By: Natalia Jucha PharmD Candidate c/o 2022
Due to the overuse and misuse of these medications, antibiotics are no longer as effective against their intended pathogens.1 In 2019, the World Health Organization (WHO) released its AWaRE Classification Database which stands for “Access, Watch and Reserve”.2 Clinicians use this database as a guide to appropriately select antibiotics for the pathogens they are fighting. The “Access” group in the WHO database identifies antibiotics used to treat common pathogens seen in clinical practice. The entire database is comprised of 180 antibiotics, 48 of which are in the access group. The “Watch” group describes antibiotics utilized in pathogens with the potential of displaying resistance; these are antibiotics that infectious disease teams focus on monitoring in different health care systems. As for the “Reserve” list, there are 22 antibiotics specified for the use in multi-drug resistant pathogens; our “last resort.” This is merely 10% of the antibiotics currently recommended through the AWaRE Classification Database, which shows the alarming need for antibiotic stewardship.
In 2016, the Centers for Disease Control and Prevention (CDC) established the Antibiotic Resistance Lab Network (AR Lab Network), where multi-drug resistant pathogens can be identified efficiently and accurately. Health Care Providers (HCPs) are expected to be familiar with resistant strains in each facility and community. All HCPs are required to be notified by the laboratory for any antibiotic-resistant pathogen as well as be responsible for informing patients and family members. Reporting unusual cases to local health departments is an additional obligation intended to protect the community.3 The world is a global community, where it is ever more difficult to control infections (as seen with the recent COVID-19 pandemic). Antibiotic resistance and multi-drug resistant pathogens are an ever-evolving problem in need of a global effort and solution.
Nosocomial infections, or infections acquired in a hospital setting, pose a unique danger for patients as they can be more difficult to control. Hospitals, nursing homes and systems with many patients in a given area exhibit a higher incidence of infectious pathogens. The acronym, ESKAPE, identifies pathogens that are deemed Infectious Disease Society of America’s (IDSA) largest threats in terms of drug-resistant tendencies: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species.4 New antibiotics are in constant demand for these pathogens that haunt health care systems and provide an additional peril to immunocompromised patients. According to the Pew Charitable Trusts Organization, as of December 2019 there are 41 antibiotics in development and are evenly dispersed between Phase 1 through Phase 3 clinical trials. About 40% of these antibiotics exhibit a potential to treat ESKAPE pathogens, and close to 25% of them exhibit a new mechanism of action.5 Although this seems like promising news, these are still medications in clinical trials. Infections spread rapidly, and if not treated correctly, pathogens will express a greater degree of pathogenicity. As seen with former antibiotic discoveries, some resistance mechanisms develop as quickly as the same year a drug is released or approved [seen with methicillin and Methicillin-Resistant Staphylococcus aureus (MRSA)].3To combat antibiotic resistance effectively, practitioners must start their work at the patient level. We are all far too familiar with patients telling us, “I felt better, so I stopped taking my antibiotic” and suddenly we feel an itch at the tip of our tongue to protest and educate. It is also important to give back to our communities by educating future generations such as children in elementary schools, middle schools, and even high schools. Pharmacy students such as ourselves and pharmacists must utilize our skill sets to improve society’s knowledge, and by doing so, health.
Amidst the rise of the COVID-19 pandemic, in late February 2020, St. John’s University’s (SJU) American Pharmacists Association – Academy of Student Pharmacist’s (APhA-ASP) Operation Public Health embarked on a mission to raise awareness about antibiotic resistance in a Brooklyn Middle School. Four SJU pharmacy students, myself included, along with the faculty advisor for Operation Public Health acted as substitute-science teachers for four different classes (6th and 7th graders). The presentation that was developed for class time outlined two major topics: “what is a pharmacist” and “antibiotic resistance”. The students seemed engaged, wanting to learn about the field of pharmacy and what role pharmacists have “in the real world”. Additionally, there was an interactive activity where we asked students about the process of a prescription – many of whom thought it was a 5-minute process! Once we felt they were more comfortable as to the role we play in society as health care professionals, we started our mini lesson on different “bugs” including bacteria, fungi and viruses, outlining the differences between them We talked about good versus bad bacteria with a True and False activity and tested their math skills with a simple dosing question for an antibiotic. Along with interactive activities and videos, we tried to give them enough background information for the bigger issue at hand, antibiotic resistance. We concluded the presentation with a Timeline of the “Bigger Picture” and what we as a society can do to collectively combat this issue.
