The Role Of Over Prescription Of Antibiotics In Leading To Antimicrobial Resistance

Research Question

There has been a growing concern regarding antimicrobial resistance which possess greater risk to the treatment of common infectious diseases. Antimicrobial resistance has become a global public health challenges as this has led to the overuse and over prescription of antibiotic worldwide. Some of these have been seen to result in prolonged illness, disability and death in the patient. The issue has resulted in major complications, longer hospitalization and high rate of mortality in patients. Currently many drugs have been developed to fight against multi-drug resistance bacteria. This has been possible after research related to mechanism of resistance. There had been wide variety of opinions regarding the causative factor for antimicrobial resistance. Through research and evidences it has been highlighted that mutations caused at the genetic level are often responsible for growing antibacterial de-sensitivity or antimicrobial resistance. Hence, this paper aims to critically review research articles that give answer regarding the role of over prescription of antibiotics in leading to antimicrobial resistance.

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The above presented problem could be further developed into a research question:

“Can over prescription of antibiotics by physicians lead to antimicrobial resistance?”

The research follows a secondary design where a number of reliable and secondary databases have been used for the gathering of sufficient information regarding antimicrobial resistance. Some of the databases which have been used over here are Google Scholar, pubmed, etc. The data have been extracted from different kind of articles such as randomised trial controls, cohort study, case control study and cross sectional study etc. The articles have been evaluated based upon their level of evidence. A strict search criterion has been applied for evaluating the articles such as use of specific keywords. For instance, a number of keywords have been used over here such as “antimicrobial resistance’, ‘over prescription of antibiotics’, ‘antibiotics resistance’. The search histories which have been generated additional to the keywords used have been neglected from the evaluation process. Additionally, the articles which have been published in English only have taken into consideration. The ones which have been printed within the last 10-12 years only have been taken into consideration.  Additionally, the CASP checklist has been used to review the articles.

A number of evidence based literature have been reviewed over here in order to understand the clinical implications of overprescription of antibiotics.  As reported by Doron and Davidson (2011), the increased rate of antimicrobial resistance have severely hampered the quality of health care services offered at the hospitals. Some of them have been represented in the form of increased rate of hospital readmission. There has been repeated incidence of central bloodline associated infections within an acute care setup.  This mainly happens due to the development of antibiotic resistance in a certain species of bacteria such as Staphylococcus aureus. The growing rate of antimicrobial resistance and the slow rate of development of the drugs have resulted in a situation of disequilibrium. As reported by Doron and Davidson (2011), some of the recent advances such as antimicrobial stewardship have been seen to improve the patient outcome by optimizing the use of antimicrobials. Antimicrobial stewardship could be defined as the duration and dosage of optimal antimicrobial treatment (World Health Organization, 2014).  The aim is to produce minimal toxicity to the patient and minimise the level of resistance which could be developed in due course of time from prolonged use of large amount doses. The antimicrobial therapy could be discussed on the basis of 4 D’s which are – right drug, right dose, de-escalation to pathogen directed therapy and right duration of therapy (Doron and Davidson, 2011). It also discussed regarding some of the factors such as abuse of antibiotics which means that the physicians preferably use some antibiotics more than the others. A randomised control trial was conducted in the above context where both physicians and patients were involved.  The activities performed on the intervention group were based upon self developed guidelines, which were aimed to enhance physician and patient knowledge, physician and patient communication skills. These were aimed at developing sufficient awareness regarding antimicrobial resistance between the stakeholders, as there is widely prevalent misnomer regarding the prescription and use of certain antibiotics. However as argued by Unemo and Shafer (2014), the study method  implied over here failed to take into consideration the  various factors which could lead to communication gaps within a multilingual setup. As reported by Crump  et al. (2015), the unsupervised use of some of the antibiotics in  the long run have been seen to  produce  severe implications upon the vital organs of the body of the patient such as liver and kidneys.

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Methodology

The methodology used in the current paper is randomised control which belongs to level 1 of the evidence based trial. The differential results obtained from the controlled and the intervention groups are used for comparison study which helps in the presentation of results. The paper could be further evaluated based upon the Critical Appraisal Skills Programme (CASP) checklist. Three broad issues are considered while appraising a randomised trial such as the validity of the test results, impact produced by the results. It was found that a higher decrease was noted in the annual prescription rates of the intervention groups compared to the control groups after attending the antimicrobial stewardship programme. The programme was continued for four years and similar results were obtained which led to further research and development in the antimicrobial stewardship programme.

