Antibiotic resistance: a Global Issue

Not only does antibiotic resistance (ABR) affect you, but it also affects global populations. Due to the ease of the sharing of genetic material between bacteria and the environmental resilience of many bacterial populations, ABR can spread quickly and efficiently. ABR is found in bacteria spanning dozens of countries around the globe and continues to be a concerning issue.

In the United States alone, a multitude of antibiotic resistant bacteria have been reported by the Center for Disease Control and Prevention. An especially worrying species of bacteria is Streptococcus pneumonia, known to cause bacterial meningitis (a serious condition involving the inflammation of membranes surrounding the brain and spinal chord). The CDC reported 1.2 million cases of antibiotic resistant Streptococcus pneumonia causing an estimated 7000 deaths in the year of 20131. This is just one example from an extensive list of antibiotic resistant strains of bacteria.

Of course, ABR is not an issue isolated to the US, or even North America. Data supplied by countries around the world to the WHO illustrate an ABR epidemic spanning the globe. This table from the BC medical journal adapted from a 2014 WHO report demonstrates the widespread presence of ABR:2

This research further demonstrates ABR as a global issue. The BC Medical Journal also describes examples like MRSA bacteria in hospitals and communities necessitating “requiring second-line treatment” causing increased treatment costs and requiring additional monitoring for side effects.2 ABR not only is detrimental to the health of its patients but also to the healthcare infrastructure surrounding those patients.

ABR is a global issue with many adverse implications making it difficult for physicians and present healthcare infrastructure to provide adequate treatment for those affected by resistant bacteria.

References:

1“Antibiotic Resistance Threats in the United States, 2013.” Center for Disease Control and Prevention. Accessed June 8, 2016. https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf.

2Wang, Sophie Y., Diana George, Dale Purych, and David M. Patrick. “Antibiotic Resistance: A Global Threat to Public Health.” BC Medical Journal, 6th ser., 56, no. BCMJ (July 2014). http://www.bcmj.org/bc-centre-disease-control/antibiotic-resistance-global-threat-public-health.

 

Ventilator Associated Pneumonia

Ventilator Associated Pneumonia, or VAP, is a troubling condition affecting 250,000 to 300,000 patients in the ICU per year in the U.S. This is caused by infection of the airways through a ventilator—a mechanical device inserted into a patient’s airways to help with breathing. Often patients are put on a ventilator during and/or after surgery. It is important to understand prevention and treatment of VAP due to its frequent incidence and potential severity.

Pneumonia is an infection of the air sacs of one or both lungs. This causes them to become inflamed making it very difficult for the patient to breathe. Any case of pneumonia is deemed concerning and can even be life threatening. Elderly people, children and persons with weakened immune systems are prone to more serious cases of pneumonia.

Photo 1: Illustration of pneumonia infection. Credit: Mayo Clinic

Photo 1: Illustration of pneumonia infection. Credit: Mayo Clinic

Different organisms can cause these pnemonia including a variety of species of fungi, bacteria and types of viruses. In the case of VAP, bacteria species Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia are attributed to higher mortality rates in patients. Many of these species of bacteria are also multi-drug resistant which complicates treatment. The first line of defense in order to reduce VAP rates is prevention.

Photo 2: Credit: CDC

Photo 2: Credit: CDC

There are several steps healthcare professionals and patients should take in order to prevent VAP. The CDC advises to keep the head of the patient raised when put on a ventilator. Furthermore, proper sanitary precautions should take place like hand washing and mouth cleaning before the ventilator is placed in the patient. Smoking is also known to increase the risk of VAP, so patients are advised to quit well before being put on a ventilator.

VAP is often a very serious condition but can be treated. The CDC cites antibiotics as the primary means for treating VAP; however, it is important to highlight the problem multi-drug resistant bacteria pose in relation to VAP. A study conducted by Clinical Microbiology Reviews found VAP is often over treated due to poor methods of diagnosis. This causes even more antibiotic resistance in healthcare settings, making sure cases of VAP even more difficult to treat. Better diagnosis and more effective treatment must be found to ensure the health of patients.

Photo 3: Credit: VAP education

In addition detriments to a VAP patient’s health, VAP is also known to be very expensive for ICUs. Duration of ICU stays are known to increase because of VAP and have an estimated cost of $5000-$20000 per case. Assuming there are 250,000 cases of VAP each year, VAP could be costing hospitals up to $5 billion/year.

