Antibiotic resistance

steddyeddy

MRSA, VRSA and VRE are among several drug resistant microbes that have emerged in the last few decades. There has been many debates in this forum regarding antibiotic resistance. I thought this being a health science forum it would be good to discuss how to combat it.

I personally think that there are several reasons for resistance e.g. the patient not finishing a course of antibiotics, antibiotics being prescribed for inappropriate indications (colds) ect. I also think the frankly backward nature of the American health care system contributes significantly. On researching this topic I cam across an interesting paper on the subject:Interventions to improve antibiotic prescribing practices in ambulatory care.

The results were interesting:

Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention.

This topic has been controversial on this thread. Whenever it's mentioned that clinicians play a large part in this you're accused of "attacking educated men". Well I'm educated too so I feel I can contribute. What measures should be taken to reduce antibiotic resistance?

Icemancometh

I think it's a good idea to start a new thread for this, didn't seem right discussing it on the other one. Part of the problem is that prescribing antibiotics is usually a no lose situation for the physician. There's usually no side effects beyond nausea, patients are happy to receive them, and it's much quicker to write a script than it is to explain why antibiotics are inappropriate. That's not to justify it, just to explain it.

I think economists use the idea of an externality to explain things like antibiotic resistance. (My understanding is that installing a house alarm is a negative externality for your neighbour, in that a burglar will rob his house instead of yours, and a well kept garden is a positive externality in that house prices might go up.) Using hydrocarbons is similar to antibiotics in a way. I benefit from cheap, abundant energy when I burn petrol, or heat my home with gas, but the environment suffers from CO2 release. You combat this by taxing hydrocarbons to reflect the negative externality of their use. I'm not sure what method can be used with antibiotics however.

BTW steddyeddy, can you provide a link for people accusing you of "attacking educated men?" I know you have a bee in your bonnet about medics, but I haven't noticed anyone accusing you of that in particular.

Edit: Sorry eddy, that was a bit unfair. Although I'm interested in seeing anyone attacking you for that (mostly because it's so obnoxious), I'd rather not derail what could be an interesting thread.

steddyeddy

Icemancometh wrote: »

I think it's a good idea to start a new thread for this, didn't seem right discussing it on the other one. Part of the problem is that prescribing antibiotics is usually a no lose situation for the physician. There's usually no side effects beyond nausea, patients are happy to receive them, and it's much quicker to write a script than it is to explain why antibiotics are inappropriate. That's not to justify it, just to explain it.

I think economists use the idea of an externality to explain things like antibiotic resistance. (My understanding is that installing a house alarm is a negative externality for your neighbour, in that a burglar will rob his house instead of yours, and a well kept garden is a positive externality in that house prices might go up.) Using hydrocarbons is similar to antibiotics in a way. I benefit from cheap, abundant energy when I burn petrol, or heat my home with gas, but the environment suffers from CO2 release. You combat this by taxing hydrocarbons to reflect the negative externality of their use. I'm not sure what method can be used with antibiotics however.

BTW steddyeddy, can you provide a link for people accusing you of "attacking educated men?" I know you have a bee in your bonnet about medics, but I haven't noticed anyone accusing you of that in particular.

Well first of all I collaborate with clinicians a lot so I don't have problems with them. Secondly you might want to read the sentence in bold out loud to yourself.

Thirdly I think there needs to be interventions somewhere. I mean if antibiotics are being prescribed inappropriately (the extreme example is antibiotics for a viral infection) then it should be vetoed somewhere along the line. E.G pharmacists.

Icemancometh

steddyeddy wrote: »

Well first of all I collaborate with clinicians a lot so I don't have problems with them. Secondly you might want to read the sentence in bold out loud to yourself.

Thirdly I think there needs to be interventions somewhere. I mean if antibiotics are being prescribed inappropriately (the extreme example is antibiotics for a viral infection) then it should be vetoed somewhere along the line. E.G pharmacists.

