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As Antibiotic Resistance Increases, Stewardship Is Critical

By Jennifer Anderson

As baby boomers age, with pneumonia and other potentially fatal illnesses that predominantly strike the elderly increasing in prevalence, it's critical to make judicious choices in prescribing antibiotics.

Excessive and unnecessary use of antibiotics must be curbed, says Elizabeth Cerceo, MD, an assistant professor of medicine at Cooper Medical School of Rowan University in New Jersey.  She explains that decades of over- and unnecessary use of antibiotics have led to resistance among increasing numbers and strains of sometimes-deadly bacteria.

However, antibiotics are essential in treating illnesses such as pneumonia, a severe lung infection. But without proper stewardship of antibiotics, there won't be enough medications available to treat diseases that require antibiotics.

Pneumonia and Antibiotics
With antibiotics, most healthy people recover from pneumonia within three weeks, according to the Centers for Disease Control and Prevention. But in the United States, approximately 50,000 people die each year from pneumonia, and globally, pneumonia is the leading cause of death among young children. People who smoke cigarettes or have asthma, diabetes, heart disease, and other underlying medical conditions are at increased risk for pneumonia.

Teena Chopra, MD, an assistant professor of internal medicine at Wayne State University in Detroit, adds that pneumonia is the No. 1 cause of hospitalization of older patients in the United States. 

People with pneumonia usually have persistent fever, chills, and fatigue. If a patient's symptoms last more than 48 hours, he or she should seek a physician's care if possible, or go directly to a hospital. Chest X-rays typically are used to diagnose pneumonia, and patients who are young and healthy usually can be treated as outpatients. Pathology reports on mucus from a cough can be used to diagnose the type of bacteria causing the pneumonia, Chopra says.

Older patients who may have less robust immune systems may present not with fever but with hypothermia, Chopra says. They might seem confused and suffer fatigue or weakness. These patients should be admitted to the hospital. "You cannot fool around with pneumonia," she says. "If bacteria get in the blood, they can get to the brain and cause meningitis, and you can have high morbidity and mortality."

Patients with pneumonia coming from nursing homes are more likely to have been exposed to antibiotic-resistant bacteria and should go directly to the hospital, she says, adding that the Centers for Medicare & Medicaid Services recently mandated antibiotic stewardship in nursing homes.

Other symptoms of pneumonia include cough, shortness of breath, chest pain, excessive sweating, and loss of appetite, according to the American Lung Association. High fever can present in one to three days.

Since pneumonia often arises as a complication of the flu, concern about pneumonia spikes during influenza season, Cerceo explains.  "We worry about people not getting vaccinated properly or when the vaccine is less than effective," she says. People aged 65 and older who have underlying medical conditions that render them particularly susceptible to pneumonia are advised to consider pneumococcal vaccine in addition to the influenza vaccine. 

Although the pneumococcal vaccine won't prevent pneumonia, it should reduce pneumonia's symptoms and severity, Cerceo explains. Both vaccines can be administered at the same time, according to Cerceo.

Aspiration, inadvertently inhaling food, saliva, liquids, or vomit into the lungs, can accompany pneumonia. Patients at risk of aspiration should be kept upright at 90 degrees for 30 minutes after eating and minimize thin liquid intake. 

Education is Key
Patients and practitioners alike need information and education on the judicious use of antibiotics, Cerceo says. Antibiotics have been around since the mid-1940s, when researchers at Oxford University published a paper that led to mass production and distribution of penicillin, according to a 2010 paper published in Frontiers in Microbiology

Finally doctors had medications to treat diseases that had wreaked havoc on patients. Demand for antibiotics soared, and as Cerceo explains, primary care providers came to believe patients who came to them essentially wanted antibiotics.

For busy physician offices, antibiotic prescriptions can offer a quick and easy treatment solution, and patients sometimes believe antibiotics are essential for a host of illnesses, including viral infections. "We need to empower patients to understand that antibiotics are not indicated for a lot of upper airway infections and should be reserved only for people severely ill and at risk for pneumonia [and other indicated diseases]," Cerceo says.

A 2002 paper in Emergency Medicine Clinics of North America reports that while "countless lives have been enhanced and saved with antibiotic use," a Pandora's box has been opened "through the casual distribution of outpatient antibiotics."

The article, by Jeffrey Louie, MD, of Children's Hospital and Clinics in Minnesota, concurs that improper distribution of antibiotics has led to an increase in penicillin resistance throughout North America and in many other countries. "Parental pressure for physicians to prescribe antibiotics also has contributed to the rise in antibiotic resistance," according to the article.

Studies show that when patients are educated about the dangers of antibiotic overuse, they often agree to a different treatment plan, Cerceo says.

Viral Pneumonia
Compounding efforts to treat pneumonia is the fact that the disease is not always bacterial. The American Lung Association reports that up to one-third of pneumonia cases in the United States are caused by viruses, often influenza, and cannot be treated with antibiotics. These viruses turn up most frequently in children and older adults—people whose immune systems have more difficulty fighting viruses.

It is impossible to tell on a chest X-ray whether pneumonia results from bacteria or a virus, and often symptoms of viral pneumonia are similar to those of bacterial pneumonia, Cerceo says. 

Depending on the severity of symptoms, other tests may be prescribed, including blood cultures, CT chest scans, nasal swab, sputum cultures, and in very serious cases, open lung biopsy, according to the National Institutes of Health's MedlinePlus website. Humidified air, corticosteroids, IV fluids, and oxygen are common treatments for viral pneumonia. Patients treated at home should drink plenty of fluids, get plenty of rest, avoid cough medicines, and take fever reducers such as acetaminophen.

Viral pneumonia can evolves into bacterial pneumonia, according to MedlinePlus, in which case antibiotics are then indicated.

Everyone is impacted when bacteria build resistance to antibiotics in one person or in a group of people—or even livestock, Cerceo says. "Resistance bred in children will be passed on to everyone eventually," she says, adding that children with ear infections, for example, in most cases do not need antibiotics.

"We are constantly developing new antibiotics, but the bacteria are faster in building resistance," Chopra explains. More than ever, she says, antibiotic stewardship is critical.

In March 2014, the Obama administration announced the development of a National Action Plan for Combating Antibiotic-Resistant Bacteria. The plan includes a five-year goal of enhancing abilities domestically and abroad for preventing and containing outbreaks of antibiotic-resistant infections. The government is prepared to contribute approximately $1.2 billion to follow through on this and other aspects of the plan, according to the news release.

The National Plan will result in the advancement of at least two new antibiotic drug candidates, nontraditional therapeutics, and new vaccinations. And at least three new drug candidates or probiotic treatments will be developed as alternatives to antibiotics.

Chopra lauds the national plan but explains that antibiotic stewardship cannot stop at the nation's borders. In India, for example, 13 billion doses of antibiotics typically are prescribed over the course of a year, compared with 7 billion in the United States. The government in India is taking steps to control antibiotic use, no longer allowing over-the-counter sales.

"[Controlling antibiotic overuse] is not going to happen with one institute or nation," Chopra says. "It has to be global."

— Jennifer Anderson is a freelance health and science writer based in Falls Church, Virginia.