Alternatives to Fluoroquinolones: Thinking Outside of the Box

Barbara Wells Trautner, MD, PhD, associate professor and director of clinical research, Baylor College of Medicine, discusses finding alternatives to fluoroquinolones and facilitating patient communication to improve outcomes

Contagion^®: With what you’ve learned, what advice do you have for your fellow practitioners in the hospital and the outpatient settings on using fluoroquinolones?

Trautner: It’s always worth thinking if there is a different agent you can use; think outside the box a little. Just because you see a kidney infection, you think of a fluoroquinolone, but can you think of something else?

I looked this up recently. I had a patient with a renal abscess and according to really good pharmacology textbook antibiotic trimethoprim sulfamethoxazole bactrim is just as effective for renal abscesses as fluoroquinolones [are], so [I thought] why don’t I just use that? I did, and the patient did fine!

It takes thinking outside the box, but you can’t spend all day mindfully thinking in medicine. We have to react fast, [and so] you have to have mental cues that lead to a rapid decision just to get through the day. Sometimes we need to stop and recalibrate our mental cues, though. That’s really what antibiotic stewardship is all about: recalibrating mental cues and embedding the right pathway.

You would advise practitioners to review their mental cues, but would you advise that stewardship programs make this more known as well?

Actually, the first person I would advise more is the patient; that’s who I’d talk to. There’s very good data on the use of cipro and anti-prosthetic infections, and bone infections, so we use them sometimes long-term to deal with osteomyelitis or an infection of a prosthetic joint. I tell the patient upfront that the antibiotic I’m going to put you on has, in some cases, caused tension rupture, and so, if you even start to get a little twinge of pain behind your heel or in your elbow, you need to stop the drug, come see your doctor, and you need to come to the emergency room. The patient has to know and be on board and I have to warn them upfront.

I tell them I’m choosing this drug because I think it’s the right drug to help deal with this deep-seeded infection you have, but I want you to be aware of this risk. With the new research that has come out, I’m also going to be thinking if someone has an aneurism—and at least some of my older patients have had an abdominal ultrasound somewhere or a cat scan to check—I might not choose 3 months of cipro on these patients.

I think stewardship programs need to be aware of this and put it on their radar. The problem is that stewardship programs are already doing what they can. I don’t know of a stewardship program out there that really backs fluoroquinolones and it’s because of those drugs’ association with Clostridium difficile outbreaks. They appear to carry a higher risk of subsequent C diff than some of the other classes of antibiotics, [and so] most stewardship programs are already after the fluoroquinolones. They already have the message; it’s about getting the message to the people using them.

What really needs to happen is that it needs to come out of individual decision making and be embedded in the computer pathways. In health care we need more IT support for it. If your patient has ever been diagnosed with an aneurism, it needs to show up in the chart, no matter where you go, and you should get a meaningful warning if you prescribe a quinolone. Electronic health records are probably a solution in the long run to a lot of our antibiotic stewardship issues, we just need to find ways to build them smarter and make them compatible with work flow and not full of annoying alerts but things that help clinicians get through their day. I don’t want any more alerts in my VA system; however, a helpful [notification] that just shows a path can be easier. This can be built into medical records. You get an X-year-old patient that has Y-conditions and they’ve had the following resistant organisms in the past. [Furthermore,] these are the antibiotics they’ve never shown resistance to, or, these are the ones they are likely to have a major adverse-effect from. That would be a smart record. It would be friendly, it wouldn’t be a blocking alert it would be like, “These are some of the things we would suggest based on the following information.”

Sounds like you need to send a message to APIC to say, do you have an antimicrobial stewardship team working to develop this software?

Really smart software that gathers more information about the patient would be good. [Software that enables you to really] look at patient’s prior culture is very important. Good research has shown organisms isolated in the urine, their resistance patterns are going to predict for up to 2 years—at least that’s as long as the study looked out—and these are the resistance patterns that are going to show up in the urine subsequently. It may not even be the same organism, but if they were resistant to cipro 2 years ago, what they have now is likely to be resistant to cipro as well.