Antimicrobial stewardship, a critical strategy in the fight against antibiotic resistance, traditionally focuses on optimizing antibiotic use to reduce resistance emergence. A thorough strategy, however, needs to take into account the significant effects that antibiotics have on the commensal gut microbiome. Drug-resistant infections are more likely to colonize environments where antibiotics, especially those classified as broad-spectrum, have disrupted the delicate balance of anaerobic commensals. This microbial imbalance increases the risk of infections in addition to being linked to the development of resistant bacteria. Although reducing the use of broad-spectrum antibiotics is a top priority in current stewardship initiatives, the impact of antibiotics on the microbiome may not be well reflected by their narrow or broad classification.

Therefore, a shift in focus is imperative, considering the relative disruption each antibiotic inflicts on commensal bacteria. Refining treatment choices and improving long-term patient outcomes need integrating microbiome analysis into clinical trials and antibiotic stewardship initiatives. One of the main principles of antimicrobial stewardship is the maintenance of commensal microbiota, which emphasizes the significance it is for protecting human health and stopping the spread of infections that are resistant to antibiotics.

To optimize gut microbiota protection, efforts are being made to create intravenous medicines with limited biliary/fecal excretion, use oral drugs that minimize exposure to the gastrointestinal tract and gut microbiota, and avoid anti-anaerobic antibiotics when clinically feasible. Furthermore, the prospect of completely discontinuing antibiotic therapy exists, particularly in cases where a few doses are needed and a clinical response is unlikely to be affected, is being considered as part of an evolved stewardship paradigm.

One key strategy involves narrowing antibiotic spectra and limiting the duration of use. The diversity of the gut microbiota is greatly impacted by the antibiotics used, with anti-anaerobic drugs causing the most significant disruption. When appropriate, advocating for the prescription of narrower spectrum antibiotics might decrease this disruption and lower the risk of opportunistic infections. Another crucial element is knowing the pharmacokinetics of antibiotics. Diverse antibiotic routes, dosages, and excretions have diverse effects on the gut flora. Compared to intravenous antibiotics, oral antibiotics, particularly those that are highly absorbed and released less through the bile or feces, have less of an effect on the gut microbiota. It’s critical to customize antibiotic prescriptions to reduce disturbance by taking into account elements including absorption, excretion, and risk for resistance, is vital for effective stewardship.

Modulating the gut microbiota to avoid infections is a new field. In certain clinical contexts, strategies to lower the risk of infection are taken into consideration, such as Fecal Microbiota Transplant (FMT), Selective Oropharyngeal Decontamination, Selective Digestive Decontamination, and Pre-Operative Oral Antibiotic Preparation.

Microbiome protection therapies, such as FMT and probiotics, are emerging as potential strategies to mitigate the negative effects of antibiotic exposure on the gut microbiome. The exceptional effectiveness of FMT in treating recurrent 𝘊𝘭𝘰𝘴𝘵𝘳𝘪𝘥𝘪𝘶𝘮 𝘥𝘪𝘧𝘧𝘪𝘤𝘪𝘭𝘦 infection (CDI) highlights the significance of reestablishing a healthy microbiome in order to ward against infections. Early probiotic administration combined with antibiotics has been shown to significantly lower the risk of CDI, indicating a possible path toward microbiome protection.

The creation of quick, affordable tests that can detect disruptions in the gut microbiota is thought to be essential for providing at-risk patients with microbiome-protective treatments. Furthermore, novel strategies such as the use of oral β-lactamases and chemically ensnaring antibiotics in the gastrointestinal tract are being investigated to stop the selection of antibiotic-resistant bacteria and preserve the health of the gut microbiome.

Topical and local administration of antibiotics, as well as alternative routes such as transdermal and nebulized administration, are being investigated to reduce systemic exposure and subsequent gut microbiome impact. Another potentially effective tactic to reduce ecologically-induced negative effects on the human microbiome is the development of precise, very-narrow-spectrum agents.

In conclusion, antimicrobial stewardship practices directly intersect with the gut microbiome. By tailoring antibiotic prescriptions, exploring targeted delivery methods, and considering modulation strategies, stewardship efforts aim not only to combat infections but also to safeguard the delicate equilibrium of the gut microbiota and curb the emergence of antibiotic resistance. Preserving the efficacy of antimicrobials and solving the worldwide health crisis will require integrating the gut microbiota into antimicrobial medication development and improving stewardship methods.

Read Further:

Rethinking antimicrobial stewardship paradigms in the context of the gut microbiome: https://tinyurl.com/bdep52me

Gut Microbiota Modulation: Implications for Infection Control and Antimicrobial Stewardship: https://tinyurl.com/a2bhjrpm

Protect commensal gut bacteria to improve antimicrobial stewardship: https://tinyurl.com/ynm9m79m