Antibiotics Administration: Factors to be Considered by Pharmacists

Antibiotics are used to either eliminate microbes or stunt their growth. They are meant to limit the pathogen attack that is debilitating the host’s systemic function.^1-7

In recent years, health care professionals have been seeing a surge in adverse effects associated with long-term use of antibiotics, as well as abuse, not only in the United States, but around the world. This brawl with antibiotics has been happening for some time and is reported based on observed adverse events or clinical studies conducted globally.^1-7,9-12

Is the trajectory a sign of highly evolving microbes, due to pattern of regimen we are currently following, or is it due to the influence and contribution of other diseases?

These concerns are yet to be identified and addressed.^8,9 However, pharmacists have a key role and responsibility in identifying and addressing factors that could help limit adverse events associated with long-term use of antibiotics.

Some studies have provided evidence that administration of antibiotics like β-lactamase inhibitors, macrolides, and fluoroquinolones is associated with increased incidence of ventricular arrhythmias and cardiovascular deaths.¹³

One of earliest reported studies on the association between fluoroquinolones and aortic aneurysm and aortic dissection was from Taiwan, based on evidences acquired from 1477 patients.¹⁴ Systemic review and meta-analysis studies showed that the role of fluoroquinolones to be a major player in inducing aortopathy, which includes aneurysm and dissection.¹⁵

These reports do not mean that only fluoroquinolone are the problem creators. There is also evidences obtained from various other studies claiming that macrolide antibiotics are associated with cardiovascular complications and death.^16-18

Some recent reports even demonstrate that elderly women are more prone to cardiovascular events and deaths when administered antibiotics long term.⁴ This study doesn’t mention the effects of 1 specific class of antibiotics, but rather focused on duration. It also emphasized that irrespective of the class, antibiotics, administered long term could cause cardiovascular events or intensify the cardiovascular risk especially in elderly women population.

Even though the focus was on the effects of antibiotics, some of these studies also mention that the underlying infection can also debilitate the cardiovascular function which could be directly or indirectly contributing towards this risk.

In December 2018, FDA issued a warning on fluoroquinolone antibiotic use, stating that this class causes rare but serious adverse events, like aortic tear or rupture ultimately leading to bleeding and death.^19,20

Pharmacists have a major role and responsibility in following the drug regimen for patients suffering from infections to make sure that the patients don’t succumb to infections, but at the same time, do not pay the penalties for administering antibiotics.

A stringent evaluation and follow up on the dose, duration and frequency of antibiotic administration should be exercised by pharmacists with consideration for the age, gender, disease background, and health history of each patient. In this way, we will be able to depose the number of severe adverse effects seen with the use of antibiotics.

