The End Of The Antibiotic Era? (Part 2)
By Stacey Baggett, Pharm.D., BCPS and Heather McCormick, Pharm.D. // January 18, 2013
Preventing Antibiotic Resistance
EDITOR’S NOTE: This article is Part 2 of a two-part series (CLICK HERE for Part 1) coauthored by Stacey Baggett, Pharm.D., BCPS and Heather McCormick, Pharm.D. The pervasive problem of emerging antibiotic resistance has been in the media recently with Centers For Disease Control (CDC) reports of the emergence of cephalosporin-resistant gonorrhea in the United States making gonorrhea much more difficult to treat.
Also, this year’s flu epidemic and the high levels of influenza-like-illness (ILI), which are viral and not amenable to antibiotic management, now being reported in 48 states creates clinical situations that may result in the inappropriate and overuse of antibiotics, which contributes to the increase in antimicrobial resistance.
BREVARD COUNTY • MELBOURNE, FLORIDA– Antibiotics have been in use for the last 70 years. At the dawn of the antibiotic era, little to no antimicrobial resistance existed. However, in recent years, healthcare providers are running out of options to effectively treat patients for various types of infection as antibiotic resistance rapidly emerges.
Inappropriate and overuse of antibiotics has contributed to an alarming increase in antimicrobial resistance worldwide. The increased incidence of multi-drug resistant organisms (MDROs) and the decrease in research and development by pharmaceutical companies for new antibiotics has been termed the microbial “perfect storm” by the Infectious Diseases Society of America (IDSA).
According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance in the United States costs an estimated $20 billion a year in excess healthcare costs, $35 million a year in related costs, and more than 8 million additional hospital days per year for patients. Healthcare-associated infections account for 1.7 million infections each year in the U.S., resulting in 99,000 deaths annually. While most concerns about resistance have focused on hospitals and healthcare related infections, the problem of antibiotic resistance has become a major concern in the outpatient setting as well. Currently, there is a global pandemic of methicillin-resistant Staphylococcus aureus (MRSA), which is seen commonly in many patients presenting with simple skin and soft tissue infections at routine office visits or in the emergency room.
‘Superbugs’ Resistant To Antibiotics
To further complicate matters, resistant organisms are getting worse in the hospital setting among the critically and chronically ill. Drug resistance can be found in respiratory pathogens, such as Streptococcus pneumoniae, and other organisms that are considered normal flora found in the intestinal tract of humans, including Klebsiella pneumoniae and Escherichia coli.
Some strains of these organisms are now known as “superbugs” and are resistant to antibiotics that are considered as a “last resort.” In addition, there are very few antibiotics in the pipeline to combat these resistant strains.
Recently, the media has been reporting on the outbreak of a strain of Klebsiella pneumoniae, called KPC (Klebsiella pneumoniae carbapenemase) at the U.S. National Institutes of Health Clinical Center in Bethesda, Maryland. KPC is resistant to almost every antibiotic available, including the carbapenems. A paper was published in August 2012 in Science Translational Medicine detailing the outbreak and tracking the patients affected by KPC at the institution from June 2011 to January 2012. According to the article, this particular outbreak affected 18 patients, with six deaths directly attributed to KPC. As of September 18th, 2012, a 19th patient has been added as a victim to the outbreak, resulting in a seventh death. These deaths occurred as a result of physicians having no antibiotics to treat these patients due to resistance. While this scenario may seem alarming, cases of KPC and similar MDROs can be found every day, worldwide.
Linked To Approximately 14,000 Deaths
Misuse of antibiotics is also contributing to an increase in cases of Clostridium difficile, a bacteria associated with an increase in antibiotic use and has been linked to approximately 14,000 deaths in the U.S. each year. Clostridium difficile can cause severe diarrhea in addition to other intestinal complications as a result of normal intestinal flora being eradicated by antibiotic use.
So, who is responsible for preventing resistance and improving antibiotic use? We all are. Physicians, pharmacists, healthcare facilities, policy makers, and patients must collaborate and implement the practices and interventions, listed in the table on the right, to be effective against this war on antimicrobial resistance.
The Center For Disease Control (CDC) has launched a campaign called “Get Smart for Healthcare,” which sets goals to optimize antimicrobial use in the inpatient healthcare settings by implementing interventions to improve antibiotic use. According to the CDC, studies demonstrate that improved antibiotic use in hospitals improves patient outcomes, decreases healthcare costs, and reduces the rate of Clostridium difficile and antibiotic resistance.
The IDSA and the Society for Healthcare Epidemiology of America (SHEA) have published guidelines for the development of Antimicrobial Stewardship Programs (ASPs), which have been shown to improve patient care and clinical outcomes, increase patient safety, prevent resistance, and decrease adverse events, including the development of antimicrobial resistance. Over time, ASPs may become a standard for all healthcare facilities; however, at this time, only California has developed an initiative to require ASPs.
In order to combat antimicrobial resistance, it has to be a joint effort. Healthcare professionals and patients must tackle this growing problem together. Otherwise, in the near future, we may be out of all options for treating potentially fatal infections.
ABOUT THE AUTHORS
Dr. Stacey Baggett is a Clinical Pharmacist at Holmes Regional Medical Center. In addition, she is a Clinical Assistant Professor and Regional Coordinator for Experiential Education for the University of Florida College of Pharmacy. She received her Bachelor of Science in Biochemistry from Purdue University and her Doctor of Pharmacy degree from Midwestern University in Glendale, Arizona. Her practice interests include Infectious Disease and Student/Preceptor Development.
Dr. Heather McCormick received her Doctorate of Pharmacy from the University of Florida in May 2011, after which she completed a Post-Graduate Year 1 Residency at Holmes Regional Medical Center. Dr. McCormick recently had the distinction of having her Residency Research paper published in the Journal of Health-System Pharmacy Residents. In her position now as a full-time pharmacist at Holmes Regional Medical Center she is focused on providing the highest quality, safest patient-centered care possible.