Antibiotic resistance in the polypharmacy mix
The World Health Organization (WHO) states that antimicrobial resistance, including antibiotic resistance, is one of the leading global public health threats. In 2019, more than 1.2 million people died as a direct result of antibiotic-resistant infections, and 4.95 million deaths were associated with the problem. To put this in context, that means that anti-microbial resistance is now associated with more deaths worldwide than either HIV/AIDS or malaria.
This situation has arisen because of the overuse of antibiotics. New strains of resistant bacteria, sometimes called superbugs, have emerged in the wake of more than 60 years of antibiotic use. These new strains are much harder to treat, making it difficult, and sometimes impossible, to treat common infections.
Understanding the impact
The rise of antimicrobial resistance has had a huge impact on medicine. We can no longer rely on common antibiotics to handle infections after surgery, cancer treatment and organ transplantation. Indeed, we may well be reaching a point when some of these treatments are no longer possible because of the risks of contracting an untreatable infection.
Doctors already have to consider carefully before reaching for the prescription pad. You may have come across this yourself: doctors will often advise waiting a few days to see if you recover or tell you that an infection is most likely to be viral in origin, and therefore that antibiotics will not help. In making a decision, they will have considered the severity of the infection, and whether you have been on antibiotics recently (in which case, resistance is more likely). Antibiotics are often prescribed only after a culture has been taken, so that the antimicrobial can be targeted more precisely.
Antibiotic resistance and polypharmacy
You may be wondering what antibiotic resistance has to do with polypharmacy. Clearly both are complex issues, demanding careful management by both patients and medical professionals. However, there are several additional issues that cause concern.
The first is that polypharmacy is common in older patients with many chronic conditions, cancer patients, and those receiving post-transplant treatment. Unfortunately, these are also the groups that are most likely to experience multiple opportunistic infections that may require antibiotics — and frequent antibiotic use is one of the risk factors for resistant infections. The second issue is that many other medications interact with antibiotics. This means that there is a genuine risk of under-dosing with antibiotics. That again is a risk factor for resistance developing — and incidentally, is why you are always told to complete the full course of antibiotics.
Best practice in antibiotic prescribing and polypharmacy
Polypharmacy can therefore amplify the existing problems associated with antimicrobial resistance. Doctors’ decisions about antibiotic prescribing are even more difficult for people already taking multiple medications. They have to weigh up factors including the risk of the infection with the risk of contributing to antimicrobial resistance, and also consider possible interactions between drugs.
However, there are also systemic actions that can be taken to address some of the issues. First, hospitals and healthcare systems can develop antimicrobial stewardship programs. The UK’s National Institute for Health and Care Excellence describes antimicrobial stewardship as “an organizational or healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness”. Stewardship programs therefore cover actions by commissioners, healthcare staff and patients, including awareness-raising, prescribing guidelines, and provision of information and resources.
The second area of action is medicines reviews. We have written about reviews before in the context of the iSimpathy project. Regular reviews of medication can identify opportunities to reduce the unnecessary use of any medication, including antibiotics. They can also ensure that people are on the optimal dose of each medication, considering their other medications. Medication reviews may also offer opportunities to change antibiotic prescriptions and prescribe narrower-spectrum drugs that target specific bacteria. This is especially useful for long-term infections, where the causative agent has been identified in culture, and can therefore be targeted more effectively.
A growing problem — but some possible answers
Antibiotic resistance — already a major global concern — can be amplified by polypharmacy. This amplification may happen both directly and indirectly. Fortunately, much of the best practice in managing polypharmacy also has a direct impact on addressing issues linked to antibiotic resistance. Perhaps the most important actions on an individual level are regular medication reviews. However, stewardship programs can also help to embed best practice at all levels, from patients and their families up to organizational level.
