Antibiotic Resistance

Antibiotics have long been used as a powerful tool for fighting infections caused by bacteria. However, improper use can actually be detrimental to your health, defeating their life-saving, healing characteristics. 

The overuse and misuse of antibiotics are leading contributors to antibiotic resistance, a problem the World Health Organization has said is one of the biggest threats to global health, food security and development today. The resistance not only challenges treatment options but opens the door to superbugs or viruses that can overwhelm our population. While it may be easy to turn the other cheek to global issues, antibiotic resistance can mean longer hospital stays, higher medical costs and increased mortality risks to you. 

So, what role can you play to slow down the creation of superbugs and what’s on the horizon in regards to new antibiotic treatment for infections?

Guests:

 Jonathan Fialkow, M.D., Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.

 
Timothy Gauthier, Pharm.D., Manager of the Antimicrobial Stewardship Clinical Program and Pharmacy Residency Program Director.

Transcript

Speaker 1:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Antibiotics are powerful tools to treat certain infections and can save lives when properly used. They either stop bacteria from reproducing or destroy them all together. However, antibiotics can't treat viral infections, though people will ask for them as a treatment for colds and flus.

The overuse and misuse of antibiotics are key factors leading to resistant threats. And some antibiotics that used to be typical treatments for bacterial infections now don't work as well or at all. So the big questions are, how do we slow down the creation of superbugs and what's on the horizon with regards to new antibiotics or treatments for infections? I'm your host, Dr. Jonathan Fialkow.

I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health. I recently had the pleasure of hosting an episode of Baptist Health's Resource Live that covered this one more. My guest was Timothy Gauthier. He's the manager of the Antimicrobial Stewardship Clinical Program and Pharmacy Residency Program Director. Let's listen in.

So Tim, this is an important topic that you and I have discussed in many form for across the community for some time, and I really appreciate your expertise in this. I think getting this message home is of paramount importance. We use certain terms like antibiotic resistance and stewardship.

And maybe start off by talking about that a little bit more. The World Health Organization, as I mentioned, has raised the alarm on this antibiotic resistance problem, big threat to global health, food security development. What does antibiotic resistance mean and are there different types of it?

Timothy Gauthier:

Yeah. Antibiotic resistance is when simply put, antibiotics don't work. And we think a lot of drugs that we have on the market today, a cholesterol pill or a blood pressure pill that we take and we don't really feel a risk of it now working in the future. And we don't have a risk because of the way that those pills work.

They work in our bodies. But antibiotics are different, they combat bacteria. And as they combat those bacteria, bacteria will develop and share ways to become resistance to those antibiotic. And so over time, the more we use our antibiotics, the more we lose our antibiotics. We really want only want to take it when we absolutely have to take them. And when we see antibiotic resistance, it becomes more difficult to treat those infections.

Dr. Jonathan Fialkow:

So on a scientific basis, is the bacteria actually evolved to not to be resistant to the functions of the antibiotics to kill them or delay their growth? What's going on from a societal standpoint that's leading to antibiotic resistance?

Timothy Gauthier:

Yeah. Any antibiotic use leads to antibiotic resistance. So even if you have a true infection and you need antibiotics, that can pressure antibiotics to, pressure bacteria to become resistant. If you are using antibiotics when you shouldn't, like for a viral infection where antibacterial is not going to have any impact, that also contributes to resistant. Or antibiotic use in agriculture contributes to antibiotic resistance.

So any antibiotic use contributes to resistance. And what we're seeing is as people use antibiotics, we don't have a lot of new antibiotics coming to the market and the drugs that we have available today are becoming less effective as antibiotic resistance spreads. And so as a society, there's this kind of wall of resistance that's continuously progressing, but there's things we can do to push back against that wall and slow that progression. And we're going to talk about some of those here today.

Dr. Jonathan Fialkow:

So I think it's fascinating. It's a low threshold, [inaudible 00:03:36] antibiotics. And it's not just an individual patient, whereas you said viruses don't respond to antibiotics, so you don't need them. But agriculture as well, which the use in the food industry and in how we gave it to the animals.