References

• Glick M. Antibiotics: The good, the bad, and the ugly. J Am Dent Assoc. 2016;147(10):771-3. Epub 2016/10/01. doi: 10.1016/j.adaj.2016.08.006. PubMed PMID: 27688222.
• Leeds IL, Fabrizio A, Cosgrove SE, Wick EC. Treating Wisely: The Surgeon's Role in Antibiotic Stewardship. Ann Surg. 2017;265(5):871-3. Epub 2016/10/21. doi: 10.1097/SLA.0000000000002034. PubMed PMID: 27735819; PMCID: PMC5378652.
• Machowska A, Stalsby Lundborg C. Drivers of Irrational Use of Antibiotics in Europe. Int J Environ Res Public Health. 2018;16(1). Epub 2018/12/26. doi: 10.3390/ijerph16010027. PubMed PMID: 30583571; PMCID: PMC6338985.
• McMullen AR, Anderson N, Wallace MA, Shupe A, Burnham CA. When Good Bugs Go Bad: Epidemiology and Antimicrobial Resistance Profiles of Corynebacterium striatum, an Emerging Multidrug-Resistant, Opportunistic Pathogen. Antimicrob Agents Chemother. 2017;61(11). Epub 2017/08/30. doi: 10.1128/AAC.01111-17. PubMed PMID: 28848008; PMCID: PMC5655097.
• Plesca CE, Luca MC, Luca AS, Constantinescu S, Iancu LS. Etiology and Resistance Profile of Isolated Strains from Severe Systemic Infections in Patients with Immunodepression--Experience of the Iasi Infectious Diseases Hospital 2011-2014. Rev Med Chir Soc Med Nat Iasi. 2015;119(4):1141-6. Epub 2016/01/23. PubMed PMID: 26793861.
• van Altena R, Akkerman OW, Alffenaar JC, et al. Shorter treatment for multidrug-resistant tuberculosis: the good, the bad and the ugly. Eur Respir J. 2016;48(6):1800-2. Epub 2016/11/09. doi: 10.1183/13993003.01208-2016. PubMed PMID: 27824604.
• Zyoud SH, Abu Taha A, Araj KF, Abahri IA, Sawalha AF, Sweileh WM, Awang R, Al-Jabi SW. Parental knowledge, attitudes and practices regarding antibiotic use for acute upper respiratory tract infections in children: a cross-sectional study in Palestine. BMC Pediatr. 2015;15:176. Epub 2015/11/13. doi: 10.1186/s12887-015-0494-5. PubMed PMID: 26561029; PMCID: PMC4642624.
• Bohora AA, Kokate SR. Good Bugs vs Bad Bugs: Evaluation of Inhibitory Effect of Selected Probiotics against Enterococcus faecalis. J Contemp Dent Pract. 2017;18(4):312-6. Epub 2017/03/30. PubMed PMID: 28349910.
• Burki TK. Good news and bad news in antibiotic prescribing. Lancet Respir Med. 2016;4(7):540. Epub 2016/06/12. doi: 10.1016/S2213-2600(16)30154-0. PubMed PMID: 27286993.
• DiNubile MJ. Noninferior Antibiotics: When Is "Not Bad" "Good Enough"? Open Forum Infect Dis. 2016;3(3):ofw110. Epub 2016/07/07. doi: 10.1093/ofid/ofw110. PubMed PMID: 27382597; PMCID: PMC4929489.
• Dutta SS. India launches strategy to curb antimicrobial resistance. BMJ. 2017;357:j2049. Epub 2017/04/28. doi: 10.1136/bmj.j2049. PubMed PMID: 28446430.
• Garcia-Basteiro AL, Saavedra B, Cobelens F. The Good, the Bad and the Ugly of the Next-Generation Xpert Mtb/Rif((R)) Ultra Test for Tuberculosis Diagnosis. Arch Bronconeumol. 2017;53(12):665-6. Epub 2017/07/15. doi: 10.1016/j.arbres.2017.05.023. PubMed PMID: 28705388.
• Chou HW, Wang JL, Chang CH, Lai CL, Lai MS, Chan KA. Risks of cardiac arrhythmia and mortality among patients using new-generation macrolides, fluoroquinolones, and beta-lactam/beta-lactamase inhibitors: a Taiwanese nationwide study. Clin Infect Dis. 2015;60(4):566-77. Epub 2014/11/20. doi: 10.1093/cid/ciu914. PubMed PMID: 25409476.
• Lee CC, Lee MT, Chen YS, et al. Risk of Aortic Dissection and Aortic Aneurysm in Patients Taking Oral Fluoroquinolone. JAMA Intern Med. 2015;175(11):1839-47. Epub 2015/10/06. doi: 10.1001/jamainternmed.2015.5389. PubMed PMID: 26436523.
• Noman AT, Qazi AH, Alqasrawi M, et al. Fluoroquinolones and the risk of aortopathy: A systematic review and meta-analysis. Int J Cardiol. 2019;274:299-302. Epub 2018/10/13. doi: 10.1016/j.ijcard.2018.09.067. PubMed PMID: 30309682.
• Cheng YJ, Nie XY, Chen XM, et al. The Role of Macrolide Antibiotics in Increasing Cardiovascular Risk. J Am Coll Cardiol. 2015;66(20):2173-84. Epub 2015/11/14. doi: 10.1016/j.jacc.2015.09.029. PubMed PMID: 26564594.
• Kang J, Kim YJ, Shim TS, Jo KW. Risk for cardiovascular disease in patients with nontuberculous mycobacteria treated with macrolide. J Thorac Dis. 2018;10(10):5784-95. Epub 2018/12/07. doi: 10.21037/jtd.2018.09.145. PubMed PMID: 30505486; PMCID: PMC6236155.
• 18. Lu ZK, Yuan J, Li M, Sutton SS, Rao GA, Jacob S, Bennett CL. Cardiac risks associated with antibiotics: azithromycin and levofloxacin. Expert Opin Drug Saf. 2015;14(2):295-303. Epub 2014/12/11. doi: 10.1517/14740338.2015.989210. PubMed PMID: 25494485; PMCID: PMC4404501.
• Meng L, Huang J, Jia Y, Huang H, Qiu F, Sun S. Assessing fluoroquinolone-associated aortic aneurysm and dissection: Data mining of the public version of the FDA adverse event reporting system. Int J Clin Pract. 2019:e13331. Epub 2019/02/28. doi: 10.1111/ijcp.13331. PubMed PMID: 30809871.
• FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients [safety announcement]. Silver Spring, MD; December 20, 2018: FDA website. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics. Accessed August 2019.