Read it out loud, still don't see the problem.

I'm not sure how pharmacists can know if a script is inappropriate or not, bar some outlandish examples. I imagine the two main sources of inappropriate prescription are hospital doctors using a very aggressive treatment regimen, and GPs treating self limiting illness. In the second category, you can usually instill enough doubt into consult to justify any single script, which is why I don't think an intervention will work on a pharmacist veto level. A more effective, but more heavy handed solution, may be to gather data on prescription rates per county, as well as what meds are being prescribed exactly. I have heard anecdotes about PCT meetings in England where the pharmacist will ask docs to justify prescriptions of co-amoxiclav for example. I think this approach, but on a bigger scale, might bear fruit.

Mrs OBumble

Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity.

I think think is the most interesting line in your quote.

It does not take a lot of time to say "if your snot turns green, then fill this prescrription and take one twice a day for seven days. But do not waste your money on the prescription otherwise." - but your average doctor seems to believe that their patients are too stupid to understand such instructions.

(I've often thought that doctors should routinely apply some sort of intelligence and scientific-literacy testing to patients, to give guidance about what type of communications and language the patients are likely to understand.)

steddyeddy

Icemancometh wrote: »

Read it out loud, still don't see the problem.

I'm not sure how pharmacists can know if a script is inappropriate or not, bar some outlandish examples. I imagine the two main sources of inappropriate prescription are hospital doctors using a very aggressive treatment regimen, and GPs treating self limiting illness. In the second category, you can usually instill enough doubt into consult to justify any single script, which is why I don't think an intervention will work on a pharmacist veto level. A more effective, but more heavy handed solution, may be to gather data on prescription rates per county, as well as what meds are being prescribed exactly. I have heard anecdotes about PCT meetings in England where the pharmacist will ask docs to justify prescriptions of co-amoxiclav for example. I think this approach, but on a bigger scale, might bear fruit.

Here's a simple way for pharmacists to know. Write down the reason the antibiotic is being prescribed. Pharmacists aren't stupid, they're highly trained individuals and they should have a good idea whether an antibiotic is appropriate or not.

steddyeddy

By the way Iceman you wrote "I know you have a bee in your bonnet about medics, but I haven't noticed anyone accusing you of that in particular."

In other words you said that I have a problem with medics but no one says I have a problem with medics.

Icemancometh

steddyeddy wrote: »

By the way Iceman you wrote "I know you have a bee in your bonnet about medics, but I haven't noticed anyone accusing you of that in particular."

In other words you said that I have a problem with medics but no one says I have a problem with medics.

A poorly constructed (and since withdrawn) sentence. I was referring to the "questioning educated men" bit, but it's a digression so best to leave it altogether I think.

Pharmacists are certainly well educated in drugs, the biochemistry, their pharmacokinetics and pharmacodynamics. But I would imagine their knowledge of disease, and clinical diagnosis of disease isn't the same as that of physicians, hence the different roles really. Besides, do pharmacists really want to deny a script that a patient has received from their doctor earlier, and deal with that whole process?

I think we're missing out on another huge area of antibiotic misuse; agriculture. I don't think it's particularly a problem in Ireland, or even in the EU, but in more intensive agricultures I believe they are used extensively, and with limited controls.

Abby19

Icemancometh wrote: »

Pharmacists are certainly well educated in drugs, the biochemistry, their pharmacokinetics and pharmacodynamics. But I would imagine their knowledge of disease, and clinical diagnosis of disease isn't the same as that of physicians, hence the different roles really. Besides, do pharmacists really want to deny a script that a patient has received from their doctor earlier, and deal with that whole process?

Regarding antibiotics - there is antimicrobial stewardship within most/all hospitals with certain abx held in reserve and you have to talk to micro or the clinical pharmacist before you could prescribe them. Having a similar system with community pharmacists probably wouldn't work the way the systems are resourced at present.

