Why is the problem of antibiotic resistance increasing, and is the problem reversible?

Sandy J. Estrada: The problem of antibiotic resistance is increasing for a number of reasons. A key contributing factor to the rise of antibiotic resistant organisms (also known colloquially as “super bugs”) is the overuse and misuse of antibiotics. This includes, but is not limited to, the prescribing of antibiotics for viral infections, taking antibiotics for longer than necessary, and using stronger/broad spectrum (or “big gun”) antibiotics when unnecessary. Other contributing factors are the use of antibiotics in animals and animal feed, and the spread of antibiotic resistant bacterial strains by the transmission of antibiotic resistance genes from one bacteria to another. Unfortunately, the problem of antibiotic resistance is not usually reversible. The goal for those working in infectious diseases is stabilization of resistance rates through more appropriate prescribing (also known as antimicrobial stewardship), better infection control, improved microbial surveillance through the use of advanced molecular diagnostic techniques and other processes.

How is antibiotic resistance going to affect medicine?

SE: Antibiotic resistance already affects medicine in many ways. There is a human cost in terms of more and longer hospital stays, additional doctor visits, decreased quality of life and even death. The CDC recently reported that antibiotic resistant organisms contribute to over 2 million illnesses and 23,000 deaths annually in the U.S. alone. Many more die by conditions made worse by the presence of an antibiotic resistant infection. In addition, the CDC reports that almost 250,000 people each year in the U.S. require hospitalization for Clostridium difficile (C. difficile) infections, which is an opportunistic infection typically caused by antibiotics killing off the “good” bacteria in the gut; at least 14,000 people die each year as a result. Most of these infections are considered preventable, with use of antibiotics as a major contributing factor.

Antibiotic-resistant infections also exact a significant economic toll to the already overburdened U.S. healthcare system. The total economic cost of antibiotic resistance to the United States economy has been difficult to calculate, but the CDC reports estimates ranging from as high as $20 billion in excess direct healthcare costs with additional costs to society for lost productivity as high as $35 billion a year in 2008 dollars. Moving forward, the human and economic toll is expected to increase dramatically unless significant changes occur, starting with more judicious antibiotic use.

What areas of medicine are going to be affected the soonest?

SE: All areas of medicine are currently being affected and will continue to be affected. Antibiotic resistant infections can happen in any medical specialty and occur in both the inpatient and outpatient settings. CDC data shows that most antibiotic resistant infections occur in the community; however, most deaths related to antibiotic resistance happen in healthcare settings, such as hospitals and nursing homes.

When do you think we're going to be "out of options" for many — or even most — infections? 

SE: There are already rare reports of certain infections for which there were no antibiotics that were effective, for example, certain C. difficile infections and carbapenemase-resistant Enterobacteriacae (CRE) infections. CRE specifically has been called the “phantom menace” by the former CDC director Dr. Tom Frieden. Whether these reports of antibiotic resistant infections will grow in number is difficult to say, but they will almost certainly increase without significant changes in our approach to antibiotic use, microbial detection and surveillance, and infection control strategies. Judicious and appropriate use of antibiotics is key.

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