Dr. Shannon Ross is an associate professor of pediatrics and microbiology in the division of pediatric infectious diseases at the University of Alabama at Birmingham.© Rob Culpepper
Shannon Ross first became aware that antibiotic resistance was a serious and growing problem during her training as an infectious disease doctor. More and more, she found herself treating patients with increasingly complicated, drug-resistant superbugs, and she concluded that something needed to be done on a broader level to slow the spread of resistant infections. As the medical co-director of the antimicrobial stewardship program at Children’s of Alabama, she now leads a team dedicated to decreasing the threat of antibiotic resistance and improving patient care through better use of antibiotics.
As part of The Pew Charitable Trusts’ Supermoms Against Superbugs initiative, Ross came to Washington, D.C., earlier this year to share her perspective with policymakers and advocate for sustained funding to support programs critical to the fight against antibiotic-resistant bacteria, including the expansion of antibiotic stewardship efforts. She spoke with Pew about the threat of antibiotic resistance, the unique risks it poses to children, and how improving the way we use antibiotics can help.
Q: Can you explain why antibiotic resistance is a problem? Should people be worried?
A: Everyone should care about antibiotic resistance because we all, at some point, are likely to get an infection; and when that happens, we’ll want to make sure we can be treated. Unfortunately, we’re currently on a trajectory where effective treatment may soon be something we can no longer count on.
Already today, even common conditions such as urinary tract infections and pneumonias are becoming increasingly resistant to our first-line antibiotics. And while we used to have lots of oral options to treat simple infections, we now see some bacteria so resistant that patients have to come into the hospital and get intravenous antibiotics because there are no more oral options able to treat those infections.
If we do nothing to curb antibiotic resistance, we’ll eventually run out of options completely and find ourselves in a “post-antibiotic” era—a world much like the one before antibiotics were developed. Even though we’ll have antibiotics, they won’t work against the bacteria that are infecting us. We’ll see patients die from very common infections, and many procedures—like C-sections and joint replacements—won’t be possible anymore because of the risk of infection. The implications are far-reaching and hard to fathom. It would be horrible. To not have anything to offer a patient who is suffering would be a failure. And it’s really scary to think that could be a possibility.
Q: Why are children particularly at risk from antibiotic-resistant infections?
A: Treating children with resistant infections is particularly challenging because they metabolize and use antibiotics very differently than adults. So we have to be careful about how we dose antibiotics. We have to give enough antibiotic to treat the infection but not cause any more harm. There are also fewer antibiotics available to treat children, because more studies have to be done to ensure safety and efficacy before the drugs can be used by the pediatric population. When we continue to see alarming new types of antibiotic resistance emerging, and fewer and fewer antibiotics able to defeat them, it’s a concern for all of us, but I worry especially about children, who have fewer options to begin with.
And then there are kids, like my daughter, who are allergic to entire classes of antibiotics. If she were to get a serious infection, she would have even fewer options. And if it’s a resistant pathogen, that would narrow the field even further. When I see patients in that kind of a situation, with a very limited number of antibiotics that even have a chance of working, I know that it could just as easily be one of my kids, and it really hits home. As a mom—like any mom—if my kids become sick, I want to make sure that they are able to be treated.
Q: What can patients do to slow the rise of antibiotic resistance?
A: One thing that patients can do is become educated about the seriousness of the problem and what they can do to be part of the solution. When patients are seeing their doctor, it’s always good to ask, “Do I absolutely need this antibiotic?” and “How long do I need to take this antibiotic?” This is important because antibiotic resistance is directly related to antibiotic use. So if we reduce inappropriate antibiotic use, we can help decrease antibiotic resistance.
Patients can also educate themselves about what types of illnesses antibiotics are and are not effective against. For example, if you have a cold or a sniffle, that doesn’t mean you need an antibiotic. Most common colds are caused by viruses, which antibiotics have no effect on. When people are sick, they understandably want something to make them feel better, but not all illnesses warrant an antibiotic.
I also make a point to educate my patients and their parents on the potential side effects of taking an antibiotic and the risks of taking them unnecessarily. The most common side effects we see are allergic reactions, such as a rash. Antibiotics can also affect your immune system, and, though not as common, they can cause potentially life-threatening illnesses like Clostridium difficile (often called C. diff), which can lead to horrible diarrhea, requiring hospitalization and treatment.
Q: How can health professionals improve antibiotic use?
A: As with patients, education about antibiotic resistance is also critical for health providers. It’s one of the most important elements to stewardship, actually. As physicians, at the end of the day, we all want to do what’s best for our patients and get them well. But oftentimes, we don’t know what we don’t know. If we’re given information on our prescribing practices and how to improve them, then, certainly, we will make changes to do what’s best for our patients. And that’s where antibiotic stewardship programs come in. Educating clinicians, and tracking and reporting antibiotic use and resistance patterns, are key elements of these programs.
Q: Tell us about antibiotic stewardship at your hospital—what does it entail?
A: We started our hospital’s antimicrobial stewardship program in 2014, and it is a key part of our ability to offer the best patient care possible. We rely on participation from health professionals across departments to make it a success. Our main goals are to track and improve antimicrobial use in the hospital and to monitor the development of any resistant bacteria. We do this by compiling data every month on antibiotics that are used, and then distributing this information to all the prescribers within the hospital so they can have an idea of their practices. Knowing our antibiotic use in the hospital allows us to set targets and goals to reduce our antibiotic use.
We also look at antimicrobial susceptibility patterns, which show what types of drugs are most likely to work against certain infections, and publish a report for the hospital showing what bacteria our patients have and what antibiotics are effective in treating them. We provide this information to all the prescribers and physicians so that they are able to make the best, most appropriate choice when treating their patients. Our hospital is part of a multicenter patient improvement collaborative, so we also report a lot of the stewardship data we collect back to this collaborative. This allows us to compare our antibiotic use rate and resistant organism rates with similar hospitals in the country, which then helps us target goals for how we can improve moving forward.
Q: How has the antimicrobial stewardship program affected your hospital?
A: The program has helped us reduce resistance rates and save lives. One recent example of this is when we saw several cases of a particularly concerning resistant organism pop up in one area of our hospital. The mechanisms we had in place as part of our stewardship program allowed us to track the data and identify the likely cause. As a result, we were able to address the problem quickly, and we have seen a significant reduction of that particular resistant organism in our hospital.
Every day, it’s my patients who motivate me to continue our stewardship efforts. Knowing that our commitment to antibiotic stewardship can play a role in getting them better faster inspires me to keep doing this important work.