Prim. Václava Adámková: People mistakenly believe that there are enough antibiotics and that they will always handle infections

What was the main topic of the expert block?

Our goal was to convey the importance of the ATB stewardship concept and raise awareness about antibacterial resistance and the correct use of antibiotics. These are non-renewable natural resources that we must take care of.

How did this concept originate?

It began to develop in the USA in the 1990s. The term stewardship originally appeared within religious services, where it meant shepherding. Experts were inspired by this term and started using it in a medical context. Shortly after, the concept was included in the recommended practices of the American Society for Infectious Diseases and the American Microbiological Society and later spread to other professional societies around the world.

Today, it is understood as a strategy aiming for the correct use of antibiotics, emphasizing not only the role of the prescribing doctor but also appealing to patients who, for example, should not insist on an antibiotic prescription for a viral infection. The roles of nurses or government officials are also mentioned.

Where is the intervention needed most?

At all levels of care. Increased attention is paid to the issue in hospitals, but there is also room for improvement in primary care, where a large number of antibiotics are prescribed and control over this is limited. In the near future, general practitioners for children and adolescents should undergo mandatory courses on antibiotic-related topics. This is an initiative from health insurance companies.

Do the perspectives of microbiologists, infectologists, and hospital epidemiologists differ?

As it turned out during the expert block, the outputs of our three presentations were practically identical. We all know that there is a problem, that antibiotics are often unnecessarily prescribed, and we try to address this situation. We also agreed that there is a lack of more binding coordination procedures and restrictions at the national level.

Do you have data on antibiotic consumption? Where is the most waste?

Data from primary care are sent to European databases, but analyses are delayed, making it harder to respond with necessary interventions. In hospitals, this is monitored in collaboration with the hospital pharmacy. I assume that antibiotics are most overused in primary care, where there is virtually no restriction on prescriptions. In hospitals, there are antibiotic centers, and prescriptions are more controlled.

Doctors often prescribe antibiotics without confirming a bacterial infection. Is this practice lege artis?

Doctors should perform a microbiological examination and confirm the presence of a bacterial infection before prescribing antibiotics. This is the correct procedure. I wouldn’t call it lege artis, but rather evidence-based. The clinical picture and probable pathogen - for example, E. coli in a urinary tract infection - don’t tell us whether the pathogen is resistant.

And does confirmed sensitivity guarantee that a specific antibiotic will cure the infection?

We never have 100% certainty. But there is an 80 to 90 percent probability that the antibiotic will work. This approach is definitely better than switching antibiotics and trying blindly to see if they work.

Which patients are most endangered by this blind shooting?

The most fragile group is definitely children. Frequent use of antibiotics in them can cause considerable damage, such as changes in the gut microbiome that can lead to various chronic diseases. In hospitals, the consequence of unconsidered antibiotic use is nosocomial infections.

Which bacteria are the most resistant?

The biggest problem we have is with gram-negative bacteria, such as Escherichia coli or Pseudomonas aeruginosa. Unfortunately, this resistance is still increasing.

What threatens us in the future?

If resistance continues to increase at the current rate, then according to WHO, infections untreatable with antibiotics could become the leading cause of death by 2050, surpassing cardiovascular and oncological diseases. Due to the rapid increase in resistance in some states, this situation could occur even sooner.

And what will we do when antibiotics stop working? Do we have any replacements?

There is currently no miracle on the horizon. Certain alternatives could be some phytopharmaceuticals. Silver particles or bacteriophages are also being tested, but the use of these substances is limited.

Has the COVID-19 pandemic worsened this situation? What role do viruses play in this?

In addition to the weakening from the viral infection itself and the increased susceptibility to bacterial superinfection, there is a negative impact on public attention focused on acute problems. Acute viral infections are visible, unlike the increasing antimicrobial resistance. We know about acute viral infections, but whether we have a resistant bacterium inside us, we don't. People also still have the false sense that there are enough antibiotics, they are available, and that infections will always be handled. And of course, hospitalization due to viral complications increases the risk of bacterial infection and the need for antibiotic treatment, closing the circle.

So how should antibiotics be correctly indicated?

It is necessary to know where the infection is in the body and what causes it. We must realize that not every antibiotic penetrates everywhere. Laboratory verification of the pathogen's sensitivity is the next step. We should not forget about fungal infections either. Antimicrobial resistance may be an even bigger problem there. Doctors should also adjust antibiotic dosages to patient weight. Under-dosing and insufficient effectiveness occur quite frequently.

MUDr. Andrea Skálová
editorial staff proLékaře.cz