Exploring the Environmental Impact of Antibiotic Overuse

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Antimicrobial resistance (AMR) is a global public health concern impacting personal and population health levels. Increases in AMR have led to the emergence of multidrug-resistant organisms (MDROs), where once an antibiotic could kill or render the pathogen ineffective, now the antibiotic has little to no impact on the infection’s clinical course. This leads to increased morbidity and mortality in humans, but the full impact is still unknown for the global public health environment.

In 2019, an estimated 2.8 million MDRO-related infections occurred in the United States, resulting in 38,000 deaths.¹ Additionally, the annual costs of treating MDRO infections exceed $4.6 billion.² At the local level, infection preventionists see the impacts of AMR daily. Patients with MDRO infections often have higher acuity with more severe illness, requiring extensive treatment methods and additional resources dedicated by the health care treatment team (eg, personal protective equipment usage, dedicated equipment, and enhanced precautions). They also often result in poorer outcomes. Isolation precautions are one infection control tool to decrease the risk of cross-transmission of MDROs in health care facilities. However, the prevention of the development of additional MDROs in health care facilities frequently falls under the work of the antimicrobial stewardship program (ASP).

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level.

The inappropriate use of antibiotics has long been a public health concern, from the emergence of methicillin-resistant Staphylococcus aureus as a significant health care–associated infection in the 1990s to the current concerns with MDR gram-negative organisms and fungal pathogens (eg, Candida auris). Antimicrobial stewardship efforts are a driving force in preventing the continued practices resulting in the evolution of resistance in these organisms.

Although AMR in microorganisms has developed due to inappropriate clinical use, extensive agricultural use and wastewater runoff have also contributed to the more significant environmental burden.³ One Health is a scientific concept where the interconnections between humans, animals, and the environment all impact community health and well-being.⁴ From a One Health perspective, the key factors influencing AMR globally are inappropriate antibiotic use in humans and animals, environmental contamination, and poor infection prevention practices.⁴ One Health focuses on understanding AMR through several methods: surveillance and reporting of AMR, following the epidemiology of MDR pathogens, understanding the impacts on human and animal health, and developing policy and process changes to decrease the risks of AMR.

Animal and agricultural use of antibiotics tends to have a broader use for prophylactic purposes and usage without clinical or therapeutic relevance. Broad-based usage as a preventive for livestock and animal populations has led to misuse and overuse related to increased resistance. In humans, prophylactic use of antibiotics is more limited, which is often due to exposure to communicable diseases or high-risk patients undergoing procedures. However, even with these stricter guidelines, inappropriate use of antibiotics is common in humans.

Other practices that impact the global incidence of MDR pathogens include food production and distribution, international travel (including medical tourism), climate change, and lack of sanitation and environmental hygiene. A more holistic approach can be appreciated as we apply these One Health concepts to local infection prevention and ASP initiatives.

The Joint Commission and other regulatory bodies have developed guidance for various aspects of antimicrobial stewardship activities in health care facilities. In January 2023, The Joint Commission updated the standards to include 12 elements of performance. These elements include ensuring the dedication of resources to ASP efforts, having multidisciplinary involvement in the program, data collection on specified metrics and reporting to the facility leadership, addressing prescribing practices for common clinical indications, and demonstrating implementation of action plans to improve performance.⁵

Similarly, the Centers for Medicare & Medicaid Services (CMS) has included ASP activities in the health care facility Conditions of Participation.⁶ Additionally, starting in January 2024, reporting of antibiotic use and antibiotic-resistance data will be included in the CMS Promoting Interoperability (formerly titled Meaningful Use) Program for health care facilities.⁷ A key component of all these requirements is that infection prevention collaborate with ASPs and actively work with stakeholders to perform surveillance reporting, analyze and interpret data, and implement evidence-based practices.

Infection preventionists should be tightly aligned with their facility’s ASP. Inappropriate antibiotic use can take the form of a mismatch of antibiotic to the pathogen, incomplete courses of antibiotics, overuse of antibiotics for colonization or nonbacterial infections, and prolonged courses of antibiotics. ASPs are accountable for addressing these issues and others. Infection prevention and ASP are 2 arms of the same preventive body, impacting patient safety and outcomes. As ASPs evolved in health care, the role of the infection preventionist has not always been well understood, as it often varies based on local levels of support and resources. Some programs have infection preventionists reporting data or statistics on pathogens of interest and MDROs, whereas others may be more intimately involved in developing policy, interventions, education, and strategic plans to advance the ASP agenda.

A standard methodology for ASP and infection prevention programs to work together is diagnostic stewardship initiatives. Diagnostic stewardship includes using microbial diagnostic tests to direct the most appropriate therapeutic interventions. These initiatives ensure patients are diagnosed accurately and are treated with the most appropriate antibiotic for the infection. Examples of diagnostic stewardship initiatives include developing criteria for proper testing of patients for urinary tract infections, bloodstream infections, and Clostridioides difficile infections. Laboratory tests can be optimized to help identify colonization vs active disease, as has been developed for C difficile with a 2-step process where an initial highly sensitive test is used first to cast a broad net, followed by a more specific toxin-based test to narrow the diagnostics.

Policy development is needed to address increasing AMR at regional and national levels. This can be accomplished with local-level policy changes to enhance and support ASP initiatives and to work with regional policy makers to push policy at a more significant community level. Continued attention by regulatory bodies will help drive the adoption of best practices for ASPs. Similarly, tying reimbursement and financial penalties to reporting efforts highlights health care leaders’ importance in increasing resource allocation and support for ASP activities.

To effectively treat patients who have infections caused by MDROs, the development of new classes and types of antibiotics must be prioritized. Antibiotic development is traditionally not a moneymaker for pharmaceutical companies; therefore, developing new ones is a low priority for drug development. Recently, 230 organizations, health care leaders, public health agencies, and industry representatives have petitioned US Congress to support the Pioneering Antimicrobial Subscriptions To End Up surging Resistance (PASTEUR) Act.⁸ The PASTEUR Act will incentivize the production of novel antimicrobial agents to offer treatment options for patients and ensure appropriate use requirements, thereby decreasing the risk of escalating AMR.

As the relationship between infection prevention and ASP grows, infection preventionists are key stakeholders in the battle against the rise of MDROs and AMR. The collaboration between the programs is a natural fit, with many parallel goals. The infection preventionist can bring preventive and MDRO mitigation strategies, public health guidance, and biopreparedness formats to the ASP initiatives. Additionally, both programs can look to the One Health concept as an example of how to have a more holistic view of AMR prevention. The environmental impacts of AMR are connected to the community and individual health of patients. The link between facility-level ASP efforts and the more significant global health outcomes can be seen in tactics such as effective surveillance, understanding the epidemiology and emerging MDROs, and diagnostic stewardship. Through these collaborative efforts, the rate of development of AMR and MDROs will decline, and overall patient outcomes and community health will improve.