Think of the last time the “BC Bug” circulated within the Boston College population. Despite all best efforts, a considerable subset of the student body contracted the illness. As much as you likely tried to avoid exposure, you probably caught the cold a few days later.  In a state of misery you might have even caved and checked into Health Services, hoping for a quick antibiotic fix and speedy recovery. However, diagnosing your ailment as a viral infection, the doctor most likely recommended fluids and rest—making the trek to the infirmary seem like a waste of time. This observation from the Boston College campus introduces a growing issue facing the medical field today: the overprescription of antibiotics.  What patients, and even doctors, often fail to realize is that this shortcut has contributed to a decrease in bacterial susceptibility and antibiotic efficacy.  Although antibiotics can appear to be a panacea for all ailments, prescriptions are only effective at treating bacterial infections and may do more harm than good when used to combat a virus.

A study in the Journal of the American Medical Association determined that in a population of 1000 ambulatory care patients in 2010, only 353 of 506 antibiotic prescriptions were considered necessary. How is it possible that approximately 30% of the antibiotics distributed in 2010 were unnecessarily prescribed?  This question stems back to the greater issue at hand: overprescription of antibiotics.  Viruses do not respond to antibiotics, and the frequent, unnecessary use of antibiotics to treat viral infections does not relieve one’s symptoms.  Rather, antibiotics can decimate the population of helpful bacteria that aid in providing defense from pathogens.  Genes conveying antibiotic resistance exist naturally in bacterial populations, and elimination of other beneficial bacteria that may have kept resistant strains in check increases the percentage of resistant bacteria. What is the consequence of this? When one subsequently develops a bacterial infection, antibiotics may no longer be effective in treating the disease.

Resistant infections are becoming all too common. The Centers for Disease Control (CDC) and Prevention report that each year, over 2 million people from the United States become infected with antibiotic-resistant bacteria. These untreatable organisms can increase severity and morbidity of what were previously mild, treatable infections. An elegant example of this is the treatment of bacterial pneumonia with penicillin. Dr. Fred Goldstein reports in The Journal of Antimicrobial Chemotherapy that “in recent years there has been a dramatic increase, worldwide, in the prevalence of so-called penicillin-resistant Streptococcus pneumoniae (PRSP),which is due, in part, to “excessive global usage of antibiotics, particularly -lactams.” Penicillin, one of the most iconic antibiotics, was once a highly effective treatment. However, Goldstein’s 1999 study found a direct correlation between antibiotic overuse, including the use of -lactams, and selection for resistant strains of S. pneumoniae, results that have been supported by subsequent research. Bacterial pneumonia is no longer as easily treated using -lactams; secondary and tertiary antibiotic options have also been exhausted in some cases. Consequently, management of hospital-acquired pneumonia is becoming an increasingly significant crisis in the healthcare field. This is just one example of the problem of antibiotic resistance.

How does resistance arise? Biologically, a bacterium can become resistant through a genetic mutation or through interactions with other bacteria. Resistance is produced by gain-of-function mutations that modify pre-existing structures in a bacterium in a way that makes them less susceptible to an antibiotic. According to the Alliance for the Prudent Use of Antibiotics, these mutations include production of enzymes to break down antibiotics, elimination of the cell target, and exclusion or ejection from the cell. Through conjugation, resistance genes may be easily transferred throughout a bacterial population. Natural selection determines whether the bacteria and its progeny will survive in the population. Drivers of resistance, such as antibiotic over-prescription, place selective pressures that favor resistant bacteria, increasing their survival. This means that when an individual person misuses antibiotics they put themselves and others at risk.

Of course, doctors aren’t the only ones to blame for the increase in resistance. Patients commonly stop a course of antibiotics too early despite the instructions of their physician. Although it may appear that the disappearance of symptoms indicates the infection has been cured, more tolerant bacteria within the original population can survive partial treatment. Infection can recur or spread to others and become less treatable, initiating a cycle of increased resistance. Indeed, the issue of overprescription may also be the responsibility of the patients who argue with their doctors about alternative treatments.  Facing the pressure of berating requests from patients and feeling inadequate sending sick patients home empty-handed, it is probable that many doctors over-prescribe just to satisfy their patients and avoid the expected confrontation. It is important that patients respect the diagnoses and treatments suggested by their physician when antibiotics are not necessary. There are also multiple causes of resistance outside of the healthcare field, such as agricultural applications and overuse of antibacterial hygiene products, that may be even be more significant drivers of resistance. However, this only proves that the stakes are too high to continue the overprescription and misuse of antibiotic medications.

Due to the increase in prevalence of antibiotic resistance, doctors and scientists must implement new solutions to combat this problem. The CDC recommends “four core actions for halting resistance: preventing infections and the spread of resistance, tracking resistance patterns, developing new antibiotics and diagnostic tests, and improving antibiotic use.” However, one must consider if the development of new antibiotics will become detrimental, starting the cycle of resistance again. If scientists focus on creating new antibiotic treatments, will obtaining a “backup plan” encourage doctors to continue overprescribing? While it is important to find effective treatments for the resistant infections that are increasingly numerous, we have to realize that the key to solving this problem begins with the appropriate use of antibiotics.

While many medical professionals are wary of the growing danger of antibiotic resistance, it is imperative that they strive to prevent overprescription.  Medical professionals have the greatest power in regulating how antibiotics are distributed. Additionally, patients must be educated about the dangers of misuse of antibiotics. Many are unaware that taking unnecessary antibiotics or not completing a course of antibiotics can significantly increase the prevalence of resistance genes–yet even more are uneducated on the impact such actions have for not only themselves, but their entire community.  Lastly, although most individuals may think that they know their own bodies best, patients must trust the verdict of medical professionals. Consider the risks. Would you rather suffer a weeklong virus now or an untreatable, life threatening bacterial infection down the road?


REFERENCES

  1. Alliance for the Prudent Use of Antibiotics (2014). About Antibiotic Resistance. Retrieved from http://emerald.tufts.edu/med/apua/about_issue/about_antibioticres.shtml
  2. Centers for Disease Control and Prevention (2014). Antibiotic Resistance Threats in the United States, 2013. Retrieved from http://www.cdc.gov/drugresistance/threat-report-2013/
  3. Fleming-Dutra, K. (2016). Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. The Journal of the American Medical Association, 310 (17). Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2518263
  4. Goldstein, F.W. (1999). Penicillin-resistant Streptococcus pneumoniae: selection by both-lactam and non--lactam antibiotics. Journal of Antimicrobial Chemotherapy, 44 (2). Retrieved from http://jac.oxfordjournals.org/content/44/2/141.full
  5. Hampton, T. (2013). Report Reveals Scope of US Antibiotic Resistance Threat. The Journal of the American Medical Association, 310 (16). Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=1758742
  6. Science-Based Medicine (2016). Overprescribing Antibiotics. Retrieved from https://www.sciencebasedmedicine.org/overprescribing-antibiotics/
  7. World Health Organization (2015). Does stopping a course of antibiotics early lead to antibiotic resistance? Retrieved from http://www.who.int/features/qa/stopping-antibiotic-treatment/en/

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