CDC Telebriefing: New Vital Signs Report - Are Prescribing Practices Putting Hospital Patients at Risk?
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Press Briefing Transcript
Tuesday, March 4, 2014 12:00 PM E.T.
OPERATOR: Good morning and thank you all for holding. Your lines have been placed on a listen-only mode until the question and answer portion of today's conference. I would like to remind all parties the call is now being recorded. If you have any objections, please disconnect at this time. And i would now like to turn the call over to Tom Skinner. Thank you, sir. You may begin.
TOM SKINNER: Thank you, Elaine, and thank you all for joining us today for the release of another CDC "vital signs," this one on improving antibiotic use among hospitalized patients. March 4th, 2014. With us today are the director of the centers for disease control and prevention, Dr. Tom Frieden and senior vice president of the American Hospital Association, Dr. John Combes. Both will provide opening remarks, and then we'll get to your questions. So I’d like to turn the call over now to Dr. Frieden.
TOM FRIEDEN: Thank you very much, and thank you all for joining us. Every first Tuesday of each month CDC releases a Vital Signs report. This is a special MMWR publication that highlights a critical public health issue that faces the country. At CDC we work 24/7 to save lives and protect people. And part of that role is to sound the alarm about health threats and do whatever we can to address those threats. Those of you who cover CDC regularly know we've been talking increasingly and with increasing urgency about the threat of antibiotic resistance and untreatable infections. As an infectious disease doctor myself, I recall patients I’ve treated who've run out of antibiotics, and I don't want to see that kind of situation spread in this country. Antibiotics are nothing short of miracle drugs. Prompt treatment of infections that lead to sepsis saves lives every day in U.S. Hospitals. And it's important that antibiotics are used promptly whenever needed. In addition, antibiotics make it possible to do many other threads that are essential for medical advances. That includes things like cancer treatment and organ transplants. If we lose our antibiotics, we will lose not only the treatment of primary infections but the treatment of infections that complicate many other conditions. Last fall we at CDC released an antibiotic resistance threat report and we outlined four key actions which are necessary to fight resistance. We need to prevent infections and the spread of resistance, track resistance patterns, find new drugs and tests, and perhaps most importantly protect the antibiotics we have today through good stewardship now. At CDC we're working on many things to implement those actions but more is needed. Today's Vital Signs shines a light on hospitals, where antibiotic stewardship can have a direct and almost immediate impact improving medical care and reducing drug resistance and infections such as clostridium difficile. The report today is about prescribing practices in hospitals. By prescribing practices I mean the entire decision-making process relating to choosing and giving a patient antibiotics, when to start them, what antibiotics to use, what dosage to use, for how long to continue them. The Vital Signs report shows that prescribing varies widely among hospitals and that practices that are not optimal are putting patients at unnecessary risk of future drug-resistant infections, allergic reactions, and intestinal infections that can be deadly from c. difficile. We aren't stopping at just identifying the problem, though. We're also providing tools, including a checklist to help hospitals and other health care facilities improve antibiotic-prescribing practices because we know that facilities and providers want to do a better job. Now, in terms of the details of the report, about half of hospitalized patients got antibiotics during their stay. The many reasons patients need hospital care, that's not particularly surprising, but what did really surprise me is that doctors in some hospitals prescribed three times as many antibiotics as others. Even though the patients were being cared for in similar areas of each hospital. This kind of wide difference does provide a warning bell. It provides the clue that a lot of improvement is possible. Although some differences are undoubtedly warranted, clearly there's a need for improvement. In addition, the report found that about 1/3 of the time prescribing practices to treat urinary tract infections in hospital patients included a potential error. Similarly, about 1/3 of prescriptions for the critical and common drug vancomycin included a potential error. Specifically, some patients were given the drug without appropriate testing or evaluation or were given drugs for too long. As we know, antibiotic exposure can drive complications and resistance. And I want to spend a moment kind of debunking a myth. There is in some quarters a myth that while I’m going to give my patients the best possible antibiotics and yes, that might be bad for other patients, but it's going to protect them well. That's actually not the case. That reasoning presupposes that there's some potential conflict between what's in the best interest of my patients and what's in the best interests of all patients. In fact, what we're finding is we're really consistent here, that by giving your patients the best possible treatment, and that means the treatment that's tailored to their possible infection and their need, not only do you protect them against a super-resistant organism or c. difficile diarrhea, but you also