Serious and Growing Problem of Antibiotic Resistance

In a current campaign to educate doctors and the public about the seriousness of the problem of antibacterial resistance, the Federal Centers for Disease Control, part of the Department of Health and Human Services, has published these worrisome statistics:

Drug-resistant pathogens are a growing threat to all people, especially in healthcare settings.

• Each year nearly 2 million patients in the United States get an infection in a hospital.
• Of those patients, about 90,000 die as a result of their infection.
• More than 70% of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them.
• Persons infected with drug-resistant organisms are more likely to have longer hospital stays and require treatment with second- or third-choice drugs that may be less effective, more toxic, and/or more expensive.

For example, the staphylococcus, a common bacterium causing skin infections, used to be exquisitely sensitive to penicillin when the drug was first introduced. Twenty years later, penicillin was no longer anywhere near as effective against the staphylococcus. A new drug, called methicillin, was designed to combat the “staph bug,” and it was widely used. Over time, strains of methicillin-resistant “super-staph” (MRSA) have also emerged.

At a recent government-sponsored conference on antibiotic resistance, some alarming data were presented on the rapid rise in resistance to antibiotics of some common bacterial causes of life-threatening illness and death. For example, the odds that staph aureus will be resistant to a once extremely useful antibiotic, methicillin, (MRSA) have increased from about 4%, in 1980, to over 55%, in 2000. Thus, clearly related to the wanton misprescribing of antibiotics to people who do not have bacterial infections or the wrong antibiotic to those who do have infections, there has been a more than 13-fold increase in resistance. For another common cause of bacterial illness and death, enteroccoccus, the resistance of these bacteria to vancomycin (VRE) has increased from about 1% in 1988 to about 27% in 2000, a 27-fold increase.

The consequences of increased resistance by bacteria to antibiotics are very serious: infections with staph aureus resistant to methicillin (MRSA), can cause ventilator-assisted pneumonia and blood infections associated with catheters in people in intensive care units (ICU). In ICU patients, infections with VRE are taking the form of abdominal or blood infections. The authors of this review on the impact of antibiotic resistance summarized the possible outcomes caused by antibiotic-resistant organisms:

• Increased mortality
• Prolonged length of hospital stay
• Need for more costly therapy and management
• Medical complications

These examples illustrate that newer, improved antibiotics are not the final answer to bacterial resistance. If new antibiotics are developed but then overused, bacteria will find new ways to develop resistance, rendering those drugs ineffective.

Many bacteria in the hospital setting have now become resistant to multiple antibiotics, and, as a result, infections with these bacteria have become a very dangerous occurrence. The only way to help stop the development of bacterial resistance is by discouraging the gross misuse and overuse of antibiotics. It makes sense to use these “magic bullets,” especially the newer ones, only when necessary so that their power will still be effective when it is truly needed.

Thus, there are both dangers and benefits to antibiotics. When you have an infection that can be cured with the proper antibiotic, the benefit of taking the drug is much, much greater than its dangers. But since there are dangers, there are compelling reasons to avoid unnecessary use of antibiotics and to select the safest and most effective ones.

What You Can Do:

Avoiding Unnecessary Use of Antibiotics or the Wrong Antibiotic

There are several basic principles that should be followed in determining the correct antibiotic:

1. Establish that an antibiotic is necessary. This means that your infection has to be the type that can be effectively treated by an antibiotic. Antibiotics are used specifically to treat bacterial infections. Antibiotics do not treat viral infections, such as the common cold. (Although there has been some heartening progress in the development of specific antiviral agents such as amantadine and acyclovir, ribavirin, AZT and other drugs for HIV infections, viral infections, for the most part, cannot be treated with drugs.)
2. Choose the correct antibiotic. It must be effective against the most likely organisms that can cause your infection.
3. Take a culture before using an antibiotic. A culture should be taken from where you have an infection, such as your throat, urine, or blood, and then grown to determine the specific organism that is causing your infection and whether it is susceptible to the preferred antibiotic. For example, if you have a urinary tract infection, the doctor should take a urine specimen and send it for culture before treating your infection. This does not mean that your infection cannot be treated right away, only that a culture is sent before you start antibiotics. In this way, if your infection persists, your doctor can determine which alternative antibiotic can be used against the bacteria. Your doctor may find out that you do not have an infection and do not require antibiotics.
4. Consider the cost of the antibiotic. This should be done when everything else is equal. If several antibiotics are equally effective, their cost should be taken into consideration when selecting a drug to use. Newer drugs on patent are much more expensive than older antibiotics that have been on the market for some time. For example, the oral cephalosporin cefuroxime (CEFTIN) is often used to treat urinary tract infections. There is no advantage between using this drug and using a generic drug such as trimethoprim and sulfamethoxazole. Cefuroxime, however, costs 12 times as much for two weeks of treatment. Clearly, in the case of a simple infection, the less expensive drug is preferred as an initial choice.

The Importance of Completing a Full Course of Therapy

It is important with any antibiotic to take the entire amount of the drug that your doctor prescribes. Often, after the first few days of taking antibiotics, you will begin to feel better. Perhaps you think that you do not have to finish your course of treatment, since you are, after all, feeling healthy. This is not the case, however. The length of the regimen that your doctor prescribes for you is designed to eliminate all of the bacteria that are causing your illness. As mentioned above, this may be as short as three days for an acute bladder infection. If you do not take all of your medication, the bacteria will not be completely eliminated and can quickly multiply, causing another infection. This infection may then be resistant to the original antibiotic.

In general, antibiotics taken by mouth are preferred if you do not require hospitalization and can take the pills without any problem. There is no advantage to having an injection of an antibiotic.

Newer Versus Older Antibiotics

Remember, newer antibiotics are more expensive than the older ones. They should be used only when an advantage can be shown over older antibiotics—for example, if the new antibiotic is more active against resistant bacteria and this has clinical significance.

In summary, antibiotics can make a world of difference when the right antibiotic is chosen for the right situation. Unfortunately, in the United States today, this is only being done a minority of the time. Questioning your doctor about why he or she is prescribing an antibiotic is a step in the right direction toward safer and better antibiotic use.