Antibiotic Resistance: Stemming the Tide of a Public Health Threat

Antibiotic Resistance:
Stemming the Tide of a Public
Health Threat
Teresa Lowery, MD, MPH, FAAFP, ABFM
Medical Health Specialist, Region 2/3
• In this webinar, we will
– Define “antibiotic resistance”; and discuss why it has
quickly become a growing public health threat.
– Discuss how health care providers and staff can help
promote discretionary antibiotic use and help decrease
the trend of antibiotic resistance.
– Discuss the appropriate use of antibiotics in common
infections seen in the outpatient setting such as upper
respiratory tract infections and in skin infections
including MRSA (Methicillin Resistant
Staphlococcoccus Aureus).
– Review some of the common facts and questions asked
regarding this topic.
Antibiotic Resistance:
The History of Antibiotics—How did we get here?
• What is an antibiotic?
– Term “antibiotic” originally referred to a natural
compound produced by a fungus or another
microorganism that kills bacteria which cause
disease in humans or animals.
– Some antibiotics may be synthetic compounds (not
produced by microorganisms) that can also kill or
inhibit the growth of microbes.
– Microbes are living organisms that multiply frequently
and spread rapidly (these are bacteria, viruses, fungi
and parasites). Some microbes cause disease and
others exist in the body without causing harm and
may actually be beneficial.
Antibiotic Resistance:
The History of Antibiotics—How did we get here?
• Antimicrobial Drug Resistance—how do we define
– It is the ability of microbes to grow in the presence of a
chemical (drug) that would normally kill them or limit
their growth.
• Why does this matter?
– As more microbes become resistant to antimicrobials,
the protective value of these medicines is reduced.
• How does this happen?
– Overuse and misuse of antimicrobial medicines are
among the factors that have contributed to the
development of drug-resistant microbes.
Antibiotic Resistance:
The History of Antibiotics—How does this
• Causes: (There is a complicated scientific
explanation, but here is a quick and fun way to
remember them)
– Natural—Selective Pressure —“Only the
strong survive”
– Mutation—Divide and Conquer —“We don’t
die, we multiply!”
– Genes Transfer—Sharing is Caring—“I will
give you what I have to save you”
• Societal Pressures—“Our fault”
 Inappropriate Use— “Just give them what
they want”
 Inadequate Diagnostics—“I don’t know what
I’m treating”
 Hospital Use—“It’s a germ’s playground”
 Agricultural Use—“What’s in that beef?”
Antibiotic Resistance: A new public health
threat? Really??
• Antibiotic resistance (AR) occurs everywhere in the
world and is not limited to industrialized nations
• Children and critically ill may be most vulnerable
• Affects healthcare settings and community at large
• The effects are far reaching and expensive
• AR is also emerging in some fungi
• Has affects with HIV, influenza and malaria treatment
• MRSA is noted to have increasing frequency
• Drug resistant Klebsiella and E. Coli species have been
isolated in hospitals
Antibiotic Resistance: Prescribing
Attitudes, Behaviors, Trends and Costs
• Patient and parent pressure—“Give Momma
what she wants” (62 percent vs. 7 percent)
• Acute Upper Respiratory Tract Infections—
“Doc, how do I get rid of this cold?” (70%
• Prescribing habits are improving, but slowly
• $1.1 Billion is spent annually on unnecessary
antibiotic Rx
• Get Smart is a national campaign which has
been launched to educate and help reduce the
number of antibiotics prescribed
AR: Use In Acute Upper Respiratory Tract
• Achoo!!! May I have an antibiotic please??
• Uncomplicated URI (Upper Respiratory Infection)–so
common, so over treated
• The Common Cold—runny nose, sore throat, cough,
sneezing and nasal congestion. Antibiotic use has
decreased but broad spectrum antibiotic use has
• The Common Color Myth of “Boogies”- If it is colored, it
is bacterial, right?? NO!!! This is not necessarily true!
• What’s the harm in treating these? AR, increased cost,
increased incidence of side effects, including
AR: Use in Upper Respiratory Tract
Infections: Is it a Cold of is it the Flu??