protect other people in the hospital and the community. So there's no conflict here between what's in the best interests of an individual patient and what's in the best interests of patients in general. On a positive note the report tells us that decreasing the need for antibiotics most closely linked with c. diff infection by 30 percent could reduce those deadly infections by 26 percent. That's almost a one to one impact. A huge impact on patient safety. The kinds of antibiotics most closely linked with c. diff include fluoroquinolones, beta-lactams with beta-lactamase inhibitors and the extended spectrum cephalosporins. While these drugs are often life-saving, prescribing them when they're not needed or for the wrong duration fuels resistance and can set patients up for more drug-resistant infections in the future. Patients getting powerful antibiotics to treat a broad range of infections are up to three times more likely to get another infection from an even more resistant microbe. So what can hospitals do to protect antibiotics for today's patients and tomorrow's as well? We're recommending strongly that every hospital in the country have an antibiotic stewardship program. Furthermore we're outlining a new checklist for hospitals because it's sometimes complicated and sometimes confusing to know what's the right thing to do and how they can work most effectively. We're identifying seven critical components of an effective stewardship program. The first is commitment. Hospital leadership has to ensure that the program has the necessary people, money, and information technology. Second, accountability, a single leader who's responsible for impact and we've seen physicians have proven very successful in this role. Third, drug expertise, having a single pharmacist leader to support improved prescribing. Fourth, action, asking each hospital to take at least one prescribing improvement action. A good example of that is implementing an automatic reassessment or pause on antibiotic prescriptions within 48 hours to make sure that the drug choice is appropriate, that maybe it can be narrowed or tailored, that the dosage is appropriate, and looking at the duration. Fifth, tracking, monitoring, prescribing an antibiotic resistance patterns from the hospital. And we're delighted that CDC's national health care surveillance network has a module to facilitate and assist hospitals in tracking both antibiotic resistance patterns and antibiotic prescribing patterns. Sixth, reporting, regularly reporting to staff, to hospitals prescribing resistant patterns, and steps that they can take to improve practices. And seventh and finally, education about antibiotic resistance to improve prescribing practices. That's the first broad strategy. The second broad strategy that we asked hospitals to undertake is to work with their local and state health departments and other health facilities to collectively prevent infections' spread and resistance. Patients are mobile. Resistant bacteria in any facility can easily land at the door of any other facility in the community. So coordinated communication and prevention efforts are critical. That includes using patient transfer forms which CDC has examples of so the receiving facility is aware of any infection. And facilities can join together to share resistance pattern information, best practices, and new ideas to improve stewardship and prevention of infections. For clinicians we've outlined three key steps to take when antibiotics are needed. First, order recommended cultures before antibiotics are given and start treatment promptly. Second, make sure the indication, dose, and expected duration are specified in the patient record. And third, reassess within 48 hours to adjust or stop the prescription as appropriate. There are more specifics in the Vital Signs fact sheet on what health care facility leaders, clinicians, health departments, and patients can do to use antibiotics well and stop resistance. CDC is working to help us all step back from the brink. We will continue to try to stop antibiotic resistance, and we'll step up our efforts even more. And you'll hear about that in a budget announcement later today. This actually is a coincidence. As I mentioned at the outset, the first Tuesday of each month we release our Vital Signs at noon. At 2:00 p.m. Today there will be the budget release. So until 2:00 p.m. The following sentence that I’m about to utter is embargoed but the budget will include for CDC a proposal of a $30 million increase for an initiative in the U.S. To establish a robust infrastructure that can detect antibiotic-resistant threats and protect patients and communities. And if you'd like more information about that, you can contact our press office or we can talk about it later. But to summarize what I’ve said so far, antibiotics are often life saving. We have to protect them before our medicine chests run empty. Last year we outlined four core actions to achieve that goal. And today we're getting specific about what hospitals can do to better protect patients and the antibiotics we need to treat them. We know that poor prescribing practices put patients at risk. Improvements both in the general interest and are something that are broadly understood to be necessary. The bottom line is that we have to protect patients by protecting antibiotics. The drugs we have today are endangered. And any new drugs we get could be lost just as quickly if we don't improve the way we prescribe and use them. If we don't improve our stewardship. And I’m really delighted to be doing this release in partnership with the American Hospital Association, and I’ll turn it over now to Dr. Combes.
