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Exploring Antimicrobial Resistance and Strategies for Pathogen Reduction in Healthcare Facilities

Antimicrobial resistance is an escalating public health issue that affects almost all healthcare environments. Antimicrobial-resistant bacterial infections occur when existing pathogenic bacteria in the human microbiome react to drastic clinical changes, thereby multiplying their numbers. This occurrence is particularly prevalent when these pathogens exhibit resistance to antimicrobial agents, leading to the disruption of the human microbiome and the subsequent loss of colonization resistance, a significant host defense. Therefore, pathogen reduction is an emerging prevention strategy to combat the transmission and infection of these antimicrobial-resistant bacteria. 

This article will tackle the fundamentals of pathogen reduction, the empirical support for its efficacy, and how it interacts with the human microbiome to provide colonization resistance while reducing infection susceptibility once colonization occurs. At the same time, the current methods of pathogen reduction and its ideal features are explored. The continuous increase and threat of multidrug-resistant organisms (MDROs) in medical settings could exacerbate the ongoing antimicrobial resistance crisis, adding fuel to complications such as illness, death, endangered patient safety, and hastened obsolescence of current antimicrobial drugs. 

Consecutive data from 2013 to 2019 showed progress in reducing deaths from antimicrobial-resistant infections by 18% overall and 28% in hospitals. However, during the COVID-19 pandemic, resistant healthcare-associated infections in the U.S. rose by 15%, potentially due to disrupted prevention practices and antibiotic stewardship. Notably, >2.8 million people are infected annually in the United States with these resistant strains, and over 4.95 million deaths were associated with antimicrobial resistance globally in 2019. 

This constant battle against bacterial antimicrobial resistance serves as a significant national health challenge. Patients colonized by pathogenic bacteria run a high risk of healthcare-associated infections, and such risk is compounded by invasive devices, surgeries, and the unintended result of antibiotics used for prophylaxis or the treatment of unrelated infections. Transmission of these pathogens can occur from asymptomatic and symptomatic patients, putting others at risk of colonization and infection. Thus, reducing pathogens in colonized patients can mitigate the risk both to those patients and the larger healthcare population.

Current strategies for pathogen reduction—ranging from deeply ingrained to experimental ones—and evidence supporting their effectiveness will be discussed. Furthermore, the looming need for future therapies leveraging the colonization resistance offered by the microbiome would be highlighted. The human body hosts a perpetual league of microorganisms (microbiota), along with the associated metabolites and surrounding environment (microbiome). These microorganisms have a significant impact on our health. 

Some bacteria can develop into lifelong colonizers of our bodies, laying embedded in the commensal landscape and can bloom to cause infection in destabilized conditions. Since colonization can last for months to years, the distinction between endogenous infection (originating from the patient’s own microbiota) and exogenous infection (originating from more recent transmission) becomes vague. Disruption of the intestinal microbial community by antibiotic prophylaxis creates opportunities for pathogens to cause infection, especially when they are resistant to the prophylactic antibiotics. 

Efforts towards pathogen reduction assume a pivotal role in preventive approaches recommended by major public health bodies against surgical site infections. For instance, the use of oral antimicrobials before elective colorectal surgery and antistaphylococcal agents in surgical patients for orthopedic and cardiothoracic procedures have been proven to prevent infections by decreasing potential pathogenic bacterial load and suppressing colonization. However, these come at the potential cost of increasing antimicrobial resistance. 

The article will also deliberate the growing need for effective pathogen reduction and decolonization techniques in light of the rapid colonization of multi-drug resistant Staphylococcus aureus. Evidence-based guidelines from the Centers for Disease Control and Prevention (CDC) have recommended decolonization and pathogen reduction strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) infections. These strategies include intranasal mupirocin and chlorhexidine bathing. Use of chlorhexidine for routine bathing has exhibited significant benefits in reducing the prevalence of multi-drug resistant organism carriage and need for hospital transfer in nursing homes. 

Furthermore, chlorhexidine also has a limited potential for unintended microbial consequences because it does not substantially disrupt the skin microbiota. However, choosing decolonization strategies that consider antibiotic prophylaxis can result in increased risk for antibiotic-associated events, including infection by Clostridioides difficile. Future approaches should aim to enrich beneficial microbe populations by preserving or restoring the human microbiome, hence providing colonization resistance against pathogens.


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