Running head: ANTIBIOTIC RESISTANCE 1

Antibiotic Resistance

Emilie Renninger

Western Washington University

April 2016
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INTRODUCTION

During a clinical round for the pre-licensure nursing program I attended, there was a

patient admitted for a Methicillin resistant Staphylococcus aureus (MRSA) infection. This was

far from unusual, as MRSA was and still is a common reason for staying in the hospital

overnight in order to receive high doses of IV antibiotics. A volunteer chaplain exiting this

patients room asked if she could talk to me for a minute as she took off her protective gown and

gloves. She proceeded to ask all sorts of questions about MRSA and why protective gear needed

to be used, why antibiotics dont always work when treating infections, and what makes the

infection resistant to methicillin. I didnt know the answer to some of her questions, so it

sparked my interest in learning more about antibiotic resistance (ABR) as I think its important

for nurses to understand the issues that patients face.

MRSA infections have become so common that the same hospital I completed those

clinical hours at actually ended up changing their policy on MRSA precautions. Typically a

patient with a history of MRSA would be under contact precautions, meaning that all visitors and

providers have to apply personal protective equipment like a gown and gloves before entering

the patients room, and take them off after exiting the room in order to prevent possible spread of

disease. With a large percentage of the public now having a history of MRSA, having contact

gear required in every room was almost counterproductive and took time away from actual

patient care. The change in this policy speaks to just how rampant and common resistant

infections are becoming.

Bacteria have the ability to randomly and suddenly mutate once in every 1,100 million

organisms. This number seems astronomical, but based on how fast bacteria can reproduce and

how many organisms live in the human body, the rate of mutation is faster than it sounds. For
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example, in only one gram of human fecal matter approximately over 100,000 million organisms

are present (Greener, 2012). If we estimate that the average daily amount of human stool weighs

even just one quarter of a pound, it would equate to 226 grams and 22,600,000 million

organisms, giving the opportunity for millions of mutations. However, it is important to address

the fact that not every mutation is going to lead to antibiotic resistance. Each mutation is

significant since the bacteriums DNA is altered, but not each adaptation directly influences the

bacterias ability to be resistant.

Generally, to acquire antibiotic resistance the bacterial organism needs to obtain a cell

wall that medication cant penetrate, gain characteristics that allow the bacteria to release

antibiotic-destroying enzymes, or be able to metabolically avoid damage the antibiotic would

cause. Basically, the bacterium is like a castle under attack by antibiotics. Mutations help the

castle build up stronger walls, acquire more artillery, and quickly repair any damages made by

the antibiotics. Eventually, all of these changes and mutations can allow the bacteria to not be

affected by antibiotics, causing an infection to be extremely difficult to treat. Unfortunately,

humans are playing a large part in the prevalence of antibiotic resistance. The problem of

antibiotic resistant bacteria is increasing as a result of antibiotic use in agriculture, over-

prescription, and incorrect patient use.

PROCESS

In my research I have narrowed down three main facilitators of resistance by using

information from government websites, scholarly studies, and credible research articles with the

help of reliable search databases including but not limited to CINAHL and Science Direct.

Search keywords included those such as, antibiotic resistance, antibiotic abuse, over-

prescription, and agriculture antibiotic use.

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OVERPRESCRIPTION

The CDC claims that over 262 million outpatient antibiotic prescriptions are written

yearly, and considers approximately half of them in to be unnecessary. These prescription

rates increase during the winter months, most likely due to the season being notorious for illness.

If incorrectly prescribed, antibiotic use can facilitate bacterial resistance. The CDC notes that

regional prescription frequencies have actually been shown to geographically correlate with

resistant microbial patterns, meaning that areas with higher prescription rates are also areas with

higher resistant cases (CDC, 2015). In an outpatient setting, bacterial infections can be tricky to

identify. Organism cultures are not often routine tests, and antibiotic prescriptions can wrongly

be considered a quick fix for routine symptoms. It has been my experience that prescriptions

keep patients happy, and give them something to come away from the hospital or clinic with

instead of just discharge paperwork. However, mindless scripts are ultimately hurting the

patients and general community in the long run by facilitating bacterial resilience.

A study completed using virtual reality technology set up the scenario of a female patient

in her sixties presenting with a cough and a sore throat. In the scenario, the patients daughter

became upset and started to demand an antibiotic prescription for her mother. The goal of the

study was to test and observe the actions of the twenty-one participants, nine of which were

physicians in training, and the remaining twelve comprising of experienced general practice

physicians. Results showed that out of the nine trainees, eight prescribed antibiotics, and seven

of the twelve general physicians gave prescriptions (Pan, Slater, Beacco, Navarro, Ballido Rivas,

Swapp, Hale, Forbes, Denvir, Hamilton, & Delacroix, 2016).

