Skip to main content
PMC home page
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 2005 Nov;81(961):680–692. doi: 10.1136/pgmj.2005.035113

Is antibiotic resistance a problem? A practical guide for hospital clinicians

G Barlow 1, D Nathwani 1
PMCID: PMC1743396  PMID: 16272230

Abstract

Antibiotic resistance is an important concern for patients, physicians, healthcare managers, and policymakers. Inappropriate antimicrobial prescribing fuels the evolution of resistance, while poor basic hygiene facilitates the spread of resistant microbes between patients and healthcare staff. The development of infection with a resistant pathogen may lead to poorer health and economic outcomes. The problem for the frontline clinician, however, is how to balance the responsibility of prudent prescribing with the risk of sub-optimally treating a patient who may be infected with a resistant pathogen. This article discusses how hospital physicians can use severity and risk factor assessment, and knowledge of local microbial epidemiology, to guide empiric antibiotic prescribing. Most patients hospitalised with a community acquired bacterial infection in the UK can still be managed with a traditional first line antibiotic(s). In contrast, regimens that account for resistance are often required in patients with hospital acquired infections, particularly if the patient is critically ill.

Full Text

The Full Text of this article is available as a PDF (137.8 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. ABBOUD F. M., WAISBREN B. A. Correlation between in vitro studies and response to antibiotic therapy in staphylococcic bacteremia. AMA Arch Intern Med. 1959 Aug;104(2):226–233. doi: 10.1001/archinte.1959.00270080052006. [DOI] [PubMed] [Google Scholar]
  2. Aspa Javier, Rajas Olga, Rodríguez de Castro Felipe, Blanquer José, Zalacain Rafael, Fenoll Asunción, de Celis Rosa, Vargas Antonio, Rodríguez Salvanés Francisco, España Pedro Pablo. Drug-resistant pneumococcal pneumonia: clinical relevance and related factors. Clin Infect Dis. 2004 Mar 1;38(6):787–798. doi: 10.1086/381886. [DOI] [PubMed] [Google Scholar]
  3. Barlow G., Sachdev N., Nathwani D. The use of adult isolation facilities in a UK infectious diseases unit. J Hosp Infect. 2002 Feb;50(2):127–132. doi: 10.1053/jhin.2001.1138. [DOI] [PubMed] [Google Scholar]
  4. Barlow Gavin D., Nathwani Dilip. Sequential antibiotic therapy. Curr Opin Infect Dis. 2000 Dec;13(6):599–607. doi: 10.1097/00001432-200012000-00004. [DOI] [PubMed] [Google Scholar]
  5. Bartlett J. G., Dowell S. F., Mandell L. A., File Jr T. M., Musher D. M., Fine M. J. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000 Sep 7;31(2):347–382. doi: 10.1086/313954. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Begg N., Cartwright K. A., Cohen J., Kaczmarski E. B., Innes J. A., Leen C. L., Nathwani D., Singer M., Southgate L., Todd W. T. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. British Infection Society Working Party. J Infect. 1999 Jul;39(1):1–15. doi: 10.1016/s0163-4453(99)90095-6. [DOI] [PubMed] [Google Scholar]
  7. Berendt Tony, Byren Ivor. Bone and joint infection. Clin Med (Lond) 2004 Nov-Dec;4(6):510–518. doi: 10.7861/clinmedicine.4-6-510. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Chaix C., Durand-Zaleski I., Alberti C., Brun-Buisson C. Control of endemic methicillin-resistant Staphylococcus aureus: a cost-benefit analysis in an intensive care unit. JAMA. 1999 Nov 10;282(18):1745–1751. doi: 10.1001/jama.282.18.1745. [DOI] [PubMed] [Google Scholar]