What are some things you can do to aid the problem of VAP? Help raise antibiotic management awareness and the threat antibiotic resistance poses. Advise family members to quit smoking as they never know if/when they may be placed on a ventilator for whatever reason. If you or a loved one ever requires ventilator use, inquire about ways you or your healthcare provider can avoid the risk of VAP.

VAP is both a serious risk to ICU patients in hospitals around the world and a major cost to the healthcare system. Proper steps have to be taken in order to prevent VAP and its associated complications. Moreover, treatment methods steering away from antibiotics must be developed and implemented especially with the abundance of multi-drug resistant bacteria.

Sources:
http://www.cdc.gov/hai/pdfs/vap/vap_tagged.pdf
http://www.mayoclinic.org/diseases-conditions/pneumonia/home/ovc-20204676
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/

Central Line-Associated Bloodstream Infections

Have you or a loved one ever needed to use a catheter for a treatment procedure in a hospital? Catheter-associated bloodstream infections also known as central line-associated bloodstream infections (CLABSI) cause illness and even death for thousands yearly. Often these infections are serious—healthcare professionals and patients must take the appropriate steps in monitoring and treating infections before severe complications arise.

Central venous catheters, also known as central lines are medical devices inserted into a patient’s large vein, typically in the neck, chest or groin in order to administer medication and/or collect blood for testing purposes. CLABSI occurs when bacteria or other harmful pathogens enter the bloodstream through a central line. Because these central lines connect to major veins, often close to the heart, in a patient’s body, these infections are deemed very serious. So who is prone to these infections?

Photo 1: Illustration of a central-line catheter placed in a patient's chest. Credit: Mosaic Life Care

Photo 1: Illustration of a central-line catheter placed in a patient’s chest. Credit: Mosaic Life Care

Patients in the ICU are known to be at risk for CLABSI. According to the Agency for Healthcare Research and Quality, 48% of patients in the ICU have central line catheters. The CLABSI rate is known to be 5.3 per 1000 catheter days, with mortality rate at 18%. This means up to 28,000 patients in the ICU die from CLABSI in the U.S. yearly. Each CLABSI infection approximately costs $26,000.

Due to the severity of these infections, prevention is of the utmost importance. Like other health-care associated infections, an essential component of prevention is proper sanitary precautions like proper hand hygiene and maintaining sterile conditions when inserting the catheter. The CDC, urges patients to minimize the frequency of visitors when being placed on a catheter to reduce the risk of infection. Furthermore, the patient should refrain from touching the catheter at any point during treatment.

While prevention is the first line of defense against CLABSI, understanding treatment mitigates severity and risk CLABSI poses. Patients should monitor their own health are watch for CLABSI symptoms like fever and/or soreness around the catheter site and alert a healthcare professional once these symptoms arise. Antibiotics can often treat these infections; however, with the rise of multi-drug resistant bacteria, treatment can be prolonged and complicated. Often, new treatments and therapies have to be considered for adequate treatment.

CLABSI is both an abundant and serious issues affecting ICU patients in hospitals around the world. Extra steps should be taken to reduce its occurrence and efforts to find adequate treatment should be taken seriously.

Sources:
http://www.cdc.gov/HAI/bsi/CLABSI-resources.html
http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

What is a Surgical Site Infection?

Surgery is a process that comes with tedious care from everyone involved. Even with careful precautions, tissue after surgery is often prone to exposure to pathogens and infection. Some of these infections can be superficial, but can also be more severe and affect internal organs. These infections are termed Surgical Site Infections or (SSI).

According to the Center for Disease Control and Prevention there are many symptoms that could indicate an SSI. Redness, pain and inflammation near or around the surgical site wound are common symptoms for an SSI. Furthermore, if a patient feels feverish or has excessive drainage of cloudy fluid from the surgical site wound, they should seek a healthcare professional immediately.

The use of antibiotics is ubiquitous in treating SSIs. The CDC cites antibiotics and additional surgery as the primary methods for treating SSIs. However, it is important to note that, like any other bacteria, bacteria in SSIs have the ability to become resistant to antibiotics. This makes the infection harder to treat and more dangerous. Alternatives to antibiotics should be sought out when dealing with SSIs.

