"The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism,"
Sir Alexander Fleming, 1945.
Since the discovery of penicillin, antimicrobial resistance (AMR) has become a significant global health threat. Over 2.8 million antibiotic resistant infections occur in the US annually. The current COVID-19 pandemic is expected to further contribute to AMR, as broad spectrum antibiotics are utilized to combat co-infections. Up to 75%-100% of those admitted to the ICU with COVID-19 are prescribed antibiotics. Individualized, targeted antimicrobial applications via susceptibility testing is a promising antidote to AMR.
Prior to their discovery, mortality due to infection was a common occurrence as antibiotics are one of the most significant contributions to modern medicine. Increased antibiotic use has increased AMR. AMR exists as microbes readily adapt to their environment. Bacteria mutate an entire generation in as little as 20 minutes and become resistant to the antibiotics for survival. The new DNA encodes for enzymes to protect the bacteria from the antibiotic. In this manner all antibiotics can lead to AMR. AMR threatens modern medicine as drug resistant infections increase, while there are currently no new promising antimicrobial agents. Life-saving antibiotics are a limited resource.
Antimicrobial stewardship is an effort to measure and improve outcomes among individual infections and reduce the incidence of resistance. Good hygiene, clinical and hospital practices and appropriate prescribing of antibiotics are aspects of antimicrobial stewardship. Identifying antibiotic resistant genes alone in a pool of fecal bacterial DNA does not contribute to antimicrobial stewardship. There may be hundreds of inactive antimicrobial resistance genes identified in a stool sample that may not even be associated with a minority pathogenic bacteria. Broad testing of stool samples for antibiotic resistant genes is academically interesting, but it is not clinically applicable. Combating AMR requires actionable microbiological data. Appropriate laboratory susceptibility testing provides evidence based treatment options as a key aspect of antimicrobial stewardship.
Direct antimicrobial susceptibility testing against viable pure isolates of bacteria and yeast provides a part of the solution. The direct approach improves treatment strategies and patient outcomes. Further non-pharmaceutical agents with antimicrobial properties, including berberine, black walnut, caprylic acid, uva ursi, oregano, grapefruit seed extract and silver, may be evaluated. Antifungals such as berberine, caprylic acid, uva ursi, plant tannins, oregano, undecylenic acid and grapefruit seed extract may also be applied. Periodic review of antibiograms to remain current with prescribing practices facilitates antimicrobial stewardship.
If this AMR trend continues, it is predicted that in 2050 deaths due to antibiotic-resistant bacteria will supersede deaths due to cancer. With the current pandemic a catalyst of antibiotic use, now is the time to take significant action. We have an opportunity to employ direct individualized antimicrobial susceptibility testing. Ordering lab tests that offer individualized antimicrobial susceptibility testing for bacteria and fungus is an intelligent clinical choice that will not only benefit your patient, but public health today and in the future.
