Keeping Patients Safe from Escalating Antibiotic Resistance

Stewardship Paired with Rapid Molecular Diagnostics Can Preserve the Effectiveness of Life-Saving Drugs

A Century-Old Miracle, Increasingly at Risk

When antibiotics entered clinical practice in the early 20^th century, life expectancy soared, and procedures such as organ transplants, chemotherapy, and open-heart surgery became possible.¹ Yet the very medicines that revolutionized care now demand careful stewardship: misuse accelerates antimicrobial resistance (AMR), causing more than 2.8 million antibiotic-resistant infections in the United States each year and killing more than 35 000 people.² Globally, AMR is estimated to contribute to 4:95 million deaths annually.³

Misuse in the Exam Room: The Numbers Tell the Story

Misuse takes several forms, but inappropriate prescribing looms large. In the United States, the CDC estimates 30-50% of antibiotic prescriptions in hospitals and 40-75% in nursing homes are inappropriate or unnecessary. In doctor’s offices and emergency departments about 30% of these prescriptions are unnecessary.⁴

A Clinician’s Dilemma: Treat My Patient or Protect the Future?

During my years as a hospital pharmacist, I led multiple antibiotic-stewardship programs aimed at reducing inappropriate prescribing. I found that clinicians understood the dangers of AMR in principle, yet at the bedside they faced an uneasy tension between protecting public health and protecting the individual patient in front of them. A provider who knows a cough is probably viral still worries, “What if a secondary bacterial infection sends this person to the hospital?” The physician examining a child with a sore throat thinks, “It won’t hurt to give an antibiotic—just in case.” Multiplied across practices, these reasonable, altruistic-seeming decisions feed an unsustainable cycle of resistance. 

Stewardship Tactics That Shift Habits

To change behavior, we launched campaigns that linked individual actions to measurable outcomes. We showed prescribers how their antibiotic use compared with peers and surfaced information on which patients later experienced adverse drug reactions or C. difficile infection.  

Because patient expectation also drives over-treatment, every exam room displayed a signed pledge: “Viral infections don’t need antibiotics. Our practice is committed to using antibiotics appropriately to combat resistance.” We also created a “viral prescription pad,” listing rest, fluids, acetaminophen, and other supportive measures so patients still left with something tangible—and so clinicians could educate, set clinical improvement expectations, and close the encounter without defaulting to antibiotics.

When Minutes Matter: Rapid Molecular Diagnostics in Practice

The tactics we employed in our stewardship programs became even more powerful when paired with rapid molecular diagnostic tests. Traditional culture methods return results days later, by which point empiric therapy is already underway. Molecular assays can identify pathogens in as little as an hour, letting providers decide during the visit whether an antibiotic is warranted. This results not only in antibiotic use that is more informed, but also patients that are, which is in line with the recently released Core Elements of Hospital Diagnostic Excellence from the CDC.⁵

What the Evidence Shows

Results presented in a recent manuscript in the American Journal of Medical Quality⁶  support the impact rapid molecular diagnostics is having on prescribing patterns, specifically in the outpatient setting. This study aimed to understand if the availability of rapid syndromic PCR-based tests, in this case providing next-day results, is being used by outpatient healthcare providers to guide antibiotic prescribing decisions in the United States.  

Conducted via a survey of outpatient providers who routinely accessed such testing, the study revealed that the vast majority of providers (97,5%) with access to this rapid testing use the test results to make prescribing decisions. Providers were approximately equally split on whether they prescribed upfront and then adjusted treatment later if needed based on results (48,6%) vs. awaiting test results before prescribing antibiotics (48,9%). 

Notably, nurse practitioners/physician assistants were significantly more likely than medical doctors/doctors of osteopathic medicine to withhold prescriptions pending results (52,1% vs 39,0%), as were primary care providers compared to urgent care providers (61,2% vs 39,1%). Furthermore, providers reported changes in their prescribing after incorporating the testing, with 57,6% noting improved self-reported accuracy of antibiotic prescriptions and 25% reporting fewer antibiotic prescriptions. 

While the results are encouraging, they show there is still a lot of room for improvement. About half of providers were waiting for results before prescribing antibiotics, but half were not. Why? Are workflows too cumbersome? Is data access delayed? Do providers need more education on interpreting results? Addressing these potential barriers is essential.

Balancing the Ledger: Costs, Consequences, and the Microbiome

Cost is another consideration. Molecular tests are pricier than standard cultures, but inappropriate prescriptions carry hidden costs: adverse drug reactions, C. difficile infection, and disruption of the microbiome that may contribute to gastrointestinal distress in the short term⁷ and chronic conditions such as diabetes over time according to emerging research.⁸ Beyond the individual lies the societal toll of AMR. Resistance has existed for millennia in nature;⁹ our goal is not to eradicate it but to slow its rise. Stewardship, informed by rapid diagnostics, is our best defense against a future in which common infections once again become deadly. 

Toward a Sustainable Future for Antibiotics

By uniting clinician engagement, patient education, and swift diagnostic insights, we can preserve antibiotic efficacy for today’s patients and generations to come.