Part I of this series outlined the three key factors that are influencing the growing problem of antibiotic resistance. This second article focuses on three ways the University of California, San Francisco (UCSF) has responded to this problem:

  1. Changes in Procurement: UCSF Medical Center has reduced its use of meat and poultry products raised with non-therapeutic antibiotics.
  2. Antibiotic Stewardship: In the health care and clinical setting, UCSF emphasizes Antimicrobial Stewardship , which recognizes antibiotics as precious resources that need to be managed sustainably.
  3. Teaching the Next Generation of Doctors and Pharmacists: UCSF has developed and implemented an interprofessional curriculum on antimicrobial stewardship. This curriculum, consisting of independent learning and an interprofessional workshop, significantly increases knowledge and attitudes that encourage collaborative antimicrobial stewardship among preclinical medical and pharmacy students.

UCSF Takes a Leadership Role on Hospital Food Procurement

UCSF has taken a leadership role in the movement to limit the use of meat raised with excessive antibiotic use. In 2013, UCSF’s Academic Senate passed a resolution calling for a phase-out of the purchase of meat raised with non-therapeutic antibiotics. Responding to this resolution, UCSF Health pooled purchasing power with other large institutions, making it possible to purchase antibiotic-free beef patties, bulk ground beef, and stew meat from Estancia Beef, an antibiotic-free meat producer based in South America. UCSF also offers a $4.50 grass-fed, antibiotic-free hamburger, and UCSF Health offers only antibiotic-free eggs and chicken breasts on its patient and retail menus.

In order to purchase more sustainable meats, UCSF trimmed conventional meat purchases with offerings such as Meatless Mondays and implemented other strategies for reducing waste, such as a hotel-style room service to patients. This on-demand system allows patients more control over food choices, reducing waste and incurring cost savings.

Stewardship in the Clinical Setting—Access not Excess

At UCSF, about 50% of patients in the hospital are on antibiotics. To reduce unnecessary antibiotic use, UCSF established a robust Antimicrobial Stewardship Program, which is part of UCSF’s Infectious Disease Management Program (IDMP), an interdisciplinary collaboration that includes infectious diseases physicians, infectious diseases-trained pharmacists, the clinical microbiology laboratory, and infection control. This multidisciplinary group comes together monthly to discuss issues, including antimicrobial stewardship.

Dr. Conon MacDougall , PharmD, a pharmacist by training, works with the Antimicrobial Stewardship Program, advising practitioners at UCSF Health on antibiotic use and selection and educating clinicians on how to best use antibiotics, in order to preserve their value for future generations. “UCSF’s program coordinates interventions to promote appropriate use of antibiotics at UCSF including selection of the optimal antibiotic drug, dose, duration, and route. Our ultimate goal is to improve patient outcomes and reduce adverse consequences of antibiotic use,” explained MacDougall.

Sarah Doernberg, MD, MAS, Assistant Professor, UCSF School of Medicine, runs UCSF’s adult antimicrobial stewardship program. ”Our goal is to make sure that antibiotics are being used appropriately—giving the right antibiotic for the right amount of time to the right patient. Antibiotics are life-saving. They’re very important and vital for many of the treatments that we give our patients. But we know from various research studies that probably about 30% of antibiotic use in people across the spectrum of care is inappropriate or unnecessary. And that’s really what we are trying to improve upon,” explained Doernberg.

“We want to make sure that current patients get the best care possible and that future patients also will be able to get the best care,” stressed Doernberg. “Doctors can page us, and when writing the antibiotic order they can consult us through the electronic medical record as well.”

Dr. Joe Guglielmo, UCSF Dean, School of Pharmacy, who helped to start UCSF’s antimicrobial stewardship, stressed, “To protect both yourself and the broader community, only use antibiotics when you absolutely have to. Not only because we worry about bacterial resistance and super infection in individuals and the community, but also because we have yet to fully understand the dramatic effect antibiotics can have on our microbiome.”

Teaching the Next Generation of Doctors and Pharmacists

Responding to the lack of curricula, UCSF has developed and implemented a comprehensive antimicrobial stewardship curriculum that is integrated throughout the second to fourth years of medical school and incorporates third-year pharmacy students. The curriculum utilizes the concept of spiral learning, where the same concept is revisited several times, but with increasing complexity. This type of learning reinforces and deepens previous learning, which better advances mastery.

The second-year component includes purposeful integration of stewardship themes throughout the foundations science microbiology block (integrates microbiology, infectious diseases, and pharmacology) and an interprofessional, case-based small group activity for medical and pharmacy students on antibiotic stewardship. As described in a recent article in Open Forum Infectious Diseases, the curriculum includes an online learning module and a two-hour interprofessional workshop session on antimicrobial stewardship that combines medical and pharmacy students, with faculty from the medical and pharmacy schools. The curriculum, including learning objectives, learning module, interactive case vignettes, and instructor materials, is freely available for access here.

During the third year of medical school, the curriculum includes an interactive case-based one-hour didactic session emphasizing responsible antibiotic use immediately prior to the start of clerkships and an online module on common infections and antimicrobial use during the medicine clerkship, followed by an interactive Jeopardy-style chief resident taught game. Fourth year medical students attend two sessions (2 hours and 1.5 hours) on common infections and responsible antimicrobial use immediately before the start of the fourth year and one week before graduation.

A unique aspect of the UCSF curriculum is that medical students interact with pharmacists involved in stewardship programs and pharmacy students are partnered with physicians involved in stewardship programs. The combination of independent learning and an interprofessional workshop proves effective in increasing knowledge and attitudes towards collaborative antimicrobial stewardship among preclinical medical and pharmacy students.

Be Part of the Solution:  Read Labels and Shop Organic

As an individual, one easy way to avoid antibiotics in your meat is to buy organic and read labels. Adherence to the U.S. Department of Agriculture’s organic rules prohibit antibiotic use on livestock and must be verified on-site by an independent accredited certifier, providing a high level of confidence that any meat or poultry labeled USDA Organic comes from animals that never have been given any antibiotics.

According to the Grow Network, other things to look for are Raised Without Antibiotics, No Antibiotics Administered, and No Antibiotics Ever. These labels signify that the meat in question came from animals raised without antibiotics, often in conditions comparable to organic (but uncertified). Avoid labels that say Antibiotic-Free—the USDA has never legally authorized the use of this term. And the USDA meaning of natural is very loose; antibiotics are fully allowed in ‘natural’ meat, making the term meaningless if you’re trying to avoid them.

In San Francisco, big grocers are going to be required to annually disclose antibiotics used in their meats, which will make it easier for consumers to identify stores offering antibiotic-free meat. The Department of the Environment will receive the reports from the some 120 large grocery outlets in San Francisco and publicly disclose the antibiotic information, under legislation unanimously approved by the Board of Supervisors. The proposal impacts large grocers in San Francisco — including Safeway, Walgreens, CVS, Grocery Outlet, Whole Foods and Bristol Farms.

Finally, if you come down with a common ailment or infection, and your doctor’s first response is to put you on antibiotics, consider suggesting the “wait and see” approach. Every doctor I spoke with mentioned that for common ailments, such as a sinus infection, antibiotics are not effective and nor necessary. Ironically, while writing this article, I finally went to the doctor for an ongoing sinus infection. They wanted to put me on antibiotics, which I agreed to because I have tried everything else. And guess what? It didn’t help at all.

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