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.