And then we eat the animals of course, which leads to some of the components as well as the antibiotics themselves. So very powerful statement that you just made, which is it's not just the use of it in an individual, but across our society. So let's talk about some of people's behaviors which might contribute to, let's say the overuse of antibiotics or the misuse of antibiotics. When people have an infection and they're given an antibiotic, whether it's appropriate or not, very often they start feeling better.

I've even had my own mother will say, "Wow, I took it. Within an hour later, it started clearing up my sore throat and cold," et cetera, et cetera. What would be the recommendation of the proper use of an antibiotic during its course? In other words, we don't want to use it indiscriminately. Is there a concern when people are taking it for the right reason and then stop it when they feel better?

Timothy Gauthier:

This is a really interesting area because for decades, societies have been telling the public, "Finish your antibiotic course or you risk antibiotic resistance." And when we reexamine that literature, what you find is antibiotic use leads to antibiotic resistance. And so actually limiting antibiotic exposure, having a shorter course of therapy when clinically appropriate can actually limit the progression and pressures on bacteria to become resistant.

So it's very difficult to change the message that you're giving to the public for 50 years. And there are instances now where if you're feeling better and you stop an antibiotic, it can be very reasonable to just, you're done with the course. We were going to go a seven day, at day three, you felt great, so you stopped at day five instead of day seven. That's okay. But I think there's two things we need to be mindful of.

Number one is why can we stop a course early? And usually that's related to our immune system. So the antibiotic is helping to kick that infection and kick that bacteria down and your immune system is taking over to fight the infection as a whole. But if you don't have a good functioning immune system, you may not be able to stop the course early.

Another thing is we want to always use antibiotics under the guidance of our healthcare professionals. So if I have been prescribed say an antibiotic for seven days for a urinary tract infection and I'm feeling much better at day three and I'm thinking about stopping at day five, I'd probably reach out and touch base with my healthcare provider to make sure there's nothing that I'm missing to ensure that I will have that clinical outcome that I'm looking for.

Dr. Jonathan Fialkow:

Again, great message and well articulated. We don't want to use them indiscriminately and inappropriately, but if you are prescribed the antibiotic, assuming for the right reason, you want to complete the course. It's funny, in my world as well, people think twice the dose of something is twice as effective or take it every other day and it's safer and what you may be doing and by taking every other day, it doesn't work at all.

It doesn't develop a level in your body that's functional or twice the dose may not all be absorbed and you understand this better than most, but we want to make sure that the antibiotics are dosed based on the scientific data for its efficacy and safety. You want to continue that course correct.

So moving on to a couple of specific questions and then certainly we want to get into the meat of the when not to use antibiotics, especially for viral infections and whatnot. So a lot of times pregnant women are prescribed antibiotics and there's a reluctance for pregnancy and stuff. What are the things that a provider must go through to think before using an antibiotic in a pregnant woman? And certainly what do we know about the safety of specific antibiotics during pregnancy?

Timothy Gauthier:

There's actually a lot of parallels with antibiotics and all drugs. And one of the messages as a pharmacist that I've learned is you don't take medication unless you really need to take it. And then when you do take the medication, make sure you take the right drug at the right dose for the right duration via the right route.

And so anytime I take a medication, antibiotic or not, I'm making sure I need it. I'm not taking 800 milligrams of ibuprofen when I could take 400 milligrams. I don't take it four times a day when I could take it twice a day. So I try to limit my exposure. And limiting exposure always reduces the chances for toxicity.

When it comes to antibiotics in pregnancy, antibiotics are actually extremely important for some pregnant women to prevent either early preterm birth and things related to progressing to having a full term baby or also infectious diseases that can be passed on to the infant. And so we use antibiotics in a number of different ways to maintain the health and safety of the mother and the baby.

