(With so many infectious diseases swarming, we are revisiting this from the 2018 archives on antimicrobial stewardship …)

When you’re sick you take drugs… right? And by taking those drugs, like say antibiotics when you have the flu, you get better… right? Wrong, very very wrong! The flu is actually a viral infection, meaning that along with getting plenty of rest the flu can only be treated with an antiviral! I sat down with Dr. Andrew Morris, an infectious disease specialist and Director of the Sinai Health System-University Health Network Antimicrobial Stewardship Program (ASP) to get to the bottom of the do’s and don’ts when it comes to taking antibiotics and to learn a bit more about the emerging global health threat of antimicrobial resistance (AMR).

Infectious disease specialists, you guessed it, identify and treat infections. Specialists use a wide range of antimicrobial agents (e.g. antibiotics, antivirals, etc.) to treat symptoms– but, as Dr. Morris describes, overuse and improper use of antimicrobials (ahem taking antibiotics when you have the flu) coupled with few antimicrobials on the market has contributed to the emerging global health crisis known as antimicrobial resistance.

 Dr. Morris defines antimicrobial resistance as “when antibiotics don’t work because the germs have outsmarted the antibiotics”. Smart germs? Well, not so much brain capacity, more of a real-world example of survival of the fittest courtesy of our friend Charles Darwin. When bacteria (for example) are exposed to an antibiotic, only the resistant survive and spread. This problem intensifies when people are unnecessarily prescribed antibiotics. These redundant, repeat exposures are like bacteria boot camp, training whole populations of bacteria to resist antibiotics, so these treatments become ineffective in the future. Imagine dying from an ear infection?!

Image credit: CDC

Thankfully, we here at Mount Sinai and University Health Network have Dr. Andrew Morris and his SHS-UHN Antimicrobial Stewardship Program (ASP) team. Composed of physicians, pharmacists, nurses, and data analysts, the interprofessional team directly interfaces with prescribers, coaches others in the healthcare team, analyzes data, and conducts research to identify best practices when it comes to treating patients like you and me! Exposed to the tragic consequences of antimicrobial resistance early in his medical career, when a young patient under his care died from an otherwise treatable pseudomonas infection, Dr. Morris yearned to improve how antibiotics were used, effectively launching his career in antimicrobial stewardship.

The SHS-UHN ASP Team: Standing (left to right): Sophia Virani, Sarwat Abbasi, Margot Renshaw, Dr. Linda Dresser, Dr. Chaim Bell, Linda Jorgoni, Dr. Shahid Husain, Dr. Lianne Jeffs, Dr. Warren McIsaac, Janice Takata-Shewchuk Seated (left to right): Dr. Sandra Nelson, Dr. Andrew Morris, Yoshiko Nakamachi, Dr. Miranda So, Dr. Mark McIntyre, Lopa Naik.

The ASP team takes a research-based approach to arrive at their recommendations, using both their successes and failures to inform decision-making on how to proceed further. And they have been pretty successful at doing just that. For example, after noticing gaps in practice for treating patients with Staphylococcus aureus bacteremia were related to high mortality, they decided the way to fill this gap was for patients to be seen by an infectious disease specialist – an easy fix which lead to a 30% drop in mortality!

According to Dr. Morris, the hardest task is to understand the cause of the problem, he explains that there are many drivers of behavior, like cultural factors, a lack of knowledge, or emotional factors so the first step is to figure out problems and then identify ways to tackle them. I stopped him there – medicine and emotions? How could they possibly be related? Dr. Morris then asked what happened when I got sick when I was little, I responded that my parents would give me medication. He then asked why… why? To make me feel better of course, which is exactly where the problem lies!

Sometimes you need medications to get better, but many times you would have healed on your own, but since you had medication, you think that’s why you got better.

This is like a placebo effect but with real medicine. Dr. Morris explains that the link between receiving antibiotics, feeling better, and associating antibiotics with making you feel better creates an attachment to antibiotics for the rest of your life. The same goes for doctors who also receive a natural feedback when they see their patients get better after they’ve administered medication. This dynamic is hard to overcome, which is why audits and coaching by the ASP team are essential for success.

And if we continue to travel down this path, of treating anything (and everything) with pills, we are going to be in big trouble. Already we are seeing the consequences of antibiotic resistance from overuse in our agricultural system, where antibiotics that are used to boost animal growth end up in our food systems or groundwater networks from manure fertilizer run off. These instances create additional opportunities for bacteria to develop resistance and for humans to be exposed. Additionally, the lack of regulation and shortage of antibiotics in low income countries, coupled with drug resistance contributes to the crisis observed. Soon enough, easily treatable infections will become life threatening, hence my ear infection example, because we no longer have medication that can effectively clear these simple infections!

Image credit: CDC

So what can YOU do? Always talk to your doctor before taking antibiotics and take them as prescribed, try to look for antibiotic free meat products, and keep up proper hygiene and sanitation practices to avoid getting sick! While there is no easy solution or silver AMR bullet, it starts with better coordination … infection prevention and control, research and development, innovation, epidemiology and surveillance of antibiotics and antibiotic resistance. In Ontario, and especially here on University Avenue, we see the positive effects of stewardship on patient experiences and population health, so at least you can find comfort in knowing Dr. Morris and the ASP team at SHS-UHN have your back!

For more, check out the Sinai Health System-University Health Network Antimicrobial Stewardship Program website!