animals.

“Get Smart: Know When Antibiotics Work on the Farm emerged due to the concern about antibiotic-resistant organisms in animal products,” Ezra J. Barzilay, MD, of the CDC’s National Surveillance Team for Enteric Diseases, said in an interview. “The program works to promote appropriate antibiotic use in veterinary medicine and animal agriculture.”

State-based programs are an important element of Get Smart on the Farm. They foster collaboration between state public health and veterinary communities and help implement community-based programs on appropriate antibiotic use in animals, according to Barzilay. These programs often include traditional campaign-like materials, such as brochures and posters.

The main focus of Get Smart on the Farm, however, is early education for veterinary students.

“We were approached by partners at veterinary schools because the people with whom we were working in academia were seeing a lack of effort in educating the veterinary community on the judicious use of these antibiotics,” said Tom Chiller, MD, MPH, associate director for epidemiological science in the CDC’s Division of Foodborne, Waterborne and Environmental Diseases.

“The program is focused on an educational curriculum for veterinary students in their first and second years,” Barzilay said. “By stressing the importance of proper prescribing practices during their formative years, the students will be more responsible and more aware of the issues of prescribing behaviors when they ultimately become clinicians.”

The veterinary curriculum is an interactive Web-based educational program with background and species-specific and case-based modules that cover microbiology, pharmacology, public health and infectious diseases.

Barzilay said the curriculum is designed to be more entertaining and engaging than typical classroom lessons. One module, for example, is a comic book space module called “Where in the World is Ella Salmonella?” Additionally, the website contains a video project of students filming themselves working with farmers and veterinarians.

“We didn’t want to add more dry, lecture-type materials,” he said. “The curriculum is meant to be interesting, easy-to-understand and adoptable.”

The Michigan State University College of Veterinary Medicine and the University of Minnesota College of Veterinary Medicine have already incorporated Get Smart on the Farm’s educational program into their curricula. Barzilay said he hopes that the curriculum will be adopted by more veterinary schools as it evolves.

Communication is essential, and notifying deans of other veterinary schools will publicize the program and help create more educational opportunities. “We’re inviting people to help us develop even more modules in this curriculum so we can really round it out and make it a 4-year program,” he said.

Global efforts

As antimicrobial resistance surfaces worldwide, other countries are now also taking action, and some are even coordinating their efforts with the United States.

“One of the exciting things this year is that we are partnering with the European Centre for Disease Prevention and Control (ECDC) to increase global awareness about appropriate antibiotic use,” Hicks said. “We also recently heard from health officials in Canada that they are going to join the effort.”

Europe and the United States are not alone in their efforts. Donna Kusemererwa, PharmD, executive director of the Ecumenical Pharmaceutical Network (EPN) in Nairobi, Kenya, also outlined the work being done in developing countries at the 2010 International Conference on Emerging Infectious Diseases.

Because churches and church-owned organizations provide up to 40% of health care services in Africa, EPN concentrates on the provision of quality pharmaceutical services in this sector, Kusemererwa said.

Funding, however, is the biggest obstacle for antimicrobial campaigns in every country. These programs will only survive if the government and other organizations are willing to support and provide the resources necessary to keep these programs afloat, Hicks said. – by Melissa Foster


POINT/COUNTER
Will Get Smart be effective in improving antibiotic overuse?

POINT

The program has the potential to be extremely beneficial in educating patients and providers about the threat of antimicrobial resistance and why judicious use of antibiotics is so important.

Resistance can develop in multiple ways. Some bacteria, for example, have genetic mutations which confer resistance by preventing an antibiotic from entering the bacteria; others produce an enzyme that destroys an antibiotic’s function. Bacteria can exchange extra-chromosomal DNA which contains antibiotic resistance genes. When you expose bacteria to an antibiotic, the treatment will leave only those that are resistant.

Over time, as we use antibiotics, the resistant organism will eventually emerge as the common strain. These strains differ from those seen in inpatient settings, indicating that the resistant strains have developed in the community.

Joseph Bocchini
Joseph Bocchini

To decrease antibiotic exposure and therefore pressure placed on bacteria to become resistant, understanding judicious use of antibiotics is essential. Because of the way antibiotics were used in the past, many patients have felt that any kind of infection, even those that are viral in nature, needs to be treated with these medications. However, this sentiment is changing.

Providers’ willingness to discuss proper antibiotic use with patients may be responsible for these marked reductions in use, suggesting that the public is willing to be educated and that physicians can increase public awareness of which infections require antibiotic therapy and which do not.

The Get Smart campaign can help deliver these messages and further facilitate communication between providers and patients. Physicians will need to individualize their approaches and use the tools that they think will be most beneficial, which will be based on their style of practice and the patient population that they serve.

Joseph Bocchini, Jr., MD, is chairman of the department of pediatrics at Louisiana State University Health Sciences Center in Shreveport.

COUNTER

The multifaceted Get Smart program is a logical approach to a major issue facing mankind. Infectious disease physicians have been preaching for decades that the overuse and inappropriate use of antimicrobials would eventually create a disastrous situation. We may be close to seeing physicians having few effective agents to prescribe. This makes it essential that the Get Smart program be successful in promoting changes in the use of available antimicrobials.

One only has to look at the history of Staphylococcus aureus. We have gone from penicillin resistance to MRSA in hospitals and now a different strain of MRSA in the community. The spread of vancomycin-resistant staph would be devastating. The panresistant organisms from India have to be contained and underscore the need for Get Smart to succeed. The myth that every illness mandates a drug must be put to rest. CME programs for years have emphasized appropriate use. Practice guidelines have been widely available. Hand washing has been promoted. Unfortunately, many prescribers still take the easy way out by writing prescriptions rather than taking time to educate patients.

R. Brooks Gainer II, MD
R. Brooks Gainer

There is still tremendous pressure on health care providers to give patients what they want. There have been physicians penalized or even terminated by HMO’s because of complaints about not prescribing antibiotics.

The issue of antibiotics in the veterinary arenas poses many problems as well. The lack of available microbiologic support in the nonacademic world encourages overuse. The veterinarians also face a lot of client pressure to prescribe. Many antibiotics are available over the counter to breeders of both large and small animals. In their defense, the use is essential for disease prevention in many situations. The issue of antibiotics being present in the human food chain creates yet another problem. Also, some veterinary agents are often used by the breeders on themselves or the family members. I hope that the growing resistance will be a wake-up call to health care providers, the public and governments. In 1966, Professor Fred Whittelsey, a retired internist who had practiced in the pre-antibiotic era, stated, “If physicians don’t change how they use antibiotics sometime in the future, they may find themselves in situations that I faced in the 1930s — that is, having only kind words and pain control to offer my dying infected patients.”

Hopefully, society will provide Get Smart with the resources to help the program succeed.

R. Brooks Gainer II, MD, the Morgantown Internal Medicine Group, West Virginia.