Antimicrobial Resistance and Human Use of Antibiotics Position Statement

Antimicrobial resistance is a growing concern in the United States with a 2004 survey by the Infectious Diseases Society of America estimating that 70 percent of hospital-acquired infections are due to antibiotic resistant bacteria. Recipients of organ transplants and those awaiting transplantation, are at special risk for infections with resistant organisms due to their increased exposure to hospital environments, including intensive care units, frequent need for invasive procedures especially around the time of transplantation, and increased antibiotic exposure. Transplant patients may be at even greater risk than others because the immunosuppressive medicines required to prevent rejection of the new organ may further reduce their ability to fight these infections. All of these factors allow the transplant recipient to serve as a reservoir of resistant bacteria. Rates of antibiotic resistant bacteria in people either awaiting transplantation or those who have been transplanted have been estimated to range between 30 and 80 percent depending on the bacteria and the type of transplant. Antimicrobial resistance is a significant problem in transplantation, contributing to increased cost of care and poorer outcomes, including decreased patient and transplant organ survival and increased deaths on transplant waiting lists.

The solution to this problem is complex and the American Society of Transplantation (AST) supports a multi-tiered approach to combating the challenge of antimicrobial resistance. Initiatives must be directed at drug development, measures to reduce the spread of these resistant organisms, and improved early detection and diagnostic systems.

In the past 10 years, what had been a rich pipeline for the development of new antimicrobial agents has started to dry up. Given the high cost of developing and implementing clinical trials for what may be a limited return on investment, pharmaceutical companies have reduced research efforts aimed at new antimicrobial drug development, focusing their efforts on developing medicines more likely to be profitable. The number of new agents and classes of drugs has been severely reduced and, at present, the future of drug development in this area appears bleak, despite the growing need for new antimicrobials. The AST favors support for incentives to develop new antimicrobials, especially those designed to combat the increasingly resistant organisms encountered in today's healthcare environment.

Although the development of new medications is critical, clearly this will not be a fast nor lasting solution, by itself, to the problem of resistance. Health care providers and patients must work together now to stem the explosion of resistant organisms. This requires the judicious use of those agents that are currently available. Many hospitals have instituted antimicrobial stewardship programs that are designed to promote the appropriate use of antimicrobials, discouraging the widespread use of broader spectrum drugs for inappropriate indications. These programs are successful at reducing the burden of resistant organisms in participating centers. Unfortunately, they are costly to maintain as they are not reimbursable initiatives, and require the ongoing involvement of qualified health care providers, including infectious diseases trained physicians and specialized pharmacists, to ensure the quality and adherence to these initiatives. Hospitals and health care settings, including long term care facilities, must be encouraged to develop these programs and they should be rewarded for their participation.

Unfortunately resistant organisms are no longer exclusively encountered in hospitals and extended care facilities. They are being increasingly recognized in community settings. Outbreaks of resistant bacteria have been seen in schools and athletic facilities, as well as outpatients being treated for commonplace infections, including those involving the throat, ears, skin, and urinary tract. It is likely that these "hard to treat" bacteria are spreading due to the rampant use of unnecessary antibiotics in the outpatient setting. In many instances, Americans expect to get antibiotics when they go to the doctor, regardless of the actual need. The AST supports the implementation of a major educational campaign to help stem this public demand. Education alone, however, will not be sufficient. In order to most safely treat our patients, improved diagnostics will be necessary.

Because resistant organisms are currently a major threat to our patients, we must have systems in place to deal with this issue now. This requires prompt recognition of these bacteria in both the hospital and community environments. The AST supports the development and implementation of enhanced diagnostics platforms for rapid identification of these organisms. This will allow both for the early and appropriate use of effective antimicrobials and the ability to prevent the spread of resistant organisms, by implementing appropriate hospital control measures to prevent patient to patient spread.  The development of these tests may require costly research and may have limited short term return on the investment, Nonetheless, it is necessary if we are to reduce the impact of resistant organisms on American health and well being.

If we are going to be successful in decreasing the spread of resistant organisms in the United States, participation of the entire health care team will be required. This means that individuals involved in the care of our patients and those with the ability to develop new technologies and medications must form a partnership committed to this endeavor. On behalf of our patients, who are at greatest risk from these pathogens, the AST supports initiatives for the development of new drugs and diagnostics, as well as those initiatives designed to educate and treat our patients judiciously for infections.

Revised and approved by the AST Board of Directors, September 6, 2011