Combating Antibiotic Resistance Via Physician Action and Education: AMA Activities
NOTE: This report represents information and AMA policy on this subject as of June 2000.
Full Text
Increasing interest has been expressed by the American Medical Association's (AMA) House of Delegates about the expanding problem of antibiotic resistance. This report describes some of the AMA's previous activities on this issue, summarizes current AMA actions on antibiotic resistance, and provides several recommendations.
Methodology
Literature searches in the MEDLINE database for articles published between 1990 to 1999 using the search term antibiotic resistance qualified with the terms prevention strategies, or prevention policies, or control strategies, or control policies, yielded a combined total of 209 references. English-language references containing information relevant to use of antimicrobials in consumer products and resistance were examined further. Additional references were culled from the bibliographies of these pertinent references.
The Antibiotic Resistance Problem
Antibiotic resistance has been a major public health concern for many years, and many aspects of this issue have been addressed in expert reviews and guidelines.1-8 The problem has increased in prevalence and is not only confined to bacteria, but also exists in fungi, viruses, and parasites.2 Resistance is a complicated phenomenon that involves the environment and the patient as well as the microbe.
Thus, resistance may arise as a result of therapy or as a result of a previous exposure to a given drug or its analog, or may be intrinsic to the microbe itself. Additionally, resistance is found not only in the hospital environment but also in the community setting and in long-term care facilities, with some hospital outbreaks directly traceable to resistant bacteria introduced from the community.9-12 Council on Scientific Affairs (CSA) Report 2 (A-00), Use of Antimicrobials in Consumer Products, discusses antimicrobial use in consumer products and its possible implications for antibiotic resistance.In developing countries, bacteria with acquired resistance is often isolated from healthy individuals, and the misuse of antibiotics by health professionals, unskilled practitioners, and laypersons, coupled with rapid spread of resistant bacteria and inadequate surveillance all contribute to the problem.6 As antibiotic resistance increases, there are now cases where no first-line options for therapy remain.3
It is obvious that no simple solution exists to deal with antibiotic resistance, and more scientific research on the genetic basis of resistance, the epidemiology of resistance emergence, and strategies that will effectively control antibiotic resistance is needed. However, existing data indicate that control strategies in hospitals have reduced the incidence of resistant bacteria.13 Additionally, optimal selection, dose, and duration of treatment will prevent or slow the development of resistance in bacteria.1 Changing hospital antibiotic formularies has been shown to reduce the incidence of specific resistant bacteria, but surveillance is important to guard against the emergence of other resistant bacterial strains.14 Improved surveillance will also provide critical information on the emergence and epidemiology of new resistant strains, and the genotypic basis of such resistance, and will provide data on appropriate therapeutic options to deal with it effectively.15-19 Study results demonstrate that education-based methods can change the prescribing habits of physicians.5 Significantly, cooperation between infection-control specialists, infectious disease specialists, clinical pharmacists, and the microbiology laboratory provides useful real time information pertaining to antibiotic choice and dosing to the prescribing physician.5 Thus, new intervention strategies are beginning to exploit this multidisciplinary education base with a cooperative approach to management of antibiotic resistance. Given the newly discovered role of transposons and integrons in multi-drug resistance through their mobility and ability to collect resistance genes,20-23 it is critical that comprehensive programs incorporating all the above-mentioned strategies be implemented.4
Previous AMA Activities on Antimicrobial Resistance
There is very little in the AMA Policy Database on the subject of antimicrobial resistance. Policy H-100.973, "Availability of Antibiotics to the General Public," focuses on education about antibiotic use and asks that: "The AMA encourage the federal government, the World Health Organization, the World Medical Association (WMA), and the International Federation of Pharmacists to promote more effective education concerning the appropriate use of antibiotics (AMA Policy Database)." However, a number of AMA activities are not reflected in policy.
In 1995, the AMA submitted a proposed statement to the WMA on "Resistance to Antimicrobial Drugs." The seven AMA proposals to address the problem of antimicrobial resistance worldwide ranged from international surveillance, to more research for vaccines and new antimicrobials, to better education of physicians and the public. This statement (as revised) was adopted by the WMA in 1996.24
AMA Board of Trustees (BOT) Report 10 (I-95), "Antibiotic Usage and Bacterial Resistance,"25 contained two recommendations, which asked the AMA to: (1) Encourage physicians to educate their patients about their antimicrobial therapy, the importance of compliance with the prescribed regimen, and the problem of antimicrobial resistance; and (2) continue to educate physicians and physicians-in-training about appropriate prescribing of antimicrobial agents, and offer physicians patient information materials that can be given to patients with prescriptions as a supplement to oral counseling. Since these recommendations were adopted as directives, they were not included in the AMA Policy Database.