However, there are certain antibiotics that should be avoided in pregnancy. And that can actually depend on what trimester of pregnancy that you're in and when to avoid those antibiotics. And so antibiotics such as sulfamethoxazole-trimethoprim, fluoroquinolones and Tetracyclines are antibiotics that you need to stop and think about what does this patient need to be treated for?

What is trimester pregnancy are they in? And what is the risk benefit in this individual? And those are kind of stopping point antibiotic classes. Whereas the penicillins type of antibiotics, so things like amoxicillin, amoxicillin clavulanic acid, penicillin, those are extremely safe antibiotics. Those tend to be go to antibiotics, not just for patients who are pregnant, but almost all antibiotic infectious indications.

Dr. Jonathan Fialkow:

So pretty much, again, very individualized, very customized. Not all antibiotics are safe for pregnancy, some antibiotics are very beneficial in pregnancy. Speak to your provider. First question is, will you benefit by taking the antibiotic and why.

Timothy Gauthier:

Yeah.

Dr. Jonathan Fialkow:

On that particular, right? Antibiotic. Which again, is a great answer to a complex question. How about alcohol? I see a lot of people that on antibiotics, they're afraid to have a sip of wine or a glass of alcohol. What would be the concerns regarding antibiotics, again, across the board or maybe some specifics and alcohol? And is it like I look at alcohol and I have a reaction? Give us some scale and scope to that question.

Timothy Gauthier:

Yeah. It's funny because the answer to every infectious diseases question is, it depends, right? So where are you in your course of your disease? How sick are you? What antibiotic are you taking? Metronidazole is known to have this disulfiram like reaction where you can get very nauseous and have vomiting. And I would not want to drink alcohol while on metronidazole, for example. In general, I think we should avoid alcohol consumption when we're ill.

We should focus on the recovery, getting rest, getting hydration, treating our symptoms as appropriate. But then on the other side of the spectrum, if someone is a heavy alcohol user that can impact their liver function. And that liver function may have an impact on the metabolism and antibiotic. And so it's always more complicated than it seems at surface, at face value. But the biggest take home, I'd say avoid alcohol consumption when you're taking antibiotics. Leave it there.

Dr. Jonathan Fialkow:

And the depends answer, which is quite frankly accurate, is your individual recommendation response would be one that should be discussed with your healthcare provider. We talked about pregnancy, what about the opposite? What about contraception? Does alcohol affect a birth control in any way?

Timothy Gauthier:

Well, in regards to...

Dr. Jonathan Fialkow:

I'm sorry, antibiotics affect that.

Timothy Gauthier:

Yes, definitely avoid alcohol while pregnant.

Dr. Jonathan Fialkow:

Alcohol on the brain.

Timothy Gauthier:

When it comes to antibiotics and contraceptives, historically there's been a lot of discussion about that topic. Current evidence suggests that many antibiotics can be taken with oral contraceptives without a major issue by any means. Again, always recommend to discuss the specifics of your case with your professional who, your licensed healthcare professional, who knows your allergies, your history, where you're at, what your goals are before making a final decision.

But yes, there are drugs, for example, like Rifampin, not a commonly used antibiotic in the community, but it can have an interaction with oral contraceptives. There's a drug, Griseofulvin, which is an antifungal that can have interactions. But that's extremely uncommonly used in the community. So not something we're super worried about, but it's worth asking your physician about as you consider if I need to take an antibiotic and which antibiotic is right for me.

Dr. Jonathan Fialkow:

Now let's start moving into some of the more common concerns. We'll start off with the concept of antibiotics in children. Obviously being a kid is a large germ exposure in their activities and whatnot. Any specific recommendations or overarching thoughts when you're going to have a child prescribed an antibiotic?

Timothy Gauthier:

I have a four year old and a seven year old at home, so I can certainly speak to personal experience. And one of the take homes that I see is antibiotics related to anxiety of the parent. Right? So am I giving my child antibiotics because it's going to help my level of anxiety and I'm going to feel emotionally better about it? Or does my child actually have a bacterial infection that may benefit from giving an antibiotic?

