What Nurses Need to Know About Antibiotic Resistance

More than 80 years ago, in 1928, bacteriologist Alexander Fleming discovered penicillin. After returning from vacation, he found a mold that had started growing in a staphylococcus culture dish inhibited bacterial growth. But it wasn’t until World War II that the new drug officially made its public health debut, when enough of it became available to allow unlimited treatment of Allied servicemen. A public service ad from that era read: "Penicillin kills gonorrhea in four hours. See your doctor today."

Well, a lot has happened since the medical establishment prematurely declared victory over infectious diseases with the discovery of antibiotics such as penicillin and sulfa drugs (which were first used in 1938). Today’s headlines are much more likely to reflect fears of new epidemics—e.g., avian flu, SARS and H1N1—and the growing public health threat of antibiotic resistance.

According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is the ability of bacteria or other microbes to resist the effects of antibiotic treatment. Instead of being killed by the drugs, the bacteria survive and continue to multiply, resulting in new strains of infectious diseases that are more difficult to cure and more expensive to treat.

Antibiotic resistance is not exactly a new phenomenon. In the 1940s and ’50s, tuberculosis bacilli already showed some resistance to Streptomycin and Isoniazid (INH). In 1998, the Institute of Medicine’s Forum on Emerging Infections reported that strains of Staphylococcus aureus resistant to penicillin were isolated as early as 1945. The chairman of the forum testified that resistance inevitably occurs as bacteria adapt to the presence of antibiotics in their environment.

Today, health care professionals have to deal with MRSA, VRE, VISA, VRSA and MDR-TB or XD R-TB. If you know what these acronyms stand for, then chances are you have taken care of a patient with an antibiotic-resistant infection. And most likely you have already been to at least one nursing conference that talked about how astronomically expensive it is to treat resistant infections, and about the high rate of mortality they cause.

How Do Bacteria Become Resistant?

How bacteria develop resistance against antibiotics is simply a manifestation of the Darwinian principle of natural selection and the struggle for existence. Bacteria evolve in order to survive.

The CDC informs us that bacteria may develop the ability to neutralize or evade the effect of the antibiotic. Exposure to antibiotics therefore provides selective pressure, which makes the surviving bacteria more likely to be resistant.

In addition, bacteria that were once susceptible to an antibiotic can acquire resistance through mutation of their genetic material or by acquiring pieces of DNA that code for the resistance properties from other bacteria. The DNA that codes for resistance can be grouped into a single easily transferable package. This means that bacteria can become resistant to many antibiotics because of the transfer of one piece of DNA. Some bacteria develop the ability to neutralize the antibiotic before it can attack, others can rapidly pump the antibiotic out and still others can change the antibiotic attack site so that it cannot affect the function of the bacteria.¹

In March 1994, Newsweek magazine published "The End of Antibiotics." The article warned the public that by means of some clever mechanism, bacteria can create resistance by breaking down the drug or by changing the bacterial cell wall so that antibiotics can’t get in.²

However, human hosts are not exactly the helpless victims we appear to be. Our society’s overdependence on antibiotics contributes to the problem. In fact, repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. We now live in the age of pills. Patients have become used to demanding antibiotics from physicians and nurse practitioners, and too often they are accommodated. An interview with a British doctor in the 1980s revealed what seemed to be a common practice at the time, not only in Britain but elsewhere: Physicians prescribe pills as a way of avoiding a more time-consuming analysis and treatment. Writing a prescription for antibiotics, whether they are really needed or not, pleases the patient and relieves the physician of his or her high case volume.

But no matter how grim the situation may be, it is not hopeless. A recent article in The Wall Street Journal reported that hospitals are turning to a new breed of antibiotic SWAT team to win the war against drug-resistant bacteria. These initiatives, known as antimicrobial stewardship programs, bring together teams of top pharmacists, infectious disease specialists and microbiologists to monitor the hospital’s use of antibiotics and restrict prescription of certain drugs—for example, Vancomycin—when their bacterial targets become resistant. These new efforts are partly the result of the federal Medicare program’s plans to not reimburse preventable hospital acquired infections, many of which are caused by antibiotic-resistant organisms.³

The Nurse’s Role in Preventing Drug Resistance

What can staff nurses do to reduce the risk of antibiotic resistance and protect their patients from developing drug-resistant infections? Here are some recommendations:

• Be vigilant about how your unit uses antibiotics; ask your local Infectious Diseases team.
   
• Actively participate in "Pharmacy Committee" meetings and learn what your hospital is doing to address antibiotic resistance.
   
• Always give antibiotics on time and avoiding skipping a dose.
   
• Check your patient’s culture and sensitivity reports and act as a patient advocate by informing the physician if the bacteria are sensitive to a narrow-spectrum antibiotic.
   
• Always observe Standard and Contact precautions when caring for patients with antibiotic-resistant infections.
   
• Participate in unit-based surveillance studies to learn about trends in resistant infection.
   
• Read evidence-based and best practice recommendations, such as those available at www.cdc.gov/drugresistance/index.htm.
   

Nurses can also play an important role in educating patients and the public about the importance of preventing antibiotic resistance. The CDC offers these patient guidelines:

• Talk with your health care provider about antibiotic resistance.
   
• Ask whether an antibiotic is really the best treatment for your illness.
   
• Ask what else you can do, rather than taking an antibiotic, to feel better sooner.
   
• Do not take an antibiotic for a viral infection like a cold or the flu.
   
• Do not save some of your antibiotic for the next time you get sick. Discard any leftover medication once you have completed your prescribed course of treatment.
   
• Take an antibiotic exactly as the health care provider tells you. Do not skip doses. Complete the prescribed course of treatment even if you are feeling better. If treatment stops too soon, some bacteria may survive and re-infect you.
   
• Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.
   
• If your health care provider determines that you do not have a bacterial infection, ask about other ways to help relieve your symptoms. Do not pressure your provider to prescribe an antibiotic.
   

The pharmaceutical revolution that started in the 20th century has saved millions of lives, but it has also brought new public health problems and challenges. In his best-selling book The Greatest Benefit to Mankind: A Medical History of Humanity, Roy Porter tells us that "the euphoria of the age of penicillin has turned to anxiety ... medicine will have to redefine its limits even as it extends its capacity."⁴ Antibiotic resistance may be inevitable, but as health professionals we must take a cue from the bacteria itself: We must evolve in the way we treat and prevent infections if the human race is to survive.

References:

• Centers for Disease Control and Prevention. "Get Smart: Know When Antibiotics Work." Available at www.cdc.gov/getsmart.
• Begley, S. (1994). "The End of Antibiotics." Newsweek,March 28, pp. 49-52.
• Landro, L. (2008). "Curbing Antibiotic Use in War on ‘Superbugs.’" The Wall Street Journal, September 3.
• Porter, R. (1997). The Greatest Benefit to Mankind: A Medical History of Humanity. W.W. Norton & Company.