DR. JOHN COMBES: Well, thank you, Dr. Frieden, and thank you for the great work that the CDC is doing in this area. And also for the opportunity to talk about what hospitals and their physicians are already doing to improve antibiotic stewardship and how we plan to continue to work with you, the CDC, and other partners on this important issue. Hospitals and their physician staff work hard to address the needs of every patient. And to ensure that the most appropriate antibiotic is given to patients who need treatment and prescribe them only when and for how long they are needed. Clinicians in hospitals are working together to identify the appropriate antibiotics for those patients whose presumptive infections will be effectively treated but which will not lead to avoidable complications and the emergence of resistance. It appears from the data in this vital signs report that our clinicians are very engaged in prescribing antibiotics for hospitalized patients. But there may be opportunities to achieve more appropriate prescribing practices including choosing the appropriate antibiotics for the clinical condition and at the optimal dose and duration of treatment. We recognize we must improve our practices. Not only for the benefit of the patients under our care but also to preserve the effectiveness of antibiotics for future patients. Over the past few years hospitals across the country have demonstrated their ability to team up with their doctors to more appropriately use prophylactic antibiotics for the surgical patient. Additionally, many organizations have reduced the need for antibiotics by preventing health care-acquired infections including the significant reductions in central line associated bloodstream infections and catheter-associated urinary tract infections. Work that was greatly supported by the CDC in partnership with America's hospitals. The lessons learned from these successes can help us achieve more appropriate utilization of antibiotics. Protecting our patients from their adverse effects while preserving their effectiveness in treating many life-threatening infections. Even before today's announcement the American Hospital Association was already working to help hospitals with antibiotic stewardship. In the past year the American Hospital Association, with guidance from its committee on clinical leadership and its physician leadership forum and other constituencies, examined and discussed the appropriate use of medical resources. We developed a top five list of hospital-based procedures or interventions that should be reviewed and discussed by both patients and their physicians prior to their use. The report, entitled "the appropriate use of medical resources," was published by the association in November of last year. It outlines the fact its driving overuse, the clinical evidence for inappropriate utilization, and some of the approaches currently under way to reduce overuse. It also included a discussion guide to begin the conversation among hospital leaders, board members, and fissions about how to approach the most appropriate use of resources and what changes it will mean for how hospitals and physicians provide care. Antibiotic stewardship is one of those five areas that are addressed in the report. To address this issue we are working with partners to create a tool kit of resources to assist our hospital members in developing anti-microbial and antibiotic stewardship programs. After the tools are identified, some of which are provided by this report and in partnership with the CDC, these resources will be disseminated widely to our membership. We anticipate the toolkit to be available later this year. We will continue to work with the association for professionals in infection control and epidemiology to develop resources for this anti-microbial stewardship toolkit as well as building off the resources developed by the CDC and highlighted on today's call. Ensuring quality patient care is the number one job for hospitals and their physicians. Hospitals have long worked hard at controlling infections. Preventing infections is a never-ending process within the organization, and new challenges and situations are emerging daily. But we recognize that more can be done and will be done. Thank you so much, Dr. Frieden, for this opportunity to collaborate with the CDC on this very important issue.
TOM SKINNER: Thank you, Dr. Combes. And Elaine, I believe we are ready for questions, please.
OPERATOR: Thank you. At this time if you would like to answer a question please press star 1 on your touch-tone phone. You will be prompted to record your name and please record your name promptly when quoted. Once again, to ask questions please press star 1. And once again, if you would like to ask a question, please press star 1. And our first question today is from Maryn McKenna from Wired.
MARYN MCKENNA: Hi. Thanks so much for doing this call and respecting the embargo, Dr. Frieden, that's quite a piece of cash you have coming your way in the budget. That's impressive. I think the question is for both of you. When I’ve spent time in hospital talking to physicians about prescribing practices, what I’ve heard over and over again is that there are some physicians — never the ones I’m talking to of course — who feel that stewardship programs are in some manner an infringement on their autonomy, that they know best what to do for their patients and they are concerned that when someone says oh, you can't use drug x, you have to use drug y, that their ability to treat their patients is impaired. Could you address that? Maybe that goes to Dr. Combes more than to Dr. Frieden.
