Introduction

The prevalence of antimicrobial-resistant pathogen strains is greater than ever, especially in health care settings. The process of a pathogen becoming resistant to environmental factors isn’t novel. However, since the discovery and implementation of antimicrobial agents, an environment that encourages an exponential acceleration of this process has culminated into the state of antimicrobial resistance (AMR) and multi-drug resistance (MDR) seen today.

History of Antimicrobial Resistance

Interestingly, antimicrobial resistance has been present even before the discovery and application of penicillin.¹ With its widespread use as an antibiotic, penicillin soon began losing the battle with resistant microbe strains. Tuberculosis was one of the first bacterial infections to quickly develop resistance to streptomycin and then reach subsequent resistance to multiple antibiotic classes.¹ This factor impacts health care and patients when these AMR pathogens share their resistant gene blueprints with other pathogens, despite not interacting with antimicrobials yet.²

Antibiotic Stewardship Strategies

Antibiotic stewardship is pivotal, considering the prevalence of non-healing wounds across health care settings. Not only does any antibiotic use risk creating more AMR/MDR strains of pathogens, but it also creates the risk of resistant strains of pathogens that could develop in the future. The Centers for Disease Control and Prevention (CDC) has published its core elements of antibiotic stewardship for hospitals, nursing homes, outpatient, limited-resource communities, and small critical access hospitals.³ The CDC also reports that, despite emphasizing and stressing antibiotic stewardship principles, many antibiotic prescription cases could be significantly improved.³

Hospital and Inpatient Settings

In hospital and inpatient settings, the CDC outlines the need to have the following components of an effective antimicrobial stewardship program:⁴

• Designated resources, hospital finances, technology, and human resources for antimicrobial stewardship
• Accountable leaders within an interdisciplinary team
• Emphasis on a pharmaceutical expert (usually the co-leading pharmacist)
• Actions such as preauthorizations, feedback, and prospective audits
• Tracking and monitoring antibiotic prescriptions and outcomes, with special attention to resistant microbe patterns and outcomes (such as C. difficile)
• Provider-level reporting to hospital leadership, pharmacists, nurses, and prescribers throughout the hospital system
• Educating prescribers, nurses, and providers regarding adverse reactions and optimal prescribing practices

Antibiotic time-outs have had an increased presence in inpatient settings with measured success. Time-outs also work well within the recommended stewardship principles, as the structure inherently demands professional involvement and assessment of patient outcomes. In addition, wounds with antibiotic resistant infections can benefit from the use of various forms of topical antibiotics, as long as it is part of the comprehensive treatment plan, combined with other advanced therapies.

Skilled Nursing Facilities

Up to 70% of skilled nursing facility residents receive a systemic antibiotic course every year.⁵ These guidelines are similar to hospital guidelines. However, they call for the astute involvement of owners and administrators—those that may often be disconnected from the rest of the medical team. Advocacy from prescribers, nurses, and pharmacists can help further educate these parties.

Outpatient Settings

Outpatient settings have a unique opportunity to educate the public about antibiotic stewardship practices and AMR pathogens. These settings can educate both practitioners and patients to be mindful of AMS. The CDC identifies the following as outpatient-based settings:⁶

• Emergency departments
• Dental practices
• Urgent care
• Specialty and subspecialty clinics
• Retail health clinics

Engaging, clear, and accurate displays can take many forms, including handouts, flyers, posters, digital announcements, and discharge paperwork. The education provided by outpatient settings can not only result in a decrease in inappropriate antibiotic prescriptions but also spur patient conversation about appropriate stewardship practices.⁶

Conclusion

AMR and MDR are more prevalent than ever, increasing chronic wound development, the severity of acute wounds, and mortality and morbidity across the health care spectrum. While antibiotics are a pivotal, historic pillar of modern medicine, inappropriate stewardship has now led to the possibility of a new prebiotic era. Antibiotic time-outs can prove to be useful in inpatient settings. Other stewardship practices are just as necessary to encompass all health care settings, including a greater emphasis on patient education and more involvement with facility owners or administration. Appropriate antibiotic stewardship practices need to adapt to each setting to foster better communication about AMR prevalence and ensure better patient outcomes and less antibiotic overprescribing. 

References

1. Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev. 2010;74(3):417-433. doi:10.1128/MMBR.00016-10
2. How antibiotic resistance happens. Centers for Disease Control and Prevention. November 9, 2021. Accessed August 26, 2022. https://www.cdc.gov/drugresistance/about/how-resistance-happens.html
3. Core elements of antibiotic stewardship. Centers for Disease Control and Prevention. April 7, 2021. Accessed September 7, 2022. https://www.cdc.gov/antibiotic-use/core-elements/index.html
4. Core elements of hospital antibiotic stewardship programs. Centers for Disease Control and Prevention. 2019. Accessed September 7, 2022. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
5. The core elements of antibiotic stewardship for nursing homes. Centers for Disease Control and Prevention. 2019. Accessed September 7, 2022. http://www.cdc.gov/longtermcare/index.html.
6. Sanchez GV, Fleming-Dutra KE, Roberts RM, et al. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep. 2016;65(No. RR-6):1–12. doi: http://dx.doi.org/10.15585/mmwr.rr6506a1