This nebulously fluffy topic ("implications of antimicrobial resistance") is presented in the otherwise pragmatic Required Reading section simply because it has previously appeared in a college paper (Question 14 from the second paper of 2000). More recently, Question 26 from the second paper of 2017 asked the candidates something a little more sensible ("discuss strategies to limit antimicrobial resistance").

One's ability to quickly answer such a broad question would be dependent on the preparation of a prefabricated rant, loaded and ready to launch at the examiners. In order for the candidates to prefabricate such a rant, the following summary is offered. It is based on a series of interesting articles, indepth familiarity with which is not mandatory.

In point form:

Implications for bedside practice

Prevention of resistance development

  • Use of some antibiotics should be restricted/reserved
    • Use in agriculture and animal husbandry needs to be limited
  • Broad spectrum antibiotics must be deployed intelligently
    • Rapid diagnostic methods to guide rapid de-escalation
  • Antibiotics must be reviewed daily, and narrowed or discontinued when appropriate
  • Infectious diseases physicians should have greater input into prescribing practices
  • Perioperative prophylaxis needs to be rationalised
  • Antibiotic cycling may be helpful in preventing the emergeance of resistant strains
  • Combination therapy may be relevant to some species (eg. rifampicin plus fusidic acid, rather than either one as a sole agent).
  • Selective digestive tract decontamination could potentially be useful
  • Scrupulous attention to source control (i.e. do not use antibotics as a substitute for source control)

Prevention of MRO transmission:

  • Routine barrier and infection control process needs complicance monitoring and regular review.
  • Surveillance for MROs must be proactive.
  • Patient isolation should be practiced
  • Decolonisation may be used in certain circumstances

Prevention of clinically relevant MRO infections in colonised patients

  • Careful monitoring of indwelling devices
  • Vaccinations

Management of MRO infections

  • Multi-drug cocktails might be helpful
  • Use of a higher concentration of a drug may defeat resistance 
  • MIC monitoring may guide dosing
  • New drugs may need to be developed
  • Novel drug combinations (eg. minocycline with loperamide) which exploit a synergy between antibiotics and non-antibiotic drugs
  • Non-drug (eg. bacteriophage, immunoglobulin, hyperbaric oxygen) therapy may become necessary

Implications for critical care service provision

Increasing healthcare costs

  • Increased cost of increased surveillance
  • Increased cost of extended spectrum susceptibility testing
  • Increased cost of increased use of consumables (eg. gloves, gowns, single room terminal cleaning)
  • Increased cost of exotic antibiotics
  • Increased cost of increased duration of hospital and ICU stay
  • Increased cost of infectious disease staff (more man-hours required)

Implications for research

  • Increased cost of developing and testing new antimicrobial agents
  • Decreased interest in antibiotic research (a trend lasting many deceades)
  • Research into non-antimicrobial strategies of infectious diseases management, such as
    • Immunomodulatory therapies
    • Therapies aimed at blocking access to host resources
    • Antiinflammatory therapies
    • Probiotics to compete with hostile bacterial growth
    • Bacteriophage therapy

References

Elliott, T. S. J., and P. A. Lambert. "Antibacterial resistance in the intensive care unit: mechanisms and management." British medical bulletin 55.1 (1999): 259-276.

Brusselaers, Nele, Dirk Vogelaers, and Stijn Blot. "The rising problem of antimicrobial resistance in the intensive care unit." Annals of intensive care 1.1 (2011): 1-7.

Niederman, Michael S. "Impact of antibiotic resistance on clinical outcomes and the cost of care." Critical care medicine 29.4 (2001): N114-N120.

Kollef, Marin H., and Victoria J. Fraser. "Antibiotic resistance in the intensive care unit." Annals of internal medicine 134.4 (2001): 298-314.

Spellberg, Brad, John G. Bartlett, and David N. Gilbert. "The future of antibiotics and resistance." New England Journal of Medicine 368.4 (2013): 299-302.

Di Bella, Stefano, and Nicola Petrosillo. "Management of antibiotic resistance in the intensive care unit setting from an international perspective."Microbiology Australia 35.1 (2014): 63-65.