Understanding Antibiotic Resistance

[icon name=”user” class=”” unprefixed_class=””]  Joanne P. Shelby-Klein BSN RN

antibiotic-resistanceAntibiotic resistance is a growing worldwide public health problem that threatens the prevention and treatment of an increasing number of micro-organisms. In fact, each year, more than 2 million people become infected with antibiotic resistant bacteria and more than 23,000 people die from these infections. (CDC,2015) To first understand what antibiotic resistance is and how it occurs, it is important to understand what micro-organisms are as well as what antibiotics are and how microbial infections can spread.

MICRO-ORGANISMS: Micro-organisms are extremely tiny single cell living things that can only be seen by a microscope. Some examples of separate types include bacteria, viruses, fungus, parasites and protozoa. They are also known as microbes. In non-medical terms they can be called “bugs” “Germs”.

ANTI-MICROBIALS: Anti- microbials are a special class of agents or drugs that are used to destroy or stop the growth of micro-organisms usually by stopping the microbe from dividing and reproducing itself.

ANTIBIOTICS: Antibiotics are a special class of antimicrobial medications that stop bacterial infections only. They do not work against virus or fungal infections. They have been used for over 70 years to treat patients with infections and have greatly decreased the death rate from infections. Antibiotics have been used for so long and for such a wide variety of infections, that bacteria have adapted to the drugs, making them less effective and leading to antibiotic resistance.

ANTIBIOTIC RESISTANCE: This occurs when a microbe, such as bacteria, continues to grow and reproduce even in the presence of an antibiotic that has been created to stop the growth process. Once bacteria are resistant to an antibiotic, the infection they cause may no longer be controlled or cured and may take a longer time to be controlled and cured.


Microbes or germs are everywhere. Some are harmless to humans while others can cause serious infections. Any type of germ can easily move from place to place and remain presentwithout anyone being able to see it. Below is a list of some ways the germs move.

  • Through the air when any type of movement or blowing air occurs. Think coughing and sneezing as a good example.
  • Items that have become dirty or contaminated especially with urine, bowel movements, vomit and blood and come in contact with another surface or human.
  • Direct contact with saliva, mucous, blood, urine, contaminated food and water, sexual contact.

You get an infection when you come in contact with a harmful germ by one of the above methods. That germ begins to rapidly grow and reproduce, multiplying in a few hours to the point it overwhelms the body’s immune system and the person begins to feel sick. The person then goes to see a medical professional and is given an antibiotic stop the germ growth. The antibiotic does its job and kills the germs and the person begins to feel better. However some healthy “normal” germs needed by the body also die or change their cell code and become resistant to the antibiotic. These resistant germs then begin to grow and divide, causing more problems for the person. These resistant germs can then be spread to other people through unknown, unplanned contact. These people then get sick and given an antibiotic to treat the infection, only this time the germ doesn’t respond to the treatment so the patient gets sicker and could die.


You can see by the above example that antibiotic resistant infections can become a serious problem and that antibiotics should be used with caution and only when under the care of an appropriate health care provider. Only an appropriately trained health care provider should prescribe antibiotics after determining if the infection is caused by bacteria or a virus. Antibiotics only work against infections caused by bacteria, certain funguses and a few parasites. They do not work against illnesses caused by viruses like colds and flu. Symptoms such as coughs, ear infections, sore throats, acute respiratory infections and nausea, vomiting and diarrhea caused by the stomach flu are caused by viruses and will not respond to antibiotics. These types of infections will usually resolve on their own. Taking an antibiotic for these virus caused symptoms will not make the infection go away faster and may in fact cause harm due to side effects and can cause normal bacteria in the body to become resistant to the antibiotic given. An infection, such as the cold or flu will have decreasing symptoms over a 5-7 day time period. An infection caused by bacteria, such as strep throat or staph aureus skin infections, will have symptoms, like a high fever for example, that does not improve or gets worse within 5-7 days.


There are many factors and causes for antibiotic resistance. These factors include both natural occurrences and those caused by human actions.

  • Evolution of the bacteria is one cause of antibiotic resistance. It is a naturally occurring event that happens as the bacteria divide into more bacteria. As the cell divides, something changes the organisms’ genetic code or the bacteria picks up a resistant trait from another nearby bacteria.
  • Use of antibiotics is probably the most important factor in the development of antibiotic resistance. Antibiotics are among the most commonly prescribed medications and can be life saving. However 50% of the time antibiotics are not prescribed appropriately, either when not really needed or given as an inappropriate dose or duration. The overuse or misuse of antibiotics can increase the development of drug resistance.
  • Patients not taking antibiotics as prescribed. This includes stopping antibiotics as soon as they start feeling better or not following the prescribers’ instructions and missing doses or taking longer than prescribed. Stopping antibiotics too soon or missing doses, leads to not all the germs getting killed, leaving some to divide and reproduce, often as resistant forms of the initial germs.
  • Patients taking antibiotics without talking with a health care provider. Patients often save unused antibiotics and when the symptoms of an infection appear, they start taking what they have left. This is a serious problem because it is not known if the infection is caused by a bacteria or a virus. Also, the germ may not be killed by this particular antibiotic. This can lead to the germ adapting itself to the antibiotic and no longer be affected by it.
  • Poor infection control practices by both patients and healthcare providers. Infection Control practices are used to control the spread of germs from one person or surface to another. If the spread of germs can be controlled, then the risk of infection goes down and there is less of a need for antibiotics and a decreased risk of antibiotic resistance developing. Patients and health care professionals all play a role in preventing the spread of infection.



One of the easiest ways to prevent the spread of germs is to wash hands frequently and properly. Hands can very easily become contaminated with germs and spread them from place to place simply because they come in contact with everything in the environment. Washing hands helps remove the germs from the surface of the skin and helps prevent them from moving place to place. Hands can be washed either by using soap and water or using the readily available Alcohol based hand sanitizers. This leads to the question of when is appropriate to use hand sanitizer versus soap and water.  It is important to remember that alcohol based hand sanitizers and soap and water should not be used at the same time. One or the other should be used. The following areusage guidelines from the World Health Organization:

  • Use soap and water to wash hands any time the hands are soiled with blood, visible dirt, urine, fecal material or after using the toilet.
  • Alcohol based hand rubs, also known as hand sanitizers, can be used for routine hand cleaning if the hands are not visibly soiled or dirty.
  • If alcohol based hand sanitizer is not available, soap and water should be used.
  • Hands should be cleaned before or after touching a patient and using any invasive devices or inanimate objects used on patients. This includes after touching any patient blood and body fluids or any non-intact skin.
  • Clean hands before and after removing and replacing any wound dressings and before moving from one body site to another.
  • Clean hands before putting on gloves or after removing gloves. Soap and water or hand sanitizer maybe used.
  • Before preparing or serving foods to patients.
  • Before and after handling any medications.


Alcohol based hand sanitizers contain a variety of active ingredients that can make it safe and effective. Some contain N-propanol, also known as propyl-alcohol, which in testing has proven the most effective. Ethanol, known as ethyl alcohol, is the least effective. (Nursing Times, 2004).  Many of the hand sanitizers available contain a combination of propyl-alcohol and Ethanol because in theory they increase the effectiveness against most germs. Alcohol based hand sanitizers that are combined with other agents such as povidone-iodine or chlorhexidine-gluconate can increase germ fighting capability.

Studies have shown that hand sanitizers that contain 60-90% alcohol work the best, due to the presence of additional water to alter the proteins located in the germs. If the concentration of alcohol in the sanitizer is above 95%, the germ killing ability is less effective due to the decreased amount of water present, leading to less germ proteins getting altered and killed. When purchasing hand sanitizers, it is best to look for 60-90% alcohol content. It does not matter if the hand sanitizer is in liquid, gel or powder form, they all work equally well as long as the alcohol content is in the correct range. Studies have also shown that alcohol based hand sanitizers are equally effective against both gram positive germs such as staphylococcus and streptococcus and gram negative germs such as escherisia coli. It is also effective against viruses such as HIV, Influenza, Methicillin Resistant Staph Aureus (MRSA) and mycobacteria. It does not effectively kill viruses such as Hepatitis B and C as well as enteroviruses and germs with spores such as Clostridium Difficile (C-Diff).

Since alcohol based hand sanitizers have been shown to be effective in preventing the spread of germs and assist in limiting the development of antibiotic resistance, it is important to know how to properly use it. Pump or squeeze a palm full of hand sanitizer into one hand and rub all over hand surfaces until completely dry. The friction motion from rubbing helps with the removal of germs and increases the effectiveness of hand sanitizer. It should take less than 30 seconds. Once the sanitizer has been used, be careful not to touch any unnecessary objects or surfaces.

The proper way to wash hands is equally as important as the proper way to use hand sanitizers. It does not matter if you use soap with antibacterial or antimicrobials. It also does not matter if the soap is in liquid or bar form.  The important thing is to use plenty of soap, water and a steady rubbing motion for at least 10 seconds. Use warm water and make sure both hands are thoroughly wet then use enough soap to cover all surfaces of the hands from fingertips to the wrists. After you scrub thoroughly, it is important to rinse thoroughly. The best way to rinse is from fingertips to wrist. This pushes the soap and germs away from the parts of the hand you will be using. Make sure all the soap is removed. The next step is to dry the hands with preferably a paper towel and make sure they are completely dry. Use the paper towel to turn off the faucets and open or close any doors if necessary. Use a paper towel to turn off the faucet to act as a barrier between clean hands and the germs on the faucet and any surfaces.

The simple step of cleaning hands helps to decrease the spread of infection and help prevent more antibiotic resistance. This action, along with careful, monitored use of antibiotics are only the first steps in combating antibiotic resistance, but they are ones that we as human beings can directly impact by our actions.


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