Antibiotic resistance is considered a significant public health concern by multiple international organizations. The US Centers for Disease Control and Prevention estimate that approximately 35,000 deaths occur in the United States each year related to antibiotic resistance.¹ Moreover, the agency predicts that millions more deaths will occur in the coming decades. By 2050, it is estimated that the number of deaths resulting from drug-resistant infections will surpass 10 million, which equates to one person dying every three seconds. The total global cost to economic output related to these deaths is estimated at US $100 trillion.²

The History of Antibiotics and Antimicrobial Resistance

Most antibiotics prescribed today are derived from natural environmental bacteria or fungi. In nature, these microorganisms compete with one another by producing antimicrobial substances and developing resistance to other antimicrobial substances. Antimicrobial-resistant bacteria and resistant genes have been discovered dating back several million years.³

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The use of antibiotics to treat humans also pre-dates the advent of modern medicine. Filamentous fungi were used to treat wounds and burns in ancient Egypt. Healers in China and Greece used musty textures to treat a variety of conditions.⁴ Penicillin was the first documented antibiotic used in modern medicine. Joseph Lister noticed the inhibitory effects of Penicillium glaucum on bacterial growth and was able to cure a nurse’s injury with the antibiotic. Alexander Fleming later popularized the use of this drug.

Over the next several decades, multiple observations of antibiosis, or the biological relationship in which one living organism kills another to ensure its own existence, were recorded.³ Commercial antibiotics were introduced in the early 20th century and were marketed heavily. Between the 1940s and the 1970s, 23 classes of antibiotics were discovered from 19 bacterial species and seven fungi.

No new classes have been discovered since the 1980s, although existing drugs have been refined.³ At every instance in which a new antimicrobial is introduced to the market, drug resistance to the antimicrobial follows shortly afterward. Antibiotic resistance first emerged within a decade of the first clinical trials of penicillin and experienced more than 50% resistance from Staphylococcus aureus by the end of the 1940s. The problem has been mitigated by the ability to innovate within the market.

Pharmaceutical companies have been able to address resistance by introducing new antibiotics throughout the decades. However, this is no longer possible. In the years between 1992 and 2012, the number of pharmaceutical companies investing in new antibiotics dropped from 18 to four.⁴ Today, there are still only four companies investing in this type of research.⁵ The heavy use of antibiotics has contributed to reducing morbidity across the globe and saves many patients' lives each year. However, research has demonstrated that up to 40% of all antibiotics prescribed are either unnecessary or serve as an inappropriate treatment modality.⁶ This overuse of antibiotics contributes to the growing problem of antibiotic resistance. Overprescription of antibiotics is especially rampant in hospital settings. Although hospital prescriptions account for only 20% of human antibiotic usage, the use of these drugs is concentrated, and hospitals are fertile breeding grounds for drug-resistant bacteria.⁴ Antimicrobial stewardship programs are gaining popularity as a way to inform clinicians on successful strategies to minimize overuse of antibiotics and slow the evolution of drug-resistant bacteria.

Antibiotic Use in Wound Care

Antibiotics are frequently used in wound care. Misuse stems from three key factors – diagnostic uncertainty about the presence of a bacterial infection, unclear clinical guidance on when antibiotics are needed, and patient demands for antibiotic prescriptions. However, treating patients with commonly used antibiotics has been shown to significantly increase the risk for future infection by an organism resistant to antibiotics, which leads to increased morbidity, hospitalization, and health care costs.⁷ Reducing antibiotic use in wound care is especially challenging, however, because of several factors:⁷

• Wound infections are frequently polymicrobial and require broad-spectrum antibiotics.
• Many wounds have frequent, recurrent infections, exposing patients to repeated courses of antibiotic therapy.
• No worldwide consensus for diagnosing infection in wounds has been achieved. Most criteria for diagnosing infection are subjective.

Long-term and continued overuse of antibiotics will continue to make wound care even more challenging as increased numbers of wounds demonstrate drug-resistance. The inability to treat infections rapidly and successfully will make it much more difficult to achieve full closure of the wound. Many wound care specialists indicate that better education on antibiotic use combined with better diagnostic capabilities can eliminate many of the unnecessary and inappropriate antibiotic prescriptions.⁷

References

1. Centers for Disease Control and Prevention. About antibiotic resistance. 2020. https://www.cdc.gov/drugresistance/about.html. Accessed February 25, 2021.

2. Goff DA, Kullar R, Goldstein EJC, et al. A global call from five countries to collaborate in antibiotic stewardship: united we succeed, divided we might fail. Lancet Infect Dis. 2016;17(2):E56-E63.

3. Durant GA, Raoult D, Dubourg G. Antibiotic discovery: history, methods, and perspectives. Int J Antimicrob Agents. 2018;53(4):371-382.

4. Shallcross LJ. Antibiotic overuse: a key driver of antimicrobial resistance. Br J Gen Pract. 2014;64(629):604-605. doi:10.3399/bjgp14X682561.

5. Plackett B. Why big pharma has abandoned antibiotics. Nature. 2020;586:S50-S52.

6. Barlam TF, Soria-Saucedo R, Cabral HJ, Kazis LE. Unnecessary antibiotics for acute respiratory tract infections: association with care setting and patient demographics. Open Forum Infect Dis. 2016;3(1):ofw045.

7. Hill R, Rennie MY, Douglas J. Using bacterial fluorescence imaging and antimicrobial stewardship to guide wound management practices: a case series. Ostomy Wound Manage. 2018;64(8):18-28.