It is increasingly important to study the clinical implications of antimicrobial resistance in therapy. As reported by MacGowan (2008), treatment of  pathogen with a drug to  which it is susceptible produced better and long lasting results than treatment of pathogens with drugs to which they are resistant. However, as argued by Holmes et al. (2016), in very few clinical establishments are the pathogens treated with a drug to which they are susceptible. In addition, early antibiotic therapy has been seen to produce better results than delayed treatment protocols. In the current study, randomised control trials were conducted were the affectivity of two specific classes of drugs was tested against each other. For instance, patients infected with co-trimoxazole bacteria such as E.coli had higher rates of clinical therapeutic failure. Additionally, women treated with Trimethoprim for the treatment of urinary tract infection were found to suffer from recurrent infections due to the resistance found in the pathogen towards the antibiotics used. However, as argued by Crump et al. (2015), the success of the method lies on the level of knowledge and expertise possessed by the clinicians.

The study conducted over here belongs to level 1 of the evidence based table as the data collection has been done from randomised control trials.  The study has been further evaluated through the CASP checklist which tests the results, the validity of the results and the importance of the results. The study took into consideration number of broad spectrum antibiotics and produced a comparative account on the results produced by each. Similar results were produced for co-trimoxazole and Trimethoprim whereas fluroquinolones produced better results. The medicines were tested in immunocompromised patients suffering from various illnesses and the results obtained were at par.

Evidence Based Literature

In this context, case control studies were conducted in patients infected with bloodstream infections. The patients were infected with third generation cephalosporin resistant Klebsiella pneumoniae and carbapenem resistant K. pneumoniae. In this respect, a retrospective case control study was conducted to find out the similar or different risk factors for both the types of infections. Positive blood cultures of the patients were used for the analysis of the test results. In the control groups patients who were admitted for 72 hours were taken into consideration and their results were matched with the results of the case studies day by day, month by month to undertake a comparative analysis.  As reported by Gallagher et al. (2014), length of stay and use of antibiotics were independent risk factors. Similar factors were found to put the patient population at risk of infection such as immunocompression, tenure of the antibiotic therapy and length of intermittent break periods.  However, as argued by von Wintersdorff et al.  (2016), mild differences in impact produced were noted based upon the antibiotic strains used. The study  undertaken over here belonged to level 3 of the evidence based table .The control method used helped in understanding the variability of  the end  results  produced along with removing the confounding biases  which may have crept within the study design. The results of the study were evaluated through the CASP checklist which suggested that it was not possible to find out the differences in risk factors for bloodstream infection. However, some of the similar aspects which could be linked with development of resistance in both the cases were increased length of hospital stay, previous antibiotics used .  However, the study failed to take into consideration the pharmacokinetics of the medicines on long term usage within the patient. For example, the use of some of the past medications may have developed immunocompression within the patients. In 11% of the cases the immunocompression could be linked with antimicrobial resistance (Gallagher  et al., 2014). Hence, a detailed inspection in the pharmacology and pharmacodynamics from the blood sample of the patient were missing over here.

As mentioned by Asante  et al. (2017), sufficient patient education is required to check the overprescription and over usage of antibiotics. In the current study, a cross sectional study was performed was 33 participants out of 379 participants were made a part of the survey process. It was found that 80% of the prescribers were already acquainted with the long term effects of antibiotics (Asante et al., 2017). They were well aware of the fact that antibiotics which were currently prescribed could become obsolete in the future. Hence, poor prescription practices and antibiotics resistance control methods were found to be the sole causes for the over prescription of some of the obsolete antibiotics (Laxminarayan et al., 2016).  The study conducted over here belonged to level 3 of the evidence based table. The CASP checklist was further used to evaluate the results of the study.  Most of the results were found to be comprehensive with the overall objectives of the research, which stated that over prescription of antibiotics were linked with growing bacterial resistance (Marston et al., 2016). and health of the children in primary care. Though, some of these have mainly been related with the age and the immunity of the patient.  However, as argued by Chung  et al. (2007), there are a number of other factors such as the living conditions of the child along with the access to equitable and proper healthcare services. The children suffered from acute respiratory tract infection of which 71 were caused by β lactam antibiotics. The antibiotic resistance was measured through the geometric mean of minimum inhibitory concentration. It was found that the presentation of amoxicillin to children in doses three times the minimum inhibitory concentration could result in development of resistant strains. In this respect a cohort of a population group was selected by the researcher where 33 children were made to undergo through the control measures. It was found that though the effect was transient it could produce much long term effects. The different levels of the study had been further evaluated with the help of a CASP checklist.

