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“While the world has spent the last two years laser-focused on the COVID pandemic, another public health threat is still lurking in the shadows: the rise of antibiotic-resistant bacteria. Antimicrobial resistance (AMR) has been recognized since the early 1900s, yet rigorous research over the past decade has illuminated the magnitude of the threat and its implications for future infection control. More than 35 thousand patients die from antibacterial resistance every year, and antibiotic-resistant infections exceed 2.8 million annually, according to a CDC report released prior to the COVID pandemic.”

Anne Meneghetti is an internal medicine physician and health care executive.

She shares her story and discusses her KevinMD article, “Combating antimicrobial resistance during COVID: What clinicians need to know.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today’s show is with Anne Meneghetti. She is a pulmonary and critical care physician and health care executive. We’re going to talk about her KevinMD article titled “Combating antimicrobial resistance during COVID: What clinicians need to know.” Anne, welcome to the show.

Anne Meneghetti: Thank you for having me, Kevin.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Anne Meneghetti: Sure. I went to med school in Dallas, Texas, and did my internal medicine internship and residency at the University of Michigan in Ann Arbor, and then went to Boston for my pulmonary and critical care fellowship. One day, I was in the pulmonary clinic at the VA, and I started thinking about how many patients I was going to see in this day, in this week, in this year, or in an entire career, and the number just seemed small to me. I had a longing to make a broader contribution to health care than I could seeing patients one at a time.

So I tried several things. I first went into research, thinking perhaps I could discover something. Then I went into health care policy and did some teaching, both of which I enjoyed, but I still had this longing to expand my impact. So 16 years ago, I found my dream job at Epocrates, and now I lead the team of physicians and pharmacists that put the content, which we curate and create in-house, into the number one medical app in the country, Epocrates.

Kevin Pho: So tell me about that transition. In full disclosure, I use Epocrates myself during my clinical day. So tell me about that journey for you and what it was like.

Anne Meneghetti: So this idea of whether I could do more from behind the scenes than I could seeing patients one at a time was a really strong longing that I had. Teaching is a great opportunity to have a greater influence. My feeling was that I could make a bigger contribution through an app like Epocrates, where a million clinicians are tapping into it and accessing that decision support. That’s how I feel like I contribute to health care now.

Kevin Pho: For those physicians who may be interested in maybe blending clinical medicine with going into medical technology or industry, what’s your advice?

Anne Meneghetti: My advice is to start by contributing in small ways: writing articles, contributing as a peer reviewer, offering to do a blog or an opinion piece. Through building those relationships with technology companies, they can grow and make that more and more a part of their career.

Kevin Pho: Is there any training that physicians need to go into medical technology or health IT or industry? Because a lot of this stuff isn’t necessarily taught during medical training or medical school.

Anne Meneghetti: Right. There are certainly things like media training that can be learned in terms of skills, writing skills, and so forth, how to write a catchy article and so forth. But I think that the key thing is that your expertise as a clinician is what’s really valuable and what’s important for sharing. So there are things that people can do to explore getting sharper, and those are also things you can learn along the way. In terms of health care IT, it’s a real thrill to work side by side with R&D engineers, product leaders, and UX designers, and to learn things from them. That on-the-job training is really a very satisfying and rich part of a role working in a health care IT company.

Kevin Pho: All right, let’s talk more about your KevinMD article. It’s titled “Combating antimicrobial resistance during COVID: What clinicians need to know.” Now, for those of you who get a chance to read your article, just walk my audience through it. Share the story and why you decided to write it.

Anne Meneghetti: Sure. Right when the pandemic hit, I noticed something change in the Epocrates app lookups. We aggregate the number of times different material is accessed in the app, and I noticed that one of the things that used to be looked up a lot was antibiotics. They used to be among the top lookups, and as soon as the pandemic hit in March of 2020, there was a dramatic shift, with reduced lookups for antibiotics, especially those used for upper respiratory infections, whereas for other types of drugs for chronic conditions, diabetes, hypertension, etc., those lookups were preserved.

