The Role of Antibiotic Stewardship in Combating Resistance

Antibiotic resistance is a serious global health concern. Every year, almost three million antibiotic-resistant infections occur in the U.S., resulting in at least 35,000 deaths [1]. By 2050, some estimates suggest that antibiotic-resistant infections could lead to 10 million deaths worldwide annually if current trends are not addressed [2]. This emphasizes the need for antibiotic stewardship programs (ASPs), which ensure that antibiotics are used responsibly. Healthcare providers, particularly those prescribing antibiotics, are at the forefront of these efforts and are crucial in combating resistance through responsible prescribing and patient education.

Understanding Antibiotic Resistance

Antibiotic resistance occurs when bacteria develop the ability to survive the effects of drugs that are meant to kill them. This resistance is driven by the selective pressure exerted by the overuse and misuse of antibiotics. Bacteria can develop resistance through mutations or by acquiring resistance genes via horizontal gene transfer, which enables them to survive even when exposed to antibiotics [3]. As resistant strains spread, treating common infections becomes increasingly complex, leading to higher morbidity, mortality, and healthcare costs.

The Issue of Inappropriate Prescribing

One of the primary contributors to antibiotic resistance is inappropriate prescribing. Data suggests that nearly 30% of oral antibiotic prescriptions in outpatient settings in the U.S. are unnecessary or inappropriate [4]. Often, antibiotics are incorrectly prescribed for viral infections, such as colds or the flu, where they offer no therapeutic benefit. Additionally, use of broad-spectrum antibiotics when narrower options would be appropriate can further exacerbate resistance by exposing more bacteria to selective pressure [5]. Such errors promote resistance and increase the risk of other complications.

Key Strategies for Providers in Antibiotic Stewardship

Healthcare providers are essential to the success of antibiotic stewardship programs. Several strategies can be employed to help reduce inappropriate prescribing and slow the development of resistance.

1. Choosing Narrow-Spectrum Antibiotics Narrow-spectrum antibiotics target specific pathogens and should be prioritized over broad-spectrum agents whenever possible. This approach reduces the impact on the patient’s microbiome and lowers the chance of resistance development. Research has shown that de-escalation from broad-spectrum to narrow-spectrum antibiotics, once a pathogen is identified, significantly reduces the risk of developing multidrug-resistant infections [6].
2. Optimizing Duration of Therapy Recent evidence suggests that shorter courses of antibiotics are often as effective as longer ones for many infections, such as community-acquired pneumonia [7]. Providers should consult current clinical guidelines to determine the optimal duration of therapy for specific infections.
3. Delayed Prescribing and Monitoring When bacterial infections are suspected but not confirmed, delayed prescribing can be an effective strategy. This involves monitoring; only prescribing if symptoms do not improve within a few days. When monitored correctly, studies show little difference in symptom control between immediate and delayed prescribing [8]. Educating patients on the nature of viral and bacterial infections is essential to gaining their cooperation in such cases.
4. Patient and Provider Education Patient education is a vital part of antibiotic stewardship. Many patients mistakenly believe that antibiotics can treat viral infections, leading to unnecessary pressure on providers to prescribe them. Educating patients about the appropriate use of antibiotics and the dangers of resistance can significantly reduce this pressure. A randomized controlled trial found that providing educational materials to patients led to a 30% reduction in antibiotic prescribing for respiratory infections [9]. Continuing education for providers is also crucial to keep updated on evolving evidence-based guidelines and resistance trends.

Challenges to Antibiotic Stewardship Implementation

Uncertainty in the source of the illness is a significant issue that leads to defensive prescribing—where antibiotics are prescribed “just in case” the infection is bacterial. The lack of rapid, reliable diagnostic tests to differentiate between bacterial and viral infections exacerbates this problem [10].

Patient expectations also play a role. Some surveys indicate that 70% of patients incorrectly believe that antibiotics are effective for treating the common cold, and many expect to leave their doctor’s office with a prescription [11]. This expectation can pressure providers to prescribe antibiotics unnecessarily, even when they are not warranted.

Resource limitations are another issue, especially in smaller healthcare settings where ASP programs may be challenging to implement. While they are mandatory in many hospitals, smaller clinics need more infrastructure or personnel to support these initiatives.

Innovations and Future Directions in Stewardship

Advances in technology are promising for enhancing antibiotic stewardship efforts. Rapid diagnostic tests, such as polymerase chain reaction (PCR) assays and next-generation sequencing, can quickly differentiate between bacterial and viral infections, thus reducing unnecessary antibiotic prescriptions [10]. As these technologies become more widely accessible, they will likely play an essential role in minimizing inappropriate antibiotic use.

Clinical decision support systems (CDSS), typically integrated into electronic health records (EHRs), are another optimistic innovation. These systems alert providers to potential drug interactions, recommend antibiotic choices based on local resistance patterns, and suggest optimal treatment durations. Studies suggest that CDSS usage significantly reduces antibiotic prescribing errors and overall antibiotic use [12].

Conclusion

Antibiotic resistance is a global health challenge that requires a concerted effort from healthcare providers, patients, and policymakers. Providers are critical in this fight, and their adherence to evidence-based antibiotic stewardship practices is essential to curbing the rise of resistant infections. By choosing narrow-spectrum antibiotics, optimizing treatment durations, employing delayed prescribing when appropriate, and educating patients, providers can help preserve the efficacy of these essential medications.

With continued technological advancements and the expansion of stewardship programs, healthcare providers will be better equipped to combat antibiotic resistance. Nevertheless, the battle against resistance requires ongoing vigilance, collaboration, and a commitment to responsible antibiotic use.

References

1. Centers for Disease Control and Prevention. (2021). Antibiotic Resistance Threats in the United States. Link
2. O’Neill, J. (2014). Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. Review on Antimicrobial Resistance. Link
3. Somerville, G. A., & Beres, S. B. (2021). Horizontal Gene Transfer and Antibiotic Resistance. Trends in Microbiology. Link
4. Fleming-Dutra, K. E., et al. (2016). Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits. Link
5. Cižman, M., et al. (2018). ​​Antibiotic consumption and resistance of gram-negative pathogens (collateral damage) Link
6. Dellit, T. H., et al. (2007). Infectious Diseases Society of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases. Link
7. Uranga, A., et al. (2016). Duration of Antibiotic Treatment in Community-Acquired Pneumonia. JAMA. Link
8. Little, P., et al. (2014). Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. The BMJ. Link
9. Delsors, E., et al. (2021). Changes in antibiotic prescription following an education strategy for acute respiratory infections Link
10. Avershina, E., et al. (2023) Clinical Diagnostics of Bacterial Infections and Their Resistance to Antibiotics—Current State and Whole Genome Sequencing Implementation Perspectives. Link
11. Kosiyaporn, H., et al. (2020) Surveys of knowledge and awareness of antibiotic use and antimicrobial resistance in general population: A systematic review. PLoS One. Link
12. Holstiege., J. et al. (2014) Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review. Link