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Antibiotic Resistance and Older Adults

By Brandi Redding

Antibiotic overuse has led to a high incidence of drug resistance. Physicians must be judicious in their prescribing habits.

Every year, more than 2 million people in the United States acquire antibiotic-resistant infections, with at least 23,000 people dying as a result, according to a new report from the Centers for Disease Control and Prevention (CDC). This is especially unnerving in light of antibiotics topping the list of the most commonly prescribed drugs. Losing effective antibiotic treatments not only inhibits the ability to fight routine diseases, but it also increases the difficulty of avoiding complications in patients with other diseases or those undergoing medical treatment, such as joint replacement, organ transplant, and cancer therapy.

Recognizing the Problem
Antibiotic-resistant bacteria are largely the result of the overprescription and inappropriate prescription of antibiotics. During the past decade, antibiotic use frequency has decreased, albeit mostly in children, and adults continue to be commonly inappropriately prescribed antibiotics, according to Lauri Hicks, DO, a medical epidemiologist in the CDC’s National Center for Immunization and Respiratory Diseases and the medical director for the Get Smart: Know When Antibiotics Work program.

Since roughly one-half of prescribed antibiotics are unnecessary or inappropriate, it’s critical that physicians use such medications only when indicated and consider whether they’re choosing the appropriate antibiotic for each patient.

Physicians frequently prescribe antibiotics for upper respiratory infections. Although they generally recognize that the majority of these infections are viral, they prescribe antibiotics anyway. “The reasons for this high frequency of inappropriate prescribing are complex,” Hicks says. “The most common justifications are diagnostic uncertainty, severe illness, and concern for patient satisfaction during their visit.”

Patient satisfaction is important on many levels, but prescribing antibiotics when they’re not warranted isn’t a solution. “It’s important that physicians validate their patients’ concerns and communicate their findings as they complete the physical exam,” Hicks says. Education is vital so the patient can understand why medication cannot be prescribed. The CDC has print materials that can be provided to patients (available at www.cdc.gov/getsmart) so they can review the information and be more knowledgeable about their physicians’ orders.

Alternate solutions for ensuring patient satisfaction include prescribing treatment for specific symptoms (eg, congestion, runny nose), suggesting over-the-counter remedies, and providing a delayed prescription (in which a prescription is given to the patient to be filled at a later date if symptoms do not improve). Delayed prescribing efficacy, especially when used in concert with print education materials, has been supported by a 2005 Cochrane Review article, according to Hicks.

It’s also important to inform patients that taking antibiotics can result in negative side effects, such as diarrhea, upset stomach, vaginitis, and interactions with other medications, and they can kill off the body’s natural population of bacteria. In addition, Clostridium difficile, a serious diarrheal infection, is associated with antibiotic use and causes at least 250,000 hospitalizations and 14,000 deaths every year. This knowledge may help keep patients from pushing for an antibiotic when it’s unnecessary.

“Whether or not antibiotics are prescribed, it is important to provide specific recommendations for symptomatic relief,” Hicks says. She says the CDC’s Get Smart: Know When Antibiotics Work program provides prescriptionlike notepads on which over-the-counter recommendations and a diagnosis can be written to help patients remember what the physician has recommended.

Taking Action
To combat antibiotic resistance, the CDC has identified the following four core actions that must be taken:

• Prevent infections, prevent resistance: Avoiding infections reduces the number of antibiotics that must be used and reduces the likelihood that resistance will develop during therapy.

“Diligent hand-washing and personal hygiene practices by physicians and patients are always important for infection prevention,” Hicks says. While the antimicrobial chemical exposure from hand washing will induce antibiotic-resistance mechanisms in bacteria, this generally doesn’t present a threat to human health. The benefit of infection prevention and personal hygiene outweigh the harms.

“Furthermore,” Hicks says, “keeping up-to-date with vaccines is a fantastic way to prevent infections before they occur. For older adults, this would include annual influenza vaccines, pneumococcal vaccines, and vaccines for tetanus, diphtheria, pertussis, varicella/zoster, meningococcal, and hepatitis A/B where appropriate.”

• Track: The CDC gathers data on antibiotic-resistant infections, causes of infections, and whether there are particular reasons (risk factors) that caused some people to get a resistant infection. Physicians can stay updated on this information and apply it to their practice.

• Improve antibiotic use/stewardship: Potentially the most important action needed to slow the development and spread of antibiotic-resistant infections is to change the way antibiotics are used. The above tips and solutions can help physicians take part in this solution.

• Develop drugs and diagnostic tests: Because antibiotic resistance occurs as a natural process of bacteria evolution, new antibiotics will always be needed to keep pace with resistant bacteria as well as new diagnostic tests to track the development of resistance. It’s important for physicians to be aware of the most current recommendations for treating different bacterial infections.

Final Thoughts
Taking these actions, and with the help of physicians and patients, the CDC hopes to keep antibiotic resistance from progressing rapidly.

“We are approaching a cliff. If we don’t take steps to slow or stop drug resistance, we will fall back to a time when simple infections killed people,” said Michael Bell, MD, deputy director of the CDC’s Division of Healthcare Quality Promotion, in a press release. “We are asking everyone who uses antibiotics, especially health care providers, health care leaders, the agriculture industry, manufacturers, policy makers, and patients to step up to this threat and fully engage with us to stop it.”

— Brandi Redding is assistant editor for Today’s Geriatric Medicine.