Discovering Treating and Preventing Antimicrobial Resistance
The threat of antimicrobial resistant organisms is a growing concern worldwide. Many health care professionals and associations have long warned against the overuse of antibiotics. However, serious outbreaks of resistant bacteria still occur around the world. In May of 2015, the World Health Organization’s (WHO’s) World Health Association (WHA) approved a plan to improve the world’s awareness of multidrug resistant organisms (MDROs), optimizing antimicrobial medicines, and reducing the instances of MDRO infections. We spoke with two JCI consultants for their advice about discovering, treating, and preventing antimicrobial resistant organisms.
1: Based on your experience as a health care professional, how do people come into contact with unwanted or unnecessary antibiotics?
Barbara Soule, RN, MPA, CIC, FSHEA: Often, antibiotics may be prescribed by physicians and other caregivers when they are not indicated by the patient’s condition. This might occur in a physician’s office, a clinic, a hospital, or a nursing care center. People can also unknowingly ingest antibiotics in the food they eat, particularly when consuming meat products. Therefore, consumers should pay attention to the labels on their food and buy products which advertise that no antibiotics were given to the animal.
Chinhak Chun, MD: A patient may be given unnecessary antibiotics at any point of care. This frequently happens at chronic care facilities. Sometimes, people even self-prescribe antibiotics via internet pharmacies.
2: What steps do you think a physician should take in order to avoid prescribing antibiotics unnecessarily?
BS: Physicians should educate patients about why they do or do not need an antibiotic and other treatment modalities. They should also use standards of care and evidence-based guidelines to make decisions about when to administer antibiotics.
CC: Physicians should use professional guidelines and culture reports, when available. They should not, however, treat laboratory or imaging test reports instead of symptoms. For example, a physician should not prescribe antimicrobials based on a written interpretation of chest X-rays or abnormal urinalysis, even though a patient does not have the necessary symptoms to indicate a respiratory tract or urinary tract infection. This is a huge issue due to increasingly fragmented care processes and instances where physicians were not properly educated as students.
3: Are there any programs or processes you think hospitals should create in order to mitigate the risks of antimicrobial resistance?
BS: Antimicrobial stewardship (AS) is a critical program for all hospitals. Evidence has shown that with this kind of program the hospital often sees reductions in resistant organisms. Organizations should also use antibiograms that show whether an organism is susceptible or resistant to an antibiotic. The real problem arises when organizations inappropriately use antibiotics and organisms develop resistances to drugs. Over time, care providers are left with fewer and fewer options for effective antimicrobial treatments for patients.
CC: Many hospitals in the United States already have antibiotic stewardship (AS) programs. These programs focus on the restriction of certain antimicrobials, monitoring their use, reporting multi-drug resistant organisms (MDROs), and an "antibiotic stewardship committee" with varying functions. Internationally the scope of AS varies. Some developing countries are just starting the restriction phase, but do not have a structured monitoring system. In the United States, monitoring the incidence of Clostridium difficile is used as a surrogate marker of MDRO control.
4: Based on your past experiences, what happens when a patient is infected by a microorganism that is potentially resistant to antibiotics?
BS: Certain MDRO infections can be difficult to treat, placing patients at risk for poor outcomes. For example, Clostridium difficile can cause severe infections, as can gram negative bacteria such as Carbapenem Resistant Enterobacteriaceae (CRE), Acinetobacter baumanii, and resistant Staphylococcus aureus. ar. Some MDRO infections can be very severe and the risks of morbidity and mortality increase dramatically. Often, the length of illness and time back to baseline health are longer in these cases.
CC: In cases where a physician has enough past data on a microorganism and background information on a patient’s case, they may reasonably come to the conclusion that the infection is multi-drug resistant. In these cases, the physician would prescribe a more potent antimicrobial. In cases where the pathogen has proven resistant to the first line of antimicrobials, caregivers should choose next steps based on empirical data or culture reports. Many hospitals publish their own antibiograms which reflect the local trend in resistance and, therefore, provide the physician with some guidelines on next steps.
5: What do you think WHO’s approved action plan means for the future of combating antimicrobial resistance?
BS: It is a start. The first step should be surveillance, with data collection to identify the areas of greatest need and where resistance is highest. Then the plan must lead to action and the implementation of measures to reduce resistance. This will take time because of the enormity of the problem and the different approaches to medicine. However, any positive movement on a global level is very good and greatly needed.
CC: It is a good move, although progress may be slow in coming. If aligned with the United States’ White House initiative against MDROs, it will lead to an increase in regulations and voluntary restriction on the agricultural use. Japan has been very productive in improving antimicrobials for decades, but other countries may step up if antimicrobial initiatives become more financially viable. Most importantly, we must educate caregivers and future physicians who are currently in medical school.
If you would like more information about our MDRO prevention and control services, or any other safety improvement measures, contact us here. This article is the second part of a two part series regarding decisions made at WHO’s WHA. To read the first part, please click here.