One of the biggest looming threats to humanity’s future is a monster of our own inadvertent creation. This isn’t a summer superhero movie plot. It’s the frightening reality of antibiotic-resistant strains of bacteria and other microbes, which arise over time as more bugs are exposed to more drugs, and evolve resistance to their effects. Two million people in the U.S. become infected each year with organisms that are resistant to antibiotics, and those infections are the direct cause of at least 23,000 deaths annually, according to the Centers for Disease Control and Prevention (CDC). And the threat continues to grow.
Specifically, they are studying the human socio-behavioral challenges involved in antimicrobial stewardship, which is the set of policies and practices that help to optimize the prescribing of antibiotic medicines in a healthcare facility. Running an antimicrobial stewardship program is an active game of military strategy in the war against superbugs that involves tracking local and global patterns of which microbes are gaining resistance against which drugs. As medical director of the antimicrobial stewardship program at CHOP, Jeffrey Gerber, MD, PhD, works with clinical pharmacists to develop procedures and guide prescribing physicians about which drugs, doses, and delivery methods should be used for which clinical indications.
But the best strategies can fail if they aren’t successfully implemented. Julia Szymczak, PhD, a medical sociologist and postdoctoral fellow in the Division of Infectious Diseases at CHOP, has brought this new socio-behavioral perspective to the Penn-CHOP center in the CDC Prevention EpiCenters program.
“The kind of approach that I take on my work is trying to uncover behavior and perceptions,” Dr. Szymczak said. “You can’t just create a guideline or a best practice and plunk it into a healthcare setting. That never works. You can even educate people and that alone doesn’t work, because it’s not just a knowledge deficit. The kinds of things that are at play are a little bit more complex.”
By investigating these complex socio-behavioral issues, Dr. Szymczak aims to learn why prescribing physicians sometimes appear to resist stewardship guidelines. Answering key questions like this one are one way the Penn-CHOP EpiCenter demonstrates its particular leadership in the realm of antibiotic stewardship.
“Instead of an antimicrobial stewardship program that just says, ‘You can’t use this for that,’ we need to talk to people and find out why they prescribe differently, what’s driving them, what are the cultural barriers,” said Dr. Gerber, an infectious diseases specialist and associate director of the Center for Pediatric Clinical Effectiveness at CHOP, and assistant professor of Pediatrics and Epidemiology at Penn. “The value to the EpiCenters is going to be huge. Nobody does what Julie is doing.”
The Penn-CHOP EpiCenter, led by Ebbing Lautenbach, MD, MPH, MSCE, professor of Medicine and Chief of the Division of Infectious Diseases at Penn, is one of 11 leading centers that discover and nationally disseminate systemic improvements in the prevention of healthcare-associated infections in areas guided by CDC priorities. Through this infrastructure, the lessons learned here can ultimately shape how antimicrobial stewardship programs are built and implemented at other healthcare facilities in the future. The number of these programs is expected to grow, both in direct response to the growing threat of antibiotic-resistant bacteria, and due to anticipated policy changes that could require greater stewardship to slow the spread of resistance. Each EpiCenter has a general focus, and the Penn-CHOP EpiCenter has been a leader in antimicrobial stewardship research and implementation.
For a medical sociologist like Dr. Szymczak, the first goal is to discover the perceptions and motivations that influence behaviors related to microbial risk. Doing this research requires both asking the right questions and making on-the-ground observations of clinicians at work.
For example, in one currently funded study focused on barriers to the use of gowns and gloves for preventing the spread of multidrug resistant organisms in various clinical settings, Dr. Szymczak has a research assistant who spends time embedded in clinical units, shadowing providers and putting on protective garb as they do. Living in that reality can offer insights into why adherence to guidelines isn’t perfect. In another project partnership with Dr. Gerber, Dr. Szymczak interviewed parents to understand their perceptions of antimicrobial use for their child’s acute respiratory tract infections.
The current nature of the work is exploratory, but Dr. Gerber and Dr. Szymczak are optimistic that insights in this area could help them gain the upper hand in the battle against superbugs. For instance, Dr. Szymczak learned from her interviews that parents were very wary about excess antimicrobial use for their children’s respiratory infections — a surprising finding, because when physicians discuss why they prescribe antibiotics unnecessarily, they sometimes cite parent demand as a reason. That contradiction raises the possibility that there could be new opportunities to enlist parents as allies in supporting stewardship efforts, as well as opportunities for physician interventions to correct the misperception. Dr. Szymczak ultimately hopes to design interventions based on social and behavioral theory to try to strengthen the fight against resistant microbes.
“The problem of antibiotic overuse is an inherently social one that will require innovative interventions informed by multiple scholarly disciplines to successfully solve,” Dr. Szymczak said. “The EpiCenters program has provided important resources to support this multidisciplinary work at Penn and CHOP.”