  9. Cosgrove Sara E., Carmeli Yehuda. The impact of antimicrobial resistance on health and economic outcomes. Clin Infect Dis. 2003 May 16;36(11):1433–1437. doi: 10.1086/375081. [DOI] [PubMed] [Google Scholar]
  10. Cosgrove Sara E., Sakoulas George, Perencevich Eli N., Schwaber Mitchell J., Karchmer Adolf W., Carmeli Yehuda. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis. 2002 Dec 13;36(1):53–59. doi: 10.1086/345476. [DOI] [PubMed] [Google Scholar]
  11. Cruciani M., Gatti G., Lazzarini L., Furlan G., Broccali G., Malena M., Franchini C., Concia E. Penetration of vancomycin into human lung tissue. J Antimicrob Chemother. 1996 Nov;38(5):865–869. doi: 10.1093/jac/38.5.865. [DOI] [PubMed] [Google Scholar]
  12. Di Perri Giovanni, Bonora Stefano. Which agents should we use for the treatment of multidrug-resistant Mycobacterium tuberculosis? J Antimicrob Chemother. 2004 Jul 28;54(3):593–602. doi: 10.1093/jac/dkh377. [DOI] [PubMed] [Google Scholar]
  13. EAGLE H. Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med. 1952 Oct;13(4):389–399. doi: 10.1016/0002-9343(52)90293-3. [DOI] [PubMed] [Google Scholar]
  14. Eady E. Anne, Cove Jonathan H. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus--an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis. 2003 Apr;16(2):103–124. doi: 10.1097/00001432-200304000-00007. [DOI] [PubMed] [Google Scholar]
  15. Edlund C., Stark C., Nord C. E. The relationship between an increase in beta-lactamase activity after oral administration of three new cephalosporins and protection against intestinal ecological disturbances. J Antimicrob Chemother. 1994 Jul;34(1):127–138. doi: 10.1093/jac/34.1.127. [DOI] [PubMed] [Google Scholar]
  16. Ewig S., Ruiz M., Torres A., Marco F., Martinez J. A., Sanchez M., Mensa J. Pneumonia acquired in the community through drug-resistant Streptococcus pneumoniae. Am J Respir Crit Care Med. 1999 Jun;159(6):1835–1842. doi: 10.1164/ajrccm.159.6.9808049. [DOI] [PubMed] [Google Scholar]
  17. Farthing M., Feldman R., Finch R., Fox R., Leen C., Mandal B., Moss P., Nathwani D., Nye F., Percival A. The management of infective gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection. J Infect. 1996 Nov;33(3):143–152. doi: 10.1016/s0163-4453(96)92057-5. [DOI] [PubMed] [Google Scholar]
  18. Guillemot D., Carbon C., Balkau B., Geslin P., Lecoeur H., Vauzelle-Kervroëdan F., Bouvenot G., Eschwége E. Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998 Feb 4;279(5):365–370. doi: 10.1001/jama.279.5.365. [DOI] [PubMed] [Google Scholar]
  19. Huang Susan S., Platt Richard. Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis. 2003 Jan 17;36(3):281–285. doi: 10.1086/345955. [DOI] [PubMed] [Google Scholar]
  20. Ibrahim E. H., Sherman G., Ward S., Fraser V. J., Kollef M. H. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000 Jul;118(1):146–155. doi: 10.1378/chest.118.1.146. [DOI] [PubMed] [Google Scholar]
  21. John C. C. Treatment failure with use of a third-generation cephalosporin for penicillin-resistant pneumococcal meningitis: case report and review. Clin Infect Dis. 1994 Feb;18(2):188–193. doi: 10.1093/clinids/18.2.188. [DOI] [PubMed] [Google Scholar]
  22. Kim T., Oh P. I., Simor A. E. The economic impact of methicillin-resistant Staphylococcus aureus in Canadian hospitals. Infect Control Hosp Epidemiol. 2001 Feb;22(2):99–104. doi: 10.1086/501871. [DOI] [PubMed] [Google Scholar]
  23. Kollef M. H., Sherman G., Ward S., Fraser V. J. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999 Feb;115(2):462–474. doi: 10.1378/chest.115.2.462. [DOI] [PubMed] [Google Scholar]
