I had a wonderful opportunity to speak at a hospital in the Richmond community this week about antibiotic resistance and stewardship; I was asked to speak by that health system's Antimicrobial Stewardship Program as part of their activities around "Get Smart About Antibiotics" week. I was asked to write up my talk so they could share it with their health system. My write-up is below.
The Crisis of Antibiotic Resistance: Are We Entering the
Post-Antibiotic Era?
In November we celebrate the CDC’s “Get Smart About
Antibiotics Week,” an event designed to raise awareness about the crisis of
antibiotic resistance and to outline possible solutions. To answer the question
of whether we are entering a post-antibiotic era: in a word, yes. But there is
hope.
Antibiotics are potentially life-saving compounds, and their
discovery has been critical to many of the medical and surgical advances we
have seen in the past 75 years. Without antibiotics patients would not be able
to survive the infectious complications of things like chemotherapy, organ
transplantation and immune suppression for rheumatologic diseases.
We truly are at a crisis point with antibiotic resistance,
especially for multi-drug resistant gram negative rods (MDR GNR). For many
patients with MDR GNR infections we have essentially returned to 19th
century medicine: in the absence of antibiotics we are left with pursuing
aggressive ‘source control’ for infected tissues, when possible. An example
would be a patient with a diabetic foot infection: whereas surgery and
antibiotics can often cure these infections, a patient with an infection with a
pan-resistant GNR may require amputation. This is not a doomsday scenario, this
is reality for many of our patients in 2015.
The CDC estimates that 2 million people acquire infections
with antibiotic-resistance bacteria yearly and 23,000 die as a direct result of
these infections. It is estimated these infections lead to upwards of 35
billion dollars in excess healthcare costs in the United States alone. These
statistics do not fully capture the scope of the problem, however, as the
morbidity associated with these infections can be significant.
Here is the problem in a nutshell: antibiotic use selects
for resistant organisms and the emergence of resistance has outpaced the
development of new antibiotics. Most of the antibiotics in use today are
natural products that organisms have been using to battle one another for
millennia; we have ‘discovered’ these and adopted them for use in humans and
animals. The antimicrobial ‘resistome’ (the resistance capacity of organisms to
overcome antibiotics) already exists in nature, presumably for most if not all
antibiotics. This is why we see resistance emerge fairly rapidly whenever ‘new’
antibiotics are deployed.
Antibiotic use extends far beyond therapeutic use in humans.
It is estimated that 70% of antibiotic use is in animals for non-therapeutic
use. Antibiotics are often used in the animal industry to grow larger, fatter
animals faster. Any solutions to the crisis of antibiotic resistance have to
span the continuum of use in both animals and humans.
Our relationship with the microbes who live on and inside is
not well understood; there is increasing evidence that there may be a symbiotic
relationship with our ‘microbiome,’ however. There are an astounding 10
bacterial cells for every 1 human cell in the human body. There is some
intriguing data that suggests altering our microbiome with antibiotics can lead
to things like allergies and obesity. Antibiotics should not be seen as
innocuous.
It is estimated 50% of all antibiotic use in human medicine
is unnecessary. The reasons for this are myriad. Front-line providers need
rapid, accurate, affordable tests to diagnose the etiology of things like upper
respiratory infections and urinary tract infections. We also need better
protocols for treating various infectious conditions informed by properly performed
clinical trials. We need better surveillance technologies to identify
antibiotic resistance and standardized, risk adjusted data on antibiotic
prescribing at the provider level.
Beyond all of the above we need new antibiotics to combat
drug-resistant bacteria. To date there is no new anti-GNR compound with a novel
mechanism of action in the antibiotic creation ‘pipeline.’ Although the FDA
approval mechanism for antibiotics has become more streamlined in recent years,
we have seen far fewer antibiotics in development. Many pharmaceutical
companies have abandoned antibiotic development altogether.
So what can be done in 2015 to combat this issue by individual
providers? First and foremost we should strive to prevent infections. Vaccinate
patients according to national guidelines, wash your hands before and after
patient contact and use appropriate contact precautions in the inpatient
environment. We can also prevent the emergence of antibiotic resistance by
optimizing our antibiotic use, especially for inpatient medicine. Record the
indication, dose and expected duration when ordering antibiotics. Take a daily
‘time out’ for each patient on antibiotics to re-assess their use and continued
need. Be aggressive with diagnostics early on to aid in de-escalation later.
And perhaps most importantly partner with your Antimicrobial Stewardship Team.
These teams exist to assist you in optimizing antibiotic use and can be a
terrific resource.
Many of our patients have already entered the
‘post-antibiotic era.’ The development of antibiotic resistance has outpaced
new drug development. The issue is complex but first and foremost we need to be
aware of just how dire the problem is and that we all have a role to play in
its solution. It has been 75 years since we saw the widespread deployment of
antibiotics. Unless major changes occur in antibiotic use and production we are
in danger of fully returning to 19th century practice for many of
our patients.
