The global crisis of multidrug resistance: how to face healthcare associated infections without effective antibiotics?

Infections caused by multidrug resistant organisms (MDROs) are severely challenging the healthcare systems worldwide. Resistance to antibacterial drugs is growing in both Gram positive and Gram negative bacteria and is increasingly related to healthcare associated infections (HAIs). Undoubtedly, multiresistant Gram-negatives, especially carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacterbaumannii, represent the cutting edge of crisis today (1). Therapeutic options for these organisms are so extremely limited that old, previously forgotten drugs, such as polymixins, have come back touse in absence of robust data guiding dosage regimens or duration of treatment. Moreover, panresistant strains have always been reported (2). Antibiotic resistance costs: the Alliance for the Prudent Use of Antibiotics (APUA) (http://www.tufts. edu/med/apua/) has estimated for United States of America alone a cost currently ranging between $24 billion and $38 billion a year. A report by the European Centre for Disease Control (ECDC) (http://www. ecdc.europa.eu/en/), focusing on four main types of infection bloodstream, lower respiratory tract, skin and soft tissue and urinary tract infections -has highlighted that resistance is causing annually an economic burden of more than 900 million euros of extra in-hospitalcosts and about 600 million days of lost productivity. In this respect, poorer countries seem to be even more disadvantaged. The poorer the country, the larger is the proportion of its health-care budget being absorbed by the cost of antibacterial drugs: indeed, antibacterial drug resistance forces healthcare to turn from cheaper, but previously largely administered drugs, to more expensive alternatives (3). Unfortunately, a synergistic combination of factors, including the evolving healthcare delivery policies and the shifting of patient demographics and underlying conditions towards higher risk profiles, is deeply changing the landscape of HAIs. All countries are involved in this global crisis with different weights attributable to a variety of concurrent factors. Just to name a few, poor healthcare resources, poor quality of antibiotics, and sometimes over-the-counter availability of antibiotics, are likely playing an important role in developing countries. In developed countries, financial crisis and cutting resources to healthcare systems along with the expanding population of old and chronically ill patients, are worsening the situation. Finally, travels, transfer of patients and the socalled “medical tourism” are bridging the boundaries between the developed and developing countries daily (4). Worldwide reports show that MDRO’s infections are increasingly serious and are in exorably spilling over into the community, mainly through different alternative healthcare settings, such as long-term care facilities (LTCFs) (5). Additionally, elderly and immunocompromised persons with comorbidities, who are recurrently going back and forth between hospitals and LTCFs, contribute to the spread of MDROs and likely represent the largest and misunderstood reservoir of MDROs within the health care network (2, 5). The second driving force of the crisis is the falling number of new antibacterial drugs approved for marketing: indeed, mainly in the field of the MDR Gram negative bacilli, the pharmaceutical industry is * Corresponding author: Caterina Mammina M.D. Adress: Department of Sciences for Health Promotion and Mother-Child Care “G. D’Alessandro”, University, Palermo, Italy. Tel: +39-916-553623 Fax: +39-916-553641 E-mail: [email protected] Volume 5 Number 2 (June 2013) 99-101