Super Bugs and Antimicrobial Stewardship

The discovery of antibiotics and similar drugs together called antimicrobial agents, have revolutionized the modern world. These drugs were very effective in reducing illness and deaths from infectious diseases since the 1940s. Because these drugs have been so widely used and for so long, the infectious organisms they were designed to kill have adapted to them, making the drugs less effective.

Every year in the United States, at least two million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections.¹ Even more alarming, experts believe that worldwide, approximately 700,000 people die each year from antibiotic-resistant infections and the number is expected to surpass 10 million per year by 2050.²

In the US 20–50% of all antibiotics prescribed in acute care hospitals are either unnecessary or inappropriate.^3,4,5,6,7,8 Just like any other medications, antibiotics can have serious side effects including adverse drug reactions and clostridium difficile infection. Patients who are given antibiotics unnecessarily are placed at risk for serious adverse events with no clinical benefits. The misuse of antibiotics has no doubt contributed to the growing problem of antibiotic resistance, which has become one of the most serious and growing threats to public health.⁹

To understand the importance of antibiotic-resistant pathogens as a global problem, on February 27, 2017, the World Health Organization (WHO) published its first ever list of antibiotic resistant “priority pathogens” – the 12 specific bacteria/bacterial families that pose the greatest threat to human health.

The list is intended to spur governments to put in place policies that incentivize basic science and advanced research and development by both publicly-funded agencies and the private sector investing in new antibiotic discovery. The WHO list is divided into three categories according to the urgency of need for new antibiotics: critical, high and medium priority.

Priority 1: Critical

• Acinetobacter baumannii, carbapenem-resistant

• Pseudomonas aeruginosa, carbapenem-resistant

• Enterobacteriaceae, carbapenem-resistant, ESBL-producing

Priority 2: High

• Enterococcus faecium, Vancomycin-resistant

• Staphylococcus aureus, methicillin-restistant, Vancomycin-intermediate and resistant.

• Helicobacter pylori, clarithromycin-resistant

• Campylobacter spp, fluoroquinolone-resistant

• Salmonellae, fluoroquinolone-resistant

• Neisseria gonorrhea, cephalosporin-resistant, fluoroquinolone-resistant

Priority 3: Medium

• Streptococcus pneumonia, penicillin non-susceptible

• Hemophilus influenza, ampicillin-resistant

• Shigella spp, fluoroquinolone-resistant¹⁰

In an effort to decrease antimicrobial resistance and inappropriate antibiotic use, different organizations including the Infectious Disease Society of America (IDSA), the Society of Healthcare Epidemiology (SHEA) and even the Joint Commission issued antimicrobial stewardship standards. In a very important decision, in June of 2016, CMS released a proposed rule change to its Condition of Participation which would, among other changes, require hospitals to implement antibiotic stewardship programs in order to participate in Medicare and Medicaid.¹¹ Thus, Antimicrobial Stewardship (AMS) quickly became the new buzzword in all hospitals across the US who want to continue to participate in CMS programs.

What is antimicrobial stewardship (AMS)? It refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration. AMS seeks to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the cost of healthcare for infections, and limit the selection for antimicrobial resistant strains.

• Leadership Commitment – Dedicating necessary personnel, financial and information technology resources.

• Accountability – Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective.

• Drug Expertise – Having a strong pharmacy presence with responsibility to improve antibiotic use.

• Action – Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment. This is known as “antibiotic timeout, eg: after 72 hours when cultures are available to guide antibiotic therapy.

• Tracking – Monitoring antibiotic prescribing and resistance patterns on a regular basis.

• Reporting – Regular reporting information on antibiotic use and resistance to physician, nurses and other relevant staff.

• Education – Education clinicians about resistance and optimal prescribing.¹²

In summary, there is an urgency in the field of infectious diseases because of increasing worldwide incidence of antibiotic-resistant organisms. Antimicrobial resistance is now recognized as a priority global health issue. In this regard, the recognition of antimicrobial resistance problem in 2016 by the United Nations is potentially a landmark event, for it heralds international awareness of the problem.¹³

There is no easy solution to this problem which is now a crisis. The statement made by Jawetz in the 1950s when he stated “the position of antimicrobial agents in medical therapy is highly satisfactory” and that the “majority of bacterial infections can be cured simply, effectively and cheaply”¹⁴ couldn’t be farther from the reality that we face today.

Part of the solution can be as simple as good hand washing by everyone, with emphasis on healthcare professionals who are directly involved in patient care. The solution can also be as complex as a partnership between the political establishment and private entities, e.g., the pharmaceutical industry to explore potential solutions to the global problem. It is almost certain that it would involve incentivizing the pharmaceutical industry in the development of new antimicrobial drug development.¹⁵ Antimicrobial stewardship (AMS) which is essentially the appropriate and judicious use of antimicrobials plays and important role in this human struggle against resistant pathogens, which, based on current data that we have, seems to be an external struggle much like the humans’ struggle against infectious disease.¹⁶

Biography

Eden M. Esguerra, MD, MSMA member since 1995 and Missouri Medicine Editorial Board Member in Infectious Disease, is in Infectious Diseases, Mercy Hospital, Joplin, MO.

Contact: eden.esguerra@mercy.net