Ask a Librarian: Antibiotic resistance and stewardship

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Antibiotic resistance happens when bacteria that cause illness become resistant to the antibiotic drugs used to treat them.

Leading causes of increased antibiotic resistance are the overuse or inappropriate use of antibiotics, including:

  • giving antibiotics to people and animals when they are not needed;
  • taking antibiotics in ways other than those prescribed;
  • self-medicating or antibiotic sharing; or
  • taking antibiotics for infections not caused by bacteria.

Antibiotic stewardship refers to the set of standards applied to the prescribing of antibiotics in order to reduce the risk of resistance, harm to patients and cost to the health system.

Here are some resources on antimicrobial resistance and stewardship selected by Joule’s Ask a Librarian team using a variety of tools included with a CMA membership or freely available online.

 

Clinical summary from DynaMed

Access DynaMed online or through the mobile app to get concise overviews and detailed recommendations, medical graphics and images, drug information from Micromedex and more.

Antimicrobial Stewardship - excerpt:

  • antimicrobial resistance is a top healthcare priority for Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO)1,4
    • high rates of resistance among organisms that cause common healthcare associated and community-acquired infections globally
    • no new classes of antibiotics have been developed since 1980s
    • antibiotic resistance develops rapidly upon release of new antimicrobial drugs, particularly in the setting of
      • overuse of antimicrobials in clinical settings
      • overuse of antimicrobials in agriculture, such as
        • soil treatment of azoles (predominantly in Europe) associated with increase in azole-resistant fungal infections
        • broad antibiotic treatment of food-producing animals
    • estimated economic impact of antimicrobial resistance in United States is in excess of $21 billion/year and 8 million additional days of hospitalization
    • issues of greatest concern to Centers for Disease Control and Prevention include
    • issues of greatest concern to the World Health Organization include
      • growing resistance among
        • Escherichia coli (a common cause of urinary tract infections, bloodstream infections, intra-abdominal infections, and foodborne infections) to third-generation cephalosporins and fluoroquinolones
        • Klebsiella pneumoniae to third-generation cephalosporins and carbapenems
        • Staphylococcus aureus to methicillin
        • Streptococcus pneumoniae to penicillin
        • nontyphoidal Salmonella and Shigella species to fluoroquinolones
        • N. gonorrhoeae to third-generation cephalosporins
  • antimicrobial stewardship programs have demonstrated efficacy for reducing antibiotic use, antibiotic costs, antibiotic-associated adverse-events, and antibiotic resistance without negative impact on patient outcomes
    • multifaceted interventions may reduce inappropriate antibiotic prescribing in ambulatory clinics (level 2 [mid-level] evidence)
    • development and dissemination of institution-specific recommendations for treatment of uncomplicated urinary tract infection in the emergency department associated with improved agreement between empiric treatment and isolated pathogen susceptibility (level 2 [mid-level] evidence)
    • in inpatient settings
      • antimicrobial stewardship interventions associated with reduced utilization of antimicrobials and reduced antimicrobial costs in intensive care units (level 2 [mid-level] evidence)
      • antimicrobial stewardship program associated with decline in infections due to C. difficile and vancomycin-resistant enterococci, reduced cost, and similar clinical outcomes (level 2 [mid-level] evidence)
      • physician-led antimicrobial stewardship program associated with reduced costs and improved rates of susceptibility in Pseudomonas aeruginosa isolates (level 2 [mid-level] evidence)
      • implementation of antimicrobial stewardship program associated with reduced cost and C. difficile infection, with no significant effect on death or readmission within 30 days (level 2 [mid-level] evidence)
      • bundled antimicrobial stewardship program associated with reduced mortality and fewer antibiotic doses (level 2 [mid-level] evidence)
      • audit and feedback program in critical care unit associated with reduced use of broad-spectrum antibiotics, reduced incidence of nosocomial C. difficile infections, and increased gram-negative susceptibility to meropenem (level 2 [mid-level] evidence)

See related DynaMed summaries:

Antimicrobial stewardship topic summary (CMA members can access full summaries for this and other topics via this link)

 

Clinical information via ClinicalKey:

ClinicalKey drives better care by delivering fast, concise answers, and deep access to evidence whenever, wherever you need it. ClinicalKey includes access to 1,000+ textbooks, 600 full-text journals, images, videos and customizable patient handouts across 30+ medical specialties

Clinical Overviews

Methicillin-resistant Staphylococcus infections (MRSA and MRSE) Updated April 24, 2020.

Clostridium difficile infection in Ferri's Clinical Advisor 2020.

