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Antibiotics: An over-prescribed epidemic causing "Super Bugs"?

General, Immune | September 6, 2014 | Author: The Super Pharmacist

bacteria, general, antibiotics

Antibiotics: An over-prescribed epidemic causing "Super Bugs"?

Bacteria are living organisms and like every living organism, they have a biological directive to grow, reproduce, and survive. Every surface of the body and almost all of the gastrointestinal tract is covered by bacteria. Some of these are innocuous, some are helpful, and occasionally some will cause human disease. This latter type of bacteria is called a pathogen. Antibiotics are prescribed to destroy pathogens, but they also destroy innocuous and helpful bacteria at the same time.

Our defense against pathogens relies on antibiotics, a healthy immune system, and helpful bacteria on and in our bodies that compete with pathogens for space and food.

How bacteria develop resistance to an antibiotic

Depending on the type, an antibiotic may be directly toxic to bacteria, may interfere with their ability to reproduce, or may simply slow down the rate at which bacteria multiply. But bacteria have their own mechanisms to fight against this assault. Each time a bacteria reproduces, it has the potential to introduce a mutation into its offspring that may make it more likely to be resistant against antibiotics. Perhaps the new bacterium has a subtle difference in itself wall, or one of the enzymes that allow it to reproduce. In essence, it is a numbers game. Pathogens have the advantage of numbering in the millions and can reproduce extremely rapidly thereby increasing the chance of creating an antibiotic-resistant mutant among their offspring.

Unless a community of pathogens is fully contained by a combination of antibiotics, the immune system, and helpful bacteria, the infectious disease will continue, and the chance of a resistant organism emerging increases.

The balance between individual patient care and public health

The balance between individual patient care and public healthPatients who seek treatment for bacterial infections deserve prompt and definitive treatment. However, it is not always possible to quickly identify the particular bacterium that is causing illness.

A physician must describe in antibiotic based on an educated guess and known probabilities of infection and disease.

While this serves the interests of the patient, is not necessarily in the best interests of the public as a whole.

Likewise, patients may not have a bacterial infection, but be treated presumptively with an antibiotic.

Each time this is done, it increases the chances of developing an antibiotic-resistant bacterium.

Empirical versus targeted treatment of bacterial infection

Bacterial cultures usually take between two and seven days before they produce actionable results. During this time, the bacterium is grown on a culture medium and subjected to antibiotic susceptibility testing. During this testing, the bacteria is placed in a dish with antibiotics—resistant bacteria will grow right next to the antibiotic while sensitive bacteria will die in a circle around the antibiotic. Since this process takes time, the patient is treated empirically with a broad-spectrum antibiotic chosen because based on factors such as the history and physical diagnosis of the patient, the most likely causative bacterium, and what is known about antibiotic resistant bugs in a particular region. Once the culture results are available, the antibiotic may need to be changed from what was chosen initially, to one that is known to be effective against a particular bacterium—usually a narrow-spectrum antibiotic.

Good antibiotic prescribing stewardship

The Infectious Diseases Society of America (IDSA) defines antimicrobial stewardship as - 

Good antibiotic prescribing stewardship“optimising the indication, selection, dosing, route of administration and duration of antimicrobial therapy to maximise clinical cure or prevention of infection while limiting the collateral damage of antimicrobial use, including toxicity, selection of pathogenic organisms, and emergence of resistance.”

In simpler terms this means:

  • Choosing the right antibiotic - the prescribing physicians should choose the most narrow-spectrum antibiotic possible for each patient
     
  • Dosage - the dosage of antibiotic chosen should be high enough to prevent or eradicate an infection
     
  • Duration - the duration that the antibiotic is given should be sufficient to fully eradicate the pathogen

These goals must be balanced with patient concerns such as side effects and dose of antibiotic.

How patients can help minimise antibiotic resistance

While healthcare is somewhat unique, it is still a service industry. Physicians have a duty to take care of their patients for the best possible outcome. There is significant pressure to satisfy each patient that appears at the hospital or in clinic. It is sometimes difficult to balance sometimes vague public health priorities with the demands of a needy patient sitting across the room.

Patients should take comfort in the fact that most common infections in outpatient settings are viral, rather than bacterial.

If your physician determines that your illness is most likely caused by a virus and wishes to take a “wait and see” approach, if you are interested in curbing antibiotic resistance you will not provide resistance of your own to this suggestion. If you are prescribed antibiotics for an illness, know that the duration of treatment was selected for reason. In other words, you should take the full course of the antibiotic regardless of whether you feel better or not. Bacteria may still be alive and reproducing inside your body but no longer causing symptoms of illness. Nonetheless, you need to eradicate them fully and the best way to do this is to take the entire course of antibiotics.

The future of antibiotic resistance

The rate at which major bacterial pathogens are developing antibiotic resistance has been called “alarming” and “critical.” Each year in the United States, over 2 million people are infected with antibiotic resistant bacteria and over 20,000 individuals die from complications related to those illnesses.

As a society, we are quickly running out of treatment options for certain types of bacteria—bacteria that can cause lethal disease.

The future of antibiotic resistanceTo provide a sense of the scope of the problem, infectious disease departments and hospital pharmacies routinely prevent other physicians from prescribing new and powerful antibiotics without prior approval. This is done so that they can hold the most powerful antibiotics in reserve as a last resort in the treatment of highly resistant strains Pharmaceutical companies are challenged in keeping ahead of emerging resistant pathogens. 

The Centers for Disease Control and Prevention (CDC) have warned that the antibiotic pipeline is nearly empty. Regulatory agencies and legislators are considering streamlined approval processes to speed development of new antibiotic drugs and to make antibiotic research more attractive to pharmaceutical companies. Unfortunately, bacteria will continue to mutate and evolve to survive as they have done for millions of years. The question remains whether the most highly evolved species on the planet can develop effective strategies and tools to keep bacterial infections at bay.

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References

Guilhelmelli F, Vilela N, Albuquerque P, Derengowski Lda S, Silva-Pereira I, Kyaw CM. Antibiotic development challenges: the various mechanisms of action of antimicrobial peptides and of bacterial resistance. Front Microbiol. 2013;4:353. doi:10.3389/fmicb.2013.00353

Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence. Feb 15 2013;4(2):192-202. doi:10.4161/viru.23706

Dellit TH, Owens RC, McGowan JE, Jr., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. Jan 15 2007;44(2):159-177. doi:10.1086/510393

Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. Mar 20 2001;134(6):506-508.

Eccles R. Is the common cold a clinical entity or a cultural concept? Rhinology. Mar 2013;51(1):3-8. doi:10.4193/Rhino12.123

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