Influenza—acute URI caused by the influenza virus A or B
Abrupt onset of fever, headache, myalgia, malaise are the cardinal
Supportive care is the foundation of treatment, but antiviral therapy
(not amantidine) may decrease the duration of illness by one day if
started within 48 hours
Who needs treatment? Pregnant women, students with severe
illness, and those with chronic illness should be treated
Empiric therapy with antibiotics should not be continued after
influenza is diagnosed unless there is concern about a secondary
bacterial process
Vaccination is the mainstay of prevention
Use in URIs
• Rhinosinusitis (or sinusitis) is defined as inflammation of
the nasal mucosa and sinuses. Symptoms include nasal
obstruction, anterior or posterior purulent nasal
discharge, facial pain, decrease sense of smell, and
cough. Students may also have sore throat, fatigue, bad
breath and headache and fever.
• Is it bacterial or viral?? How would you know?
– The diagnosis of a bacterial cause should not be made until
symptoms have persisted for at least 10 days or after initial
improvement followed by worsening of symptoms.
– Also Look for 1) purulent nasal discharge 2) maxillary tooth
pain 3) unilateral maxillary sinus tenderness 4) worsening
symptoms after initial improvement.
Rhinosinusitis cont’d
• Watchful waiting and symptomatic treatment if follow up
can be ensured for mild bacterial sinusitis is advised but
worsening symptoms within 7 days warrant the use of
• The clinical cure rate for treated vs. placebo was 90% to
80% in studies.
• Amoxicillin is first line, while Bactrim or Septra can be
used for students allergic to Penicillin (PCN), alternatives
include (cephalosporins, macrolide family, respiratory
• Conflicting studies regarding length of treatment (5 days
vs. 10 days) and dose (high dose e.g., 1000mg tid or
875mg bid).
• A different antibiotic is justified if symptoms worsen in
within 7 days.
Use in URIs
• Otitis Media—diagnosis requires an acute onset of
symptoms, the presence of middle ear effusion and
signs and symptoms of middle ear effusion.
• Amoxicillin is first line treatment. If no response in 48-72
hours, reexamination of student is necessary and
Augmentin (amox with clavulanate) should be initiated.
Bactrim should not be used for PCN allergic, instead
(macrolides, cephalosporins are alternative treatment).
• Longer courses of antibiotics (more than seven) have
lower failure rates than shorter courses for more severe
diseases, 5-7 days may be effective in milder cases.
• Serous otitis (non-acute otitis with effusion) should not
be treated with antibiotics.
Pharyngitis and Tonsillitis
• Mostly viral (especially if accompanied by sneezing,
cough, watery eyes, mild headache, mild body aches,
runny nose and low grade fever—less than 102F).
• When bacterial, the leading pathogen is group A, betahemolytic Streptococcus.
• Testing for rapid strep A is advised for possible
diagnosis and treatment with appropriate antibiotics to
avoid rheumatic fever and reduce communicability.
• When Rapid Strep A testing is not available, the Centor
Criteria can be used to aid in diagnosis. This criteria is
based on the age and the presence of absence of fever,
tonsillar erythema or exudates, anterior cervical
lymphadenopathy and cough.
Modified Centor Criteria for
Pharyngitis and Tonsillitis
Clinical finding
Absence of cough
Age 3-14 yrs
Age 15-45
Older than 45
Ant. Cervical Lymphadenopathy
Tonsillar erythema or exudates
Pharyngitis and Tonsillitis
• The recommended treatment is a 10-day
course of penicillin (PCN). Erythromycin can be
used in patients who are PCN allergic.
Amoxicillin, azithromycin and first generation
cepholosporins are appropriate alternatives.
(Sulfonamides and tetracyclines have
questionable efficacy.)
• There is no need for post treatment test of cure
of culture after treatment
• Acutely by definition is inflammation of the vocal
cords and larynx lasting less than 3 weeks.
Symptoms include muffling of the voice
(hoarseness), sore throat, and other classic URI
symptoms such as cough, fever, runny nose and
• Studies have found that antibiotic treatment does
not reduce the duration of symptoms or lead to
voice improvement.
• Symptoms are usually self limited; syndrome is viral
(90% of time) and does not respond to antibiotic
Bronchitis (acute) is defined as a self-limited inflammation of
the large airways (including the trachea) that presents with
cough and possibly phlegm production.
Signs and symptoms also include soreness in chest, fatigue,
mild headache, mild body aches, low-grade fever, watery eyes
and sore throat.
Predominantly viral in cause, therefore antibiotics are not
needed in most students.
Purulent sputum alone is not an indication for an indication of
antibiotic therapy. Expect cough to last 2 weeks for most
students (and as long as 6-8 weeks for some students).
Advise individualized care focusing on symptom relief, as well
as explaining to students why antibiotics are not indicated.
