By Barry C. Fox, M.D., University of Wisconsin
Antibiotics have been around since the 1940s and are commonplace these days. Then why the sudden heightened interest now? Well, unfortunately, antibiotic-resistant germs are becoming much more common and, to further complicate things, the development of new antibiotics has stalled over the past two decades.
What Is Contributing to the Acceleration of Antibiotic Resistance?
The World Health Organization has proclaimed concern over antibiotic resistance over the last few years. The ability to develop antibiotics has decreased over time. This includes the inability to discover new molecular targets in bacteria, and the failure to find target drugs that exhibit antimicrobial properties.
Another disturbing problem is there are disincentives to the pharmaceutical industry to develop drugs that are only taken for limited periods of time, which have limited financial incentive when compared with drugs for chronic illnesses such as hypertension or diabetes. Since 1983, there has been a stunning decline in the number of antibiotics discovered.
Take the example of the prescription antibiotics for respiratory tract infections that includes sinusitis, ear infections, sore throats, and chest colds. Respiratory illness accounts for an overwhelming majority of outpatient antibiotic use. Antibiotics are prescribed by primary health-care providers for these conditions about 50 percent of the time.
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Why Do Doctors Prescribe Medicine When It Is Not Really Needed?
It is known that antibiotics don’t work for viral illnesses, and there’s increasing evidence-based medicine that ear and sinus conditions get better within 10 days with or without antibiotics. Also, only five percent of adult sore throats are caused by streptococcus that requires antibiotics. Antibiotics are really only needed to be prescribed for respiratory conditions somewhere between five to 10 percent of the time.
So why is there such a discrepancy between prescribing habits and the actual need? Well, there are factors in motion that can easily lead to antibiotic overprescription.
From a patient’s standpoint, they might have been treated with antibiotics in the past for the same condition and had the impression, correctly or not, that they improved due to the antibiotic.
From a health-care provider’s perspective, it takes time to explain to a patient why they might not need an antibiotic. They also want to satisfy their patient’s expectations, out of concern that the same patient might go down the street to another provider that prescribes antibiotics.
The situation is only magnified by the acuity of the illness, meaning visits to urgent care centers and emergency departments are likely to have even more implicit pressure to yield an antibiotic prescription.
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People, Doctors Have to Get Smart
The CDC has been aware of this patient and provider paradox for at least the past decade and has initiated a campaign known as Get Smart to educate patients and families about the need, risk, benefits, and side effects associated with antibiotic prescriptions. It also provides educational tools for health-care providers to make it easier for patients to understand why antibiotics might not be appropriate.
The use of antibiotics kills not only the intended bacteria but also has collateral damage on good bacteria. This has made Clostridium Difficile the top urgent health-care threat to the United States (caused by an overgrowth of these bad bacteria in the colon). In a macro sense, people have a vested interest in ensuring antibiotics are only prescribed when necessary.
In a hospital setting, the percentage of antibiotics prescribed that are either unnecessary or incorrectly used is, remarkably, no different than in the outpatient setting, 50 percent. Patients in the hospital, however, have little or no choice in the decision-making process of whether they receive antibiotics or not.
The Antimicrobial Stewardship: A Team of Professionals in Every Hospital
Who is going to protect the patients? Well, a concept has evolved over the past decade known as antimicrobial stewardship. Its intention is to use antibiotics wisely and safely. An antibiotic stewardship team is composed of professionals who review antibiotic prescribing habits in the hospital for each individual patient as well as overall antibiotic prescription trends.
Another dimension in antibiotic resistance is the widespread use of antibiotics in food-producing animals, which amazingly accounts for nearly 80 percent of antibiotic use overall. More than 75 percent of this use is just for fattening animals.
This use, especially with subtherapeutic antibiotic concentrations, contributes to the emergence of antibiotic-resistant bacteria in food-producing animals that can be transmitted to humans.
Fortunately, there are legislative efforts moving forward in the United States that bring pharmaceutical manufacturers, the American Dairy Association, as well as health departments together to agree to limit the use of antibiotics in food-producing animals to medicinal purposes only.
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Slowing Down the Speed of Resistance Development in Bacteria
In 2014, President Obama issued both an Executive Order and a U.S. national strategy to combat antibiotic-resistant bacteria, and this included establishing a task force for combating resistant bacteria.
To stimulate new antibiotic development, the Food and Drug Administration, or FDA, is also trying to motivate pharmaceutical companies to devote time and money to the research and development of new antibiotics, including passing the Generating Antibiotic Incentives Now Act.
The FDA can also designate a potentially new antibiotic as a fast-track antibiotic and grant it priority review. This requires all federal health-care programs to have antimicrobial stewardship, strengthening national surveillance and international collaboration efforts against resistant bacteria, and promoting the development of next-generation antibiotics.
Common Questions about What Can Be Done to Stop Antibiotic Resistance
The primary reason is patients don’t wait for explanations and they could just as easily get the medication they want from another doctor that is willing to prescribe it to them. So doctors have to try and meet the patient’s expectations despite knowing how drug resistance will grow.
Antibiotics should only be used when necessary. So one way to improve the use of it is not trying to force our doctor to prescribe medication that we want even when the doctor deems it unnecessary. If most of us did this it would slow down the rate of growth in drug resistant microbes.
An antibiotic stewardship team is usually composed of pharmacists, infectious disease physicians, and microbiologists. This team’s job is to make sure unnecessary antibiotics aren’t prescribed so it doesn’t lead to drug resistant bacteria.
