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   Table of Contents     
LETTER TO EDITOR  
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 163-165
Key factors in antibiotic resistance


1 Department of Research and Innovation; Department of Orthopaedics, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
2 Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
3 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
4 Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

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Date of Submission29-Aug-2019
Date of Acceptance04-Sep-2019
Date of Web Publication26-Nov-2019
 

How to cite this article:
Yellapu V, Roma N, Ngo V, Kaur P, Snyder R. Key factors in antibiotic resistance. J Global Infect Dis 2019;11:163-5

How to cite this URL:
Yellapu V, Roma N, Ngo V, Kaur P, Snyder R. Key factors in antibiotic resistance. J Global Infect Dis [serial online] 2019 [cited 2019 Dec 11];11:163-5. Available from: http://www.jgid.org/text.asp?2019/11/4/163/271715




Sir,

Antibiotic resistance (AR) continues to be a public health concern that affects close to 2 million Americans each year.[1],[2] In comparison to other nations, the United States is one among the highest consumers of broad-spectrum antibiotics with a minimum of 4.3 defined daily doses per person. When we consider the cumulative antibiotic dosage, it is approximately 10–20 daily doses per person.[3],[4] Despite regulations regarding the antibiotic usage, we seem to be consuming antibiotics at an astounding rate. We know that continued prescribing of antibiotics increases the development of infections due to resistant pathogens. While your paper touched on the factors that need to be addressed in developing countries, we would like to mention factors that developed nations with high rates of AR should be addressed.


   Increased Antibiotics Research Top


Recently, the United States had a shortage of penicillin G, an essential medication as listed by the World Health Organization.[5],[6] While this deficit is resolved due to the increased production at the request of the Food and Drug Administration (FDA), such a shortage of an essential medication should not have occurred in the first place. This medication deficit was due to fewer pharmaceutical companies producing penicillin. Many pharmaceutical corporations no longer research and manufacture antibiotics due to a narrow profit margin.[7] Currently, only four major companies still have a designated “antibiotics division.” Pew Trusts reports that there are 42 new antibiotics in different phases of development, and only one of these is being produced by a large company with a sustainable supply chain.[8] Government entities need to provide incentives for larger companies to research and produce new antibiotics along with a strong supply chain to ensure a sustained production of essential antibiotics.


   Decreasing the Use of Environmental Antibiotics Top


The environmental use of antibiotics refers to using antibiotics in livestock. In 2015, it was noted that 70% of total ingested antibiotics actually came from the consumption of animal products.[9] Over the next decade, it is estimated that consumption of antibiotics from livestock will increase by roughly 70%.[10],[11] The FDA has made significant efforts in curbing the use of antibiotics in animals. For example, since 2017, it has been illegal to use “medically important” antibiotics for the growth of livestock. The FDA defines “medically important” antibiotics as those that are used frequently to treat human infections. Since the implementation of this law, there has been a 43% decrease in the sales relating to livestock containing antibiotics.[12] Another issue is the unnecessary use of antibiotics on livestock. Many farmers find it economically viable to prophylactically treat all their livestock rather than having to quarantine and treat once the infection becomes present.[13] Educating farmers on antibiotics might help curb this problem. [Table 1] lists countries with the highest use of antibiotics in livestock and the drug resistant index. It is vital to identify ways to further reduce the amount of antibiotics used in livestock to prevent further progression of AR.
Table 1: Antibiotic use in livestock and in hospitals globally

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   Proper Antibiotic Stewardship Top


There are several things that health professionals can do regarding proper antibiotic prescribing. They can be more discerning in how often they prescribe antibiotics, closely monitor for AR, keep a clean healthcare environment, talk with their patients regarding proper antibiotic use, and discuss ways to prevent infection including improving personal hygienic practices.

Recent studies have indicated that 30%–70% of prescribed antibiotics at the hospital are suboptimal: using broad-spectrum antibiotics for empiric therapy when a narrower spectrum antibiotic would be appropriate.[14],[15],[16] Consideration for earlier infectious disease referral should be undertaken not only for complicated cases but also for uncomplicated infections when there is a question regarding the optimal antibiotic prescription.[14] Proper education regarding the surrounding hospital community being treated as good levels of AR should be reviewed with the medical staff.[15] The United Kingdom currently uses specialized pharmacists to train the health-care professionals in antibiotic choice, thus reducing health care-associated infections, particularly Clostridium difficile infection.[16]

Policy-makers can also do their part by creating methods to improve surveillance, prevent and control of outbreaks, promote regulation of cleanliness and hygiene in hospital settings, and distribute information to the public about AR. An example of a surveillance measure is the Centers for Disease Control and Prevention's AR maps which show AR [Figure 1].[17] Proper antibiotic stewardship is a combination of awareness of the individual prescriber, as well as education and research on a national and even global level. An example is legislation such as the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms Act (DISARM) introduced in 2019 to promote AR research.
Figure 1: (a) This figure shows the percentage of resistance (2014) in each state when comparing all health care-associated infections. Nevada and the Northeast states seem to have the highest rates of resistance. (b) This figure shows the percentage of resistance (2014) in each state when comparing all health care-associated infections. Southern states seem to have the highest rates of resistance

