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Wise Use of Antibiotics: Shifting From Stewardship to Sustainability

Column Author: Annie Wirtz, PharmD, BCPPS

Column Editor: Rana El Feghaly, MD, MSCI | Director, Infectious Diseases Clinical Services; Director, Outpatient Antibiotic Stewardship Program; Medical Director, Vaccines for Children (VFC) Program

 

As I write this article, Kansas City is entering the hottest week of the year with a heat index value ranging from 105 to 110 degrees.1 While we may never get used to the shock of each heat wave, unfortunately these extremely hot summer days are not foreign to us. Over the past 10 years, the United States has experienced record-setting high temperatures, with 2023 being the hottest year to date. Since the 1970s, average temperatures have increased rapidly ranging from 0.32 to 0.51 F per decade.2 Globally, climate change is a major concern as it significantly impacts humans, plants and wildlife. Increased global temperatures have led to erratic weather patterns, more natural disasters (e.g., hurricanes, wildfires, floods, droughts), reduced water supply, rising ocean water levels, seasonal disruption, and significant negative impacts on ocean life.2  

Unknown to many, climate change also impacts infection spread and development. As the planet warms, disruptions in ecosystems and various pathogens lead to increases in infections. With warmer temperatures and more rainfall, diseases transmitted by vectors such as mosquitoes, ticks or rodents become more abundant and transmissible.3 One example is the increase in cases of dengue virus infection observed in the United States. In June 2024, the Centers for Disease Control and Prevention (CDC) issued a Health Alert Network Health Advisory reporting that between January and June 2024, 9.7 million cases of dengue fever were reported in the Americas, double the number of cases in all of 2023.4  

As health care providers, our duty is to be good “stewards” of resources. Although the focus has traditionally been on antibiotic and diagnostic stewardship, the term “stewardship,” which means the careful and responsible management of resources entrusted to us, is much more encompassing.5 Sustainability has recently become a global focus. While sustainability includes stewardship, it adds a focus on the future: how can we meet our current needs without destroying what will be available for future generations? Both focus on preserving resources, and long-standing and effective models of stewardship within health care (e.g., antimicrobial stewardship programs) can provide a framework for increasing sustainability.5 As health care providers, we should educate ourselves on our own contributions to the environment, so we too can make the transition from stewardship to sustainability.   

 

The Health Care System Greatly Contributes to the Climate Change Crisis 

Global increases in temperature are occurring due to significant greenhouse gas emissions (GHGe) worldwide. GHGe are produced from various human activities. GHGe released within the Earth’s atmosphere trap heat and result in higher sustained temperatures. Examples of GHGe include carbon dioxide (80% of GHGe), methane (12% of GHGe), nitrous oxide (6% of GHGe), and additional fluorinated gases.6 Health care systems contribute to 8.5% of United States GHGe, with approximately 35% of these produced from hospital systems.5 GHGe can be produced directly by the hospital, such as through on-site boilers and anesthetic gases as well as indirectly, such as transportation of patients and employees, waste management, pharmaceuticals and medical supplies, and many others (Click here for more).7  

Various regulatory agencies have focused on building “sustainable health care.” The White House and the U.S. Department of Health and Human Services developed the Health Sector Climate Pledge, which includes 943 hospitals that aim to reduce GHGe by 50% by 2030 and reach zero GHGe by 2050. The Joint Commission (TJC) recently developed a voluntary Sustainable Healthcare Certification program for U.S. hospitals which includes measurement of baseline and ongoing GHGe as well as opportunities to reduce GHGe.8,9    

 