Pharmacists are very well qualified, the same medicines might have different prescribing regimens depending on what it is treating - and I have received phone calls from pharmacists about prescriptions I have written, e.g. if a dose is unusual to them, sometimes if only a few medications has changed, do others stay the same. Also about patients unwell and looking for additional medications.

I for one welcome feedback from my colleagues, it could be very easy to have an incorrect dose written, and this is an additional failsafe within the system. They see the pt every time they pick up their script, as opposed to once every few months (depending on when you rotate your posts as an NCHD you may never have seen that pt before and may never see them again) so probably have a better idea of the pts baseline.

Handwriting prescriptions in a rush during a busy clinic is less than ideal. Electronic prescribing would be easier, especially for repeat pts, and they could have the licensed doses for many medicines listed thus helping reduce/eliminate errors.

steddyeddy

Icemancometh wrote: »

A poorly constructed (and since withdrawn) sentence. I was referring to the "questioning educated men" bit, but it's a digression so best to leave it altogether I think.

Pharmacists are certainly well educated in drugs, the biochemistry, their pharmacokinetics and pharmacodynamics. But I would imagine their knowledge of disease, and clinical diagnosis of disease isn't the same as that of physicians, hence the different roles really. Besides, do pharmacists really want to deny a script that a patient has received from their doctor earlier, and deal with that whole process?

I think we're missing out on another huge area of antibiotic misuse; agriculture. I don't think it's particularly a problem in Ireland, or even in the EU, but in more intensive agricultures I believe they are used extensively, and with limited controls.

Oh yea of course. I think agriculture might surpass both patient and doctor as being the primary cause of multi drug resistant strains. That's often overlooked in these conversations. Another major problem is the American health care system. If you only treat a certain amount of the population then you create reservoirs of these bacterium to grow and mutate in. Making them harder to treat in the patients that have got health insurance.

No a pharmacist wouldn't know as much about diseases as a doctor. They should know that antibiotics aren't effective on viruses for instance. Although I'm sure no doctor would admit to prescribing for viral infections on a prescription.

Dingle_berry

Interesting that nobody has mentioned taking a sample, waiting 3-4 days and prescribing strictly according to the sensitivity testing. It wouldn't solve the issue of patient compliance but could a GP take the sample, write a general prescription for antibiotics and the pharmacist fill that from the lab results, with pertinent information like kidney function etc.

steddyeddy

Dingle_berry wrote: »

Interesting that nobody has mentioned taking a sample, waiting 3-4 days and prescribing strictly according to the sensitivity testing. It wouldn't solve the issue of patient compliance but could a GP take the sample, write a general prescription for antibiotics and the pharmacist fill that from the lab results, with pertinent information like kidney function etc.

Well how many GPs are going to be treating patients requiring immediate and aggressive antibiotic treatment?

Dingle_berry

steddyeddy wrote: »

Well how many GPs are going to be treating patients requiring immediate and aggressive antibiotic treatment?

Not being a GP myself I wouldn't be able to answer that. But good question, would there be many patients requiring aggressive antibiotic therapy? Could they follow the same regimen an in-patient with query sepsis would follow I.e. Broad spectrum therapy until sensitivities are known then switch?

_Tombstone_

ResistanceMap

Why India Is A Hotbed Of Antibiotic Resistance And Sweden Is Not

thegreatgonzo

[QUOTE=Icemancometh;
I think we're missing out on another huge area of antibiotic misuse; agriculture. I don't think it's particularly a problem in Ireland, or even in the EU, but in more intensive agricultures I believe they are used extensively, and with limited controls.[/QUOTE]

To be honest I think the problem is underestimated. I'm working as a vet nurse in the Munster area where there would be some very large dairy farms. I'm concerned about the amount of antibiotics I have to supply to farmers who just come in and request it.

_Tombstone_

The Age of Infection

challengemaster

steddyeddy wrote: »

Oh yea of course. I think agriculture might surpass both patient and doctor as being the primary cause of multi drug resistant strains. That's often overlooked in these conversations.

