Navigating Antimicrobial Resistance
By Jeni Miller
As more patients request antibiotics for managing many types of illnesses, it is no surprise that antimicrobial resistance (AMR) is on the rise.
According to the CDC, 2.8 million antimicrobial-resistant infections occur every year in the United States, with 35,000 deaths. Antimicrobial resistance is also responsible for Clostridioides difficile (C. diff), a bacterium that can cause serious intestinal infections and possibly even colon cancer. The CDC stated C. diff causes at least half a million infections in the United States each year. Multidrug resistance exacerbates the problem.1
Rebecca Perez, MSN, RN, CCM, senior manager of education for the Case Management Society of America (CMSA), notes that tuberculosis also is becoming resistant, resulting in nearly 500,000 cases around the globe as part of an increasing trend.2
“The research and development of new antibiotics … is expensive, and the ones we have are losing their effectiveness due to antimicrobial resistance,” Perez notes. “Since 2017, only two antibiotics have been FDA approved that represent a new class of action.”
“As we gather more evidence, we see more clearly and more worryingly how fast we are losing critically important antimicrobial medicines all over the world,” World Health Organization Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, said in 2020.3 This upward trend is becoming more common, and healthcare professionals are asking how they can discourage the misuse and overuse of antibiotics to help mitigate the effects of antimicrobial resistance.
The Importance of Patient Education
Case managers are in a critical position as healthcare advocates and patient educators. They should consider continuing education on the topic of antimicrobial resistance and how to help patients better understand the delicate nature of antibiotic use.
Unfortunately, antibiotics are routinely misused due to several factors. “The misuse use of antibiotics is related to attitudes and culture,” Perez explains. “People will ask for an antibiotic as soon as they begin to experience symptoms, like cough, runny nose, [and more]. People believe if they start an antibiotic as soon as possible, they will avoid worsening symptoms. Most upper respiratory infections are viral in nature, and antibiotics are not effective. Bacteria, fungi, and parasites can change over time. Bacteria inherently survive, mutate, and adapt as they are exposed to antimicrobials.”
The authors of a study published in 2021 discussed how antibiotics are increasingly sold through online pharmacies, often without a prescription. The rise of telemedicine during the COVID-19 era has caused a further increase in excessive antibiotic prescriptions. In low- to middle-income countries, the problem is even worse.4
But even in the United States, misconceptions about antibiotics abound. The study authors noted “43% of parents of a child with cold symptoms believed that antibiotics were necessary.” Patients and their families do not seem to distinguish between viral and bacterial infections when considering the use of antibiotics — and physicians too readily prescribe them. The older the physician, the authors found, the more likely they are to prescribe.
The issues are many, but providers are taking seriously the need for antimicrobial stewardship, an effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.
Antimicrobial stewardship also elevates recommendations for the “optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance,” Perez notes.
While case managers are not involved in the prescribing of antibiotics, they can play an integral role in advocating and educating patients and families about the appropriate use of antibiotics.
CMSA shared that “case managers can support [antimicrobial stewardship] by educating patients on the dangers of overuse and misuse of antibiotics, facilitation, and coordination of needed diagnostics to determine if antibiotics are indicated, ensure patients understand their antibiotic prescription and are adherent with the treatment protocol, and collaborate with all members of the interdisciplinary team for optimal health outcomes. The only way to slow the resistance to antibiotics is to practice and reinforce antimicrobial stewardship.”5
If case managers are alert to the challenge and open to opportunities for education, they can successfully work through their role to help patients make the best choices regarding antibiotic usage. First, it is important for hospital case managers to be aware that 25% of patients who receive antibiotics in the hospital will develop an antibiotic-associated adverse event. These events can lead to more testing and longer lengths of stay, according to the Agency for Healthcare Research and Quality.6
“Case managers can assist with antimicrobial stewardship, especially in ambulatory and community settings,” Perez says. “Helping patients understand why antibiotics must be used appropriately will be the greatest challenge. First, the case manager must comprehend the dangers of [antimicrobial resistance].”
Basic education for patients and families might include counseling them and reinforcing that “most upper respiratory illnesses are viral in nature and antibiotics are not effective in combating viruses,” Perez adds. “In a manner that will be understood, case managers can explain that microorganisms are capable of adapting due to overuse, that antibiotic resistance leads to greater health risks, and to instruct and reinforce infection prevention measures, such as good handwashing, avoiding people with known illnesses, and good environmental cleaning.”
Perez reiterates the greatest opportunity to participate in antimicrobial stewardship is in the outpatient setting, where 80% of antibiotic prescriptions occur.
- Centers for Disease Control and Prevention. About antimicrobial resistance. Page last reviewed Oct. 5, 2022.
- Friedland JS. Tuberculosis in the 21st century. Clin Med (Lond) 2011;11:353-357.
- World Health Organization. Record number of countries contribute data revealing disturbing rates of antimicrobial resistance. June 1, 2020.
- Blaser MJ, Melby MK, Lock M, Nichter M. Accounting for variation in and overuse of antibiotics among humans. Bioessays 2021;43:e2000163.
- Case Management Society of America. Antimicrobial Resistance: A Case Manager’s Guide to Antimicrobial Stewardship. 2023.
- Agency for Healthcare Research and Quality. AHRQ Safety Program for Improving Antibiotic Use. September 2022.
As more patients request antibiotics for managing many types of illnesses, it is no surprise that antimicrobial resistance is on the rise. According to the CDC, 2.8 million antimicrobial-resistant infections occur every year in the United States, with 35,000 deaths.
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