Antibiotic resistance takes center stage

June 22, 2016

The growing problem of antibiotic resistance remains one of the most prominent stories in healthcare, and increasingly one of the hottest ongoing news stories of any kind in the United States. In late May, news broke of the discovery of a strain of E. coli in a middle-aged Pennsylvania woman that was found to be resistant to colistin, the traditional drug of last resort for the bacterium. The strain became resistant not through mutation but via the acquisition of a plasmid, a bit of DNA that carries the antibiotic-resistant gene. The migration of plasmids from bacterium to bacterium is common, suggesting that more events like this one may be inevitable.

“The recent discovery of a plasmid-borne colistin-resistance gene, mcr-1, heralds the emergence of truly pan-drug resistant bacteria,” write the authors of the study that revealed the news, published online in the journal Antimicrobial Agents and Chemotherapy. All of the authors are affiliated with Walter Reed National Military Medical Center.

As it happens, the strain was not resistant to the class of antibiotics known as carbapenems. But the plasmid-borne colistin-resistance gene could transfer to any so-called “superbug,” including carbapenem-resistant enterobacteriaceae.

“The medicine cabinet is empty for some patients,” says U.S. Centers for Disease Control and Prevention (CDC) Director Thomas Frieden, MD, MPH. “It is the end of the road for antibiotics unless we act urgently.”

In that context, the CDC and the National Quality Forum (NQF) issued guidance to help hospitals better manage the use of antibiotics. The NQF’s Antibiotic Stewardship in Acute Care: A Practical Playbook is based on the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs.

The CDC estimates that the inappropriate use of antibiotics causes antimicrobial resistance that leads to two million illnesses and 23,000 deaths annually. In addition, antibiotic overuse and misuse have spurred the spread of Clostridium difficile infections that can cause life-threatening colitis. NQF’s National Quality Partners (NQP) has galvanized NQF member organizations and others to tackle this national priority.

“Antibiotic resistance is a public health crisis that can strike anyone with devastating effects,” says Arjun Srinivasan, MD (CAPT, USPHS), associate director for healthcare associated infection prevention programs, division of healthcare quality promotion, CDC, and co-chair of NQP’s antibiotic stewardship action team. “The Playbook provides a flexible structure with real-world examples for hospitals to use as they create high-quality antibiotic stewardship programs that meet the needs of their communities.”

Examples of strategies in the Playbook include the importance of team-wide, systematic approaches to assess when patients need antibiotics and when treatment should be adjusted; educate staff, family, and patients about appropriate antibiotic use; and track and report antibiotic prescribing, use, and resistance.

Just in time, because here may be some more ominous news: According to a study released last month, antibiotic-resistant bacterial strains may have an advantage that scientists had not anticipated. It has been thought that antibiotic resistance is associated with a fitness cost, meaning that bacteria that develop antibiotic resistance must sacrifice something in order to do so. Because of this, proper use of antibiotics should result in susceptible strains eventually replacing resistant ones.

According to the new research published in Bioessays, however, it appears that antibiotic-resistant strains might also be fitter and more virulent, which may have profound impacts on the control and treatment of bacterial infections.

Some surveys suggest that public understanding of antibiotic resistance may be sketchy; for example, significant numbers of people surveyed seem to think that people, not pathogens, develop resistance. The months and years ahead are likely to see considerable efforts at public—and professional—education to the nature of this threat.