And so as we go through that process, what I default to is, well, what does my physician say? What does my pediatrician say? What is their recommendation? And I know these conversations are very difficult because I have them with my wife all the time. I have kids that are, my kids are in daycare, they're in school, and they bring things home.

So one of the main messages is follow the recommendations of your provider. As you're doing that, make sure you bring the signs and symptoms that your child has to the prescriber so they have all the information. And you can use shared decision making with your provider to decide what is the diagnosis. And then use that diagnosis to guide whether or not antibiotics are indicated and which antibiotic would be indicated for what duration of time.

Dr. Jonathan Fialkow:

So I think you bring up a bigger point, which I'm going to editorialize a little bit since it's part of the topic, which is the doctor will listen to the signs and symptoms and say, "This appears to be a bacterial infection. I believe it's safe to give your child antibiotics." But not infrequently the doctor will make the decision based on what they perceive the parents expectation is. And let's talk about that a little bit.

Whereas a parent, you want your child to get better if you think it's an antibiotic. That might actually subtly push the doctor into recommending it thinking, "Oh, it doesn't hurt, let's take it anyway." [inaudible 00:13:06] So let's talk a little bit more on that specifically.

You alluded to in a couple places. Why don't we want to prescribe or take an antibiotic as a child or an adult if it's really not necessary, if it's not going to make the problem better. Because it's a virus or an inflammatory thing. So let's talk a little bit more about that. And it could be about to the society, but also to the body. What would be the reason we would want someone to not feel, "Oh, it's what the heck. It's just to be safe, let me take an antibiotic."

Timothy Gauthier:

Absolutely. So on one side it's toxicity. Anytime you take a drug antibiotic or not, you risk toxicity, anaphylaxis or allergic reactions from penicillin type antibiotics, Cephalosporin type antibiotics are actually pretty common in general. And so that is a risk that you impose when you are consuming one of those products.

And so visits to the emergency room in pediatric patients is something that's been studied pretty well in that regard. Another side of it is when you're taking an antibiotic, you're going to be taking hopefully the first line antibiotic. And then if you need an antibiotic in the future, you're probably going to be taking the second line antibiotic. And then if you need to take an antibiotic later, maybe you're taking the third line.

Dr. Jonathan Fialkow:

[inaudible 00:14:15] That means if the first one doesn't work, then you take a different family and then a different family. Right?

Timothy Gauthier:

Yeah. And there's reasons why a drug is a first line antibiotic, right? It's going to be safer, it's going to be more effective, it's going to be maybe easier to consume the, it's not three times a day, it's just once a day. And so when you start to use antibiotics, you start to kind of go down that chain. And you don't want to start to go down that line if you don't need to. And so preserving the efficacy of antibiotics, it relates to only using them when you really need to. Because when you need them, they'll be there and ready to use.

There's a physician named John Rex, and he refers to antibiotics as fire extinguishers. Right? You don't want to play with the fire extinguisher, but when there's a fire, you want to be able to use the fire extinguisher and you want it to work. And if there was something that would make that fire extinguisher not work, then you'd probably want to avoid it. And that's what we can see with antibiotics. When you don't use the antibiotics, you don't pressure them to become resistant, then you preserve that likelihood it'll work.

Dr. Jonathan Fialkow:

How about some of the other things, if you're willing to comment on? I know there's a lot of concerns regarding super infections. There's thoughts that chronic sinusitis might be from an overuse of antibiotics killing healthy bacteria. We know the microbiome, the bacteria in the gut can be very much effective.

There's even thinking that obesity might be related in some way to antibiotic use. You don't have to get into the deep science of those evolving concepts, but can you talk a little bit about how use of antibiotic might wind up harming healthy bacteria in parts of our body?

Timothy Gauthier:

We call that collateral damage of antibiotic use. Right? So we have one organism maybe that's causing an infection, but very few antibiotics work on a single organism, most work on whole groups of organisms or multiple groups of organisms. And so you're just really cluster bombing your whole microbiome. And that can have a lot of different repercussions as you alluded to.