Opportunities for Sustainability in Health Care 

A recent publication by Doshi, et al. in the Journal of the Pediatric Infectious Diseases Society highlights the importance of reducing GHGe within health care, specifically calling the infectious diseases community to action. Overall, clinical patient care is the largest contributor to health care emissions, so it is important that we assess our own practices.5 A framework developed by the Providence health care system uses the mnemonic “WE ACT” (Waste, Energy/water, Agricultural/food cycle and anesthetic gas, Chemicals and pharmaceuticals, Transportation) to highlight five key areas of focus to reduce GHGe within health care.1In keeping with the theme that sustainability includes stewardship, both antimicrobial stewardship and diagnostic stewardship program activities have targeted these five key areas, especially, with reducing waste.5 For example, many antimicrobial stewardship programs have focused on reducing antimicrobial waste. A recent assessment of antimicrobial waste at Children’s Hospital of Atlanta reported that 58,607 antibiotic doses were wasted in two calendar years.11 At our institution in 2018, an average of 51 antimicrobial doses were wasted each day. This assessment prompted us to evaluate and implement quality improvement work targeting antimicrobial waste in postoperative patients. An example within diagnostic stewardship is the focus on reducing unnecessary blood cultures. The Bright STAR collaborative implemented an algorithm that reduced the number of blood cultures obtained in pediatric intensive care unit patients by 33% across 14 institutions.12 This algorithm is particularly helpful currently given the severe shortage of blood culture bottles in U.S. hospitals.       

 

How Can I Get Involved? 

Given the immense contributions of health care systems to GHGe, there is a call to action for health care providers to shift focus from just stewardship to sustainability. As individuals, we can evaluate ways to reduce GHGe in our everyday life (resources here). At our health care institutions, we can evaluate the “WE ACT” target areas, including piggybacking on projects already being addressed by existing antimicrobial and diagnostic stewardship programs. In doing so, we are ensuring that future generations have the resources they need. For more information and how to get involved in climate change, check out the following advocacy groups: Union of Concerned Scientists, Medical Society Consortium on Climate and Health, Health Care Without Harm Physician Network, and Sustainabil-ID (sustainabilityiddocs@gmail.com).5  

 

 

References: 

  1. Lanier J. Jacob’s radar: hottest week of the year ahead. Published July 28, 2024. Accessed July 30, 2024. https://fox4kc.com/weather/jacobs-radar-hottest-week-of-the-year-ahead/ 
  2. United States Environmental Protection Agency. Climate change indicators in the United States, Fifth Edition. Published July 2024. Accessed July 30, 2024. https://www.epa.gov/system/files/documents/2024-07/climate_indicators_2024.pdf 
  3. Piscitelli P, Miani A. Climate change and infectious diseases: navigating the intersection through innovation and interdisciplinary approaches. Int J Environ Res Public Health. 2024;21(3):314. 
  4. CDC Health Alert Network. Increased risk of dengue virus infections in the United States: CDCHAN-00511. Centers for Disease Control and Prevention. Published June 25, 2024. Accessed July 30, 2024. https://emergency.cdc.gov/han/2024/han00511.asp#print  
  5. Doshi S, Vuppula S, Jaggi P. Healthcare sustainability to address climate change: call for action to the infectious diseases community. J Pediatric Infect Dis Soc. 2024;13(6):306-312. 
  6. Overview of greenhouse gases. United States Environmental Protection Agency. Last updated April 11, 2024. Accessed July 30, 2024. https://www.epa.gov/ghgemissions/overview-greenhouse-gases.  
  7. Singh H, Eckelman M, Berwick DM, Sherman JD. Mandatory reporting of emissions to achieve net-zero health care. N Engl J Med. 2022;387(26):2469-2476. 
  8. Assistant Secretary for Health (ASH). Health sector commitments to emissions reduction and resilience. U.S. Department of Health and Human Services. Content last reviewed July 10, 2024. Accessed July 30, 2024. https://www.hhs.gov/climate-change-health-equity-environmental-justice/climate-change-health-equity/actions/health-sector-pledge/ 
  9. Sustainable Healthcare Certification. The Joint Commission. Accessed July 30, 2024. https://www.jointcommission.org/what-we-offer/certification/certifications-by-setting/hospital-certifications/sustainable-healthcare-certification/ 
  10. Environmental stewardship at Providence: WE ACT 2022 year in review. Accessed July 30, 2024. https://blog.providence.org/blog/environmental-stewardship-at-providence-we-act-2022-year-in-review 
  11. Fan LK, Lu L, Fernandez AJ, Jaggi P. Antibiotic waste in a pediatric healthcare system: wasting drugs that are in limited supply. Infect Control Hosp Epidemiol. 2024;45(2):231-233. 
  12. Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: Results of the Bright STAR collaborative. JAMA Pediatr. 2022;176(7):690-698. 
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