Highly resistant microbes or “superbugs” are becoming increasingly common as many physicians encounter antimicrobial resistance in their everyday practices.
“Healthcare providers are now faced with clinical scenarios, where selecting an antibiotic to treat an infection is becoming increasingly more difficult, and in some cases impossible,” writes Ari Frenkel, board certified infectious disease and internal medicine physician, in an article published by ThermoFisher Scientific.
Frenkel is co-founder of Arkstone Medical Solutions, a biomedical technology company that uses artificial intelligence and machine learning to democratize infectious disease expertise across many clinical settings.
Arkstone estimates that the global threat due to antimicrobial resistance includes:
- 700,000 worldwide annual deaths due antimicrobial resistance
- 50 percent of outpatient antibiotic prescriptions are unnecessary or inappropriate
- $20 billion estimated addition cost to the U.S. healthcare system each year
UTIs Diagnosis and Treatment Could Have Ripple Effect
Frenkel says improving how healthcare providers diagnose and treat urinary tract infections (UTIs), one of the most common types of infection seen by providers in the outpatient setting and a significant catalyst of antibiotic prescriptions, could have a profound ripple effect across the U.S. healthcare ecosystem.
“A focus on improving how healthcare providers diagnose and treat UTIs can have a profound effect on limiting risks of antimicrobial resistance, direct patient care and their subsequent outcomes, and the costs to the healthcare system,” writes Frenkel.
“Antimicrobial Stewardship” programs – efforts put in place to improve antibiotics utilization – are endorsed by the Centers for Disease Control and Prevention (CDC), as well as the World Health Organization.
“Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance,” says the CDC.
Resistant Genes: Growing Threat as Some Bacteria Become Resistant
“One of the ways in which bacteria become resistant is through the acquisition of resistance genes,” writes Frenkel. “These resistance genes can be shared between species of bacteria, rapidly amplifying the spread and threat of these organisms.”
Frenkel cites the OXA-48 resistance gene as an example of how bacteria can become resistant.
“The rapid emergence of oxacillinase (OXA-48) like [carbapenemase] is alarming,” said a Journal of Global Infectious Diseases scholarly article.
Carbapenemase-producing Enterobacteriaceae (CPE) or carbapenem-resistant enterobacteriaceae (CRE) are Gram-negative bacteria that are resistant to the carbapenem class of antibiotics, considered the drugs off last resort for severe infections.
“Of all the becta-lactam antibiotics, carbapenems possess the broadest spectrum of activity and the greatest potency against bacteria. Because of this, they are often reserved for more severe infections or used as “last-line” agents,” says Drugs.com.
Bacteria that can evade this “last line of defense” is troubling with the CDC reporting in the 2019 Antibiotic Resistance (AR) Threats Report that more than 35,000 die each year in the U.S. as a result of more than 2.8 million antibiotic-resistant infections.
“Antibiotic resistance has the potential to affect people at any stage of life, as well as the healthcare, veterinary, and agriculture industries. This makes it one of the world’s most urgent public health problems,” says the CDC.
Why UTIs are in the Antibiotic Spotlight
UTIs are in the spotlight because they are one of the most common types of infection seen by healthcare professionals in outpatient settings.
“Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments,” said an article in the American Society for Microbiology Journal. “Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting.”
The article says that from 2010 to 2015, $56 billion was spent on antibiotics in the United States, of which 59.1 percent occurred in the outpatient setting, usually in community pharmacies.
In 2016, there were 3.7 million office visits and 2.6 million ED visits for UTIs in the United States.
UTIs are also a concern in hospitals, skilled nursing, and long-term care facilities.
“UTI is the second most frequent infection in long-term care facilities and the most common cause of hospitalization for bacterial infections,” says an article in the Annals of Long-Term Care.
The article says that it has been common practice to prescribe antibiotics to long-term care patients, even when they are asymptomatic.
“This approach, however, often does more harm than good, leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria,” said the article authors.
Three Points of Focus on Improving UTI Antibiotic Use
Frenkel says there are three important points to consider when improving how antibiotics are employed to fight UTIs:
- Education: Learning the distinction between symptomatic bacteriuria and asymptomatic bacteriuria can improve antibiotic prescriptions. Bacteriuria is the presence of bacteria in a patient’s urine. Frenkel says that with few exceptions, asymptomatic bacteriuria does not require antibiotics.
- Antibiotic Choice: Appropriate antibiotic selection is key to antimicrobial stewardship and can have a significant impact on patient outcomes. Frenkel says that certain antibiotics, such as fluoroquinolones like ciprofloxacin and levofloxacin, should be reserved when no other options are available, due to adverse reactions associated with their use. Broad-spectrum antibiotics, like meropenem and ertapenem, should only be considered when resistant microbes are suspected.
- Duration: Shorter courses of antibiotics can be just as effective as longer durations, according to Frenkel. Longer durations expose patients to more potential side effects and the longer the exposure to an antibiotic, the higher the risk of developing an antibiotic resistant infection.
“Without drastic change and intervention antimicrobial resistance will continue to worsen,” Frenkel concludes. “Intervention [regarding} the management of UTIs can provide significant impact in the reduction of antibiotic use. Education on the appropriate criteria for treatment, the antibiotic of choice, as well as the appropriate duration of therapy, is vital for an optimal and effective antimicrobial stewardship.”
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