There are many ways to prevent SSIs. Healthcare workers should pay careful attention to sanitation and prevent the spread of germs. Patients should also refrain from shaving near the surgical site as razors can irritate the skin and promote infection on the surgical site. Both patients and healthcare workers should observe the surgical site before, during and after the surgery in order to prevent infection, or diagnose and treat an infection as soon as possible. These precautions in tandem with treatments alternative to antibiotics will serve to minimize the risk of SSIs.

References:
https://www.cdc.gov/HAI/ssi/faq_ssi.html

Antibiotic Resistance: More prevalent in certain countries

While antibiotic resistance (ABR) is recognized as a global issue, it is important to note that ABR is more prevalent in some countries over others. In developed countries, over prescription and use of antibiotics on livestock are overwhelming contributors to ABR; however, ABR in developing countries appears to be virulent. Why are these countries more prone to ABR?

Often, developing countries possess antibiotics readily available to the public. According to an article from the Institute of Medicine Forum on Emerging Infections, antibiotics in many developing countries are available for purchase without a prescription.1 This leads to self-medication where the patient acquires and uses antibiotics without consulting a healthcare professional—something that is often difficult to do in impoverished areas. Epidemiologist Keith Klugman from the Bill & Melinda Gates Foundation states that the problem of ABR is especially prevalent in Brazil, Russia, China, and India. Self-medication promotes the spread of ABR both in patients and the community; the use of antibiotics in this context is often superfluous and unnecessary.2

Another source of ABR in developing countries are in hospitals. The Institute of Medicine Forum on Emerging Infections states that large hospitals must employ antibiotics regularly due to the close proximity of patients increasing their susceptibility of infection1. These antibiotics are often administered without proper diagnosis and foster environments conducive to ABR. Inadequate protocol for or improper practices from healthcare workers increase the likelihood of patients being infected, which ultimately leads to administering more antibiotics. ABR in hospitals is a pronounced problem in developing countries.

So what practices will minimize the spread of ABR? Healthcare infrastructure in developing countries should limit the availability of antibiotics and require prescription and/or consultation with a healthcare professional; antibiotics should only be used when deemed necessary and when proper diagnosis is acquired. Hospitals should develop improved protocol and train healthcare workers in order to minimize the spread of infection and therefore reduce the necessity of antibiotics. Obviously these practices would require extensive logistical planning and associated cost, but initiating a conversation about them is important nonetheless.

References

1“Factors Contributing to the Emergence of Resistance.” NCBI. 2003. Accessed June 10, 2016. http://www.ncbi.nlm.nih.gov/books/NBK97126/.

2Reardon, Sara. “Antibiotic Resistance Sweeping Developing World.” Nature.com. May 06, 2014. Accessed June 10, 2016. http://www.nature.com/news/antibiotic-resistance-sweeping-developing-world-1.15171.

Antibiotic Resistance

Have you ever had to pay multiple visits to a doctor because the prescribed medication for illness just wasn’t working? This might occurred because of a natural phenomenon termed ABR or antibiotic resistance. So what is ABR? According to the Alliance for the Prudent Use of Antibiotics of the Tufts University Medical School, antibiotic resistance “occurs when an antibiotic has lost its ability to effectively control or kill bacterial growth”1. The bacteria become resistant to certain antibiotics and such therapy is rendered ineffective.

Bacteria achieve antibiotic resistance through natural phenomenon related to genetics and evolutionary mechanisms. Some bacteria in a population appear to be resistant to a specific type of antibiotic (or multiple antibiotics) due to random genetic mutation. Once antibiotics are deployed on the site of infection, the non-resistant bacteria are eliminated and the resistant bacteria are left alive. The antibiotics create a “selective pressure” that promote the survival of the resistant bacteria1. Furthermore, these bacteria will reproduce and their offspring inherit the resistant traits thus creating a new fully resistant population.

Bacteria also have multiple robust mechanisms that enable the proliferation of ABR. Their offspring can inherit resistant traits “vertically”, or they can share genetic information with other bacteria “horizontally” through a process termed conjugation1. Adding to the fact that bacteria can survive on many surfaces and travel easily on unsuspecting flights and water travel, ABR is able to spread amongst bacteria quickly.

Studies conducted by the World Health Organization show that ABR is not only a concern for the future, but also a very current worldwide issue. In 2013, there were approximately 480,000 cases of multi-drug resistant Tuberculosis evident in around 100 countries2. Like other cases of antibiotic resistant bacteria, multi-drug resistant Tuberculosis requires extended and arduous methods of treatment as the bacteria is stubborn to common antibiotic treatment.

