While the widespread overuse and misuse of antibiotics is frequently cited in discussions of increasing bacterial resistance, there are instances where even correct use for an individual patient raises the question of potential harm to others. A prevailing paradox in antibiotic therapy is that what is good for the one may be bad for the many.
Physicians are ethically compelled to help the patient in front of them, but in giving them antibiotic therapy they may inadvertently contribute to the rise of resistant organisms that threaten other patients. A recently published perspective piece by three leading antibiotic experts presents a novel argument to reframe the paradigm.1
“Antibiotics are unique because they are the only pharmaceutical agents that have transmissible loss of efficacy over time,” they argued. “Other drug types should work as well in the future as they do today. However, because of the inevitable occurrence and transmission of antibiotic-resistant bacteria from patient to patient, every patient’s use of antibiotics affects the future ability of every other patient to use those same antibiotics. Antibiotics are a shared community property or trust, and clinicians, healthcare organizations, patients, and the public are bound together in the need to protect these drugs from misuse.”
Individual practitioners understandably may perceive antibiotic restrictions or enforcement beyond recommendations as limiting their autonomy to practice medicine, they conceded.
“However, misuse of antibiotics does not just harm the individual, it has a negative health effect on everyone in society,” the authors observed. “The indulgence of individual practitioner freedom regarding antibiotic choices therefore must be tempered by the knowledge that inappropriate use of antibiotics affects society at large.”
To be effective, antibiotic stewardship programs must incorporate best practices, which include dedicating sufficient resources to the program, appointing a single leader to be accountable for performance, having appropriate antibiotic expertise, implementing action plans, monitoring bacterial resistance, reporting antibiotic usage to staff, and providing education. However, further improving antibiotic use will require increased accountability and transparency at the societal level, they noted.
“A parallel can be drawn between antibiotic stewardship and infection prevention,” the authors stated. “Hospitals have been required to have infection prevention programs for many decades. Yet no transformative progress in reducing healthcare-associated infections occurred until society began requiring public reporting of infection rates and linking such rates to pay-for-performance measures. This shift toward greater accountability and transparency in healthcare-associated infections has led hospitals to vest infection control programs with the authority to implement critical improvements. A similar shift could substantially accelerate efforts to improve antibiotic use.”
For drugs other than antibiotics, appropriate use generally mirrors the way the drug was proven to be effective and safe in clinical trials. In contrast, “effective” and “safe” are necessary, but not sufficient, to define appropriate use of an antibiotic.
“Consider an antibiotic that has a broad spectrum of activity that includes both highly resistant bacteria and also more common susceptible bacteria for which many other antibiotics already exist. Use of such a drug to treat common susceptible bacteria drives resistance to the drug among bacteria that are more difficult to treat and for which no other options are available.”
For example, fluoroquinolones are the only oral antibiotics that reliably can be used to treat infections caused by gram-negative bacilli, including antibiotic-resistant bacteria such as Pseudomonas and Acinetobacter. Thus, routine use of these agents to treat skin, urinary tract, or respiratory tract infections caused by susceptible bacteria, when other treatment options are available, conflicts with fundamental antibiotic stewardship principles. The consequence is selection of resistant bacteria such that fluoroquinolones can no longer be reliably used to treat common infections or infections caused by more resistant bacteria.
“Yet the fluoroquinolones are approved to treat skin, urinary tract, and respiratory tract infections, and national guidelines recommend these agents to treat such infections, making it difficult for stewardship programs at the hospital level to prevent such use,” the authors concluded. “Given that antibiotics represent a shared societal trust, the regulatory approval process and national practice treatment guidelines governing use of antibiotics should not be based solely on considerations of efficacy and safety, as they are for all other drugs. Rather, for antibiotics, the regulatory approval process and national practice guidelines should incorporate fundamental principles of antibiotic stewardship.”
- Spellberg, B, Srinivasan A, Chambers HF. New Societal Approaches to empowering Antibiotic Stewardship. JAMA Published online February 25, 2016. doi:10.1001/jama.2016.1346.