  24. Lamb V. A., Mayhall C. G., Spadora A. C., Markowitz S. M., Farmer J. J., 3rd, Dalton H. P. Outbreak of Salmonella typhimurium gastroenteritis due to an imported strain resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole in a nursery. J Clin Microbiol. 1984 Dec;20(6):1076–1079. doi: 10.1128/jcm.20.6.1076-1079.1984. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Lim W. S., van der Eerden M. M., Laing R., Boersma W. G., Karalus N., Town G. I., Lewis S. A., Macfarlane J. T. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377–382. doi: 10.1136/thorax.58.5.377. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Luna C. M., Vujacich P., Niederman M. S., Vay C., Gherardi C., Matera J., Jolly E. C. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest. 1997 Mar;111(3):676–685. doi: 10.1378/chest.111.3.676. [DOI] [PubMed] [Google Scholar]
  27. Magee J. T., Pritchard E. L., Fitzgerald K. A., Dunstan F. D., Howard A. J. Antibiotic prescribing and antibiotic resistance in community practice: retrospective study, 1996-8. BMJ. 1999 Nov 6;319(7219):1239–1240. doi: 10.1136/bmj.319.7219.1239. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Mandell L. A., Marrie T. J., Grossman R. F., Chow A. W., Hyland R. H. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis. 2000 Sep 7;31(2):383–421. doi: 10.1086/313959. [DOI] [PubMed] [Google Scholar]
  29. Murray B. E. Vancomycin-resistant enterococcal infections. N Engl J Med. 2000 Mar 9;342(10):710–721. doi: 10.1056/NEJM200003093421007. [DOI] [PubMed] [Google Scholar]
  30. Nicolle L. E., SHEA Long-Term-Care-Committee Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001 Mar;22(3):167–175. doi: 10.1086/501886. [DOI] [PubMed] [Google Scholar]
  31. Nyström P. O. The systemic inflammatory response syndrome: definitions and aetiology. J Antimicrob Chemother. 1998 Jan;41 (Suppl A):1–7. doi: 10.1093/jac/41.suppl_1.1. [DOI] [PubMed] [Google Scholar]
  32. Pallares R., Liñares J., Vadillo M., Cabellos C., Manresa F., Viladrich P. F., Martin R., Gudiol F. Resistance to penicillin and cephalosporin and mortality from severe pneumococcal pneumonia in Barcelona, Spain. N Engl J Med. 1995 Aug 24;333(8):474–480. doi: 10.1056/NEJM199508243330802. [DOI] [PubMed] [Google Scholar]
  33. Pfeiffer R. R. Structural features of vancomycin. Rev Infect Dis. 1981 Nov-Dec;3 Suppl:S205–S209. [PubMed] [Google Scholar]
  34. Powell M., Sanderson P. J. Resistant coagulase-negative staphylococci in hospital patients. J Hosp Infect. 1987 Jan;9(1):48–53. doi: 10.1016/0195-6701(87)90095-8. [DOI] [PubMed] [Google Scholar]
  35. Rodríguez-Baño Jesús, Navarro Maria Dolores, Romero Luisa, Martínez-Martínez Luis, Muniain Miguel A., Perea Evelio J., Pérez-Cano Ramón, Pascual Alvaro. Epidemiology and clinical features of infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in nonhospitalized patients. J Clin Microbiol. 2004 Mar;42(3):1089–1094. doi: 10.1128/JCM.42.3.1089-1094.2004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Safdar Nasia, Maki Dennis G. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, gram-negative bacilli, Clostridium difficile, and Candida. Ann Intern Med. 2002 Jun 4;136(11):834–844. doi: 10.7326/0003-4819-136-11-200206040-00013. [DOI] [PubMed] [Google Scholar]
  37. Saint S., Bent S., Vittinghoff E., Grady D. Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis. JAMA. 1995 Mar 22;273(12):957–960. [PubMed] [Google Scholar]
  38. Saïd-Salim Battouli, Mathema Barun, Kreiswirth Barry N. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen. Infect Control Hosp Epidemiol. 2003 Jun;24(6):451–455. doi: 10.1086/502231. [DOI] [PubMed] [Google Scholar]
