When more than 300 health care providers showed up in Concord on Wednesday for a conference about antibiotic resistance, they encountered something unexpected: a pop quiz.

Standing at the front podium, Dr. Benjamin Chan, the state epidemiologist, described a classic case of a common type of pneumonia and asked people to use the clickers on their tables to choose which of five antibiotics they would prescribe.

The top choice of the crowd was erythromycin. That seems reasonable since this is one of the most commonly prescribed antibiotics around.

Except for one problem: Due to past overuse, Chan said, about a third of the time erythromycin doesn’t work on that type of pneumonia in New Hampshire anymore.

The fact that so many providers would choose it even though the pneumonia bacteria has evolved to shrug it off, is one reason we’re seeing an increase of disease resistance to all sorts of antibiotic drugs. People use way too many antibiotics, even when they’re not appropriate, and this is causing more diseases to evolve so that fewer drugs can cure them.

Antibiotics have become an entire set of miracle drugs in the 90 years since the discovery of penicillin, so disease resistance to them is a major public health concern.

The CDC estimates that each year in the United States, 2 million people become infected with bacteria that are resistant to antibiotics and “at least 23,000 people die each year as a direct result of these infections.”

New Hampshire doesn’t have such specific data about drug resistance. In fact, one of the topics that frequently came up at Wednesday’s symposium concerned the difficulty in pinning down such data, due to the many ways that antibiotics are distributed in the fragmented health care system.

The state is monitoring drug-resistant strains of gonorrhea and a family of germs known as CRE, often encountered in hospitals. The New Hampshire Division of Public Health has created an Antimicrobial Resistance Advisory Workgroup with more than 50 professionals from a slew of health care fields to figure out ways to tackle the problem.

And Chan described the state’s “biogram,” a spreadsheet that shows how often more than two dozen common types of disease-causing bacteria are resistant to 17 different antibiotics in New Hampshire.

The breadth of the concern was reflected in Wednesday’s symposium, which filled a major conference room at the Grappone Center to overflowing. Srinivasan, who attends many such meetings, said he was impressed by how big it was “for a pretty small state.”

More than half the more than 300 attendees were nurses or physicians, but almost 15 percent were veterinarians, since antibiotic overprescription is also a problem with dogs, cats and farm animals, and a large number represented testing labs, pharmacies and public health nonprofit groups. There were even a few dentists.

“This is not any one person’s problem to fix. This is a community, a state, a national, an international problem,” Chan said.

It’s a patient problem, too – both in ways it can hurt us and in ways we make things worse by demanding antibiotics because we’ve decided in advance that’s what we need.

“Patients say, ‘I’m going to come in and I want penicillin,’ ” said Tracey Collins, RN, director of quality improvement for Frisbie Memorial Hospital in Rochester. “If we tell them, ‘You don’t really need it, you have a virus’ … then you have a disappointed patient. They may go elsewhere, to urgent care, a walk-in clinic, until they can get penicillin. It’s a significant issue.”

In fact, amid all the medical terminology and biotech discussion at Wednesday’s symposium, one of the most effective tools against antibiotic overuse looked to be plain-language posters that tell patients “Antibiotics aren’t always the answer” and which explain, among other things, the difference between diseases caused by a virus, which antibiotics can’t treat, and those caused by bacteria.

Just putting up similar posters in waiting rooms, where bored patients will see them while waiting to be called, has been shown to reduce antibiotic prescription rates by 10 percent, Srinivasan said.

Many hospitals and other institutions have created positions to oversee what is known as antibiotic stewardship, overseeing how all aspects of the health care system deal with the use of these medicines.

“You can’t have nurses alone drive the solution; you can’t have pharmacy drive it,” Collins said. “And if staff is told you can go to a meeting (about antibiotic stewardship) but you’ll have to work extra to make it up, that doesn’t work. … There has to be buy-in from everybody.”

The symposium was sponsored by the Division of Public Health Services together with the Foundation for Healthy Communities and The New England Quality Innovation Network-Quality Improvement Organization.

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