I began to recognize that because offices are closed, there are stay-at-home orders, and people are masking and social distancing and quarantining, there are a lot of reasons why people might not be getting infections like respiratory infections, or not seeing the doctor about them. I began to wonder, is this going to be a silver lining of the pandemic? Perhaps when it comes to antibacterial resistance, fewer antibiotics are going to be handed out and prescribed, and perhaps that’s going to lead to less pressure on resistant organisms. So I began to get interested in that theme, and sure enough, reports started coming out that the antibiotic prescribing patterns were changing as a result of the pandemic.

The story of how COVID has affected antimicrobial resistance is really two stories: the inpatient side and the outpatient side. On the inpatient side, there were actually more antibiotics given. The CDC just came out with a report, in fact, in July of this year, where they reported that of COVID inpatients, three-fourths of them, almost 80 percent, were given antibacterial agents. And yet reports show that there’s only a 9 percent bacterial superinfection rate for a typical COVID inpatient. So a lot of antibiotics are being given, and as a pulmonary and critical care clinician by training, I understand that impulse to cover broadly, especially early on in the pandemic, when we really didn’t know what the course of severe illness was going to be like.

But as a result, the CDC reported that there was a 15 percent increase in resistant organisms, hospital-onset resistant organisms, and deaths during the first year of the pandemic. That’s a serious and sobering statistic, especially given that in the years prior, there was a steady decrease in hospital-associated infections through the hard work of the antimicrobial stewardship committees and so forth. So we really took a wrong turn in terms of antimicrobial resistance on the inpatient side during the pandemic so far.

But on the outpatient side, there’s a different story. What we were seeing in the Epocrates app, fewer lookups for typical antibiotics given for upper respiratory infections, did bear out, and there were fewer antibiotics prescribed, especially for URIs, in the first year of the pandemic. There’s some concern that that might be rebounding, though, in 2021 and this year. But it was a very positive trend, and it was great to see that there is less antibiotic prescribing on the outpatient side.

In terms of resistance patterns on the outpatient side, it’s not quite clear, because we don’t really have a lot of data. Inside hospital settings, they routinely track the organisms, the prevalence, and the susceptibilities, but on the outpatient side, it’s really hard to get that data to know, in a patient’s community, is there a lot of MRSA? Is there a lot of resistant group A strep, etc.? Those are difficult data to get a hold of.

Kevin Pho: So we’re speaking in mid-August 2022. Are you seeing prescribing patterns going back to pre-pandemic patterns?

Anne Meneghetti: With the drug azithromycin, there seems to be more of a rebound. But there was a significant decrease in prescribing of antibiotics for respiratory infections during the first part of the pandemic, which was really heartening to see, because as you know, there’s so much inappropriate antibiotic prescribing for viral URIs and bronchitis.

Kevin Pho: Now, going forward, I’m an internal medicine primary care physician. What are some things that we can do to help stem the potential tide of superbugs and drug-resistant pathogens?

Anne Meneghetti: Great question. The first thing that clinicians can do is to prevent infections from happening in the first place, and not just bacterial infections, like through vaccines for pneumococcus and meningococcus. Viral vaccines actually have an effect on antimicrobial-resistant bacteria. For example, with flu shots, if people get flu shots, they’re less likely to get severe flu, and one of the leading causes of death in severe flu is bacterial superinfection with MRSA and other things causing pneumonia. So if people are vaccinated against COVID and influenza, even though those are viruses, that can translate into less superinfection with bacteria in severe cases, which can put pressure on antimicrobial resistance.

Kevin Pho: One of the things that you mentioned was that the pace of new antibacterial agents is lagging. So what do you see that trend leading to?

