The current state of antibiotic resistance: A cautionary tale

It's difficult to imagine a world without antibiotics. Had the world not undergone its "Golden Age of Antibiotics" in the 1940s, modern medicine would look drastically different. Antibiotics have been a boon to modern medicine, allowing physicians to perform open surgeries while minimizing the risk of infection. Outside the hospital, splinters and ear infections are no longer death sentences.

 

It sounds nightmarish, the thought of dying from something as simple as an ear infection, but given the current path of antibiotic resistance, the world is on the fast-track to returning to a state eerily similar to before the discovery of antibiotics, and such a dystopic state could be closer than expected.

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In the words of the World Health Organization, "A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century."

According to the Centers for Disease Control and Prevention, approximately 2 million people are infected with antibiotic-resistance bacteria each year, and 23,000 people will die as a direct result of such infections. That number does not include the number of people who die from complications relating to infections.

Several bacteria have already produced specific antibiotic-resistant forms, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterobacteriaceae. Now, other pathogens are developing resistance to antibiotics, largely due to overprescribing or inappropriate antibiotic use.

Problem No. 1: Overprescribing
Antibiotics changed the way society approaches medicine, but they became a catch-all treatment for many ailments.

"Our society has really leaned on antibiotics as a quick fix and doesn't understand the negative consequences of using antibiotics," says Kavita Trivedi, MD, principal of Trivedi Consults and chair of the education committee of the Society for Healthcare Epidemiology of America. "They can help prevent a lot of problems, but we've swung the other way of the pendulum."

Nearly one-half of all prescribed antibiotics are inappropriate, estimates Dr. Trivedi. Reasons for overprescribing antibiotics vary from the clinical to the legal to questions regarding knowledge of antibiotic use, Dr. Trivedi suggests.

The clinical and legal elements often go hand-in-hand, as physicians may prescribe an antibiotic in case of the event a patient develops an infection. Not only does the clinician want to thoroughly treat the patient, but the prescription also covers a potential liability for undertreatment or malpractice by taking the extra step to prescribe the antibiotic as a precaution. However, it is this very precaution and the prescribing of the antibiotic that perpetuates the cycle of resistance.

"Our society is more litigious," Dr. Trivedi says. "We're more concerned about being sued as healthcare providers if we miss one bacterial infection when most likely the problem is a viral infection, so we treat with antibiotics in that circumstance as well."

What's more, antibiotic resistance is a significant economic strain on the economy. Not only does overprescribing lead to significant costs just in paying for prescriptions — a recent study in Infection Control and Hospital Epidemiology estimates unnecessary antibiotic prescriptions could exceed $163 million over three years — but the residual costs of patient care add up.

"It's because of the poorer outcomes of patients with resistant infections that they end up staying in our hospitals longer and are more often transferred to post-acute care facilities instead of going home," Dr. Trivedi says. "From an economic standpoint, resistant infections are certainly costing our whole healthcare system more money."

The issue with antibiotic R&D
Among all this discussion, questions regarding new drug development are frequently asked. Why don't pharmaceutical companies just make new antibiotics to which bacteria have not yet developed resistance?

The answer is in the question asked. The bacteria have not yet developed resistance. But, chances are, in any handful of years, they will.

And herein lies the problem: Pharmaceutical companies are not investing in developing new antibiotics because there is no profit to be made in this industry anymore. "Many pharmaceutical companies have dropped out of the whole antibiotic development market because they have learned from a profit standpoint when you develop an antibiotic you have the potential to develop resistance, then your antibiotic becomes one that can't be used," Dr. Trivedi says.

Even if a pharmaceutical company were to develop a new, novel antibiotic, the nature of such drugs is that patients take them for a specified period of time, usually no more than a couple of weeks. Compare that to drugs for managing chronic conditions, such as antihypertensive drugs which one takes once a day for the rest of his or her life, and the lack of incentive to direct research and development dollars toward antibiotics becomes clear, Dr. Trivedi suggests.

In a market that is driven by profit, new antibiotics won't do.

The focus then shifts away from new drug development and back to the drawing board. "We have to operate under the assumption we are not going to have any new antibiotics to work with in the next decade," says Dr. Trivedi.  "Therefore, it is imperative we use the antibiotics we have today more prudently."

Knowledge is power
Physicians are aware of the growing threat of antibiotic resistance, so the rate of overprescribing and inappropriate use seems incongruent. However, 80 years of encouraging clinicians to use antibiotics isn't easily changed. Additionally, frequent patient demands for antibiotics also contribute to the problem.

Dr. Trivedi suggests negotiating with patients as a start to opening the door to patient education and improved prescribing practices. For example, if a patient comes to a clinic with a clear viral infection, the clinician can initially refuse the antibiotic but offer to reassess the situation in a couple of days. "This allows for more discussions with patients on treatments and options instead of deciding something on day two [of the illness] instead of not having data on day five," Dr. Trivedi says.

Another booster to education could be reporting antibiotic use, much like hospitals are required to do for healthcare-associated infections.

Dr. Trivedi suggests the federal government could implement similar reporting requirements on antibiotic use and resistance in healthcare facilities as they have for infections. "As this information is publicly available, administrators get more interested in what those numbers actually are," she says. "We could have the consequence of administrations focusing on this issue if we make it publicly available."

What else can the feds do?
The federal government has the ability to play a tangible, actionable role in the fight against antibiotic resistance. In fact, the current administration has already made moves demonstrating the importance of the issue and the government's priority to address it.

In September, President Barack Obama signed an executive order establishing a task force for combating antibiotic-resistant bacteria. The task force is charged with implementing antimicrobial stewardship guidelines and recommendations outlined by the President's Council of Advisors on Science and Technology in what is known as the PCAST report. (Disclosure: Dr. Trivedi helped advise the PCAST report).

The PCAST report outlines eight recommendations for the federal government to spearhead to help address the growing rates of antibiotic resistance: making antibiotic resistance a national priority, strengthening the capacity for surveillance and response, supporting fundamental research for new antibiotics, boosting clinical trials, implementing mechanisms for commercial antibiotic development, advancing current antibiotic stewardship programs in human healthcare, advancing antibiotic stewardship programs in agriculture and ensuring effective international coordination.

A societal, not clinical shift
Without the promise of new antibiotics and with the growing concern over patient safety, infection control and clinical quality, the federal government has a critical role in ramping up best practices and educational initiatives surrounding antibiotic resistance.

President Obama has already started turning those wheels with the signing of the executive order. Additionally, Dr. Trivedi says an increase in funding and support for research and innovation are important to the cause, which are tenets of the PCAST report.

But, the change will be slow.

"It's not that healthcare providers are meaning to use a lot of antibiotics," says Dr. Trivedi. "It's the way we have learned medicine in the past 20 to 30 years….We have to change the way we think about antibiotics and practice more as though antibiotics are a societal medication rather than a patient-specific medication since the decision to use antibiotics effects society at large."

More articles on antibiotic resistance:

C. diff meets its match in natural gut flora
Antibiotic stewardship programs cut pediatric LOS, readmissions, finds study
The 4 most commonly administered antibiotics

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