A Guide to Antibiotic Resistance

Antibiotics are a powerful tool in fighting infectious diseases. However, the overuse of antibiotics can lead to antibiotic-resistant “superbugs,” leaving the public vulnerable to infections that were once easy to cure and possibly resulting in death. According to the Antibiotic Resistance Action Center at the George Washington University’s Milken Institute School of Public Health, without changes to how antibiotics are currently being utilized, the mortality rate for antibiotic-resistant infections will continue to grow.

There are many components to antibiotic stewardship that can reduce the occurrence of antibiotic resistance. Areas of focus can include antibiotic overuse in clinical medicine, pharmaceutical development of new antibiotics and the antibiotic misuse in livestock raised for food production. 

Antibiotic resistance occurs when bacteria mutates to become less vulnerable to existing medications. This can occur when bacteria are exposed to an antibiotic but not killed by the medication, potentially making the germs stronger and harder to kill. While antibiotics are beneficial to maintaining health in many ways, misuse of antibiotic drugs can contribute to the growing threat of difficult-to-treat infections in humans and in animals. In fact, The World Health Organization has said antibiotic resistance is one of the largest threats to global health.

“Anytime you’re using [antibiotics], you’re potentially fueling the evolution of drug-resistant bacteria,” said Dr. Lance B. Price, professor at the George Washington University’s Milken Institute School of Public Health and co-director of the Antibiotic Resistance Action Center. “So, it [requires] us to use them very carefully, only when absolutely necessary.”

The rise of antibiotic-resistant infections poses significant danger for public health. Without interventions to mitigate the risks associated with antibiotic resistance, this issue will continue to grow.

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The issue of antibiotic resistance is multifaceted, resulting from a variety of causes. This can include unsafe practices used in clinical medicine, the amount of pharmaceutical research focused on antibiotic development and the misuse and overuse of antibiotics in livestock.

There are many factors that contribute to antibiotic overuse in clinical settings. For example, studies have shown that clinicians at urgent care facilities over-prescribe antibiotics in situations where patients may not have a bacterial infection. Price said this may sometimes be due to the insistence of pushy patients, fear of “the one-star review” and the limited time urgent care clinicians have with patients to educate them on antibiotic stewardship.

Price also acknowledged the cost of care can lead to poor practices. For example, rapid point-of-care diagnostics allow clinicians to determine not only if there is a bacterial infection but also what type of bacteria is causing the infection, allowing for the prescription of certain types of antibiotics that are more targeted.

“The problem is the financial incentive,” Price said. “The payers, such as insurance companies, would rather pay for a $5 prescription than a $100 diagnostic test.”

The development of new antibiotics is a necessary component when fighting antibiotic-resistant bacteria. The process of developing drugs is long and may not result in a viable product: Based on historical data, 1 in 5 drugs developed to fight infectious disease that reach the point of human testing end up receiving FDA approval.

In addition to the time it takes to develop new antibiotics, the return on investment is lower than that of more lucrative drugs. This has led many large companies to focus research on other areas of medicine. According to Pew Charitable Trusts, “over 95% of the products in development today are being studied by small companies rather than the large pharmaceutical firms that once dominated this field.”

The livestock industry has a long history with the overuse of antibiotics. For many years, antibiotics were commonly used in the United States to reduce the time and money spent to bring an animal to market size. The practice of using antibiotics for growth promotion was banned in 2017 by the FDA (PDF, 118 KB). While this has reduced the use of antibiotics in meat production, the problematic use of antibiotics is still present in the United States and around the world.

According to Laura Rogers, deputy director for the Antibiotic Resistance Action Center, more than 13 million pounds of antibiotics are sold for use in animal production per year in the United States. Antibiotic overuse in livestock can include giving animals low levels of medicine consistently to prevent infections.

Price said some caretakers may utilize low-dose antibiotics as opposed to giving livestock better food and living conditions in order to prevent infection. “That just fuels the growth of drug-resistant bacteria,” he said.

In addition to harming animals, antibiotic misuse ultimately affects the consumer.

“The meat that we see in the grocery store may be contaminated with bacteria — and a lot of times, drug-resistant bacteria,” Price explained. “Those bacteria make their way to people, and then they can cause drug-resistant infections.”

There is much work to be done at the macro level to combat the issue of antibiotic resistance, including the implementation of best practices in livestock care and stewardship initiatives in clinical care. However, Price said that there are also actions individuals can take to help the cause and promote personal health.

“I think that we need to become better consumers of antibiotics, both in terms of the food products that we buy and how we approach medicine,” Price said. “We all have to lead this antibiotic stewardship movement in terms of how we behave as patients, as clinicians and as consumers.”

There are a variety of reasons consumers are reevaluating what meat products they buy, including personal health, climate change concerns and animal welfare. To reduce the risk of encountering antibiotic-resistant bacteria — and avoid supporting bad practices — Price recommends buying meat products from companies that do not use antibiotics in livestock for disease prevention.

“You can vote with your dollar, and you can do it for personal and public good reasons,” Price said.

However, some companies may use other labels that misrepresent their food production practices. Look for the following when purchasing meat and poultry products:

Department of Agriculture Organic Seal 

Is it raised without antibiotics? Yes. 

Abstaining from use of antibiotics in animals raised for meat, poultry, dairy and eggs is one requirement in order to claim a product as organic. 

“Raised Without Antibiotics,” “No Antibiotics Ever” 

Is it raised without antibiotics? Yes.

These claims mean the animals used for food production should have never received antibiotics, though few programs test animals to ensure no “cheating” happens.  

“No Medically Important Antibiotics” 

Is it raised without antibiotics? No. 

This claim generally means that antibiotics that are currently used in humans were not used on the animals used in food production. However, the use of any antibiotics can still lead to antibiotic resistance that affects people.  

“No Critically Important Antibiotics” 

Is it raised without antibiotics? No. 

Companies that utilize this phrasing generally abstain from using some medically important antibiotics that are used to treat humans. This practice can still lead to the development of antibiotic-resistant infections. 

“No Growth-Promoting Antibiotics”

Is it raised without antibiotics? No. 

This label is not meaningful, as the FDA banned the use of antibiotics in animals for the purpose of growth promotion.

Note: “Antibiotic-free meat” is sometimes used as shorthand for meat produced by animals that were raised without antibiotics. All meat and poultry products are legally required to be devoid of antibiotics, meaning animals treated with antibiotics must go through a withdrawal period before being processed. 

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Questions to Ask About Your Antibiotic Prescription

To promote antibiotic stewardship, Price said patients can ask their provider questions when receiving an antibiotic prescription to better understand their plan of care and the medication they are receiving. 

1

What infection am I being treated for?

2

What type of antibiotic am I being prescribed?

3

Is this antibiotic the first line of treatment for the type of infection I have?

4

Is this a narrow spectrum antibiotic (i.e., an antibiotic that only targets the bacteria known to cause a specific infection)?

5

When and how should this antibiotic be taken (e.g., time of day, with or without food, total days of treatment)?

6

What are the potential adverse effects of this medication?

Citation for this content: MPH@GW, the online MPH program from the Milken Institute School of Public Health at the George Washington University.