DR. JOHN COMBES: Well, I’d be happy to address that. I think there is a confusion about what professional autonomy means. Professional autonomy means doing the best for the patient and as you heard Dr. Frieden say, good anti-microbial stewardship is not only good for the population of patients but also good for that individual patient. Choosing the right antibiotic for the right duration and avoiding the potential complications is in the best interest for the patient. As physicians we can't have all the knowledge at our fingertips. Health care has become more of a team sport. We need the support of a clinical pharmacist, the infection control staff, as well as our infectious disease doctors to make sure we're choosing the right antibiotic among the plethora of antibiotics that are out there. The one that is focused on the presumed infection of the patient and is used in a targeted way over the shortest period of time. I think when we talk about professional autonomy it's not the right to choose what we want. It's the right to practice the best evidence-based medicine that's available. And oftentimes that support has to come from a team of people who understand the organization's resistance patterns, the way that drugs work within that organization, and the ones that are most appropriate to prevent complications and to preserve the effectiveness of the antibiotics.
TOM FRIEDEN: This is Dr. Frieden. I would just second everything Dr. Combes says and point out that what we're suggesting is not that hospitals limit the antibiotics that are used but that hospitals look at their data and come up with a plan appropriate to their patient population, a plan that's led in most cases by a physician, and then track that. What we've heard from hospitals is that often when they do implement such a program they may identify a few physicians whose prescribing isn't quite consistent with what they think the best practices are. And then by having a standardized approach they can then assess that approach to see if its working and they can discuss with individual physicians if they think there are differences. But fundamentally, it's about basing the decisions on the appropriate data that's appropriate for that hospital.
MARYN MCKENNA: Can I ask a follow-up question?
TOM SKINNER: Yes, you may.
MARYN MCKENNA: So actually, it's an unrelated question. So, Dr. Frieden, obviously today is just the first announcement, and so it's more of a wish list than a done deal. But what's CDC going to do with increased funding for anti-microbial resistance?
TOM FRIEDEN: It really very much follows what we recommended last year. It would allow us to extend the detect and protect approach. It would help us support states and hospitals to implement stewardship programs like the one that we're recommending here. It would allow us to improve the rapid detection of anti-microbial threats as well as the detection of outbreaks around the country. I think one of the things that makes us so focused on anti-microbial resistance is not only is it a really serious problem but it's not too late. We can reverse drug resistance. And we anticipate that if funded over a five-year period, and this is the 2015 proposal is $30 million for 2015, over a five-year period we anticipate that we would be able, working in partnership with the Hospital Association, with health care providers, with CMS and others, we would be able to reduce the rate of C. Difficileby half, preventing thousands of deaths and hospitalizations and health care costs, and also reduce the deadliest bacteria, CRE, carbapenem-resistant enterobacteriaceae, by half as well by implementing programs such as this and responding rapidly to reverse rates.
TOM SKINNER: Next question, Elaine.
OPERATOR: Thank you. Our next question is from Valerie Bauerlein from Wall Street Journal.
VALERIE BAUERLEIN: Thank you. And Dr. Frieden, you just addressed my question, the concrete goal over a five-year period to reduce C. difficile by half. But could you talk a little bit about what gives you hope that it's not too late?
TOM FRIEDEN: So first off, when you come to C. diff, if you look at what different systems have done and what some countries have done, they've been able to reduce rates by half with stewardship programs, sometimes combined with environmental cleaning or control or isolation programs. So we think it's possible because it's been done. In terms of CRE, we've also seen communities be able to really use the detect and protect mechanism to identify patients to make sure it stops spreading and then to isolate those patients until they either clear the organism or at least isolate them so they don't spread it to others. So I think in both cases this isn't just theory. We've seen systems. We've seen countries do this. And I’m very confident that if we invest we'll be able to do it here.
VALERIE BAUERLEIN: Are there any systems or countries that we should take a look at?
TOM FRIEDEN: Let me ask Dr. Srinivasan if he wants to comment. I know that the UK has cut their C. diff rate drastically. Dr. Srinivasan?
ARJUN SRINIVASAN: Thank you, Dr. Frieden. Yeah, i think the UK is a wonderful example of what can happen when you work in a coordinated way to reduce antibiotic use and the impact that can have on clostridium difficile. As Dr. Frieden mentioned, over the past seven years the United Kingdom has engaged in a robust effort throughout the country to reduce the use of the antibiotics that are most associated with clostridium difficile. So exactly what we talk about in the MMWR Vital Signs report. And what they have seen is a more than 50 percent reduction in the use of those targeted agents, and they've seen a roughly 70 percent reduction in clostridium difficile over the past six to seven years. So a very dramatic example of the impact of improving antibiotic use on reducing clostridium difficile.
