Few people alive today remember a time when there were no antibiotics. Before penicillin arrived on the front lines of World War II, many lives and limbs were lost not on the battlefield, but in the days after when even small wounds could become lethal infections.
As the public began to think of antibiotics as cure-alls that would always be there to protect us, we began to use or misuse them in ways that taught germs to be smarter and more dangerous. Today, the CDC lists antibiotic resistance near the top of the ten most serious concerns facing public health.
"There will always be emerging infections, but the big challenge today is microbes that become resistant to antibiotics. We are running out of drugs to fight them," Peter Pappas, MD, chair of UAB's Antimicrobial Stewardship Program, said. "There are a few new antibiotics, but most of them are combinations of other drugs. We're not seeing much that would be a game changer in the pipeline.
"New antibiotics are expensive to develop, and since they are typically used only a short time, it is hard to risk the investment of time and money. We need other incentives to encourage new antibiotic development. Meanwhile, our best hope is protecting the effectiveness of the antibiotics we have.
"In antimicrobial stewardship, we face two different challenges. In an inpatient hospital setting, patients tend to be sicker and may encounter almost any type of microbe. In outpatient settings, patients often come to a physician's office expecting a prescription for an antibiotic even for viral infections an antibiotic can't help. If a prescription has to be written before the infection can be identified and the patient doesn't come back to the office for months, changing treatment can be complicated. Even when an antibiotic is appropriate, it is difficult to verify that the patient is being compliant."
UAB's Antimicrobial Stewardship Program has been in operation for more than a dozen years and has expanded to include UAB West and a hospital in Anniston. Hospitals in Alexander City and Sylacauga are gearing up to join the program.
"The emphasis is on teaching our residents and patients how to use antimicrobials judiciously. In urgent situations where we have to begin treatment before we can identify the infection, that also means being ready to adjust the treatment plan if we find the germ isn't sensitive to the drug or if we need a different combination of medications," Pappas said.
MRSA is a classic case of what can happen when antibiotics are used inappropriately.
"We started out with gowns and gloves when we detected MRSA," Pappas said. "It was originally a hospital acquired infection, but it is now so widespread that patients can pick it up anywhere. We're trying to keep other microbes from doing the same, but we are already seeing resistant strains of malaria, tuberculosis, salmonella and typhoid. Antivirals are under less pressure because they are used less often, but multiresistant herpes and CMV are a threat.
"One of our biggest concerns now is a hospital acquired fungal infection, Candida auras, which has been found in India and Pakistan with a few cases in the US. It causes fever, sepsis and death. If it gets out on a global basis, it could be devastating."
UAB's Antimicrobial Stewardship Program has been quite successful, and Pappas hopes that the residents trained in the judicious use of these drugs will take what they have learned with them as they go into practice.
"We hope to develop an outpatient program soon to help local medical practices," Pappas said. "Physicians are under tremendous pressure to prescribe antibiotics for viral infections. Some patients feel shortchanged when they don't get an antibiotic, even when it won't help. They don't understand what antibiotics are for and what can happen if they are misused.
"Patients need to know that an unnecessary antibiotic isn't just an unnecessary expense. It can affect their microbiome and leave them open to other infections. They need to understand why they should take antibiotics as prescribed when they do need them. If they stop when they are feeling better but before the infection is gone, they are teaching the germ to become smarter. Next time, if their antibiotic no longer works, they may have to step up to a more powerful drug. Some of these stronger antibiotics can be extremely expensive and have their own side effects.
"We need more awareness of antibiotic resistance. We don't need antibiotics for every illness, but when we do, we need antibiotics that work."