What Is Antibiotic Resistance? Why Is It a Problem?
Since the 1940s, antibiotics have been the cornerstone of infectious disease therapy. Their remarkable healing power invites widespread and often inappropriate use, which leads to antibiotic resistance and consequent treatment complications.
Antibiotics are prescribed for infections caused by bacteria -- the common cold and flu are generally caused by viruses; thus, antibiotics are ineffective.
How and When to Take AntibioticsSometimes bacteria find a way to fight the antibiotic you are taking and your infection won't go away. When antibiotic resistance develops, your doctor must prescribe a different antibiotic in order to fight the infection.
Multiple-drug resistance occurs when bacteria are resistant to more than one antibiotic. This is generally the rule rather than the exception among resistant bacteria. This situation has largely occurred through the sequential use of multiple different antibiotics. The first antibiotic began by selecting a single resistance gene. Eventually, however, bacteria resistant to the first antibiotic picked up resistance to others as they were introduced into the environment. It's like a snowball rolling downhill, becoming bigger and stronger and not losing what it had acquired before.
Causes of Resistance
Antibiotics in the News
Residues in FoodThere is an increasing presence of multi-drug-resistant organisms in human intestinal flora. Evidence suggests that these organisms are being introduced into the human population from animal feed for animals that we consume. Also, by frequent exposure of antimicrobials. The WHO and FDA decided to reexamine the 1996 policy that limits the daily exposure of Americans to no more than 1.5 mg of antimicrobial residues in food. Due to the public health impact of increasing bacterial resistance, FDA will review newer data on residues in food and effects on intestinal flora.
Auit A. Lancet 1999; 354: 1190.
FDA to Withdraw ApprovalThe U.S. Food and Drug Administration Center for Veterinary Medicine (CVM) is withdrawing its approval of two fluoroquinolones for use in poultry. According to an FDA statement, consumption of poultry that contains fluoroquinolone-resistant Campylobacter is the main cause of fluoroquinolone-resistant Campylobacter infection in humans. The drugs are enrofloxacin, manufactured by the Bayer Corp., of Shawnee Mission, Kansas, and sarafloxacin hydrochloride, manufactured by Abbott Laboratories, of North Chicago, Illinois.
New Federal InitiativesConcerned individuals currently have the opportunity to comment on two important new federal initiatives to curb antibiotic resistance: 1) interagency action plan to combat antimicrobial resistance and 2) a bill from Senator Kennedy and to amend title III of the Public Health Service Act to enhance the Nation's capacity to address public health threats and emergencies.
Medical ProgressDr. David Heymann, Executive Director for Communicable Diseases at the World Health Organization, and Dr. Jeffrey Koplan, Director of the U.S. Centers for Disease Control and Prevention recently issued a press release entitled "Drug Resistance Threatens to Reverse Medical Progress."
WHO warns in its recent annual report on infectious diseases, "Overcoming Antimicrobial Resistance," that the world is facing a dangerous situation as once-effective medicines are becoming increasingly ineffective. Dr. Gro Harlem Brundtland, Director-General of WHO, stated that, "We risk losing these valuable drugs -- and our opportunity to eventually control many infections."
Clinical PracticeIn a recent Clinical Infectious Disease article, researchers found that single-dose therapy for acute bacterial cystitis, in women, is less effective than longer durations. A three-day course of TMP/SMX is considered the current standard. B-lactams are considered inferior for three-day therapy. It is important to note that to control emergence of resistance, quinolones should not be used as first line agents, unless there is existing resistance to TMP/SMX (Bactrim). For acute pyelonephritis in young non-pregnant women, with normal urinary tract anatomy, 14 days of therapy is adequate. Quinolones are preferred for mild cases that can be treated orally. Severe cases require hospitalization, and parenteral quinolones, aminoglycosides (with out ampicillin) or an extended-spectrum cephalosporin can be used. However, note that gram positive organisms should be treated with ampicillin or amoxicillin. Please realize that these recommendations are based on the antimicrobial susceptibilities of pathogens during the late 1990s, and can change regionally where resistance patterns are occurring. Therefore, careful monitoring of trends is essential.
Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and pyelonephritis in women. Clinical Infectious Disease 1999 Oct., 219: 745-58.
InterventionsKaiser Permanente in Denver, Colorado examined the effects of antibiotic use for acute bronchitis. An educational intervention was aimed at primary care providers and 2500 households receiving services. Additionally posters in waiting rooms distinguished between chest colds and bronchitis and actively discouraged the use of antibiotics for the former. After the intervention, there was a 26% reduction in the use of antibiotics and a 28% reduction in the number of office visits. This article stressed the significance of the public health crisis in antimicrobial resistance of common respiratory pathogens. In addition, that problem should be foremost on the minds of providers, when they are prescribing medications.
Gonzales R., et. al. JAMA 1999.
Overuse of AntibioticsPrompted by the rise of drug-resistant "superbugs" that are not killed by standard antibiotics, Massachusetts officials and insurers have begun questioning doctors' prescribing practices and warning that overuse and misuse of drugs may be breeding the next generation of superbugs right here.
State findings suggest that some doctors may be contributing to overuse of the drugs by prescribing them without seeing the patient or by giving in to patients' demands for antibiotics even when they're not needed. Overuse of antibiotics increases the chance that bacteria can breed new strains able to survive the drugs effects.
Richard Saltus, Globe Staff, 5/3/2000.
The Treatment of AIDSWith great concern, I read the recent report by Donald G. McNeil, which describes recommendations by the World Health Organization and the United Nations AIDS program to provide "regular doses" of the antibiotic cotrimoxazole for the prevention of bacterial and parasitic diseases in AIDS patients in Africa. I understand why the recommendation has been made, but am worried by the potential consequence of this action -- the emergence of resistance to the drug.
Dr. Stuart Levy.
New AntibioticsThe drug, Zyvox, can fight deadly bacteria that had learned to defeat the best antibiotics doctors could throw at it. And more arrows will fill doctors' quivers soon, with six drugs awaiting FDA approval and another 11 in late stages of clinical testing.
About a third of the 150 million antibiotic prescriptions written each year are inappropriate. One study found that as many as 70% of patients with colds and upper respiratory tract infections and other ailments most often caused by viruses -- which can't be treated by antibiotics -- were prescribed antibiotics anyway.
Doctors confronted with these alarming trends are quick to point fingers. A forthcoming survey of Massachusetts doctors by the Alliance for the Prudent Use of Antibiotics (APUA), for instance, finds doctors often blaming patients who demand antibiotics when they feel bad. Some complain about drug company marketing. Others say heavy workloads imposed by HMOs makes proper diagnosis difficult.
USAToday Zyvox. May, 2000.
CDC WarningIn an effort to reduce the growing numbers of drug-resistant bacteria, officials at the Centers for Disease Control and Prevention (CDC) are urging physicians to stop prescribing antibiotics where the drugs are not necessary. Director of Antimicrobial Resistance for the CDC, Dr. Richard Besser, told an audience of physicians attending a medical conference that each year US physicians write $50 million worth of prescriptions that are ineffectual and unnecessary. A common reason for unnecessary prescriptions is patient demand for treatment.
"We are facing a crisis because doctors are pressured to prescribe antibiotics for the common cold and inner ear infection, yet we know that it is not prudent to do so."
Draft Public Health Action Plan to Combat Antimicrobial ResistanceThis notice announces the availability of a document for public comment entitled Draft Public Health Action Plan to Combat Antimicrobial Resistance. The Action Plan provides a blueprint for comprehensive and coordinated efforts of Federal agencies (CDC, FDA, HHS, and NIH) in addressing the emergence of antimicrobial resistance (AMR). The Plan will target human medicine, veterinary medicine, environmental issues, and use of antimicrobials in agriculture. Part I of the Plan focuses on domestic issues. Since AMR transcends national borders and requires a global approach to its prevention and control, Part II of the plan, to be developed subsequently, will identify actions that more specifically address international issues.
The Plan includes a summary and a list of issues, goals, and action items addressing 4 focus areas: Surveillance (detection of problems and informing action to address them), Prevention and Control (promoting prudent use of antimicrobials and preventing transmission of infections), Research (gaining fundamental knowledge necessary to develop appropriate responses), and Product Development (translating research findings into clinically useful products to prevent, rapidly diagnose and treat infections). For each action item, collaborator agencies/departments and timelines are specified. The agencies encourage the involvement of non-federal partners. The Interagency Task Force will monitor, and if necessary, update the Plan, during the coming years.
Contact: The Office of Health Communication, National Center for Infectious Diseases:
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