The one that's overlooked that definitely is responsible is cleaning agents. I don't have the paper off hand, but a few years back I remember a paper being published by someone in the Microbiology department of NUIG outlining that the use of disinfectant cleaning agents induced multiple antibiotic resistance that the surviving bacteria had NEVER encountered before, hence could not possibly have developed resistance through normal means.

Actually, link:

http://www.nuigalway.ie/our-research/spotlight-on-research/disinfectants-may-promote-growth-of-superbugs.html

challengemaster

challengemaster wrote: »

The one that's overlooked that definitely is responsible is cleaning agents. I don't have the paper off hand, but a few years back I remember a paper being published by someone in the Microbiology department of NUIG outlining that the use of disinfectant cleaning agents induced multiple antibiotic resistance that the surviving bacteria had NEVER encountered before, hence could not possibly have developed resistance through normal means.

Actually, link:

http://www.nuigalway.ie/our-research/spotlight-on-research/disinfectants-may-promote-growth-of-superbugs.html

That's very interesting. I hadn't realised disinfectants could have this effect.

Kurtosis

Icemancometh wrote: »

I think we're missing out on another huge area of antibiotic misuse; agriculture. I don't think it's particularly a problem in Ireland, or even in the EU, but in more intensive agricultures I believe they are used extensively, and with limited controls.

Agricultural use always seems to be overshadowed by human prescribing in debates about antibiotic resistance. The fact is both are contributing to the problem and deserve attention in terms of ways to slow the development of resistance.

Came across this story that California are introducing restriction on veterinary use, banning use of antibiotics for growth promotion and restricting use in disease prevention. It seems mad that these uses, particularly for fattening up, are still permitted anywhere.

Mucco

Rapid diagnosis would make a positive difference.
ie instead of prescribing a broad spectrum which may be only partly effective, a targeted antibiotic could be given immediately, thus ensuring the bacteria are destroyed and reducing resistance. This could also reduce antibiotics for viruses etc..
Ideally, such a diagnostic would have a ~15 min turnaround so the patient can wait in the surgery.

Dingle_berry

Mucco wrote: »

Rapid diagnosis would make a positive difference.
ie instead of prescribing a broad spectrum which may be only partly effective, a targeted antibiotic could be given immediately, thus ensuring the bacteria are destroyed and reducing resistance. This could also reduce antibiotics for viruses etc..
Ideally, such a diagnostic would have a ~15 min turnaround so the patient can wait in the surgery.

And what assay offers that?

sambucus nigra

http://europepmc.org/abstract/med/25966643

Can't find a full free copy of the paper, but sounds promising from abstract!

In this study, we developed and compared four protocols to prepare a bacterial pellet from 944 positive blood cultures for direct MALDI-TOF mass spectrometry Vitek® MS analysis. Protocol 4, tested on 200 monomicrobial samples, allowed 83% of bacterial identification. This easy, fast, cheap and accurate method is promising in daily practice, especially to limit broad range antibiotic treatment.

Although I doubt we'll be seeing an MS in every GP surgery in the country (!), it could certainly be feasible for hospitals with an in-house med-lab.

Dingle_berry

sambucus nigra wrote: »

http://europepmc.org/abstract/med/25966643

Can't find a full free copy of the paper, but sounds promising from abstract!



Although I doubt we'll be seeing an MS in every GP surgery in the country, it could certainly be feasible for hospitals with an in-house med-lab.

MALDITOF in every GP surgery? Lol!
Even if the machines were affordable, the individual tests aren't. Also though the MS part may take 15mins it still requires the pre-analytical steps.

Some of the larger micro labs already have MALDITOF but they still require culture first.

Mucco

Dingle_berry wrote: »

And what assay offers that?

Some automated PCR assays can give results in ~11mins. Not sure if this would apply for bacteria though.