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It is significant to note that the symptoms the patient presented with (cough and sore

throat) were not indicative of a bacterial infection, meaning that the prescriptions were most

likely given to improve patient and family satisfaction. Whats more is that the trainee doctors

were the group that gave out the most antibiotic prescriptions. The study was able to conclude

that the more experienced physicians were ones that held their ground the most and not give

prescriptions (Pan et al., 2016). The trainees are physicians soon going into practice and

because of this it is imperative that they have proper education regarding appropriate

circumstances for antibiotic prescription.

However, in the trainees defense dealing with disruptive and demanding visitors is

justifiably stressful. Healthcare providers have a desire to make patients feel better, and the line

separating patients wants and needs can become complicated and uncomfortable to handle.

Upon reflection of the virtual reality simulation one participant noted, I could see the situation

developing and the issue it was examining and I became a little uncomfortable when the time

came to say that no antibiotics were necessary (Pan et al., 2016).

The report did not reveal if this individual ended up giving a prescription or not, but it is

clear that the situation made them uneasy. One can imagine how providers might feel torn

between good customer service and what is ethically and medically best, especially when a large

portion of modern practice seems to be surrounded by patient satisfaction reports. A recent study

in England actually showed that the amount of antibiotic prescriptions had a correlation with

patient satisfaction ratings. The less prescriptions, the lower the satisfaction rates, and vice

versa. (Ashworth, White, Jongsma, Schofield, & Armstrong, 2015).

INCORRECT USE
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Another major factor promoting antibiotic resistance is incorrect patient usage. The CDC

notes that antibiotics are not always needed to treat an illness, and should only be used for

bacterial infections. This means that when taken for viral infections such as common colds,

respiratory ailments and influenza, antibiotics are essentially useless and instead give

opportunistic bacteria time to adapt. It is recommended that patients only use antibiotics

specifically prescribed to them, and complete the entire course of medication as ordered by their

physician (CDC, 2015). I can think of numerous instances when Ive been witness to antibiotic

abuse, and I even recall times as a child when I was part of the problem. From not finishing the

entire dose of prescribed medicine because it tasted bad and my symptoms were gone, to my

grandmother hoarding leftover doses in her ancient medicine cabinet; I had been exposed to and

influenced by improper ways. Had we been aware of the repercussions, Id like to think we

would have acted differently. Patient education is an important aspect of any healthcare process,

and with the growing issue of antibiotic resistance, a certain level of urgency should be placed on

following prescribed orders. In addition, it may be useful to educate clients on why following

those orders is important to their health and safety. This way, patients might have a better

understanding of the issues and be more inclined to follow directions.

AGRICULTURE

Antibiotic use in farming is a highly overlooked factor in the discussion of antibiotic

resistance. A frightening result of farm usage is how easy humans can be exposed to resistant

organisms by consuming or even just preparing meat products originating from inappropriately

antibiotic-fed animals. According to the American Nurse, out of the total amount of antibiotics

sold in America around eighty percent are given to previously healthy animals living in tight,
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unsanitary quarters to ensure the animals health and promote growth (American Nurse, 2015).

During the growth process and before butchering, farm animals without infections or diseases are

commonly provided feed and grain that contain antibiotics. This use of medication simply as a

prophylactic measure and without presence of a bacterial infection greatly adds to and promotes

resistance,

Genetically superior bacteria remaining on the animal can then spread to humans through

ingestion or contact with the animals raw or undercooked meat, petting or touching the animal,

or by coming in contact with the animals waste products. To help reduce risk and exposure to

resistant organisms, it is recommended to purchase nontherapeutic antibiotic-free meats (Martin,

Thottathil, & Newman, 2015). A downside to this solution is that antibiotic-free products are

commonly thought to be more expensive than the meats that do contain antibiotics, pushing

consumers away.

