The patients who get the most courses of antibiotics are as expected, the ones who get the most infections, and these infections are often recurrent at the one site. A few examples are the elderly person who gets recurrent urinary tract infections, the toddler who gets recurrent otitis media, or the patient with chronic obstructive pulmonary disease (COPD), who gets recurrent bouts of bronchitis.
The antibiotic selection pressure on such patients is often intense, and one can often see by observing their microbiology results over time, that the infecting organisms become increasingly resistant, until multi-drug resistant organisms (MDROs) appear, and the clinician is forced to resort to less routine and more exotic antibiotics to treat the infection.
Whilst some of these “infections” will absolutely require antibiotics, many don’t, and many more were probably not bacterial infections in the first place.
What these patients really need is “An Antibiotic Free Period” . A period where the playing field is level. When MDROs have to compete against their susceptible counterparts in the absence of selection pressure, the increased fitness of the susceptible bacteria will win in the end. (This may take a while, and varies from patient to patient, and from organism to organism, but it will happen eventually.)
MDROs really don’t like level playing fields, they much prefer the odds slanted in their favour…
How can the microbiology laboratory assist in creating antibiotic free periods for patients?
Well we can add a comment to the result, for example “Uncomplicated otitis media does not routinely require antibiotic therapy” or “The isolation of pseudomonas from a patient with COPD does not imply acute infection.”, etc., etc.
or we can simply withold susceptibilities. For example an E. coli in a urine from an elderly Rest Home patient could have a comment along the lines of: “No clinical details have been provided with this sample. Asymptomatic bacteruria occurs in a significant proportion of elderly patients. If this patient has urinary symptoms, and they are continuing, please contact the laboratory for antimicrobial susceptibilities.”
It is my experience that the presence of an MDRO on a microbiology result report causes a reflex reaction from the requestor and increases the chance that the patient will be treated with antibiotics.
However the exact opposite should really apply. The threshold for treating an infection caused by an MDRO, as opposed to a susceptible one, should go up, not down.
One of the roles of microbiology laboratories, and clinical microbiologists, should be to facilitate antibiotic free periods where the opportunity arises…
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