The crisis of antibiotics: From empirical to directed prescription

Dear Editor,

We read with great interest the editorial by Cisneros Herreros,¹ in which he completely dissected and succeeded in addressing the issue of the antibiotics crisis, outlining the causes and solutions. Resistance to antimicrobials is still a major healthcare issue with a significant socio-economic impact, and we would like to offer some comments regarding the possible solutions.

The increase in the volume of information is vast in all sectors of life, and the need for continuous, regulated and objective training among professionals is unquestionable, even more so in the current context, where we are treating an increasingly ageing, comorbid, instrumentalised and treated population. The uncertainty in the evaluation of the infectious process in such a fragile context, in which the earliness of the diagnosis and the optimisation of the treatment are capable of changing the comorbidity period and patient survival, requires a precision medicine.

Precision medicine is defined as prevention or applied treatment, depending on the individual needs of the patients, determined based on genetic, biomarker, phenotypic and psychosocial characteristics, which distinguish some patients from others, despite them having a similar clinical picture.² Precision medicine in infectious disease involves harnessing all the knowledge and technology available to reach a diagnosis, stratify the risk and better adapt the antibiotic treatment earlier, especially in critically-ill and vulnerable patients.

Different scenarios should be considered depending on genetic or epigenetic response patterns in the host, proposing a treatment directed not only at the pathogen, but also at the host, by evaluating the infection model, clinical insufficiencies, severity, comorbidity, and resistant-pathogen selection factors. It is a medicine that should seek to plan a more effective (which reduces mortality) and safer (with a reduced ecological impact) antimicrobial strategy. The current approach, based on resistant-pathogen selection factors, does not lead to better-adapted antibiotherapy, since these scales lack sufficient sensitivity and specificity for this.^3–6

We are therefore working on the basis of the following premises: (1) infection is a common reason for consultation; (2) the complexity of patients is progressively greater, as are the cases of infection due to multidrug-resistant (MDR) bacteria, including community-acquired bacteria; (3) the initial aetiological diagnosis is less common and conditions empirical decision making, which generates a high rate of antibiotherapy inadequacy; and (4) the inadequacy of the initial treatment leads to resistance, morbidity and mortality, and an increase in costs.⁷

In the last decade, microbiological diagnosis has seen a significant development aimed at providing preliminary or definitive results more quickly, based on genetic and molecular biology technology. In line with that indicated, and in order to improve antibiotherapy prescription, in addition to the essential training strategies, it is vital that the use of rapid microbiological diagnostic techniques that help reduce the number of patients who receive treatment is implemented and generalised in an empirical manner. The greatest problem with its application are the costs associated with this generalisation.

It has been explained that inappropriate initial treatment is associated with an increase in mortality in critically-ill patients,⁸ which may determine the need to administer broad-spectrum or next-generation antibiotics to ensure the effectiveness of the antibiotherapy. Precision medicine must also be precise in terms of therapy, by offering each patient the best therapeutic alternative available for their clinical process, early and in an intensive manner. This action should be based on an implementation of the fastest microbiological diagnostic techniques that allow the treatment to be adjusted and de-escalated early, with the aim of reducing mortality without impacting on the ecological niche.

This type of precision medicine could be cost-effective even beyond the context of critically-ill patients. Therapeutic failure would significantly increase the costs, through increasing the consumption of resources, prolonging the average hospital stay, requesting new, additional tests, and the higher rate of readmission,^9,10 which should be considered when evaluating the costs derived from using a precision medicine.

Therefore, we believe the application of a precision medicine in the diagnostic and therapeutic process for each patient, which helps us optimise the antimicrobial treatment safely and at a lower ecological cost, is necessary. This is, without a doubt, the present and the future of our approach to infectious diseases.