Aging Begins at 30

The Antibiotic Resistance Problem

"Ian, why would you specialize in infectious disease when penicillin has taken care of all that?" I was asked in 1949. Times have changed. Organisms by antibiotic selection or cross infection by antibiotic resistant particles called plasmids have become resistant to antibiotics multiple antibiotics. How can we maintain the miracle of antibiotics? The key to the proper use of antibiotics is to use them like a sharp-shooting rifle and avoid any blunderbuss approach. Easy to say but hard to do.

Perhaps you received an antibiotic that worked so well that you quit halfway and kept the left over capsules "for the next time." You contributed to antibiotic resistance. Perhaps you or your doctor thought a dose of antibiotics for the common cold "would do no harm." It would and did. Inappropriate use of antibiotics leads to selection of resistant organisms and is amplified by person-to-person spread. We call this antibiotic selection pressure.

Hospitals are the most common sites of antibiotic resistance development. Environmental contamination takes place in Intensive Care Units where the concentration of patients, bacteria, antibodies and dirty hands is high, but problems exist throughout the hospital.

Gonorrhea developed its resistance in the community. Oral intercourse prostitutes in the Far East have gonococci and meningitis causing meningococci in their throats at the same time. We pray that resistance to penicillin does not transfer by plasmids from the gonococci to the meningococci.

Problems include the formerly mild infections (now lethal) by skin staphylococci which secrete a slime in which they hide from scavenging white cells and high killing antibiotic levels on intravenous lines and other devices. Round, dark staining organisms, originally from the bowel called enterococci which can invade the blood stream, have successfully developed resistance to various antibiotics and are now only sensitive to vancomycin, an antibiotic that has to be given intravenously. Recently, 13% have become resistant to vancomycin. Synercid, a new antibiotic, is almost ready for general use. Will it be ready in time? Pneumococci cause pneumonia in adults and pneumonia and middle ear infection in children, but 17% are resistant to penicillin and 13% to the expensive penicillin-cousins called third generation cephalosporins. Fluoroquinolones (ciprofloxacin) were hailed as new cure-alls, but antibiotic resistance is developing fast. Organisms with exotic names such as Acinotobacter and Enterobacter cloacae are getting hard to kill with antibiotics, but I think I've told you enough.

What can be done? First, the public and medical personnel need to be educated and reeducated about the problems. Each hospital has to have a team of experts (infectious disease consultant, microbiologist, specialist nurse, and pharmacist) who can define practices that minimize antibiotic resistance development and who can institute a method to recognize outbreaks of antibiotic resistance. Restrictions need to be imposed on the indiscriminate use of antibiotics.

Prevention of infection by antibiotics is rarely useful such as in recurrent urinary tract infection with structural abnormalities, recurrent otitis media, a past history of rheumatic fever, in close contact with certain specific disease producing organisms such as Hemophilos type B or tuberculosis, newborn eye infections, and with certain septic surgical wounds, or bites. Otherwise, "prevention" by antibiotics is dangerous.

Every six months a pocket-sized guide to the resistance of organisms in hospital is needed and advice on a list of of second-line alternate antibiotics.

The more you use an antibiotic the faster you lose it. There is a place for reserving especially useful antibiotics and for "crop rotation" in the use of antibiotics. The loss of good antibiotics is alarming but not necessarily fatal. Prudent use is indicated.

An initial broad approach with blunderbuss (cover all the bases) antibiotics in the seriously ill patient using expensive imipenem is justified, provided that antibiotic resistance tests are done immediately and a search is made to provide a narrow spectrum tailor-made antibiotic in 48 to 72 hours.

I've been kept busy ever since 1949 by "organisms that penicillin didn't take care of."

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See related Patient Topics Antibiotics, Infection Control, Infections, Procedures and Therapies or Safety.

See related Provider Topics Infections, Procedures and Therapies or Safety.

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