Throughout the 40 minutes we had with each class, the students exhibited incredible focus on the topic at hand. We had many students that asked about current events such as COVID-19, the Fiscal Year 2020 President’s Budget for Health and Human Services, and general follow up questions about how to stay safe from infections. Although we aimed to answer many questions about antibiotic resistance, there seemed to be an overwhelming amount of questions about COVID-19, which at the time hadn’t even had its first case in the United States. Some questions included:
· How is coronavirus different than the regular flu or cold?
· When will we have a vaccine?
· How fast can a vaccine be developed?
· What are the signs and symptoms of coronavirus?
· How are the symptoms different from other infections?
· How can we avoid/prevent catching the virus?
· Where did the virus actually come from?
· How does coronavirus spread?
· Is there any treatment for this virus?
· Is the United States allocating enough money for the medical system this year?
· Why is coronavirus such a threat to the United States?
Having 11 and 12-year-old children asking these questions in the span of 5-10 minutes, you’d think you’re subbing in for Governor Cuomo at a Statewide Press Conference with a room full of relentless reporters. Throughout this presentation, I gained a better appreciation for the knowledge and curiosity these younger students displayed about current events and topics that they don’t have exposure to during their normal science classes. The students’ excitement on the subject of antibiotic resistance, bacteria and COVID-19 truly parallels general society because it is important for the public to understand basic scientific concepts that can affect their health, especially in urban areas. Seeing this parallel between younger students and the general public, I am confident that members of society are not only more knowledgeable than we think, but ask the right questions due to their curiosity.
Schools and education systems are responsible for preparing students for the future and fuel their passion. The public-school system fails to give students the ability to fuel their curiosity unless students are already in a supportive environment and driven to achieve their goals. Not all students have the drive to explore their interests unless they gain exposure. Public schools in New York city should openly invite alumni to speak to current students about the field they chose to go into as well as what problems the future generation can face within that field. My experience with these extremely intelligent middle school students showed me that with the right delivery, children can excel in understanding current situations, ask valid questions and express genuine interest. The topics that we discussed with these middle school students are only a small portion of what pharmacists are bound to overcome in their careers for the greater good of society. Healthcare is an area that affects all individuals, but is only a small stitch in society’s greater fabric. Acknowledgements:
I would like to thank Yumi Lee, PharmD. BCPS for encouraging me to write about my experience and further reflect on the impact this event had on younger students. I would like to express special thanks to my mentor, Lane Nguyen, PharmD. BCPPS for providing feedback and guiding me in the construction of this article. His thorough review process and extensive conversations helped reignite my passion for antibiotic resistance and necessary antibiotic stewardship.
- Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T Peer-Rev J Formul Manag. 2015;40(4):277-283.
- WHO-EMP-IAU-2019.11-eng. Published online 2019. https://apps.who.int/iris/bitstream/handle/10665/327957/WHO-EMP-IAU-2019.11-eng.xlsx?ua=1
- Centers for Disease Control and Prevention (U.S.). Antibiotic Resistance Threats in the United States, 2019. Centers for Disease Control and Prevention (U.S.); 2019. doi:10.15620/cdc:82532
- Drug Resistance – There is No Escape from the ESKAPE Pathogens. Accessed November 6, 2020. https://emerypharma.com/blog/eskape-pathogens-explained/
- Tracking the Global Pipeline of Antibiotics in Development, April 2020. Accessed November 6, 2020. https://pew.org/2UCFs46