Evidently, ABR is a current real-world issue with the potential to further escalate. This issue should be studied and better understood in order to develop alternatives to remedy the problems ABR creates.

References:

1 “General Background: About Antibiotic Resistance.” APUA. 2014. Accessed June 08, 2016. http://emerald.tufts.edu/med/apua/about_issue/about_antibioticres.shtml.

2 “Antimicrobial Resistance.” World Health Organization. Accessed June 08, 2016. http://www.who.int/mediacentre/factsheets/fs194/en/.

Overuse of Antibiotics in Livestock contributes to ABR trends

Farmers use antibiotics to ensure harmful pathogens like bacteria do not go on to live on the shelves of grocery stores and on the dinner table. While this may be comforting, there is an unfortunate overuse of antibiotics in livestock farming. This overuse contributes to the escalation of the ABR issue and can lead to infections of humans by resistant bacteria.

Livestock is often treated with antibiotics to prevent illness but overuse promotes an increased risk of ABR. The Beef Cattle Research Council explains that an antibiotic Metaphylaxis must often be used to combat respiratory illness with new feedlot calves due to high stress and confined spaces1. Antibiotics like these are often necessary to keep feedlot cattle healthy and prevent further transmission of bacteria to other cattle and even humans. Unfortunately, farmers often use antibiotics in a non-therapeutic matter. According to an article from the Union of Concerned Scientists, antibiotics are sometimes employed to fatten up livestock and increase feeding efficiency2. Antibiotics are also used liberally in a preventive manner in an attempt to prevent bacterial infection in livestock.

The overuse of antibiotics in livestock, like the over prescription of antibiotics in humans, fosters the growth of resistant bacteria. Irresponsibly deployed antibiotics in livestock farming promote the survival of resistant bacteria. These bacteria is often able to survive on the animals after they have been slaughtered and can even make their way to grocery stores and dinner tables. This can potentially lead to the infection of humans by drug resistant bacteria—infections requiring extensive time and therapy to treat.

How do we minimize the damage done by the use of antibiotics in livestock? Obviously the must be employed in some capacity to keep our food clean and healthy, but there must be methods in administering antibiotics responsibly and sparingly. The Beef Cattle Research Council advises farmers to follow certain measures that prevent ABR. Examples include treating infections promptly, obtaining the proper diagnoses before using antibiotics and ensuring the proper dose are given to the animals. The use of antibiotics in livestock must be monitored and better practices be put in place in order to deescalate ABR.

http://www.beefresearch.ca/research-topic.cfm/antimicrobial-resistance-11#avoid
http://www.ucsusa.org/food_and_agriculture/our-failing-food-system/industrial-agriculture/prescription-for-trouble.html#.V1nMSJMrJsM

ABR affects Non users as much as users of antibiotics

If you are not a frequent user of antibiotics, then ABR should not be a concern, correct? This is not true. In reality, ABR (antibiotic resistance) affects everyone—non-users and users of antibiotics alike. The biotechnical nature of ABR allows for a sharing of resistant traits amongst bacteria and populations of bacteria. In other words, ABR in bacteria elsewhere can exchange information through several pathways with bacteria that could ultimately affect you.

“Horizontal” transmission of ABR amongst bacteria is a common way for ABR to spread amongst bacteria and across bacterial populations. A study conducted by Cecilia Dahlberg et al of the University of California explored the mechanism in which bacteria transmit and receive genetic information. They found that bacteria could exchange segments of their DNA through a process termed conjugation *. Bacteria are able to transmit and receive plasmids (vehicles for DNA transport) that often carry sequences that code for antibiotic resistance. ABR can be exchanged between bacteria through this mechanism frequently. Furthermore, conjugation was observed to occur between different species of bacteria illustrating the robustness of ABR through this method of transmission *.

Mechanisms like conjugation enable the spread of ABR from populations of bacteria exposed to antibiotics to other populations of bacteria not necessarily exposed to the same environment. This means that ABR is an issue not limited to communities and environments surrounding frequent users of antibiotics—it affects everyone.

References:
* Dahlberg, Cecilia, Maria Bergstro¨m,, Margit Andreasen, Bjarke B. Christensen, Søren Molin, and Malte Hermansson. “Interspecies Bacterial Conjugation by Plasmids from Marine Environments Visualized by Gfp Expression.” Oxford Journals. December 12, 1997. Accessed June 9, 2016.
http://mbe.oxfordjournals.org/content/15/4/385.full.pdf.

