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Conversations with the Director: Arjun Srinivasan, MD

August 28, 2013

Arjun Srinivasan

Arjun Srinivasan, MD, (Capt, USPHS) associate director for healthcare-associated infection prevention programs in the Division of Healthcare Quality Promotion (DHQP), met with CDC Director Tom Frieden, MD, MPH, July 12, 2013, for a Conversation with the Director.

Antibiotic resistance and healthcare-associated infections (HAIs) are topics of great interest to CDC Director Thomas Frieden, MD, MPH. So much so, these infections are on CDC’s list of Winnable Battles. He recently discussed the issues on National Public Radio’s (NPR) All Things Considered, pointing out that, “We estimate at CDC that about half the antibiotics prescribed to patients are either unnecessary or inappropriate.”

Clearly, an enormous problem. And yet, when Arjun Srinivasan, MD, (Capt, USPHS) associate director for healthcare-associated infection prevention programs in the Division of Healthcare Quality Promotion (DHQP), met with Frieden July 12, 2013, for a Conversation with the Director, you might easily have concluded the two were old college buddies having a friendly chat. They finished each other’s sentences, laughed at each other’s jokes, told stories about medical school experiences and shared many personal details. They spoke easily and excitedly on many topics, often with medical jargon. It was easy to see they had a great time and would have enjoyed a far longer conversation in a more casual setting. But once they got down to business, Frieden began asking about Srinivasan’s role in DHQP and the division’s structure and operations.

One of the division’s main jobs is to combat HAIs. Frieden was particularly curious about how DHQP worked with the Centers for Medicare and Medicaid Services (CMS). He quoted a CMS official who said that in 20 years, this is the most that CMS and CDC have worked together.

One area where the agencies are cooperating is “value-based purchasing,” sometimes called “pay for performance.” That is, Medicare has several financial incentives for healthcare facilities to avoid unnecessary costs and improve quality of care. They also have financial penalties for negative consequences, such as illness, injury, and death. Reducing HAIs is a big part of value-based purchasing, explains Srinivasan. “We’re working with CMS on revising some of the conditions of participation for infection control in hospitals. My big push is to put antibiotic stewardship into a condition of participation for infection control.” But getting healthcare facilities to be more selective about when and to whom and in what dosages to dispense antibiotics isn’t easy.

Frieden and Srinivasan

Frieden and Srinivasan agree that scientists have a tough job ahead. Finding an antibiotic that can keeps HAIs at bay while at the same time getting buy-in from healthcare providers for restricting or managing use requires not only financial resources but also a paradigm shift.

Besides persuading staffs to comply with recommendations, there are funding and perhaps even political battles to be won. Srinivasan wants a chance to show policymakers how cost effective stewardship really is. “What we’re trying to tell people is you don’t necessarily have to have this expensive, fancy stewardship program where you have to hire an infectious disease doc and an infectious disease pharmacist. There are simple, easy interventions that you could implement with hospitalists, with front-line providers. And so that’s a big push that we’re working on now, to take this concept of stewardship and shift it to the concept that, ‘Look, this is just using drugs correctly. Everybody can do this.’” Srinivasan’s group is evaluating the use of an antibiotic checklist for healthcare providers in various locations. The checklist could be embedded in patient treatment records. It reminds providers to reassess the use of antibiotics on the third day of treatment—what he’s calling an “antibiotic time out.”“We want them to evaluate it on a number of fronts,” Srinivasan said. “We don’t just want process measures—we want them to measure Clostridium difficile, antibiotic resistance, readmission, length of stay; we want hard outcomes. We’ve designed it to be a long intervention, so we can try to demonstrate that if you do these kinds of reviews properly, you can have a big impact. And cost is another big issue that we’re looking at.”

Srinivasan tells people he is passionate about antibiotic stewardship. And judging by his disappointment with the dramatically slowing rate at which new antibiotics have been developed, it is easy to see why. Frieden shares his anxiety. “I’m a little concerned,” Frieden said, “that beyond stewardship and developing new antibiotics, the issue of patents has also become an obstacle. What are we really going to do?”

“I honestly don’t know that we have a single answer for the problem,” Srinivasan said. “The biggest thing that’s under our control is the use piece, because I don’t think we have much influence over how companies are going to invest. I think drug discovery in this area is going to be tough.”

“You’d think it would be getting easier,” Frieden replied.“A lot of people who work in this field say we’ve already found all the easy [antibiotics]” Srinivasan said. “And so, now, the new antibiotics are going to be very, very tough targets.”

Frieden and Srinivasan agree that scientists have a tough job ahead. Finding an antibiotic that can keeps HAIs at bay while at the same time getting buy-in from healthcare providers for restricting or managing use requires not only financial resources but also a paradigm shift.

But, for all his concerns, Frieden remains optimistic. As he told NPR, “We’ve got new tools. We can diagnose resistance in hours for some organisms instead of days. We’ve got more commitment from hospitals in the US and from leaders around the world to identify and stop drug resistance. And one thing we do know is, it’s possible to turn this around. I’m confident we’ll do that.”

This Inside Story by Luis Luque.

CDC Connects Story Manager: Kathy Chastney

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