Vancomycin-Resistant Enterococcus (VRE) in Ferri's Clinical Advisor 2020

Book chapters:

Molecular Mechanisms of Antibiotic Resistance in Bacteria in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Chapter 18, 222-239.e3

Mechanisms and Detection of Antimicrobial Resistance in Principles and Practice of Pediatric Infectious Diseases, Chapter 290, 1467-1478.e4

Principles Governing Antimicrobial Therapy in the Intensive Care in Critical Care Medicine: Principles of Diagnosis and Management in the Adult, Chapter 48, 788-806.e7

Resistance to Antibacterial Drugs - Basic principles of antimicrobial chemotherapy in Rang & Dale's Pharmacology, Chapter 51, 649-660

 

Free information sources

CMAJ

Jennie Johnstone, Gary Garber and Matthew Muller. Health care-associated infections in Canadian hospitals: still a major problem. CMAJ  September 09, 2019  191 (36)  E977-E978

Robyn Mitchell, Geoffrey Taylor, Wallis Rudnick, Stephanie Alexandre, Kathryn Bush, Leslie Forrester, Charles Frenette, Bonny Granfield, Denise Gravel-Tropper, Jennifer Happe, Michael John, Christian Lavallee, Allison McGeer, Dominik Mertz, Linda Pelude, Michelle Science, Andrew Simor, Stephanie Smith, Kathryn N. Suh, Joseph Vayalumkal, Alice Wong and Kanchana Amaratunga; for the Canadian Nosocomial Infection Surveillance Program. Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys. CMAJ September 09, 2019 191 (36) E981-E988

Lauren Vogel. Dramatic rise in VRE infections linked to abandoned control measures. CMAJ August 06, 2019 191 (31) E876; DOI: https://doi.org/10.1

Caroline Mercer. Education needed — for doctors and patients — to reduce inappropriate antibiotic prescriptions. CMAJ  May 06, 2019  191  (18)  E514-E515

Kevin C. Katz, George R. Golding, Kelly Baekyung Choi et al for the Canadian Nosocomial Infection Surveillance Program. The evolving epidemiology of Clostridium difficile infection in Canadian hospitals during a postepidemic period (2009–2015). CMAJ  June 25, 2018  190  (25)

CMAJ Open

Kevin L. Schwartz, Bradley J. Langford, Nick Daneman, Branson Chen, Kevin A. Brown, Warren McIsaac, Karen Tu, Elisa Candido, Jennie Johnstone, Valerie Leung, Jeremiah Hwee, Michael Silverman, Julie H.C. Wu, and Gary Garber. Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data. cmajo 8:E360-E369; published online May 7, 2020.

Jennifer A. Pereira, Allison McGeer, Antigona Tomovici, Alex Selmani, and Ayman Chit. Incidence and economic burden of Clostridioides difficile infection in Ontario: a retrospective population-based study. cmajo 8:E16-E25; published online January 30, 2020

 

Guidelines and other information

National

Antimicrobial stewardship - Pan-Canadian Public Health Network. Published on: 2016. Accessed on August 30, 2020.

Antimicrobial stewardship in daily practice: managing an important resource - Canadian Paediatric Society. Published on: 2014-05 Reaffirmed: Jan 1 2020. Accessed on August 30, 2020.

Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection - Association of Medical Microbiology and Infectious Disease Canada. Published on: 2018-06. Accessed on August 30, 2020.

Antibiotic-Resistant Organisms (AROs) – Infection Prevention and Control Canada (IPAC). No date. Accessed August 30, 2020.

Antibiotic (antimicrobial) resistance – Government of Canada. Date modified: 2018-11-16. Accessed on August 30, 2020.

Using Antibiotics Wisely – Choosing Wisely Canada. No date. Accessed August 31, 2020.

 

International

Antibiotic / Antimicrobial Resistance (AR / AMR) – Centers for Disease Control. Updated on July 20, 2020. Accessed on August 30, 2020.

Antibiotic resistance – World Health Organization. Updated on July 31, 2020. Accessed on August 30, 2020.

 

Patient education resources

How to make sure antibiotics are the right choice – Caring for Kids – Canadian Paediatric Society. Last Updated: November 2016. Accessed August 30, 2020.

Antibiotic Resistance – Medline Plus. Page last updated on 17 August 2020. Accessed August 30, 2020.

About antibiotic resistance – Government of Canada. Date modified: 2019-11-27. Accessed on August 30, 2020.

Need more information or have a clinical question on any other topic of interest? Contact the Ask a Librarian team to request a literature search.

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This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about physician-led innovation? Please connect with us at jouleinquiries@cma.ca.

About the author(s)

Joule’s medical librarians are the professionals behind “Ask a Librarian”, a service for all CMA members looking for clinical search expertise. This experienced team of librarians can support you by searching on your behalf, teaching you effective search strategies or training you to use our clinical resources.

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