Antibiotic Stewardship

Antibiotic Stewardship 

by JP Saleeby, MD

http://cme.medscape.com/viewarticle/731689 John G. Bartlett, MD

To open up, I want to make it perfectly clear the intentions of this article by stating a few facts.  These are facts back up by loads of peer-reviewed publications.  These facts are likewise rational and logical.

• Fact:  Antibiotics save lives.
• Fact:  Antibiotics reduce morbidity and mortality in severe and life threatening infections.
• Fact:  Antibiotics have in the past 20-years been over-prescribed.
• Fact:  Antibiotics are necessary in the practice of good medicine and new guidelines need to be followed in light of present day resistance.

It is both intuitive and evidence based that appropriate use of antibiotics in modern medicine have saved thousands of lives.  Prior to the discovery of the antibiotics (antimicrobials) infection was a leading cause of death in humans.  Today, many life threatening illnesses such as pneumonia, sepsis, flesh-eating bacterial infections (necrotizing fasciitis), or meningitis are so dangerous, that delay in antibiotic therapy can cost a life.

For those pseudo-healthcare practitioners that are blinded by sheer bias and hatred toward contemporary western medicine (and suffer brain squeeze because their craniums are so far up their rectums), spouting the foolish notions that "you don't need antibiotics" or "antibiotics are never good for you", be warned.  Those reading this article that are experiencing a grave illness due to a microbe should be aware that those advocating the cockamamie notion that all things antibiotic are evil, should run as fast and far away from those practitioners.  Furthermore, they can and should be held culpable for the death of a patient should they intentionally delay people from getting life saving antibiotic therapy.  Intuitive practitioners, some chiropractors and those who favor wave eagle feathers and crystals over folks in an attempt to cure a complex septic patient should put their unsubstantiated opinions and bias' aside and refer their patients to a medical doctor for definitive care.  No need to stain you hands with blood over an idiotic notion unfounded by any empirical evidence.  Enough ranting about unfounded prejudice against antibiotics amongst healers.

While there is no question about the helpfulness of antibiotics, it is also true that since their inception they have been abuse and over prescribed.  Now we realize the ills of haphazard and unbridled use as we see resistant organisms appear more often and on the rise.

According to Dr. J. G Bartlett in a Medscape CME published in November of 2010 entitled "Addressing the Rising Tide of Antimicrobial Resistance" he spells out the rise of the top six microbes that are defying our current regiment of antibiotic therapy.  They are Enterobacter, Staph. aureus, Klebsiella, Acinetobacter, Pseudomonas aeruginosa and Enterococcus.  In the US methicillin-resistant Staphylococcus aureus (MRSA) is on the rise with some 94,360 cases a year and 18,650 deaths annually reported by Kelevens et. al., in JAMA in 2007.  Those are some fierce numbers for a bacterium that only 10 years ago was only seen in hospital ICUs and nursing homes.  Now greater than 60% of cultures of abscesses in my local region culture positive for MRSA.  The whole penicillin class of drugs (Amoxil, Keflex, etc.) is useless against MRSA.  Clostridium difficile infections are another example with diagnosed cases on the rise and antibiotic resistance mounting as well.  Death by C. difficile infection has taken an exponentially rise since 1999.

Furthering the crisis of antimicrobial resistance and of great concern is that in the last ten-years the development of new antibiotics and antibiotic classes has all but dried up.  A 2004 report by the Infectious Disease Society of America (IDSA) stated that there is“antibiotic discovery stagnation” were we are witnessing bad bugs with no new drugs to fight them.  An example of how slow we are to develop new antimicrobials is seen in a study published in 2009 in the Clinical Infectious Disease journal by Dr. H.W. Boucher reporting that between 1983 and 1887 sixteen new antibiotics were developed.  From 1993 - 97 ten antibiotics were developed and this dropped to only five from 2003 - 07 and from 2008 projected until 2012 only one new antibiotic coming to market.  From the 1930's through the 1970's there were eleven new classes of antimicrobials developed by pharmaceutical companies, with only four classes in the 1950, and during the 2000's only two new classes were developed.  The 1980s and 1990's saw a dry spell, with no new antibiotic-class development. These are scary numbers considering the rapid rise in microbial resistant organisms just in the past decade.

http://cme.medscape.com/viewarticle/731689 John G. Bartlett, MD

So while antibiotic use is necessary and critical in the very ill, judicious use is necessary to save our "big guns" for those really bad infections.  Most pharangitis infections are viral and despite this fact many GPs would prescribe antibiotics just to appease an anxious patient, and not treat the real root cause.  This practice has to stop.  No one will argue about utilizing a broad spectrum aggressive antibiotic regiment in a septic patient, but we need to look at the evidence of stopping drugs when cultures are negative and using effective shorter courses.  Evidence is mounting that a three day course of antibiotics for community acquired pneumonia (CAP) is as effective as a seven- or ten-day course.  On the other side of the continuum, those that don't advocate the use of antibiotics at all will harm the really sick.  We must reach a happy medium.

JP Saleeby, MD is an emergency room physician who practices integrative medicine in solo practice.  His weltanschauung is practical, pragmatic and not at all crunch or granola.  For more information visit www.saleeby.net

© 2010