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
“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
The CDC’s multifaceted Get Smart programs, however, advocate
fighting resistance through judicious use of the existing antibiotic pipeline.
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
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
The campaign advocates paying attention to certain prescribing
practices, such as writing dose, duration and indication on antibiotic
“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,”
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
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.
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
“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.
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
“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
“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
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.
As antimicrobial resistance surfaces worldwide, other countries are now
also taking action, and some are even coordinating their efforts with the
“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
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
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
Will Get Smart be effective in
improving antibiotic overuse?
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
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
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.
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
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
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
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
R. Brooks Gainer II, MD, the Morgantown Internal Medicine Group, West