Antibiotics might save a life—but not without a challenge

Globally, an estimated 1.25 million deaths in 2019 were caused by antimicrobial-resistant bacterial infections. In 2018, antimicrobial resistance was estimated to cause 5,400 deaths in Canada. The justified concern around antibiotic-resistant bacteria has worked its way from the hospital to the public, with news of antibiotic resistance frequently making the headlines. As such, it is a danger that all healthcare professionals are trying to mitigate.

Dr. Brian Cuthbertson of Sunnybrook Hospital agrees that there are many misuses of antibiotics. And while antibiotic resistance is a threat that results in increased illness, suffering, and death, he is urging critical care doctors to consider both the benefits and drawbacks of prescribing antibiotics to the sickest patients in the hospital.

The beginning of a journey to challenge biases

Dr. Cuthbertson’s journey in antibiotic use in the critical care wing began in 2008 after reading a literature and evidence review from Dutch researchers that proved controversial. The article suggested that antibiotics saved lives in critical care. That sounds obvious, but it went against decades of medical teaching.

“The article was massively controversial because the classic teaching is, go sparingly with antibiotics. It’s such a classic message that people perhaps under-do the amount of antibiotics they use in critically ill patients,” says Dr. Cuthbertson. He reminds us that antibiotics can save lives by preventing critically ill patients from acquiring infections from their hospital visit.

Before he began this current CIHR-funded study, Dr. Cuthbertson and some colleagues partnered with a psychologist to investigate why critical care doctors are overly cautious aboutthe use of antibiotics. They found that doctors held strong beliefs about the use of these treatments, and so they began thinking about ways to change those biases.

“As a clinician, you say ‘wait a minute, why is this evidence base building and building and no one is following it? You’re looking at your colleagues and saying, why are we doing this, why are we not doing this,” asks Dr. Cuthbertson.

A large study with the potential to save many lives

To counter these entrenched biases, Dr. Cuthbertson knew he needed a large trial, one that was big enough to deflect criticism. His team recruited 13,000 critical care patients in Canada and Australia to test whether healthcare professionals could increase antibiotic use without in turn exacerbating antibiotic resistance. The trial recently completed in Australia and will be over by Summer 2023 in Canada, with results expected by the end of 2023.

This research, Dr. Cuthbertson says, has the potential to save a lot of lives. He’s predicting a 4% reduction in mortality in the Canadian trial, which would save 20,000 lives a year. But he has to wait until the conclusion of the trial to see what they’ve achieved.

To combat his own biases, Dr. Cuthbertson doesn’t know the preliminary results of his own trial, but an independent data-monitoring committee gave him the green light to continue

“That could mean there’s a small benefit, a big benefit, but probably means there’s not a big harm, that it’s safe for our patients,” he says. “We don’t want to know any results at this stage … that’s good trial practice.”

Looking for results that can impact the health of Canadians

The Australian team will publish their research first, but even if their research had positive results, the case is different in Canada. The types of infections acquired in hospitals vary all over the world, so the Canadian study might have different results—what Dr. Cuthbertson wants, he says, is “to have a result that impacts the health of Canadians.”

“I don’t want to give antibiotics to Canadians if it doesn’t help the patient that I’m giving it to and potentially harms other patients by driving antibiotic resistance,” says Dr. Cuthbertson. “As a doctor I’d love to show benefit for my patients, but as a scientist, I want to get the truth.”

Dr. Cuthbertson knows that he has an uphill battle ahead of him. Critical care doctors are not going to embrace increased antibiotics use quickly. Many who know of Dr. Cuthbertson’s research—even some who are involved in it—are openly skeptical. His findings might have to change the biases and practices not only of intensive care doctors, but nurses, medical microbiologists, infectious disease specialists, and others. It’s a whole team approach. But he hopes his study is the one that changes medical practice.

This article was adapted from a piece written and published by the Canadian Institutes of Health Research. Read the complete article here.