And they're studying this in the context of many different disease states, which are not even necessarily infectious related. And so the first thing that comes to mind is a C. difficile, which is clostridium difficile. It's a diarrhea related organism. And C. diff, what happens is you clear out all its competitors and C. diff can then flourish and cause lots of diarrhea and be a really bad time for everybody.

Dr. Jonathan Fialkow:

Be life threatening, huh?

Timothy Gauthier:

It can absolutely be life threatening. Thousands of people die in this country every year of C. diff. It's horrible. It's one of the things that we try to every day avoid. But it's something that is a risk when you use virtually any antibiotic.

And so when we look at antibiotic use, we really want to again, measure the risk versus the potential benefit. And that's a moving target. And it all depends. So then I go back to the physician and look for their assistance and what is reasonable at this time if I should take an antibiotic or not.

Dr. Jonathan Fialkow:

It's very profound. We don't want to scare people to use antibiotics. Again, they're incredibly life saving in the right setting, but we want people to be judicious and just don't look at them as a panacea, going back to that just to be safe mentality. Talk for a second about amoxicillin shortage.

I was mind boggling in one of the more prominent newspapers I was reading this morning about amoxicillin shortage. The lead in was in this season of increasing cold and flus, there's an amoxicillin shortage. So talk about what amoxicillin shortage really is, but talk about the evil and the disconnect in that lead in comment by the newspapers regarding colds and flus and amoxicillin.

Timothy Gauthier:

Yeah. I think that was a somewhat unfortunate communication there where you're putting a viral infection and that being prevalent in the community on top of using antibiotics that don't work for viral infection. So if you have a viral infection and you have it for a significant amount of time, I'm talking weeks, absolutely, you can maybe start to worry about a superimposed bacterial infection.

And then using amoxicillin in that case may be fairly reasonable. But from the outset it was runny nose, stuffy, watery eyes, that's not a case where you're going to, right? Go to antibiotics because those are symptoms of typical viral infections. And so on one hand it's important that there isn't amoxicillin shortage that's going on.

It seems that there are formulations available. So depending upon the pharmacy, they may not have formulation A, but maybe they have formulation B. And it does seem that it's going pretty well overall. I'm not seeing it get worse, which is important. And I agree with the notion that coupling, talking about viral infections with antibiotics is not necessarily a good idea.

Dr. Jonathan Fialkow:

Yeah. Just promotes that wrong message. Let's go take some questions from the audience. Again, you've been... From the viewers, you've been wonderful in articulating these important concepts regarding proper antibiotic use and concerns regarding the inappropriate use. First question would be actually a good one.

What should I take alongside antibiotics to protect the good bacteria in my body? Meaning if someone's on a particular kind of antibiotics, is there anything they should do to maintain the good bacteria health? And to that end, if you're able to comment, can you comment on probiotics a little bit if you have a comfort level in commenting on that?

Timothy Gauthier:

Yeah. So the data in the area of probiotics is not consistent to say the least. And so it goes back to what is the risk versus what is the benefit. And so the benefit is thought to be replenishing your microbiome. And the risks really are quite low. One is it can be costly, depending upon which probiotic you're using, you may have to go out to the pharmacy, to the drugstore, what not to procure it.

So that is an effort you have to make. And then also, there's actually cases where patients were taking probiotics and that organism, that fungi got into the bloodstream of the patient and caused an infection. And so there are actual risks that come along with taking probiotics. And the benefits are just really not clear. So my personal recommendation is that I do not recommend consistent probiotic use or use of these types of replenishing substances while taking antibiotics.

However, I will note that the science in this area is advancing, and especially for patients that have a history of clostridium difficile infection, I think we're going to see some really cool things come out in the next four, five, 10 years that may change the game in regards to what interventions could be made to help replenishing that host microbiome. But not certainly for anyone who's taking amoxicillin, but for patients with specific risk factors for bad outcomes related to, for example, C. diff.