TOM FRIEDEN: And I would just add to that that regardless of the system of payment this is about hospitals getting together, agreeing on protocols, and then implementing those protocols.
TOM SKINNER: Next question, Elaine?
OPERATOR: Thank you. Our next question is from Brian Krans from Healthline news.
BRIAN KRANS: Hi. Yeah. I know that the FDA is working to currently lower antibiotic use in livestock by asking the pharmaceutical companies to change their labeling. Is there any push toward the FDA to institute a kind of program like that where there would be stricter labeling, what kind of antibiotics can be used and when in humans?
TOM FRIEDEN: I think really what we're focusing on here is use in hospitals. Dr. Srinivasan, anything more you'd like to add?
ARJUN SRINIVASAN: No, I don't think so. I think that as you're suggesting the solution here is not to change the labeling of the drugs but to really improve the way the drugs are used in clinical practice. And that's where we want to really get people to focus on, and we want to develop the infrastructure within hospitals so that every clinician who prescribes a drug knows exactly how to use that drug optimally in the circumstances of their particular hospital.
BRIAN KRANS: Thank you.
TOM SKINNER: Next question, please.
OPERATOR: Thank you. And our next question is from Jim Dwyer from New York Times
JIM DWYER: Hi. I was wondering if the new guidance or the enhanced guidance conflicts with or bumps into the guidelines for early administration of antibiotics in cases of suspected sepsis.
TOM FRIEDEN: I’m glad you asked that question because there's actually absolutely no conflict there. We certainly agree. Anytime someone has suspected sepsis, they should be evaluated promptly and treated promptly. What we're saying is start promptly but also have systematic reassessment. And if you look at the very strong sepsis protocols out of New York State, they have in their protocol get the diagnostic workup promptly, start treatment promptly, and have a systematic reevaluation. And that's exactly what we're calling for. So I'm glad you asked that because there can be the misperception that there's some conflict between these approaches. But that's not the case. We're not saying use — don't start patients on antibiotics. We're saying use antibiotics wisely. And that means start treatment soon but get the tests before you start that treatment, and those are part of the New York state regulations and assess them systematically. Assess the patient systematically after 48, 72 hours so you can determine whether or not you can tailor the antibiotics or a change in some other way.
JOHN COMBES: This should not be looked at as sort of a bureaucratic obstacle to good clinical care. This is good clinical care. This is really encouraging patients to — physicians to work up their patients completely before starting the antibiotic, promptly choose an antibiotic that covers the presumptive cause of the illness, and then reevaluate that. When cultures return, 48 hours, to make sure you have the right antibiotic that's treating the right infection and is sensitive to it. That's nothing more than good clinical care. I think what's happening here is we're asked to better organize our resources within the hospital to support that good clinical decision-making. And that's what an antibiotic stewardship program is all about.
TOM SKINNER: Next question, please.
OPERATOR: Thank you. Our next question is from Bridget Kuehn from JAMA Medical News.
BRIDGET KUEHN: Hello. Thank you for taking my question. I wanted to ask if — how the program will work to — I know with CRE there was a lot of exchange of the passage in between, say, long-term care facilities and hospitals and sort of inter — how do you plan to address interfacility transmission of these infections?
TOM FRIEDEN: So, this is one reason we've encouraged hospitals to work regionally and work with their state health departments, because often public health can serve as an honest broker to draw people together, to pool information on anti-microbial resistance patterns. Let me ask first Dr. Srinivasan and then Dr. Combes to comment further.
ARJUN SRINIVASAN: Thank you. You're absolutely right. And in fact, that's one of the reasons why we highlight as one of the critical steps not just the things that individual hospitals need to do but we highlight the fact that we need to work collaboratively. And I think what we've also seen is that when hospitals work collaboratively and even include working with nursing homes and other types of health care facilities that there is a lot that they learn from that work with each other that helps them all improve antibiotic use. So it ends up being a win-win when those facilities get together and work together on those types of strategies to improve use and reduce the spread of these organisms. Dr. Combes?
