Understanding Antibiotic Resistance and How to Prevent It

By: Fidel Lim, DNP, CCRN

Faculty- NYU College of Nursing

More that eighty years ago Alexander Fleming identified Penicillin. After returning from vacation, he found that a mold inhibited bacterial growth around a staphylococcus culture dish. It wasn’t until D-Day in 1944 when the drug fully made its public health debut, when enough of it became available to allow unlimited treatment of allied service men suffering from infections.

A World War II ad reads: “Penicillin kills gonorrhea in four hours. See your doctor today.” Well, a lot has happened since the medical establishment prematurely declared victory over infectious diseases with the discovery antibiotics (Sulfa was the first antibiotic used in 1938). Today’s headlines are much more likely about fears of new epidemics like the Ebola, Middle East Respiratory Syndrome (MERS) and Clostridium infection the growing menace of antibiotic resistance.

Antibiotic resistance is not exactly a new phenomenon. In the 1940s and 50s Streptomycin and INH (Isoniazid) already showed some resistance to the TB bacilli (Porter, 1997). According to the 1998 report of the Institute of Medicine’s forum on Emerging Infections, strains of Staph Aureus resistant to Penicillin were isolated as early as 1945. The chairman of the forum testified that resistance inevitably occurs as bacteria adapt to the presence of antibiotic in their environment.

Today we have MRSA, VRE, VISA, VRSA and MDRTB or XD RTB. If you know what these letters stand for, then chances are you have taken cared of a patient with a resistant infection. And for sure you have already been to at least one conference telling us how astronomically expensive it is to treat resistant infections, not to mention the high rate of mortality.

How do Bacteria Become Resistant?

How bacteria develop resistance against antibiotics is simply a manifestation of the Darwinian notions of the struggle for existence. Bacteria evolve in order to survive. The CDC informs us that bacteria may develop the ability to neutralize or evade the effect of the antibiotic. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant.

In addition, bacteria that were at one time susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped in a single, easily transferable package. This means that bacteria can become resistant to many antimicrobial agents because of the transfer of one piece of DNA. Some bacteria develop the ability to neutralize the antibiotic before it can do harm, others can rapidly pump the antibiotic out, and still others can change the antibiotic attack site so it cannot affect the function of the bacteria (for the full article, log on to http://www.cdc.gov/drugresistance/threat-report-2013/

In March 1994, Newsweek magazine published “The End of Antibiotics.” The article warned the public that by means of some clever mechanism, bacteria creates resistance by dismembering the drug, by changing the bacterial cell wall so that antibiotics can’t get in or by pumping out the antibiotics out of the bacteria.

Human hosts are not exactly the helpless victims in the creation of resistance. We live in the age of pills – patients often demand antibiotics from physicians and Nurse Practitioners and too often they are accommodated. An interview with a British doctor in the 1980s revealed what might be a common practice at the time, not only in Britain but elsewhere. It informed that prescribing pills was a way of avoiding a more time-consuming analysis and treatment. Writing a prescription (antibiotics) pleases the patient and relieves the physician of his or her high case volume. Repeated and improper uses of antibiotics are primary the causes of the increase in drug-resistant bacteria.

However, no matter how grim the predictions may be, the situation is not hopeless. A Wall Street Journal article “Curbing Antibiotic Use in War on ‘Superbugs’” (September 3, 2008- reported by Laura Landro)  informed us that hospitals are turning to a new breed of antibiotic SWAT team to win the war against resistant organism. The effort known as antimicrobial stewardship programs will team top pharmacist, infectious disease specialists and microbiologist. This group will monitor the hospital’s use of antibiotics and restrict prescription of certain drugs (for example: Vancomycin) when they become resistant. These new efforts is partially the result of the federal Medicare program plans not to reimburse preventable hospital acquired infections, many of which are cause by resistant organisms.

Nurses’ Role in Preventing Antibiotic Resistance

As a Staff Nurse:

• Be vigilant with how your unit utilizes antibiotics – ask your local ID team
• Actively participate in “Pharmacy Committee” meetings and learn what your hospital is doing to address antibiotic resistance
• Always give antibiotics on time and avoiding skipping a dose
• Check your patient’s Culture and Sensitivity reports and act as a patient advocate by informing the M.D. if the bacteria are sensitive to a narrow-spectrum antibiotic (preferred than a broad-spectrum antibiotic)
• Always observe Standard and Contact precautions when caring for patients with resistant organism infections
• Participate in unit-based surveillance studies to look at trends of resistant infection
• Read evidence-based and best practice recommendation by logging on to: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11

What the General Public Can Do to Prevent Antibiotic Resistance

The CDC recommends:

• Talk with your healthcare provider about antibiotic resistance:
  • Ask whether an antibiotic is likely to be beneficial for your illness
  • Ask what else you can do to feel better sooner
• Do not take an antibiotic for a viral infection like a cold or the flu.
• Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
• Take an antibiotic exactly as the healthcare provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect.
• Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
• If your healthcare provider determines that you do not have a bacterial infection, ask about ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.

The pharmaceutical revolution that started in the 1950s has no doubt saved millions of lives, but is has also brought in new unimaginable problems. In his best selling book “The Greatest Benefit to Mankind: A Medical History of Humanity, Roy Porter tells us “the euphoria of the age of Penicillin has turned to anxiety…medicine will have to redefine its limits even as it extends its capacity”. Antibiotic resistance may be inevitable, but we must take a cue from the bacteria itself: we have to evolve in the way we treat and prevent infections if we are to survive.

References

Global consensus conference on infection control issues related to antimicrobial resistance: final recommendations. American Journal of Infection control. 1999;27(6):503-13.

Porter R. The Greatest Benefit to Mankind: A medical history of humanity. New York: W.W. Norton and Company:1997.

Begley S. The end of antibiotics. Newsweek. 1994; March 28:49-52.

Landro L. Curbing antibiotic use in war on ‘superbugs’. Wall Street Journal. September 3, 2008.

Barry J. The great influenza. New York:Viking:2004.

CDC. Get smart: know when antibiotics work. Available at: http://www.cdc.gov/drugresistance/community/anitbiotic-resistance-faqs.htm. Accessed on September 15, 2008.