Antibiotic Resistance is expected to take more lives than cancer

Antibiotic resistance or ABR is a current real-world issue and is escalating with time. As of 2014, ABR was estimated to be responsible for 700, 000 deaths annually1. The implications of antibiotic resistance are also important to discuss. Countries around the world are expected to incur a high economic cost with the rise of ABR and there is little incentive for entrepreneurs and researchers to develop more antibiotics. Furthermore, left unsolved, experts believe antibiotic resistance to take more lives than cancer in the near future.

According to a study chaired by internationally published economist and antibiotic resistance expert Jim O’Neill, ABR is expected to take 10 million lives annually by the year 2050. The current conservative estimate for ABR-associated deaths is 700,000. This illustrates the growing problem of ABR and the need to find viable solutions. 10 million deaths per year are more than the 8.2 million annual deaths attributed to cancer.

There are several reasons why ABR is a pressing issue and continues to be a problem. Firstly, antibiotics are usually overprescribed and foster conditions that lead to antibiotic resistance through evolutionary mechanisms in bacteria. This problem is especially prevalent in third world countries. Secondly, researchers and investors have little economic incentive to produce antibiotics. Antibiotics are difficult to research and develop and regulatory approval is challenging. Additionally, the venture is not very profitable. According to the US National Library of Medicine National Institutes of Health, the net present value (NPV) of a new antibiotic is about $50 million compared to an NPV of $1 billion for a drug that treats neuromuscular disease.2

Fortunately, many distinguished scientists and institutions around the world recognize the problem of ABR. New technologies like antimicrobial Photodynamic Therapy (aPDT) are providing alternatives to antibiotics that are both economically viable and counter the problem of antibiotic resistance. Plenty of evidence shows that ABR should be a concern to everyone, can affect everyone. and will ultimately lead to many deaths in the near future if left alone. Efforts should be focused in developing alternatives to antibiotics and solving the ABR problem.

1“The Review on Antimicrobial Resistance.” AMR-Review. 2014. Accessed June 15, 2016. https://amr-review.org/sites/default/files/AMR Review Paper – Tackling a crisis for the health and wealth of nations_1.pdf.

2Ventola, C. Lee. “The Antibiotic Resistance Crisis: Part 1: Causes and Threats.” Pharmacy and Therapeutics. 2015. Accessed June 15, 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378521/.

ABR is a Problem because we are not creating enough new antibiotics to deal with ever changing superbugs

The New England Journal of Medicine, in a 2010 study, found that “health care providers prescribed 258.0 million courses of antibiotics in 2010, or 833 prescriptions per 1000 persons”1. Over 80% of the population of the US was given a prescription for antibiotics in the year of 2010—there is no indication for a decrease in these numbers for following years. Moreover, this study found that an estimated 50% of these prescriptions were unnecessary. This overprescribing of antibiotics further strengthens the selective pressure on bacterial populations escalating the problem of antibiotic resistance or ABR. With an increase in ABR, new and alternative antibiotics must be employed to cure infections until improved methods are utilized that remedy the problem of ABR. However, the development of new antibiotics may see a bleak future.

Discovering and employing new antibiotics is slowing down. According to Brad Spellberg of the David Geffen School of Medicine at UCLA, only 2 types of antibiotics were approved from 2008 to 2012 compared to the 16 approved from 1983 to 19872. The slowdown of antibiotic research and approval is attributed to three factors: scientific, economic and regulatory2. Spellberg explains, “Drug screens for new antibiotics tend to re-discover the same lead compounds over and over again”. Finding unique antibiotic solutions is now an arduous and also expensive process—the astronomical cost of developing and approving new antibiotics provides little incentive for companies to take part in.

The current regulatory system relevant to antibiotics put in place by the FDA also inhibits the speed and efficiency at which antibiotics can be approved. The FDA approves antibiotics based on “disease state one at a time”2. This causes “companies [to] spend $100 million for a phase III program and as a result capture as an indication only one slice of the pie.”2. The problematic structure of this regulatory system strongly contributes to the overall difficulty in developing new antibiotics.

With the increasing difficulty of developing antibiotics and the associated high cost, prospecting investors in this field have little incentive to pursue this venture. New alternatives to antibiotics must be found in order to fight disease for those in need, provide economic incentive for researchers and investors, and remedy the ever-increasing threat of ABR.

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