  39. Seaton R. A., Steinke D. T., Phillips G., MacDonald T., Davey P. G. Community antibiotic therapy, hospitalization and subsequent respiratory tract isolation of Haemophilus influenzae resistant to amoxycillin: a nested case-control study. J Antimicrob Chemother. 2000 Aug;46(2):307–309. doi: 10.1093/jac/46.2.307. [DOI] [PubMed] [Google Scholar]
  40. Seppälä H., Klaukka T., Vuopio-Varkila J., Muotiala A., Helenius H., Lager K., Huovinen P. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. N Engl J Med. 1997 Aug 14;337(7):441–446. doi: 10.1056/NEJM199708143370701. [DOI] [PubMed] [Google Scholar]
  41. Servais H., Tulkens P. M. Stability and compatibility of ceftazidime administered by continuous infusion to intensive care patients. Antimicrob Agents Chemother. 2001 Sep;45(9):2643–2647. doi: 10.1128/AAC.45.9.2643-2647.2001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Singer Mendel E., Harding Ian, Jacobs Michael R., Jaffe Dena H. Impact of antimicrobial resistance on health outcomes in the out-patient treatment of adult community-acquired pneumonia: a probability model. J Antimicrob Chemother. 2003 Apr 14;51(5):1269–1282. doi: 10.1093/jac/dkg220. [DOI] [PubMed] [Google Scholar]
  43. Singh N., Rogers P., Atwood C. W., Wagener M. M., Yu V. L. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000 Aug;162(2 Pt 1):505–511. doi: 10.1164/ajrccm.162.2.9909095. [DOI] [PubMed] [Google Scholar]
  44. Solomkin Joseph S., Bjornson H. Stephen, Cainzos Miguel, Dellinger E. Patchen, Dominioni Lorenzo, Eidus Robert, Faist Eugen, Leaper David, Lee James T., Lipsett Pamela A. A consensus statement on empiric therapy for suspected gram-positive infections in surgical patients. Am J Surg. 2004 Jan;187(1):134–145. doi: 10.1016/j.amjsurg.2003.03.006. [DOI] [PubMed] [Google Scholar]
  45. Steinke D. T., Seaton R. A., Phillips G., MacDonald T. M., Davey P. G. Prior trimethoprim use and trimethoprim-resistant urinary tract infection: a nested case-control study with multivariate analysis for other risk factors. J Antimicrob Chemother. 2001 Jun;47(6):781–787. doi: 10.1093/jac/47.6.781. [DOI] [PubMed] [Google Scholar]
  46. Talan D. A., Stamm W. E., Hooton T. M., Moran G. J., Burke T., Iravani A., Reuning-Scherer J., Church D. A. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA. 2000 Mar 22;283(12):1583–1590. doi: 10.1001/jama.283.12.1583. [DOI] [PubMed] [Google Scholar]
  47. Threlfall E. J., Fisher I. S. T., Berghold C., Gerner-Smidt P., Tschäpe H., Cormican M., Luzzi I., Schnieder F., Wannet W., Machado J. Trends in antimicrobial drug resistance in Salmonella enterica serotypes Typhi and Paratyphi A isolated in Europe, 1999-2001. Int J Antimicrob Agents. 2003 Nov;22(5):487–491. doi: 10.1016/s0924-8579(03)00262-0. [DOI] [PubMed] [Google Scholar]
  48. Travers Karin, Barza Michael. Morbidity of infections caused by antimicrobial-resistant bacteria. Clin Infect Dis. 2002 Jun 1;34 (Suppl 3):S131–S134. doi: 10.1086/340251. [DOI] [PubMed] [Google Scholar]
  49. Wenzel Richard P. The antibiotic pipeline--challenges, costs, and values. N Engl J Med. 2004 Aug 5;351(6):523–526. doi: 10.1056/NEJMp048093. [DOI] [PubMed] [Google Scholar]
  50. Wongsrichanalai Chansuda, Pickard Amy L., Wernsdorfer Walther H., Meshnick Steven R. Epidemiology of drug-resistant malaria. Lancet Infect Dis. 2002 Apr;2(4):209–218. doi: 10.1016/s1473-3099(02)00239-6. [DOI] [PubMed] [Google Scholar]
  51. Wright S. W., Wrenn K. D., Haynes M., Haas D. W. Prevalence and risk factors for multidrug resistant uropathogens in ED patients. Am J Emerg Med. 2000 Mar;18(2):143–146. doi: 10.1016/s0735-6757(00)90005-6. [DOI] [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES