Developing an Intervention Assignment – Fauzia Bagum, BS, PA-S

Antibiotic Resistance

Problem StatementShould public health efforts be implemented to reduce antibiotic resistance in New York State?

Background

Bacteria are microscopic, single-celled organisms that can be found virtually everywhere. They are present in soil, tundra, the ocean, and even the human body. Bacteria are classified as prokaryotes commonly known to be detrimental to the human body. Commensal bacteria, however, coexist within our bodies that are quite essential for our survival. In fact, microbiologist David A. Relman, states there are about 10 times more microbial cells than human cells in the human body. The majority of those bacteria is found in the gut and helps with digestion and elimination. Disruption of gut bacteria can cause disorders like Crohn’s disease. Then there are the common bacteria that harm the human body like Streptococcus pneumoniae, Clostridium, Escherichia coli, and Staphyloccocus aureus. In order to kill the harmful bacteria, antibiotics are most effective. The use of antibiotics however cannot diffenciate between good and bacteria. Therefore, along with killing the bad bacteria, we lose a portion of our good bacteria as well. This can lead to irregular symptoms like diarrhea, vomiting, allergic reaction, abdominal pain, and/or rash.In addition to damaging the natural flora of our digestive systems, antibiotics most seriously can cause resistance amongst bacteria. After repeated disturbance from antibiotics, bacteria mutate into a different strain and then are resistant to the antibiotic. When bacteria become resistant, medicines may no longer work and infections can become difficult or even impossible to treat. Antibiotic resistance is a phenomenon where infectious bacteria are no longer susceptible to previously effective antibiotics. According to the CDC, each year in the United States, at least 2 million people are infected with antibiotic resistant bacteria. This leads to about 23,000 deaths each year. One major influence of antibiotic resistance is because antibiotics are one of the most commonly prescribed drugs used in human medicine that can save lives. However, up to 50% of the time, antibiotics are either prescribed when not needed, incorrect doses, and/or incorrect duration. Because of such errors, there is a large spread of infections and death that could be prevented with public health effort.

Landscape- Key Stakeholders

Any kind of mention concerning an interest in change in pharmaceuticals brings attention to a variety of stakeholders. The stakeholders could either support or oppose the any forms of implementations. Some stakeholders would be:

State legislaturesPharmaceutical industryHealth insurance industryFood IndustryHealthcare providersThe general public

Political/Legal Factors: State legislatures would be a crucial stakeholder to making any change in trying to formulate a control over the access and distribution of antibiotics. The New York State Department of Health (NYSDOH) would be able to set standards and limits to who and when antibiotics should be prescribed to patients. It is most likely the NYSDOH would be supportive in trying to take control of antibiotic resistance because ultimately this would save lives as well as lower the costs of unnecessary medical expenses. If statutes were to be passed, this would influence healthcare providers to think twice before prescribing antibiotics unnecessarily, and the public from having expectations of receiving antibiotics from every “sick visit”.

Economic Factors: Pharmaceutical companies would be highly opposed to any restrictions over excess prescriptions of antibiotics. Antibiotics are very inexpensive to make and economical to sell. In the Queens County, 30 tablets of penicillin VK 250mg costs on average around $11. If there are restrictions on how often and how much a person should be prescribed with antibiotics, it would be a big loss for the big pharma. In the opposing side, health insurance companies would be over-joyed if there were a limit to antibiotics being prescribed. This would save them from having to spend costs in antibiotics.

Practical Factors: In a practicality level, it would be a challenge to enforce restrictions to prescribing antibiotics so often. For example, most times when a clinician is not too sure whether a person has a viral or bacterial cold before blood work is completed, antibiotics are prescribed temporarily until reports are received, just in case. Then there are occasions when the clinician is confident the patient has a viral cold and just has to wait out the symptoms. However, the patient is usually unsatisfied with the visit if they made the travel to see a clinician from their day to not receive a prescription to show nothing for their efforts. Insistent on how they believe antibiotics have helped them before and the clinician does not know any better, the patient causes controversy until most clinicians give in and prescribe the usual “Z-pack”.

Options and Analysis

One option to reduce the spread of antibiotic resistance in New York State would be to expand antimicrobial stewardship programs to improve infection prevention and control practices in all hospitals, private clinics, and nursing homes. These programs would make clinicians more accountable for their prescriptions, educate them about resistance and optimal prescribing, tracking and reporting. In 2012, the Internet Security for Tracking Over-Prescribing (ISTOP) was passed in NYS to control opioid abuse and diversion. A similar Prescription Monitoring Program could be implemented to have a bit more control over the extraneous antibiotic prescriptions that are being written. Some disadvantages to this option would be to have providers question their diagnosis of a bacterial infection or lack of which can significantly harm the patient’s health and might even cause death. Also, denying antibiotics to a patient who may think they know better might create conflict and waste time and therefore create low satisfaction of the patient’s care.

Another option to reduce the spread of antibiotic resistance in NYS would be patient education. Through consultations, television ads, pamphlets, billboard, etc., patients would be informed how antibiotics do not work for viral infections like the common cold, most coughs, and most sore throats. They only work on bacterial growth and infections. Antibiotics would be doing more harm than good like causing an upset stomach, diarrhea, rashes, or allergic reactions. In addition to taking antibiotics unnecessarily, they can become immune to the medication for when they might actually need it in the future and suffer from serious ailment. They should not pressure their healthcare provider to prescribe antibiotics if they are diagnosed with a viral infection. And for when they are prescribed antibiotics, they should be sure to follow the entire course as directed to completion, even if they start to feel before beforehand. They should only stop if their provider directs them to stop. Also, old doses should not be saved for another time and self-medicate without consultation with their provider. Extra doses should be discarded and not shared with another person. A few disadvantages to educating the population about antibiotic resistance is the ability to reach people of all races and ethnicities. New York is a melting pot of people from all over the world and many do not speak or understand English too well. Informing them will require a lot of time and resources. In addition, there are also many people with low health literacy, this would also take time and resources to ensure the population understand the significance of this phenomenon.

A third option to improving the spread of antibiotic resistance in NYS would be to prevent the infections from spreading in the first place. If infections are avoided from the beginning, it reduces the necessity of antibiotics, which ultimately reduces the likelihood that resistance will occur during the course of treatment. Ways to reduce the chances of a bacterial infection are to: wash hands, cleaning surfaces and bedding, immunization, safe food preparation, keeping a distance when others are infected, and using antibiotics as directed only when necessary. A disadvantage to trying to avoid infections in the first place is a difficult one to follow through for a large amount of the population. Most people are usually careful and make an attempt to avoid infections through safe food preparation, immunization, and washing their hands. However through chance, we are often infected unintentionally through unknown food contamination, shaking unclean hands, or touching unclean surfaces.

A fourth option would be to reduce the amount of antibiotic exposure to animals and agriculture. This leads to antibiotic resistance in bacteria that can spread to humans and other animals whether through direct/indirect contact or contaminated food. An example of a bacterium that can be ingested through food is Salmonella. The CDC estimates over 1.2 million exposures and 450 deaths a year in the United States due to non-typhoidal Salmonella. Majority of the time infection can be avoided through safe food handling of poultry, storage, and preparation. Some disadvantages to this option would be to having the food industry comply with a reduction in using antibiotics in animals and agriculture. The use of antibiotics ensures the most profitable growth and less waste.

Recommendation

Amongst the options provided in ways to reduce the phenomenon of antibiotic resistance in NYS, I believe the second option of patient education would be most beneficial and effective to follow. This is because, no matter how many rules and regulations are to be implemented, the patient would appreciate none of it unless he/she is educated about the dangers of over exposure to antibiotics. For example, ISTOP has been implemented for about 5 years but there is still opioid abuse and diversion still taking into affect today. People are aware of the dangers of overdosing and side effects of narcotics, but they still crave it because of addiction and pleasure even they do not require it anymore. The same could be avoided (addiction does not apply to antibiotics) with antibiotics if patients are informed how antibiotics are used from the beginning of their health care and how over exposure can lead to antibiotic resistance in the near future should they require treatment. Yes it would be a bit of a struggle to educate the population, including who have low English proficiency or literacy, but by spreading the word and a bit of resilience, thousand of lives could be saved from infection and possibly even death.

References

http://www.livescience.com/51641-bacteria.html

https://www.cdc.gov/drugresistance/about.html

https://www.cdc.gov/drugresistance/pdf/4-2013-508.pdf

https://www.health.ny.gov/professionals/protocols_and_guidelines/antibiotic_resistance/

https://www.healthwarehouse.com/penicillin-vk-250mg-tablets-5643.html

http://paindr.com/istop-progress-in-nys-opioid-abuse-diversion/

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/antimicrobial-stewardship?source=search_result&search=antibiotics&selectedTitle=1~150

https://www.cdc.gov/drugresistance/pdf/4-2013-508.pdf

https://www.cdc.gov/salmonella/general/