Dr. Jonathan Fialkow:

I think that's fair. And things like yogurt and kimchi and sour [inaudible 00:20:29] and those fermented products do seem to be good sources of bacteria or healthy bacteria for our gut, but not specifically to take a tablet that has a particular kind of probiotic in it. Again, a broad one, but I think it's worth answering, what are the main, or let's put the term more common side effects we see with antibiotics.

Timothy Gauthier:

Yeah. So antibiotics definitely can virtually all cause nausea, vomiting, diarrhea, abdominal discomfort. Those are your common ones. And then as you start to pick out a certain antibiotic, they all have their own risks. So renal toxicity is one that we see with antibiotics used in the hospital, but it really depends again on which antibiotic you're talking about.

In general, your risk for toxicity is going to go down when you use a lower dose of medication. And so using that right dose is important to mitigating the chances for toxicity and then exposure. So the duration of time that you take it or also relates to your risk. So going back to that right dose for the right duration. You want to take enough so that it treats the infection, but you don't want to take so much that you cause yourself to get nauseous and start vomiting.

An example of that is like metronidazole, which is used for a couple different infection types. But metronidazole, when you take it, two grams at once or one gram at once, you get a lot of nausea and vomiting. But if you take 500 milligrams, you see a lot less nausea and vomiting, but you still regardless get metallic taste in your mouth. So there's always toxicities and there's always side effects of antibiotics.

Dr. Jonathan Fialkow:

So I think the side effects, you talked about toxicities, rashes could be another one. Talk for a second about anaphylaxis though. When someone really has a reaction that's obviously really something they need to act on, what would be the signs and symptoms of that and how should someone react?

Timothy Gauthier:

Yeah, so if someone is having an anaphylactic reaction, they're going to have trouble breathing, they can have swelling over their throat. And if that happens, that's a medical emergency, you need to call 911 immediately. That's not something to play around with at all. Penicillin allergies, about 10% of the people in this country are labeled with a penicillin allergy.

Only about 10% of those people actually have a penicillin allergy. So there's a lot of inappropriate penicillin allergies. But still, if you could have anaphylaxis, you have to be careful about it. And there are actually ways to test for a penicillin allergy, there's something called penicillin skin testing.

So if you have a penicillin allergy, you don't know if it's real or not, you can actually go get penicillin skin testing. And if your allergy history was anaphylaxis, you're actually one of the best patients to test for that because you can lose your penicillin allergy over about five to 10 years, which is something people don't really know. But given that penicillins are some of the best, most safe antibiotics, it's worth being aware of.

Dr. Jonathan Fialkow:

So to have that weapon available for future infections for someone who might otherwise be thinking that they can't take it.

Timothy Gauthier:

Exactly.

Dr. Jonathan Fialkow:

Worth the endeavor. Last question, and again, the big question, the $30,000 question so to speak, is what can we do as a society to help fight antibiotic resistance? You came up with a lot of components, but let's see your final message, Tim, here it is.

Timothy Gauthier:

Yeah, there's two messages. Number one is I think don't demand antibiotics from your prescriber. Work with your prescriber to establish a diagnosis and use that diagnosis to guide what therapies are appropriate. Sometimes that's antibiotics, sometimes it's not. The second thing is we really need to focus on infection prevention, which is hand hygiene using what we call personal protective equipment in the hospital.

So things like gloves and gowns. But preventing the spread of these organisms from one patient to another is just as important as using antibiotics wisely. And so as antibiotics stewards using antibiotics wisely, we also need to be infection preventionist and be implementing interventions to ensure we don't pass these organisms from one patient to another.

Dr. Jonathan Fialkow:

This has been great conversation, Tim. And again, I appreciate your expertise and your passion in maintaining antibiotic stewardship and educating all of us regarding proper use of antibiotics.

Timothy Gauthier:

To our listeners, if you have a comment or a suggestion for future topic, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. We'd love to hear from you.

Speaker 1:

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