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In conclusion, addressing these three problems of increasing incentives for research and production of antibiotics, decreasing environmental antibiotic usage, and proper antibiotic stewardship are vital to decreasing AR globally and locally. We believe that with continued collaborative efforts, we will hopefully reduce the threat of AR in the coming years.[18],[19],[20],[21]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Cooper MA, Shlaes D. Fix the antibiotics pipeline. Nature 2011;472:32.  Back to cited text no. 1
    
2.
Hampton T. Report reveals scope of US antibiotic resistance threat. JAMA 2013;310:1661-3.  Back to cited text no. 2
    
3.
The Center for Disease, Dynamics Economics and Policy. ResistanceMap: Antibiotic resistance 2019. Available from: https://resistancemap.cddep.org/. [Last accessed on 2019 Jul 30].  Back to cited text no. 3
    
4.
Ventola CL. The antibiotic resistance crisis: Part 1: Causes and threats.P T 2015;40:277-83.  Back to cited text no. 4
    
5.
Nurse-Findlay S, Taylor MM, Savage M, Mello MB, Saliyou S, Lavayen M, et al. Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: An evaluation from multi-country surveys and stakeholder interviews. PLoS Med 2017;14:e1002473.  Back to cited text no. 5
    
6.
Wyber R, Taubert K, Marko S, Kaplan EL. Benzathine penicillin G for the management of RHD: Concerns about quality and access, and opportunities for intervention and improvement. Glob Heart 2013;8:227-34.  Back to cited text no. 6
    
7.
Langreth R. Antibiotics Aren't Profitable Enough for Big Pharma to Make More. Bloomberg Businessweek; 2019.  Back to cited text no. 7
    
8.
Talkington, Kathy. “Antibiotics Currently in Global Clinical Development.” The Pew Charitable Trusts, Feb. 2014, https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2014/antibiotics-currently-in-clinical-development.  Back to cited text no. 8
    
9.
O'Neill J. Antimicrobials in agriculture and the environment: Reducing unnecessary use and waste. Rev Antimicrob Resist 2015;1:1-44.  Back to cited text no. 9
    
10.
Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, et al. Global trends in antimicrobial use in food animals. Proc Natl Acad Sci U S A 2015;112:5649-54.  Back to cited text no. 10
    
11.
Cuong NV, Padungtod P, Thwaites G, Carrique-Mas JJ. Antimicrobial usage in animal production: A review of the literature with a focus on low- and middle-income countries. Antibiotics (Basel) 2018;7. pii: E75.  Back to cited text no. 11
    
12.
Dall C. FDA Reports Major Drop in Antibiotics for Food Animals. Center for Infectious Disease Research and Policy; 2018.  Back to cited text no. 12
    
13.
Lhermie G, Gröhn YT, Raboisson D. Addressing antimicrobial resistance: An overview of priority actions to prevent suboptimal antimicrobial use in food-animal production. Front Microbiol 2016;7:2114.  Back to cited text no. 13
    
14.
Charani E, Cooke J, Holmes A. Antibiotic stewardship programmes – What's missing? J Antimicrob Chemother 2010;65:2275-7.  Back to cited text no. 14
    
15.
Goff DA, Kullar R, Goldstein EJ, Gilchrist M, Nathwani D, Cheng AC, et al. Aglobal call from five countries to collaborate in antibiotic stewardship: United we succeed, divided we might fail. Lancet Infect Dis 2017;17:e56-63.  Back to cited text no. 15
    
16.
Gilchrist M, Wade P, Ashiru-Oredope D, Howard P, Sneddon J, Whitney L, et al. Antimicrobial stewardship from policy to practice: Experiences from UK antimicrobial pharmacists. Infect Dis Ther 2015;4:51-64.  Back to cited text no. 16
    
17.
Center of Disease Control and Prevention. Antibiotic Resistance Data.2018. Available from: https://gis.cdc.gov/grasp/PSA/MapView.html. [Last accessed on 2019 Jul 30].  Back to cited text no. 17
    
18.
Hwang TJ, Carpenter D, Kesselheim AS. Paying for innovation: Reimbursement incentives for antibiotics. Sci Transl Med 2015;7:276fs9.  Back to cited text no. 18
    
19.
The Center for Disease, D.E.P., ResistanceMap: Animal Use. 2019.https://resistancemap.cddep.org/AnimalUse.php.  Back to cited text no. 19
    
20.
The Center for Disease, D.E.P., ResistanceMap: Antibiotic Use.2019.https://resistancemap.cddep.org/AntibioticUse.php  Back to cited text no. 20
    
21.
Tracking global trends in the effectiveness of antibiotic therapy using the Drug Resistance Index. BMJ Global Health, 2019. 4(2): p. e001315.  Back to cited text no. 21
    

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Correspondence Address:
Dr. Vikas Yellapu
801 Ostrum Street, Bethlehem, Pennsylvania 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgid.jgid_115_19

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