Attributes

RCT

RCT

case control  sectional study

cross sectional study

cohort study

suitability of the research design

The research involved both the physician and  the patients which helped in understanding The importance of patient -physician interaction in controlling the overprescripton of antibiotics

The randomised control trials conducted over here helped in understanding the clinical implications of the antimicrobial resistance for therapy by evaluating the  number of conditions in which early intervention of antimicrobial therapy is beneficial

The research compared the difference in the level of infection caused by the same bacterial species. It helped in the evaluation of  some of the factors such as  difference in duration of administration of medication, immunodeficiency of the patient

The study design adopted helped in evaluation of the problem on a large scale

The use of antibiotics is common among children to control respiratory illness. The cohort study design helped in understanding the presentation of the problem within the target population

potential bias and confounding errors

The difference in the level of understanding between the physician and the patient could affect the end quality of the results

The lack of research with certain bacterial strains could affect the end quality of the results

consideration of similar bacterial species could lead to confounding biases as similar levels of toxicity will be presented

The limited knowledge regarding bactericidal effects on different pathogens affected the end quality of the results

The  age and socio economic  conditions serve as important delimiters

evaluation of ethical considerations

 The cultural sensitiveness was taken care of while conducting the study within a multilingual setup

The confidential details such as identity of the patients were not shared while conducting the research

For conducting the randomised control trial due considerations were taken from the patient. hence , at no stage of the research process the patients could be forced to delve out important information

None of the participants were forced during the survey process and the confidential details of the candidates were hidden during the survey process

For the child participating within the cohort group for the research study due consultation should be done with their parents

Clinical Implications of Antimicrobial Resistance in Therapy

It had been difficult for the researcher to collect the exact details of some of the studies due to being at an arm’s length from the research organization. Additionally, the limited participation of the participants also affected the end quality of the results (Llor & Bjerrum, 2014). In my opinion the cross sectional and randomised control trials helped in comparing different conditions and parameters for the development of bacterial resistance. It also helped in understanding the different misnomers present regarding the use of antimicrobial therapy and the limiters such as the lack of effective knowledge present within the people. The RCTS emphasised upon the importance of patient physician communication and their importance in developing sufficient awareness at the local and the national level which could be implemented in the form of policies and regulations. The lack of research and awareness regarding the behaviours of different pathogen strains affects the success of the antimicrobial program.

Conclusion

The current assignment focuses upon the aspect of antimicrobial resistance and the effect produced by it upon current healthcare system.  Some of these have resulted in the presentation of more serious health problems such as increased rate of hospital readmission and recurrence of infections such as central bloodline associated infections.  Some of the therapies which have been discussed over here are antimicrobial stewardship programme and implementation of educational interventions. The educational interventions have been seen to reduce the ill practices such as the over the counter prescription of obsolete medicines which could produce long term health effects within the patient.  

References 

Asante, K. P., Boamah, E. A., Abdulai, M. A., Buabeng, K. O., Mahama, E., Dzabeng, F., … & Gyansa-Lutterodt, M. (2017). Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; a cross-sectional study. BMC health services research, 17(1), 422.

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Chung, A., Perera, R., Brueggemann, A. B., Elamin, A. E., Harnden, A., Mayon-White, R., … & Mant, D. (2007). Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. Bmj, 335(7617), 429.

Crump, J. A., Sjölund-Karlsson, M., Gordon, M. A., & Parry, C. M. (2015). Epidemiology, clinical presentation, laboratory diagnosis, antimicrobial resistance, and antimicrobial management of invasive Salmonella infections. Clinical microbiology reviews, 28(4), 901-937.

Doron, S., & Davidson, L. E. (2011, November). Antimicrobial stewardship. In Mayo Clinic Proceedings (Vol. 86, No. 11, pp. 1113-1123). Elsevier.

Gallagher, J. C., Kuriakose, S., Haynes, K., & Axelrod, P. (2014). A case-case-control study of patients with carbapenem-resistant and third-generation cephalosporin-resistant Klebsiella pneumoniae bloodstream infections. Antimicrobial agents and chemotherapy, AAC-03564.

Holmes, A. H., Moore, L. S., Sundsfjord, A., Steinbakk, M., Regmi, S., Karkey, A., … & Piddock, L. J. (2016). Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 387(10014), 176-187.

Laxminarayan, R., Sridhar, D., Blaser, M., Wang, M., & Woolhouse, M. (2016). Achieving global targets for antimicrobial resistance. Science, 353(6302), 874-875.

Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic advances in drug safety, 5(6), 229-241.

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Marston, H. D., Dixon, D. M., Knisely, J. M., Palmore, T. N., & Fauci, A. S. (2016). Antimicrobial resistance. Jama, 316(11), 1193-1204.

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von Wintersdorff, C. J., Penders, J., van Niekerk, J. M., Mills, N. D., Majumder, S., van Alphen, L. B., … & Wolffs, P. F. (2016). Dissemination of antimicrobial resistance in microbial ecosystems through horizontal gene transfer. Frontiers in microbiology, 7, 173.

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