JOHN COMBES: Yeah. What we are seeing our hospitals do now is to reach out to their public health agencies to understand the environment in which they're operating, what is the public health environment. Additionally, we've been working more and more closely with long-term care facilities, particularly around the causes of readmissions as well as their antibiotic resistant patterns. And the more we have these conversations, as Dr. Frieden has said, the more we learn and are able to better take care of the patients and return them to an environment that's safe for them and that prevents them from being readmitted to the hospital. So we're taking very seriously that our hospitals are one part of a continuous system of care and beginning to engage all parts of that system in making those transitions smoother and making sure we understand the environment that we're receiving the patient from.
TOM SKINNER: Next question, Elaine.
OPERATOR: Thank you. Our next question is from Stacey Singer from the Palm Beach Post.
STACEY SINGER: Hi. Thanks for taking my question. I've been doing some research on this, and it looks — what I’m hearing in my community is that the transferring issue is a huge one, that some of these long-term acute care hospitals never know if they're being transferred patients with multidrug resistant infections and when they send them back out or if they have an outbreak they're not informing the hospitals, so doctors are transferring patients into an outbreak situation with neither the doctor nor the patients knowing. You're talking about these transfer forms as sort of a voluntary thing, but they've been on the board for quite a while. And here at least nobody's using them. In fact, nobody's reporting these conditions either. At this point are regulations needed? Would you look to see states implement regulations?
TOM FRIEDEN: There are many states that are doing more and more in this space. And what we hope is that there will be coordinated work, that each of the institutions will recognize that it's in all of their interests to work across the region. Again, I’ll ask Dr. Srinivasan and Dr. Combes to comment further.
ARJUN SRINIVASAN: Thanks, Dr. Frieden. I think that's exactly right. These issues are critical at the local level. What's important here as you're pointing out is making sure that the facilities that transfer patients to each other most commonly communicate with each other closely. So this really is something where there is a need for facilities to come together and we've seen very good examples of health departments being that honest broker Dr. Frieden mentioned to get facilities together. Many places have taken steps to do this proactively and to communicate effectively. And so what we want to see is facilities and communities come together to decide what are the best ways to do that. Dr. Combes?
JOHN COMBES: We have very good examples of organization that's are working together to smooth out these transitions and to keep each other informed of either outbreaks or particular problems with a particular pathogen. And that we have a whole part of the AHA. That concentrates on this, and it's called hospitals in pursuit of excellence. And there are case studies of organizations that have done a better job and sort of the exemplar of the how to work closely with your surrounding facilities. We work very hard to spread that out to our membership so that while there are pockets in the country where this may not be happening yet it's our goal to make sure that everybody understands what these practices are and how best to achieve the smoother transition for the patients to prevent some of these complications.
TOM SKINNER: Elaine, we'll take two more questions, please.
OPERATOR: Thank you. Our next question is from Cheryl Clark from Health Leaders Media.
CHERYL CLARK: Thanks very much. I wonder if you can comment more on the variation and whether you could say that there's a particular type of hospital, say, a hospital with more surgical patients than medical patients. Maybe they're overenthusiastically observing SCIP measures and BVP, like you had with the four-hour for suspected pneumonia patients where there was a bit of overenthusiastic antibiotic prescribing. Can you talk about who we need to pay attention to more acutely, who's doing it right and who's doing it wrong with the variation?
TOM FRIEDEN: Dr. Srinivasan?
ARJUN SRINIVASAN: Thank you. That's an excellent question, and it's the one that we are asking now. And I think the next step for us is having described the variation is to determine what the contributing factors to that variation are. And that's exactly the type of work that we intend to move forward with next.
TOM SKINNER: Last question, Elaine.
OPERATOR: At this time I am showing no further questions. As a reminder, to ask a question please press star 1.
TOM SKINNER: Elaine, I think we'll conclude the call. We'll have Dr. Frieden just provide some closing comments, and then we'll conclude the call. Thank you.
TOM FRIEDEN: Thank you all very much for joining us. The bottom line here is we have new data showing quite a bit of variability of antibiotic prescribing practices in hospitals. We have identified practices that can be greatly improved and are working collaboratively and collegially with hospitals and others to improve those practices. We've outlined an effective approach to anti-microbial stewardship in hospitals, and we think that if these and other recommendations are followed we will be able to drastically reduce both deadly C. diff infections and the nightmare bacteria infections with CRE over the coming years. So thank you all very much for your interest.
TOM SKINNER: Elaine, this concludes our call. Reporters wanting additional information or if they have additional questions can call the CDC press office at 404-639-3286. Thank you once again for joining us.
OPERATOR: Thank you. And this does conclude today's conference. You may disconnect at this time.
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