Very important to differentiate pneumonia and influenza from
bronchitis because antibiotics are indicated for pneumonia.
If student has fever and rigors, get chest x-ray.
Few cases of atypical bronchitis are caused by Bordetella
pertussis or atypical bacterial such as Chlamydia pneumoniae and
Mycoplasma pneumoniae. However, these are usually also self
Suspected cases of pertussis should be treated with macrolides
early in the course of the disease to help prevent spread rather
than to change the course of the disease. (Suspect if cough
greater than 14 days). Treatment prophylaxis is advised for close
household contacts and roommates.
MRSA: The Not So New Threat
• Methacillin Resistant Staphlococcus Areus
• Staph Aureus, commonly known as staph, was
discovered in 1880s. During this era, it commonly
caused painful skin and soft tissue conditions such as
boils, scalded-skin syndrome, and impetigo. More
serious forms can progress to bacterial pneumonia and
bacteria in the bloodstream-both of which can be fatal. S.
Aureus can also be acquired from improperly prepared
and stored food and can cause a form of food poisoning.
• In 1940-1950s developed resistance to PCN. Methacillin
was introduced at this time to treat it, but in 1961, strains
of resistant S. Aureus to methacillin were identified.
MRSA: The Not So New Threat
MRSA can be categorized according to where it was acquired:
hospital-acquired MRSA (HA-MRSA) or community-associated
Our students for the most part, would fall into the latter category of
CA-MRSA is caused by newly emerging strains unlike those
responsible for HA-MRSA and can cause infections in otherwise
healthy persons with no links to healthcare systems.
Infections typically occur as skin or soft tissue infections, but can
develop into more invasive, life threatening infections.
May occur most often in those who are involved with football,
wrestling, as well as those kept in close quarters (e.g., soldiers),
inmates, childcare workers, and residents of long-term care
CA-MRSA Transmission
• Origin can be elusive, but close skin to skin contact
and sharing personal items such as towels, razors,
sports equipment, compromises in personal
hygiene and limited health care contribute to
• Most often enters the body through a cut or scrape
and appears in the form of a skin or soft tissue
infection such as a boil or abscess. The site
involved is usually red, swollen, warm and painful
and is often mistaken as a spider bite. Often
students may report that it started off as a pimple.
CA-MRSA Diagnosis/Treatment
• Tissue sample or fluid from boil is often obtained for
culture from a spontaneously draining site or via incision.
• Culture and sensitivity should be obtained in order to
make a certain diagnosis.
• Keep in mind that not all pimples and skin lesions are
MRSA. It may be folliculitis or cellulitis caused by typical
skin bacteria.
• Mild to moderate skin infections may be treated with
incision and drainage as first line treatment. Oral Bactrim
and Clindamycin are often used as first line antibiotics
for moderate skin infections for a 10 day course. More
severe infections may require a longer duration of oral
course, IV antibiotics or hospital admission for treatment.
CA-MRSA Prevention
• The best defense against spreading MRSA is
to practice good hygiene:
– Proper hand washing
– Showering promptly after exercising
– Keeping cuts and scrapes clean and covered with a
bandage until healed
– Avoiding contact with other people’s wounds or bandages
– Avoid sharing personal items, such as towels, washcloths,
razors, clothes or uniforms
– Washing sheets, towels and clothes that become soiled
with water and laundry detergent with bleach and hot water
when possible. Drying clothes in hot dryer rather than air
drying also kills bacteria in clothes.
Common Questions and
• Are antibacterial-containing
products (soaps, household
cleansers, etc. better for preventing
the spread of infection?
• And does their use add to the
problem of resistance?
Common Questions and
• Can antibiotic resistance develop
from acne medication?
Common Questions and
• Do probiotics have a role in
preventing or treating drug
resistance or drug-resistant
Common Questions and
• What can we do for our students to
help them feel better if antibiotics
won’t treat their illness because it is
caused by a virus?
Common Questions and
• How do we effectively educate our
students (and colleagues) about
the real dangers and public health
crisis of antibiotic resistance?
Antibiotic Resistance:
• As health care workers, we owe it to our profession
and to our patients (students) to do always do what
is ultimately in their and our society’s best interest.
This may mean making the very difficult decision to
not use antibiotics when they are not warranted.
• We can help prevent the spread of antibiotic
resistance by only prescribing antibiotic therapy
when likely to be beneficial to our students, using
an agent that targets the likely bacterial pathogens
and using the antibiotic for the appropriate dose
and duration.
Your Questions and