Antibiotic Resistance: An Editorial Review With Recommendations
July 2011 | Volume 10 | Issue 7 | Original Article | 724 | Copyright © 2011
Ted Rosen M.D.
Within a relatively short period of time after the first antimicrobial drugs were introduced, bacteria began exhibiting varying degrees of resistance. The excessive use (and abuse) of antibiotics in agriculture, and in both human and veterinary medicine, has played a critical causative role in the development of antibiotic resistance, which is now recognized as a global public health threat. Increasing concern over this issue should impact the practice of cutaneous medicine and surgery, as dermatologists can easily adopt new healthcare delivery patterns that might reduce the development of antibiotic resistance and still achieve acceptable treatment outcomes. Dermatologists should seriously consider any and all alternative therapies before committing to an extended course of antibiotic therapy for disease entities that are almost certainly not infectious. Conversely, dermatologists should carefully and closely adhere to dosage and duration recommendations when using antibiotics to treat a bona fide infectious disorder.
J Drugs Dermatol.2011;10(7):724-733.
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The successful treatment of bacterial infections improved significantly after sulfonamides were discovered to possess antibacterial properties in the late 1930s and especially when penicillin became available in the mid-1940s. The effect of penicillin on Streptococcus pneumoniae, the then leading cause of infectious disease and death worldwide,1 was particularly dramatic. However, within a relatively short period of time after antimicrobial drugs were introduced, bacteria began responding by exhibiting various forms of resistance. This author is among many worrying about the issue of antibiotic resistance. This problem is expanding in scope (number of different organisms exhibiting resistance, number of antibiotic agents for which resistance mechanisms are spreading) and in dimension (number of places worldwide where antibiotic resistance is prevalent). In fact, the ever-increasing problem of antibiotic resistance is viewed today as a serious threat to global public health.2 The problem has become sufficiently severe as to lead to this alarming quotation: “It has been a rarity for a physician in the developed world to have a patient die of an infection for which there are no therapeutic options. These cases highlight troubling issues that soon might soon be relevant across the Untied States.”3
The excessive use and misuse of antibiotics in humans, animals and agriculture are critical factors driving a growing resistance problem. The widespread availability of various inexpensive antibiotics has made it all too easy for patients to request, or to demand, antibiotic treatment, and for physicians to prescribe antibiotics for incompletely evaluated or unspecified infections, or for unverified disease states.
What Are the Mechanisms of Resistance?
Antibiotic resistance occurs when strains of bacteria no longer respond to antimicrobials used to treat infections caused by those microbes. Although some species of bacteria are inherently resistant to one or more classes of antimicrobial drugs, cases of acquired resistance in populations of bacteria that were once susceptible are of greater concern.4 Basic microbiology dictates that use of antibiotics significantly reduces the population of antibiotic-susceptible strains, resulting in the selective survival and multiplication of resistant organisms. Such organisms thrive due to reduced micro-environmental competition for essential nutrients and water. Resistant organisms can also transfer genetic material to other species, which exacerbates the problem by leading to an increased number and variety of microbes demonstrating resistance.4,5
Antimicrobial resistance can occur via several mechanisms, including: prevention of the ingress of the antibiotic into the target organism's cytoplasm, alteration of or compensatory over-elaboration of the antibiotic target, destruction of the antibiotic, or enhanced function of microbial efflux pumps (wherein the organism pushes the antibiotic out of the cell).4 Normally susceptible groups of bacteria may become resistant to antimicrobial agents via random mutation or by acquisition of genetic information that encodes resistance from other, unrelated bacteria. Many bacteria have become resistant to multiple classes of antibiotics via genetic exchange mechanisms.4