At the 17th Annual Science Reporters Meeting held in October 1998 at the Duke University Medical Center, North Carolina, AMA BOT member Timothy T. Flaherty, MD, delivered a speech on antimicrobial resistance and what patients and physicians should do to minimize this threat. Such media exposure helped educate both the public and physicians about antibacterial resistance.
The Journal of the American Medical Association (JAMA) published a Patient Page on antibiotic resistance that physicians can copy for their patients (October 14, 1998).26 The Patient Page enables physicians to educate their patients about the risks of antibiotic resistance and on what steps they can take to alleviate the situation.
Current AMA Activities on Antimicrobial Resistance
Collaborations with Federal Agencies. The AMA is currently working with the Centers for Disease Control and Prevention's (CDC) National Center for Infectious Diseases on different projects that focus on remediating the negative public health impact of antimicrobial resistance. In this regard, the AMA will be reviewing the federal government's inter-agency Task Force on Antimicrobial Resistance report on the public impact of antibiotic resistance. According to J. Todd Weber, MD, from the Office of the Director, National Center for Infectious Diseases, the CDC hopes to publish this report in the Federal Register in 2000. It is expected that recommendations pertinent to physicians will be summarized and made as widely available as possible, eg, via posting on the AMA Web site and notifications to specialty societies. Finally, the AMA and the CDC are discussing other possible relationships to address the urgent problem of increasing antimicrobial resistance and its impact on public health. This includes working with the CDC to implement some of the strategies detailed in its recent infectious disease control plan for the 21st century.27 Examples of potential actions include developing and implementing educational and public health programs that will prevent the emergence and spread of drug-resistant organisms; disseminating appropriate recommendations and guidelines for the prudent use of antibiotics; and developing, implementing, and evaluating educational and behavioral interventions that limit the emergence of resistant organisms by modifying the practices of health care providers.
The AMA is also actively participating in the Food and Drug Administration's (FDA) current workshops on the "framework" document.28 This draft document proposes a risk-based strategy to investigate and evaluate the risk to human health of antibiotic resistance related to the use of antibiotics in food-producing animals. To better estimate this human health risk the FDA recently released a draft risk assessment on fluoroquinolone resistance in Campylobacter,29 which concluded that the risk to a person living in the United States of being negatively affected by a fluoroquinolone-resistant strain of Campylobacter when the resistance was associated with the consumption of chicken was 1 in 61,000.29 As such, the FDA is now considering methods to balance the important roles antibiotics play in animal health and husbandry with the extremely undesirable consequence of antibiotic resistance developing in pathogenic strains that infect humans. The AMA will remain active at future FDA workshops on this critical and highly controversial issue, provide input into the final version of the "framework" document, and continue to keep the nation's physicians informed as necessary.
Collaborations with Specialty Societies. The AMA will actively pursue possible collaborations with medical specialty societies on methods to control antibiotic resistance. Potential areas for collaboration include developing physician education programs, exchanging information on upcoming activities on antibiotic resistance, and providing assistance to physicians in educating patients. For example, the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) is developing an antibiotic resistance awareness program with particular emphasis on clinical practices. The CSA has contacted the Vice President for Education at ACP-ASIM, to offer possible assistance and discuss collaborative opportunities on this venture.
Collaboration with the National Health Council. The AMA will be represented on the Planning Committee for a National Conference on Antibiotic Resistance to be held in April 2000, sponsored by the National Health Council. It is anticipated that AMA input into the conference agenda will create educational and developmental opportunities for both physicians and nonphysicians on this critical issue.
RECOMMENDATIONS
The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 2000 AMA Annual Meeting:
- The AMA amends Policy H-100.973 to read as follows:
The AMA: (a) Encourages the federal government, the World Health Organization, the World Medical Association, and the International Federation of Pharmacists to promote more effective education concerning the appropriate use of antibiotics, (b) strongly urges physicians to educate their patients about their antimicrobial therapy, the importance of compliance with the prescribed regimen, and the problem of antimicrobial resistance; (c) will continue to educate physicians and physicians-in-training about the appropriate prescribing of antimicrobial agents; (d) encourages the use of antibiotic resistance management programs; these education-based programs should be multidisciplinary and cooperative (ie, including infectious disease physicians, infection-control specialists, microbiology laboratory personnel, and clinical pharmacists); and (e) encourages continued scientific research on the issue of antibiotic resistance.
- The title of Policy H-100.973 is changed to read as follows:
Combating Antimicrobial Resistance through Education
- The AMA will continue to collaborate with the appropriate federal agencies, other medical specialty societies, and other appropriate public health organizations to address the urgent problem of increasing antimicrobial resistance and its impact on public health.
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References
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Also see the AMA's Infectious diseases Web site
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