Drug-resistant bacteria reaching crisis stage

Problem may require more aggressive approach

Pharmacists and other health care professionals must be aggressive in fighting against drug-resistant bacteria — or face serious consequences, infectious disease control specialists say.

A panel of these specialists recently convened in New York to discuss the problem of drug-resistant bacteria. The panelists expressed concern that a growing number of patients have developed bacterial infections that respond poorly, or not at all, to commonly used antibiotics. Particularly troubling are cases of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant S. aureus (VRSA) reported by the Centers for Disease Control and Prevention (CDC).

"The potential ramifications [of these infections] are staggering," said panelist Neil Fishman, MD, director of the department of health care epidemiology, infection control, and the antimicrobial management program at the University of Pennsylvania Medical Center in Philadelphia. He also was a representative of the Society for Healthcare Epidemiology of America in Mount Royal, NJ.

Panelist Martin Blaser, MD, issued a warning. "We can no longer be complacent about the threat posed by antibiotic-resistant bacteria," said the chairman of the department of medicine at New York University School of Medicine and a representative of the Infectious Diseases Society of America in Alexandria, VA. "The fact is, we are simply running out of options. We’re already seeing infections that fail to respond to the first or even second antibiotic prescribed. If we continue on this course, we’re going to find ourselves back in the Dark Ages, when serious infections had no cure."

Antibiotics should not be used as if they have no impact; instead, their use should be guided by the obvious fact that they do have an impact, says Michael Rybak, PharmD, MS, FCCP, president of the Society of Infectious Diseases Pharmacists in Austin, TX, and professor of pharmacy and medicine at the Eugene Applebaum College of Pharmacy and Health Sciences at Wayne State University in Detroit. Rybak also co-chaired the recent panel. As a pharmacist, he is pleased that he had the opportunity to open the session on such a topic and describe the problem with antibiotic-resistant bacteria before the other panelists commented.

"Unfortunately, antibiotics are not like our laser-guided weapons used in various wars that target one organism and only affect that one organism," he says in later remarks to Drug Utilization Review. "When you take an antibiotic and it is absorbed or infused, it goes after that one organism, but it also has activity against many other organisms. Commonly, this is where the problem of resistance occurs; patients now harbor organisms that are potentially resistant to that antibiotic that they received."

The patients then could pass that resistance on to others by transmitting the resistant organism. For instance, a pediatric patient could pass it on to an adult, an immunocompromised patient to other individuals. "This is how resistance spreads from one person to another," Rybak says.

Overprescribing antibiotics and using them improperly has led to bacteria developing resistance to the drugs. But it can be difficult for some clinicians to resist the demands of patients who just want something to help them feel better, even if they have a virus.

The World Health Organization in Geneva, Switzerland, analyzed 10 studies at teaching hospitals worldwide in 2000 and found that 40-91% of antibiotics prescribed were inappropriate. The study also found that health care workers often did not follow basic hygiene practices, such as washing hands and changing gloves between patient visits.

"Like it has always been said, it takes a minute to prescribe an antibiotic, but it takes about 15 minutes not to," Rybak says. "In many cases, we give antibiotics for colds and viruses. They have no activity against those pathogens."

He sees a movement now in health care toward waiting to prescribe an antibiotic, if the patient is not too ill. The patient will improve if he or she has a virus. Clinicians also might take a culture to determine whether the patient has a bacterial or viral infection.

As another way to address the problem, the panel emphasized the need to reinvigorate research on the development of vaccines that may prevent bacterial infections and new antibiotics that kill bacteria using novel mechanisms of action.

Large pharmaceutical companies, though, don’t always see the value of developing new antibiotics, Rybak says. "The research that is required to go into antibiotics is high; the cost margin is terrible. It’s difficult for them to take a venture into the antibiotic field because the profit margin is small compared to that of chronic drugs."

For this reason, development of new antibiotics often has fallen to smaller companies. However, if the company only has the one antibiotic in development and the U.S. Food and Drug Administration does not end up approving it, the company might not have the resources to try again.

It is important, then, for the government to encourage larger companies to try to develop new antibiotics, because the profits from other drugs can help them survive a drug that does not get approved, Rybak says. "Somehow a partnership with the government needs to encourage that."

That possibility leads Rybak to suggest a more aggressive stance in the treatment of drug-resistant bacteria: If health care professionals can rise to the challenge of infectious diseases such as severe acute respiratory syndrome (SARS), maybe the same approach can work with antimicrobial resistance.

"Like SARS, the threat posed by resistant bacteria is scary," Rybak said in his opening remarks at the panel. "Our fear is that we are simply running out of options, and this situation is only going to get worse in the months and years to come if we do not collectively do something about it now."

Leaving aside tuberculosis, in which the patient is isolated immediately when treated in a hospital setting, patients with a drug-resistant organism may not be isolated, depending on the type of organism they have, Rybak says. Instead of being complacent about antibiotic resistance, why don’t clinicians put the same effort into treating it that they would invest in a disease like SARS?

Not seeing the immediacy of drug-resistant organisms is a stumbling block, he says. "We just think it’s not going to affect us. If we don’t see people dropping dead like they might from SARS, we don’t concern ourselves."

The goal is to stop the problem before someone gets very sick with no antibiotic working against the infection, he adds. "It’s not too long in the distant future before we have organisms that don’t respond to anything."