Dingle_berry

Mucco wrote: »

Some automated PCR assays can give results in ~11mins. Not sure if this would apply for bacteria though.

11mins from DNA extraction to direct result or 11mins from loading PCR mix into the machine to results of raw data that need to be extracted/translated/interpreted?

steddyeddy

Dingle_berry wrote: »

11mins from DNA extraction to direct result or 11mins from loading PCR mix into the machine to results of raw data that need to be extracted/translated/interpreted?

No that's highly unlikely.

steddyeddy

Well Maldi wouldn't be as good as electro spray ionisation when it came to determining bacteria species IMHO. Maldi is still brilliant and can be cheaper. Either way mass spec isn't likely to happen for a while and GPs wouldn't have the expertise or time for pre-treatment.

Either way GPs are over prescribing antibiotics. I think a simple solution would be to state the reason the antibiotic is prescribed on a prescription and if nonsense the pharmacist would veto it. My pharmacist told me there's endless cases of some GPs prescribing antibiotics at the drop of the hat for trivial things. It doesn't require physical techniques like mass spec or NMR it requires common sense.

Taco Chips

Perhaps a good practice to bring in would be encouraging GPs to write post dated prescriptions for antibiotics for bacterial infections that should resolve on their own within 2-3 days. i.e, patient presenting with a mild LRTI. If the infection is still persisting with symptoms equally as bad or getting worse then fill the medication. Some docs on here more qualified than me might know, is this a workable policy?

sambucus nigra

Taco Chips wrote: »

Perhaps a good practice to bring in would be encouraging GPs to write post dated prescriptions for antibiotics for bacterial infections that should resolve on their own within 2-3 days. i.e, patient presenting with a mild LRTI. If the infection is still persisting with symptoms equally as bad or getting worse then fill the medication. Some docs on here more qualified than me might know, is this a workable policy?

Last 2 times I've been to the GP I've come away with such a prescription, although I was advised to only fill if symptoms persisted/got worse, not forced to wait (or rather, the pharmacist wasn't forced to wait to dispense). I didn't need actually to fill on either occasion.

I don't know if the delayed dispensing date helps - IMO it would be better to not prescribe at all and have the patient return after 2-3 days if necessary.

steddyeddy

One certainty is that things re not OK the way they are. Antibiotics are being over prescribed and resistance is increasing. I know Europeans are limited by the bacterial resistance inducing American health care systems but we should still play a role in this.

echo beach

sambucus nigra wrote: »

Last 2 times I've been to the GP I've come away with such a prescription, although I was advised to only fill if symptoms persisted/got worse, not forced to wait (or rather, the pharmacist wasn't forced to wait to dispense). I didn't need actually to fill on either occasion.

That can work well if the patient is clear what the intention is.

I don't know if the delayed dispensing date helps - IMO it would be better to not prescribe at all and have the patient return after 2-3 days if necessary.

Having patients return after 2-3 days seldom suits either the patient or the doctor.
Delayed dispensing dates often aren't that useful. A patient, especially a child or older person, can deteriorate very quickly, in hours rather than days and presenting a post-dated prescription can put the pharmacist in an awkward position.
Antibiotic prescriptions should also have a 'do not dispense after' date. Often patients present a prescription written some time earlier that they didn't use. It is still legally valid but may not be appropriate, posing another dilemma for the pharmacist.

_Tombstone_

Why New Antibiotics Never Come to Market

“We’ve discovered six antibiotics in the recent past,” Fenical said. “Of those, three to four have serious potential as far as we know, including anthracimycin. But we have no way to develop them. There are no companies in the United States that care. They’re happy to sell existing antibiotics, but they’re not interested in researching and developing new ones.”

It’s estimated that more people will die from bacterial infections than cancer by 2050.

Antibiotic surge revealed by seasonal maps

gctest50

mcr-1 says: look at what i can do !

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2815%2900424-7/abstract