Infections Inside Out: Rise of the Resistance – How Antibiotic Resistance Impacts Healthcare Infections

This is the fourth post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part three here.

The rise of antibiotic resistance is one of the greatest threats in healthcare today. According to the Centers for Disease Control and Prevention (CDC), every year in the United States approximately 2.8 million people develop an infection from antibiotic-resistant bacteria and over 35,000 people die.

“She was in her 70s when she was admitted to the hospital with sepsis. Her right hip was infected, and unfortunately, this was not the first infection. Two years prior, she had fractured her femur and developed osteomyelitis. She had several prior hospitalizations, but they were all in another country. Now, cultures were obtained from the head of the femur and yielded Klebsiella pneumoniae. This member of the Enterobacteriaceae family is usually easily killed by many antibiotics. However, this time testing showed that not only did this bacteria demonstrate resistance to a powerful class of antibiotics known as carbapenems (due to the presence of New Delhi metallo-betalactamase (NDM), but even more frightening, it was resistant to all other antibiotics available. The patient ultimately succumbed to septic shock.”

– Chen, Lei, et al. “Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae-Washoe County, Nevada, 2016.” MMWR. Morbidity and mortality weekly report 66.1 (2017): 33-33

How did this happen?

In truth, this has always been happening. Since the discovery of penicillin in 1928, we have been faced with the reality of the ongoing evolution of antibiotic resistance. So much so, that in his Nobel lecture, Sir Alexander Fleming addressed the risk of resistance if caution was not used in the administration of penicillin.

“But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving a penicillin overdose and poisoning the patient. There may be a danger, though, in underdosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

Sir Alexander Fleming, Nobel Lecture, 1945

Since the onset of our first antibiotic, we have continued to see bacteria with resistance to antibiotics, including within 1–2 years from the release of the antibiotic to the description of the new resistance. Based on this, the CDC publishes a report on the biggest antibiotic-resistant threats in the U.S. The 2019 report has 18 pathogens listed as either an urgent, serious or concerning threat. Several of these bacteria will be familiar to you from prior posts — Methicillin-resistant Staphylococcus aureus (MRSA) and Carbapenem-Resistant Enterobacteriaceae (CRE), C. diff, and Candida auris (C. auris).  Others, such as carbapenem-resistant Acinetobacter and multi-drug resistant Pseudomonas aeruginosa are of urgent and serious concern, respectively, and still play significant roles in many healthcare-associated infections (HAIs).

What can we do about it?

With multiple antibiotic resistant organisms (AROs) threatening human health, focusing on prevention of continued resistance is of paramount importance. This profound public health threat resulted in a national action plan for combating antibiotic-resistant bacteria in 2015. Key aspects of this plan include improving antibiotic stewardship and adherence to infection prevention and control strategies.

Sir Alexander Fleming had it right — inappropriate use of penicillin, or any antibiotic, can result in resistance. And just as resistance has been with us since the discovery of penicillin, so has unnecessary antibiotic use. Approximately 30% of antibiotics given in US hospitals are inappropriate – based on suboptimal choice or unnecessary overall. Yet, we know that it is exposure to antibiotics that drives the evolution of resistance, and not just exposure of antibiotics to a single individual. Overuse of antibiotics in a hospital, or ward, may portend resistance to multiple patients.

Therefore, improving antibiotic use through stewardship principles is a critical step towards preventing further antibiotic resistance. The CDC has published Core Elements of Hospital Antibiotic Stewardship Programs, yet uptake of these principles is incomplete. The Infectious Diseases Society of America (IDSA) has also published guidance for implementing stewardship programs. Additionally, the Centers for Medicare and Medicaid Services have instituted requirements for antimicrobial stewardship, further highlighting the importance of this intervention. Finally, each healthcare professional can join in public health advocacy for stewardship through the CDC U.S. Antibiotic Awareness Week (scheduled for November 18-24, 2021).

But, combating antibiotic-resistant with stewardship is not enough. Infection prevention and control practices synergistically help prevent ongoing spread of these organisms. Practices that decrease the bioburden of bacteria from the environment, including from the hands of healthcare workers, are absolutely necessary. These strategies then decrease the likelihood of transmission of AROs from one patient to another.  From hand hygiene to transmission-based precautions to decrease transmission of multidrug resistant organisms (MDROs) to environmental cleaning and disinfection, infection prevention and control is quintessential in the fight against antibiotic resistance.

Thankfully, Antibiotic Resistant Doesn’t Mean Disinfectant Resistant

Monitoring for these organisms within the facility aids in recognition of possible developing outbreaks and assists in determining where the transmission may have occurred. For instance, the Agency for Healthcare Research and Quality (AHRQ) has a toolkit to assist with CRE control and prevention, which would have been a critical component for preventing both the infection and death of our patient above.

As part of these programs, we must recognize that environmental contamination with AROs or MDROs, is an essential weapon in this fight. Ensuring that the physical environment is clean, specifically frequently touched areas, cannot be understated in importance.

As infection prevention and control professionals, it is imperative that we recognize the profound threat that antibiotic resistance plays in our fight against HAIs. With inevitable use of antibiotics during our lives, we are all at risk and we all need to do our part to wage war on these formidable foes.

Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare.