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The wrong antibiotic for the wrong person can be life-threatening
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In the world of medicine, there is no “one size fits all.”
Take a hypothetical case involving a patient we’ll call Mike, who just returned from fighting in Afghanistan as a paratrooper. He’s excited to see his two little girls for the first time in months. When showering, he notices an infection on his leg, which doesn’t heal after a week. Mike feels increasingly worse, develops a fever and is short of breath. Mike makes a visit to the ER, is admitted to the hospital and is started on vancomycin. His infection resolves after a few days, and he expects to be released after 4 days in the hospital. Although he was initially feeling better, his legs and ankles begin to swell, and he becomes excessively tired and fatigued. Mike’s condition worsened because he was in the early stages of acute kidney failure. What the hospital didn’t realize when prescribing vancomycin is that, although Mike was in the best shape of his life, he had compromised kidneys, which increased his chances of developing vancomycin-induced acute kidney injury. Mike’s simple hospital stay just turned into a long and costly hospital visit.
Everyone has a unique biological and genetic profile that can respond differently to the same treatment. The individuality of our medical history requires the development of a personalized treatment plan. In the last decade, the concept of customized treatments has become more prevalent in large hospital systems that have ample resources. In well-funded medical fields, such as immuno-oncology, personalized treatment plans are becoming more prevalent. Other fields, including infectious diseases, lag behind this model.
Antibiotics are among the most frequently prescribed drugs in the United States. Almost all clinicians prescribe them daily, making the proper use of these drugs more relevant today than ever before. A dangerous course of antibiotics might be administered if a clinician is not aware of complicating conditions.
Many antibiotics have the potential to induce severe side effects. For example, some fluoroquinolones, such as levofloxacin, can cause confusion, low blood sugar and tendon inflammation, which in rare cases can lead to tendon rupture. Vancomycin can induce acute kidney damage and inflammation of the veins (thrombophlebitis). It is therefore imperative that an antibiotic fits an individual’s medical history because certain patient populations are at greater risk for adverse events associated with certain antibiotics. One population at greater risk for antibiotic-associated side effects is patients with obesity. Patients with obesity often have multiple conditions that make them more vulnerable to adverse events from medications. Also, many antibiotics require weight-based dosing, and weight-based dosing of patients with obesity on their actual weight may lead to a greater frequency of adverse events due to an overexposure of the drug. Many weight-based antibiotic doses were developed in normal-weight patients, and it is unclear if dosing on actual body weight is appropriate for patients with obesity.
In recent years, there is an increased emphasis on identifying optimal personalized treatment approaches.
To maximize antibiotic use, researchers are employing cutting-edge mathematical modeling techniques to identify patient- and treatment-related factors that promote optimal patient-centered outcomes. This includes use of advanced pharmacoepidemiologic and comparative effectiveness methodologies, which aid in determining optimal targeted treatment strategies for the individual patient. State-of-the-art pharmacokinetic and pharmacodynamic models can also be used to design antibiotic dosing schemes that optimize the efficacy of antibiotics while minimizing the drug dose. However, research cannot improve patient care unless the knowledge is transferable. To this end, educating treating clinicians on the best strategies for developing personalized treatment plans needs to become common practice.
Let’s consider Mike’s case. If he had been treated by a physician who was more aware of his medical history, his hospital stay would have had a totally different outcome. The doctor would have prescribed an antibiotic that was not associated with inducing kidney injury, and Mike would have left the hospital on day 4, saving him and the hospital time and money.
In summary, patients must be treated as individuals, particularly in the prescription and dosing of antibiotics. Scientific breakthroughs matter to patients only if treating physicians are aware of the advances. Efforts should focus on the development of personalized patient care strategies that improve outcomes, reduce the likelihood of drug-induced toxicities and decrease the health care costs associated with the side effects. Every physician should be educated on the importance of selecting the right antibiotic, at the right dose, for each patient.
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- Thomas P. Lodise, PharmD, PhD, is a professor at the Albany College of Pharmacy and Health Sciences in Albany, New York.
Disclosure: Lodise reports receiving consulting or grant support from Achaogen, Allergan, Melinta Therapeutics, The Medicines Company, Merck, Motif Bio, Paratek, Tetraphase Pharmaceuticals and Theravance.