Antibiotic Stewardship: Part Two
Antibiotic Stewardship ESKAPE
This is not “escape” spelled incorrectly. ESKAPE is an acronym coined by the Infectious Diseases Society of America (IDSA) to emphasize the main resistant bacteria that have emerged over the years. ESKAPE stands for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, and Enterobacter species. More people now die of methicillin-resistant S. aureus (MRSA) infections in US hospitals than that of HIV/AIDS and tuberculosis combined. Some multiple drug resistant (MDR) Pseudomonas and carbapenem-resistant Klebsiella can only be treated with a rarely used toxic antibiotics (which may or may not work). How has this occurred and what steps is the United States healthcare system doing about it?
Bacteria, like us humans, want to survive. When they are threatened consistently by an antibiotic, they evolve and develop numerous methods of resistance. Some of these ways include changing cell wall thickness so the antibiotic cannot enter, mutations of antibiotic target sites, developing enzymes thatinactivate antibiotics, and increasing elimination of the antibiotic out of the bacteria cell. It is typically thought that inappropriate prescribing of antibiotics is what has lead to this resistance. This is only partially true. It is the general use of antibiotics that creates bacterial resistance. Thus, if all inappropriate prescribing was eliminated, antibiotic resistance would still occur (but at a slower rate). Other excessive exposure to antibiotics occurs during livestock feeding (about 28 million pounds in 2010) and environmental exposure in sewage.
Governmental action and legislation has helped to battle bacterial resistance. One key issue is the lack of new antibacterial agents available to treat resistant bugs. Only two antibiotics were approved by the FDA between 2009 and 2013. One reason for this is the increased cost associated with developing new antibiotics compared to other forms of medications. A second reason is that there is less of an incentive to develop antibiotics when bacteria may develop resistance quickly. Legislation has been passed or pending that helps incentivize pharmaceutical companies to develop new antibiotics by tax credits and help phase out the use of antibiotics in livestock.
Another main strategy for battling resistance is mandating antibiotic stewardships in long term care (SNFs) homes. SNFs are at increased risk of developing resistant bacteria simply because elderly are more likely to receive antibiotics. A stewardship program helps decrease the number of antibiotics prescribed, total days of antibiotic use, and promotes targeted therapy of less potent antibiotics. More appropriate prescribing leads to a slower rate of resistance.
As long term care health professionals, we may not have much control over the development of new antibiotics and certain governmental action. However, through a stewardship program, we can help decrease the number of ESKAPE bugs and improve patient outcomes in our homes.
If you would like to read more about bacterial resistance, please visit the following CDC website: https://www.cdc.gov/drugresistance/about.html
Grant Walker, PharmD