A call to join the fight against bacterial resistance

DR. ARMITAGE is a professor of medicine, department of medicine, division of infectious diseases, at Case Western Reserve University, Cleveland, Ohio.

DR. McMILLAN is professor of pediatrics, vice chair for pediatric education, director of the pediatric residency program at Johns Hopkins University School of Medicine, Baltimore, iMd, and editor-in-chief of Contemporary Pediatrics.

DR. BESSER is director, Coordinating Office for Terrorism Preparedness and Emergency Response, Centers for Disease Control and Prevention, Atlanta, Ga.

The authors, manuscript reviewers, and staff editors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article, which is adapted from Patient Care, an Advanstar publication.

The number of pathogens that resist treatment with antibiotic agents has risen steadily during the past decade, spreading the problem of increasing resistance from hospitals, nursing homes, and other closed settings into the community, complicating the treatment of acute otitis media (AOM), community-acquired pneumonia (CAP), skin and soft tissue infections, and cystitis. Pneumococcus species that are resistant to both penicillins and cephalosporins are becoming more common; by 1998, 24% of invasive isolates in the United States were resistant to penicillin and 14% were resistant to three or more drug classes.¹ Although widespread use of the 7-valent conjugate pneumococcal vaccine (PCV7) has been associated with a steep decline in the incidence of invasive pneumococcal disease and in the number of cases involving resistant isolates, pneumococcal resistance continues to complicate management of many common infections, and resistance is becoming more frequent in other bacterial pathogens. Most recently, the late 1990s saw the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the community.^2,3

The adverse consequences of increasing bacterial resistance include:

The causes of resistance

The roots of overuse

Patient misconceptions about the role of antibiotics in medicine contribute to overprescribing. The results of a 1998-1999 survey, for example, found that 27% of respondents believed that antibiotics could end a cold more quickly, 32% thought that taking antibiotics for a cold prevented more serious illness, and 48% expected to receive a prescription when they were sick enough from a cold to seek medical care. In the same survey, 58% of respondents were unaware that antibiotic use posed any dangers at all to themselves or to the health of the community.⁴

Although many clinicians believe that patients expect a prescription for an antibiotic, studies indicate that the perception of dissatisfaction may be mistaken or that dissatisfaction can be mitigated.^5-7 Patients want both sympathy and reassurance that their office visit is a reasonable reaction to their distress. Although some patients may be satisfied only with a prescription for an antibiotic, others may be satisfied by expressions of concern and support. Time constraints on patient visits may lead some clinicians to believe that prescribing an antibiotic is easier and faster than educating patients about, for example, the difference between viral and bacterial infections.

Drug manufacturers also share the blame for inappropriate prescribing, by promoting expensive, patent-protected drugs. In addition, the current malpractice climate gives rise to the perception among physicians that prescribing an antibiotic is safer than taking the chance-however remote-of a treatment failure that could lead to a malpractice complaint.

Dearth of new drugs. Market economics has resulted in the lack of new antibiotics. A recent search of FDA databases revealed that approvals of new antibacterial agents decreased by 56% over the past 20 years, and, of 506 drugs under development at the time of the search, only six were antibacterial agents. This situation is serious, especially for infections with gram-negative pathogens, and because of the reported increase in the number of infections that lack effective treatments.⁸