Implications of increasing antibiotic resistance on ICU practice

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