Case study / public health


Discussion Board: ONE HEALTH Case Study

Please answer questions below

Below you will find a case study. Read through the case study, and answer the questions. You assignment must be at least 500 words or more.

Antibiotic Resistance: It’s With Us for the Long Run

It was too good to be true: When penicillin was first introduced in clinical practice during World War II, it had dramatic impacts on a range of infectious diseases, from pneumococcal pneumonia, to gonorrhea to staphylococcal wound infections. No randomized controlled trials were needed to demonstrate its efficacy or effectiveness compared with previous treatments. In short order, however, higher dosages of penicillin were required, and by the early 1950s, penicillin stopped working altogether for many infections.

In the 1950s, new classes of antibiotics were developed that headed off a crisis. However, it was already apparent that bacteria had the ability to develop resistance to antibiotics using a range of mechanisms. The more aggressively antibiotics were used, the more common resistance became, especially in hospitals where antibiotics had literally become standard operating procedure.

In addition to the use of antibiotics to treat bacterial infections, it became common clinical practice to try antibiotics as a first-line approach when the cause of the problem was not clear or was most likely due to a virus. In addition, it was found that antibiotics could modestly increase the growth rate of many animals raised for food. Widespread use of antibiotics in farm animals allowed the development of feedlots and whole industries devoted to raising animals together in close quarters. By the late 20th century, animal use of antibiotics far exceeded human use. In recent years, routine feeding of antibiotics to animals has been banned in much of the developed world but has only recently been curtailed in the United States. These antibiotics may end up in public water systems, where the runoff from feedlots contaminates streams and groundwater. It has been called a “double hit”: We get antibiotics in our food and drinking water, both of which promote bacterial resistance.

By the early years of this century, the problem of antibiotic resistance returned with a vengeance. Methicillin-resistant Staphylococcus aureus infections, or MRSA, became widespread not only in the hospital but in the community as well. Healthy athletes as well as those undergoing outpatient surgeries were now at risk for life-threatening diseases. Community-acquired MRSA skin infections are increasingly common in groups that share close quarters or experience more skin-to-skin contact, such as team athletes, military recruits, and prisoners. However, MRSA infections are being seen in the general community as well, including in individuals without known risk factors.

The problem is broader than staphylococcal infection; in fact, the vast majority of bacteria that cause infections in hospitals are resistant to at least one of the antibiotics previously used for their treatment. Recently, gram-negative infections, which are the most common causes of urinary tract infections and an increasingly frequent cause of pneumonia and postsurgical infections, have often become resistant to multiple antibiotics. The CDC estimates that over 20,000 people per year die in the United States alone from antibiotic-resistant bacterial infections.

A number of mechanisms can confer bacteria with antibiotic resistance. For instance, bacteria may chemically modify the antibiotic, making it inactive through physical removal from the cell, or modify the antibiotic’s target site on the bacteria so that the bacteria do not provide a receptor for the antibiotic. Despite our increasing understanding of the mechanism of antibiotic resistance, no new classes of antibiotics have been developed and approved since the early 1990s.

Reducing the consequences of the existing antibiotic resistance is critical. Increased hand-washing and use of other sterilizing procedures is under way in healthcare institutions. Parallel precautions might be needed in athletic and fitness facilities. Early nonantibiotic treatments of wounds and other acute conditions may also become necessary.

Previously unrecognized impacts of overuse of antibiotics are increasingly being recognized. These are likely to include increases in childhood asthma and in juvenile idiopathic arthritis. There is even suggestive evidence of an increase in childhood obesity associated with early use of antibiotics. These previously unexpected impacts are all being linked to changes in the human microbiome that are due to overuse of antibiotics. The human microbiome consists of billions of bacteria and other microbes that live outside and inside all human beings, most commonly in the gastrointestinal tract.

Reducing or eliminating the routine use of antibiotics in healthy animals is being encouraged by the FDA on a voluntary basis. The FDA would need additional legal authority to require a veterinarian’s prescription before antibiotics may be used, which would limit their use to animals with specific conditions or diseases.

New approaches to reducing the development and spread of antibiotic-resistant bacteria are under way, and new classes of antibiotics are under investigation. Before clinical approval, they will need FDA approval, either through the traditional or expedited review process. Once approved, the FDA will need to decide whether they should be available for all licensed prescribers or restricted to specifically qualified prescribers and/or specific conditions/diseases.

Alternative or complementary approaches, such as greater reliance on vaccinations, may reduce the need for antibiotics. For instance, vaccines to prevent pneumococcal and meningococcal bacterial disease have been highly successful. Use of nonprescription probiotics, or “good bacteria,” has been shown to improve the tolerance for, and at times the effectiveness of, existing antibiotics. They are increasingly being used as a routine adjunct to treatment and possibly for prevention.

New approaches to antibiotic resistance may come from the rapidly expanding understanding of the relationship between human health, animal health, and ecosystem health. The issue of antibiotic resistance to treatment is not new, and it is not going away.

Discussion Questions

  1. What are the positive and negative aspects of routine use of antibiotics on animals raised for food use? What types of restrictions, if any, do you favor?
  2. If a new class of antibiotics is developed and approved by the FDA, what type of restrictions should be placed on its use, if any?
  3. What interventions do you recommend for reducing the impact of bacteria that are already resistant to multiple antibiotics?
  4. How should the recently recognized impacts of antibiotic overuse affect recommendations for use of antibiotics in primary care practice?
  5. What One Health concepts are illustrated by this case study?

Suggested Reading

  1. S. Food and Drug Administration. Combating antibiotic resistance. (Links to an external site.). Accessed December 1, 2016.
  2. Centers for Disease Control and Prevention. National Strategy to Combat Antibiotic- Resistant Bacteria. (Links to an external site.). Accessed December 1, 2016.
  3. World Health Organization. Antimicrobial resistance. (Links to an external site.). Accessed December 1, 2016.

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