American Public Health Association
January 1, 1999

Policy Number 9908: Addressing the Problem of Bacterial Resistance to Antimicrobial Agents and the Need for Surveillance

The American Public Health Association,

Recognizing the rapid increase in antibiotic resistance in the United States and worldwide¹ and understanding the complex nature of this problem, including the selective pressure of overuse and misuse of antibiotics in human medicine, the use of subtherapeutic levels of antibiotics in animal feeds, and the rapid global spread of resistant bacteria;² and

Acknowledging that in the United States, 190 million daily doses of antibiotics are ordered in hospitals with twenty-five to forty-five percent being unnecessary, 145 million courses of antibiotics are prescribed with twenty to fifty percent being unnecessary, and four million pounds of antimicrobials are used therapeutically in animals (and 16 million pounds are used as growth promoters) with forty to eighty percent being unnecessary;³ and

Being aware of bacterial resistance to all available antibiotics;⁴ and

Recognizing that prescriptions are written for upper respiratory tract infections to satisfy patients' demands,⁵ although the antibiotics have little or no benefit;⁶ and

Being aware of the decrease in antibiotic use following educational intervention involving both health professionals and patients;^7,8 and

Acknowledging the need for local surveillance because of geographic variation in resistance patterns,⁹ the inadequacies of the current surveillance systems for antibiotic resistance,¹⁰ and that only $55,400 of the total $74 million total dollars for surveillance was available for antimicrobial resistance;¹¹ and

Acknowledging that the restriction of antibiotic use resulted in decrease in the resistance level in certain organisms;¹² and

Recognizing the increase in societal costs because of infections caused by bacteria resistant to antibiotics as indicated by the assessment of the Office of Technology Assessment (citing that antibiotic resistant bacteria generated a minimum cost of $1.3 billion in the United States in 1992), the costs of increased hospitalization of patients with community acquired resistant bacteria, and a higher attributable mortality associated with infections caused by methicillin resistant Staphylococcus aureus (as compared to methicillin sensitive Staphylococcus aureus);¹³ and

Being aware of the agencies and organizations addressing this problem: the Centers for Disease Control and Prevention's strategy for addressing the antimicrobial resistance threat,¹⁴ the World Health Organization Executive Board's call for increased work against antimicrobial resistance,¹⁵ and the Food and Drug Administration's (FDA's) Advisory Committee on Antibiotic Resistance statement in October 1998, that "Microbial development of resistance to the presently available drug therapies is a public health issue of accelerating importance;"¹⁶ therefore

1. Encourages the education of health professionals about the judicious use of antibiotics through clinical practice guidelines and other educational processes;

2. Encourages the development of educational material for patients to increase their understanding of antibiotic usage;

3. Urges strengthening of state public health departments' surveillance to determine patterns of resistance and to detect increases in resistance in a timely manner through surveillance efforts supported by CDC and to actively disseminate that information to health care providers;

4. Urges the Center of Veterinary Medicine of the FDA to work for regulations eliminating the non-medical use of antibiotics and limiting the use of antibiotics in animal feeds; and

5. Supports the introduction of legislation for additional funding for population studies addressing antibiotic resistance and to improve the surveillance network.

1. World Health Organization. Executive Board calls for work against antimicrobial resistance to be stepped up. Press release, January 30, 1998.
2. Levy SB. Antibiotic resistance: an ecological imbalance. Antibiotic Resistance: Origins, Evolution, Selection and Spread. Ciba Foundation Symposium 207, 1997.
3. Cohen M. Antibiotic Use. Antimicrobial Resistance, Issues and Options. Institute of Medicine, Washington, DC: National Academy Press, 1998.
4. Levy SB. Clinical Care. Resistant Organisms: Global Impact on Continuum of Care. International Congress and Symposium Series 220, 1998.
5. Schwartz B, Dowell S. CDC program activities and progress to date. The C.A.USE. April 1997.
6. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 1997;278:901-904.
7. Gonzales R, Steiner LF, Lum A, et al. Decreasing antibiotic use in ambulatory practice. JAMA. 1999;281:1512-1519.
8. Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. Br Med J. 1999;318:715-716.
9. American Society of Clinical Pathologists Study Group. United States geographic bacteria susceptibility patterns. Am J Clin Path. 1998;109:144-152.
10. Fidler DP. Legal issues associated with antimicrobial drug resistance. Emerging Infectious Disease. 1998;4:1-12.
11. Tenover F. Surveillance and the Laboratory. Antimicrobial Resistance, Issues and Options. Institute of Medicine, Washington, DC: National Academy Press, 1998.
12. Carbon C, Bax RP. Regulating the use of antibiotics in the community. Br Med J. 1998;317:663-665.
13. Rubin R. The Costs of Antimicrobial Resistance. Antimicrobial Resistance, Issues and Options. Institute of Medicine, Washington, DC: National Academy Press, 1998.
14. Centers for Disease Control and Prevention. Preventing Emerging Infectious Diseases. 1998;14.
15. See 1, supra.
16. Food and Drug Administration. Advisory Committee on Antibiotic Resistance, October 15, 1998.