Anne Meneghetti: Yes, the CDC reported in 2019 that we can consider ourselves already in the post-antibiotic era. The pace of new antibiotic agents is really lagging. Things are very slow to come to market, and yet the resistance rates are increasing a lot. Even if new agents do come to market, there’s a lot of likelihood that those new agents are also going to have resistance developed against them. So there are some new approaches, like antibody therapies, bacteriophages, and fecal microbiota transplants. There are some cool things coming down the pike, but essentially, the basics of antimicrobial stewardship apply as they ever did. The future of antimicrobial resistance is really in the hands of the prescriber.

Kevin Pho: We’re talking to Anne. She is a pulmonary and critical care physician and health care executive. Her KevinMD article, which we were talking about today, is titled “Combating antimicrobial resistance during COVID: What clinicians need to know.” So, Anne, what do you foresee the next year or two bringing when it comes to antimicrobial resistance? You mentioned that there is an uptick in superbugs in the inpatient setting, and it’s unclear in the outpatient setting. What do you foresee the next few years bringing?

Anne Meneghetti: Right. Well, there’s a dearth of data about susceptibilities in the outpatient setting, especially by location. So one of the things I’m really passionate about is bringing that data into the hands of clinicians, and so the teams at Epocrates are hard at work on gathering that data. We have a patent on a software that aggregates and presents bacterial susceptibility data by zip code that we’re working very hard on, so stay tuned on that.

But in the meantime, respiratory infection season is upon us. So in addition to getting people vaccinated for flu and COVID, because that has an implication for bacterial superinfection, the other things clinicians can do are to really decrease the diagnostic uncertainty about whether there is a bacterial infection to treat: using procalcitonin in some cases, and tests for viruses. We know they’re not perfect, for example, the COVID tests and flu tests, but testing can help clinicians decide whether or not to prescribe an antibiotic at all.

I think it’s so important to acknowledge patient symptoms when there is a viral URI, to offer them symptom relief, and to really hear them out, reassure them, and educate them about the side effects of antibiotics. Not only are they presenting potential harm for the patient, but they do have that impact on fueling antibiotic resistance.

The other thing clinicians can do is think about the duration of antibiotics. We used to emphasize, “Oh, take the full course. Don’t stop short.” But now there’s been a new tailoring of the duration of antibiotic therapy. Every single day that a patient is exposed to antibiotics is a day that can present risk for harm, and so the durations recommended by the Infectious Diseases Society of America and the CDC are now shorter.

Yet another thing we can do is to critically examine penicillin allergies. A lot of times, there’s a documented penicillin allergy in the chart, but is it really a valid hypersensitivity reaction or not? Really investigating and evaluating whether that’s a true hypersensitivity reaction can help open up other options, like beta-lactams, that might otherwise lead us to prescribe more overly broad antibiotics.

Kevin Pho: So you mentioned how medical apps like Epocrates can present the prescriber with perhaps real-time sensitivity data or real-time prevalence of bacterial resistance by zip code. What do you envision that looking like in a typical workflow?

Anne Meneghetti: What I would imagine, when this functionality is made available in the Epocrates app, is that a clinician could say, “OK, I’m seeing a patient with a skin infection in Cincinnati, Ohio. Is this an area where there’s a lot of MRSA or not?” Or, “I’m seeing a pregnant woman with a UTI in, let’s say, Florida. Is there a lot of resistant E. coli in this area or not?” So it can really support, I think, empiric therapy decisions in a way that goes beyond just the educated guesses that we have to do today.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Anne Meneghetti: I think the most important message is that the future of antimicrobial resistance in bacteria is really hanging upon the decisions that prescribers make today, and upon the teams who are accountable for infection control and prevention, and those who are accountable for making sure people are getting their routine vaccinations and catch-up vaccinations. It’s all on us, and it’s really an important issue of our time, and it’s only getting more serious.

Kevin Pho: Thank you so much for sharing your time and insight. Thanks again for being on the show.

Anne Meneghetti: Thank you, Kevin, for drawing attention to this vitally important area.