Imagine the United States of America when a simple skin infection from a scrape causes a 10 percent chance of dying. Out of every 1,000 women who give birth, nine will die, and out of the 1,000 infants born, up to 30 percent will die. It is difficult to imagine, but these are the alarming statistics prior to antibiotics in the early 1900’s.
Vast improvements have been made since then in life expectancy and public health. Yet, these advancements are now being set back. Microbes are evolutionary clever, responding to their environment to evade death. In the past, resistance was not as rapid as the pharmaceutical market exploded with new antibiotics. But now, the problem is a crisis. Superbugs with multiple drug resistances wreak havoc in hospitals faster than countermeasures are developed.
The threat is global, as one resistant strain can rise and spread to other parts of the world. The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) claim that antibiotic resistance is one of the greatest threats to human health worldwide. Every year, more than 23,000 people die in the U.S. from these infections, and many more from the associated conditions, costing an estimated $70 billion yearly.
Many reasons exist for the accelerated resistance pace. First, according to the CDC, up to 50 percent of all the antibiotics prescribed for patients in the U.S. are not needed or are not optimally prescribed, for a variety of reasons and pressures. This misuse/overuse is a major contributor for the rise in resistance. Second, antibiotics used in sick animals, and in animal growth and infection prevention, aid in resistant strain development, which can ultimately spread to humans. Third, a lack of antimicrobial drug discovery due to scientific, practical, and economic challenges have made this an unattractive market investment. Lastly, the U.S. lacks a comprehensive system for monitoring and responding to antibiotic resistance. In each of these areas, improvements can be me made to delay antibiotic resistance from occurring.
Currently, the U.S. does not have regulations in place for antibiotic stewardship programs. Essentially, antibiotic stewardship is a union of infection control and antimicrobial management to reduce collateral damage. These programs work towards the optimal selection, dosage, and duration of antimicrobial treatment resulting in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. They have been shown to reduce colonization with antibiotic-resistant organisms, infection rates, and cost.
Recently, President Obama’s Council of Advisors on Science and Technology suggested regulations to the Centers for Medicare & Medicaid Services (CMS) to require antibiotic stewardship programs in hospitals. Reimbursement incentives for antibiotic stewardship could be used as a condition of participation for Medicare or for eligibility to receive federal grants or funds. Under such conditions, a hospital should have written policies and procedures whose purpose is to improve antibiotic use, and a designated leader (such as a physician) responsible for program outcomes of antibiotic stewardship activities in the hospital.
Other improvement possibilities exist and include: Documenting an indication for all antibiotics, as well as dosage and duration, or even a so-called “antibiotic time-out,” where practitioners review appropriateness of any antibiotics prescribed after 48 hours from the initial orders. Additionally, technology and electronic medical records not only allow for delivery of antibiotic indicators and appropriate duration of therapy, but also the development of disease-specific care pathways for best practices. Further, community consumption could be monitored. These are only a few of many initiatives that can be put into practice.
A bacteria resistant to all known antibiotics is just as scary as it sounds. Unfortunately for us, it already exists, and we may be helping to create it. In the war against these evolutionarily perfect killers, antibiotic stewardship is needed just as much as new tools and weapons are. Until the new silver bullet arrives, let’s try and conserve the antibiotics we have. Preserving drug efficacy in the face of rising multidrug-resistant pathogens is vital. We must continue applying pressure to federal, private, and civil society to be accountable and proactive, before it’s too late.
Jesse O’Shea is a medical student.
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