However, this idea is not always accurate. The Consumer Reports National Research

Center revealed that the average price for chicken breast containing antibiotics in the U.S in 2012

was $3.17 per pound. At the same time, the study noted that consumers found antibiotic free

chicken at places like QFC and Whole Foods for seventeen cents to a dollar cheaper. Based on

this data, not all antibiotic free products have to be unaffordable to common people. This is good

news for defeating resistance, but not all areas are going to have access to stores like QFC and

Whole Foods. It has been my experience that Whole Foods and QFC tend to be located in areas

of higher populations such as big-city suburbs rather than more rural areas. Consumer Reports

held a nation-wide poll, which showed that only fifty seven percent of the shoppers claimed to

have access to antibiotic free meats in their local supermarkets (Consumer Reports, 2012).
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SYNTHESIS

The CDC taught us that geographical areas connected with increased antibiotic

prescription rates have larger issues with resistance (CDC, 2015). Basically, there are hot spots

around the nation where resistant bacteria are more abundant. With modern travel so popular

theres essentially nothing stopping fast spread of bacteria from those hot spots to other areas.

The source of the issue needs to be addressed and taken care of or else the situation wont

resolve. The problem is similar to the idea of taking care of a bug infestation. Each bug can be

individually sought out and eliminated, but in order for the problem to be solved the bugs nest or

hive would have to be destroyed. This would involve targeting those geographical hot spots and

paying closer attention to anti-resistant methods in those areas.

The CDC and Martin, Thottathil, and Newman gave recommendations to help fight

resistance, and they both basically agree that it is important to avoid antibiotics if they arent

necessary (CDC, 2015), (Martin, Thottathil, & Newman, 2015). If an antibiotic isnt clinically

indicated, physicians should hold their ground, not prescribe it, and instead educate patients on

why a prescription isnt going to be given. Surveys might find satisfaction rates increase in lieu

of prescriptions if patients start to have a solid understanding of what a virus is compared to a

bacteria and what appropriate treatment is for both. But why does any of this matter? Why cant

we continue to use antibiotics how we are? Eventually, all bacteria may become resistant. This

would mean a simple infection could become a death sentence because there would literally be

no way to treat it. No medicine, no remedy, no prescription.

CONCLUSION

In conclusion, humans are obviously playing a large part in the growing problem of

antibiotic resistance. Its going to take a large, unified effort to tackle the issues from agriculture,
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to over prescription and patient misuse. Fighting ABR must be a group effort. Many people

believe that the world is heading a direction where antibiotics will eventually become useless,

and common illnesses will once again kill thousands. Imagine cutting your finger while

preparing dinner, getting an infection that medicine cant help, and then dying. We live in a

world thats taken advantage of antibiotics, not appreciated them and are now dealing with the

ramifications. Ive learned a lot since my encounter with the chaplain, and hopefully by

education and raising awareness we can spread the knowledge needed to combat antibiotic

resistance.
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Resources

Antibiotics in meat - Consumer Reports. (2012, June). Retrieved May 07, 2016, from

http://www.consumerreports.org/cro/2012/06/antibiotics-are-widely-used-by-u-s-meat-

industry/index.htm

Ashworth, M., White, P., Jongsma, H., Schofield, P., & Armstrong, D. (2015). Antibiotic

prescribing and patient satisfaction in primary care in England: Cross-sectional analysis

of national patient survey data and prescribing data. British Journal of General Practice,

66(642), E40-E46. doi:10.3399/bjgp15x688105

Greener, M. (2012). Protecting the antibiotic miracle. Nurse Prescribing, 10(6), 288-291.

Retrieved from http://ezproxy.library.skagit.edu/login?

url=http://search.ebscohost.com/login.aspx?

direct=true&db=c8h&AN=2011589293&site=ehost-live

Martin, M. J., Thottathil, S. E., & Newman, T. B. (2015, December). Antibiotics overuse in

animal agriculture: A Call to Action for Health Care Providers. American Journal of

Public Health, pp. 24092410

Pan, X., Slater, M., Beacco, A., Navarro, X., Bellido Rivas, A. I., Swapp, D., Delacroix, S.

(2016). The responses of medical general practitioners to unreasonable patient demand

for antibiotics - A study of medical ethics using immersive virtual reality. PLoS ONE,

11(2), 115.

Tough limits set on antibiotic use. (2015). American Nurse, 47(6), 55.

United States Center for Disease Control and Prevention National Center for Emerging and

Zoonotic Infectious Diseases. Antibiotics aren't always the answer. (2015, November 16).

Retrieved April 28, 2016, from http://www.cdc.gov/features/getsmart/

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United States Center for Disease Control and Prevention National Center for Emerging and

Zoonotic Infectious Diseases Division of Healthcare Quality Promotion. Measuring

outpatient antibiotic prescribing. (2015, November 17). Retrieved April 29, 2016, from

http://www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-

prescribing.html