Selected Issues in Antibiotic Resistance

Richard Alan Gleckman, MD

Disclosures
In This Article

Abstract and Introduction

The emergence of strains of bacteria resistant to the currently available antimicrobial compounds contributes to increased morbidity, mortality, and health care costs. Antibiotic resistance is one of a number of reasons why antibiotic therapy can fail. Through appropriate antibiotic administration and effective implementation of infection control practices, physicians can help stem the tide of increasing bacterial resistance. Alternative novel approaches should be developed to prevent and treat bacterial infections. Ancillary therapies merit increased attention, since these adjunctive measures can exert a critical role in the successful management of bacterial infections.

After 65 years of lifesaving antimicrobial therapy, we are witnessing a worldwide explosion of drug resistance among bacterial pathogens. The impact of this development has included increased morbidity, mortality, and health costs.[1] Listed in Table 1 are the mechanisms by which bacteria develop resistance.

It has always been the naive hope that the continuous discovery of new antimicrobial agents would provide clinicians with the upper hand in the battle against pathogenic bacteria, but it is apparent that bacterial resistance is increasing at an alarming rate despite the creativity of the pharmaceutical industry. The hope now is to slow this process of drug resistance through infection control and intelligent antimicrobial prescribing practices until novel alternative approaches are developed to prevent and treat bacterial infections.

Table 2 lists some of the educational and restrictive measures employed in hospitals to influence antimicrobial prescribing patterns; the fundamental premise of these measures is that appropriate antimicrobial stewardship will slow the emergence of bacterial resistance. Additional efforts used to forestall the development of antimicrobial-resistant bacteria include the following[2]:

  • Streamlining empiric antimicrobial treatment when culture results become available.

  • Replacing certain drugs, such as third-generation cephalosporins, with other agents that are presumably less likely to foster resistance, such as piperacillin-tazobactam in combination with an aminoglycoside.

  • Cycling of antibiotics.

This article is not intended to be an exhaustive review of the subject of antibiotic resistance. It is meant to focus on some selected aspects of the problem and to offer a clinician's perspective on how to approach this continuing threat to the effective management of bacterial infections. I have elected not to comment on some very serious issues, including vancomycin-resistant strains of Staphylococcus aureus and Enterococcus species and multidrug-resistant Mycobacterium tuberculosis, Salmonella species, and Acinetobacter baumannii, but to concentrate on some of the more common infectious disorders and to try to dispel some myths about drug therapy.[3,4]

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