Current View on Obstacles in Proper Use of Antibiotics and the Role of Biomarkers in Infection Diagnosis
In the fight against antibiotic resistance, principles for the proper use of antibiotics (ATB) have been introduced globally. The following overview briefly describes the obstacles in leading rational antibiotic therapy and considers the use and benefits of biomarkers.
Antibiotic Resistance
The occurrence of antibiotic resistance and the associated ineffectiveness of older ATBs is becoming an increasingly serious problem. Bacteremia caused by multi-resistant strains poses a significant burden on the healthcare system. In this context, the concept of minimal use of new preparations is applied with the crucial goal of ensuring that the currently used ATBs remain effective for as long as possible.
Although there are no objections among physicians to the proper use of ATBs without their misuse or improper use, there are obstacles that make it difficult to implement and supervise established antibiotic programs. In the case of severe infections, such as sepsis, it can be challenging to choose the appropriate ATB that considers these programs while also avoiding concerns about treatment failure.
A review article published in December 2022 describes the current situation and examines the obstacles in leading antibiotic stewardship programs (ASPs − Antibiotic Stewardship Programs) and the benefits of using biomarkers.
Obstacles to Rational Antibiotic Therapy
Surveys conducted worldwide have shown that the main obstacles are a lack of time and staff, inadequate compensation for leading ASPs, and a lack of guidelines or suitable manuals.
Useful measures leading to the improvement of ASPs include ensuring full-time specialized staff and implementing clinical decision support computer systems. However, these measures are not easily applicable, both in terms of time consumption and increased costs.
Biomarkers
Some biomarkers, such as C-reactive protein (CRP), procalcitonin (PCT), and presepsin are promising tools in ASPs due to their use in diagnosing and prognosing sepsis. In addition to CRP, PCT, and presepsin, other promising biomarkers are also actively studied.
C-reactive Protein
The suitability of an algorithm for determining the initiation and duration of antibiotic therapy using CRP has been evaluated in several studies. It was found that such an algorithm allowed for a reduction in the duration of ATB use by 1.45 days in randomized controlled trials and by 1.15 days in cohort studies. The results may be biased as the overview included only 7 studies, 5 of which concerned the discontinuation of antibiotic treatment in patients with neonatal sepsis.
CRP, which is relatively commonly determined in clinical practice, has its limitations, including its potential increase in other conditions besides infectious diseases. Another disadvantage of CRP is its slow response compared to the other mentioned biomarkers.
Procalcitonin
Several studies have addressed the use of PCT for the initiation or discontinuation of antibiotic therapy. Recent research has demonstrated the usefulness of algorithms based on PCT levels, leading to a reduction in the duration of ATB use. Reducing the duration of use helped with proper antibiotic therapy in various patient groups and, in some cases, also shortened patient stays in intensive care units. There was also a noted lower relative risk regarding mortality.
Presepsin
Presepsin, which has been used in recent years, appears to be a promising biomarker. According to the results of a multicenter prospective study, the analysis of presepsin levels led to a reduction in the duration of ATB use compared to the group following general treatment guidelines. However, there is currently a lack of sufficient relevant data to assess its usefulness, and comprehensive meta-analyses are needed.
Summary and Conclusion
The most difficult problem worldwide in rational antibiotic treatment is the lack of personnel, time, and appropriate supportive data. Given the shortage of qualified healthcare staff and other organizational issues in healthcare, particularly in hospital management, this situation is not easily solvable. Nevertheless, the determination of biomarkers is a suitable indicator for the initiation, non-initiation, or interruption of antibiotic treatment within the diagnosis of infectious diseases.
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Sources:
1. Kim C.-J. Current status of antibiotic stewardship and the role of biomarkers in antibiotic stewardship programs. Infect Chemother 2022 Dec; 54 (4): 674−698, doi: 10.3947/ic.2022.0172
2. Action Plan of the National Antibiotic Program of the Czech Republic (AP NAP) for the period 2019−2022. Available at: www.svscr.cz/wp-content/files/zvirata/AP_NAP_2019_-_text.pdf
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