CORRESPONDENCE
Broad- and narrow-spectrum antibiotics: a different
approach
Clin Microbiol Infect 1998; 4: 56-57
We welcome the comment of Dr Acar (Clin Microbiol
Infect 1997; 3: 395-6) questioning a lifetime usage of
the terms ‘broad- and narrow-spectrum antibiotics’. It
appears he now realizes that there is no clear definition
of these terms and he boldly suggests that we cease
using them. We agree whole-heartedly. We adopt a
different approach to antibiotic usage which Dr Acar
may find more understandable and acceptable.
Traditionally, microorganisms are categorized using
the Gram stain. Antibiotics can be classified by their
activity against a spectrum of microorganisms. The
more species of organisms that are killed, the broader is
the spectrum of activity. Antibiotics only active against
Gram-positive bacteria such as flucloxacillin, are narrow
in their spectrum, whilst antibiotics capable of lulling
both Gram-positive and Gram-negative bacteria, such
as cephradine, are broad in their activity [l].
We advocate describing antibiotic activity accord-
ing to the intrinsic pathogenicity of the micro-
organism targeted by the antibiotic rather than its
Gram stain. The ratio between the number of patients
infected by a particular microorganism and the number
of patients carrying that organism in throat and/or gut
i r defined as the intrinsic pathogenicity index (IPI) for
a particular microorganism [2]. The patient’s carrier
state allows us to classify the microorganisms into three
groups. Indigenous flora, including anaerobes and
viridans streptococci, are low-level pathogens and
rarely cause infections despite being carried in high
concentrations (IPI between 0.01 and 0.03). High-level
pathogens such as Salmonella species have an IPI
approaching 1.O. We have identified about 14 potential
pathogens characterized by IPIs between 0.1 and 0.3.
Out of 10 patients who carry potentially pathogenic
microorganisms (PPM), one, two or three may develop
one or more infections with these PPMs. We make a
distinction between ‘community’ and ‘hospital’ PPMs
depending on the severity of underlying disease. The
‘community’ PPMs such as Haemophilus influenzae,
Staphylococcus aureus, Streptococcus pneumoniae and
Eschericliia coli are carried by previously healthy
individuals whilst ‘hospital’ PPMs, the typical
opportunistic aerobic Gram-negative bacdli (AGNB),
including Klebsiella, Enterobacter, Serratia, Citrobacter and
Pseudomonas species, are carried by people with an
underlying pathology, either chronic, such as diabetes,
or acute, including pancreatitis or burns. Recent work
56
shows that the carriage rate of these opportunistic
AGNB was increased to 50% in a mixed intensive care
population with an average APACHE I1 score of 15
[3,41.
The normal indigenous flora in the oropharynx
and gut characterized by a low IPI is vital for normal
physiology [5]. It produces vitamins [ 6 ] ,contributes to
the renewal of throat and gut mucosa [7]and promotes
reabsorption of water [8]. Moreover, normal anaerobic
flora is important in controlling acquisition, carriage
and subsequent overgrowth of the 14 aerobic potential
pathogens [9]. Overgrowth has recently been
recognized to be an independent risk factor for colon-
ization and infection of internal organs [lo]; trans-
mission via hands [ l l ] ; and the presence of resistant
mutants amongst potential pathogens [12]. Once a
particular PPM reaches the level of 1O5 colony-forming
units/mL in saliva, the chance of isolating the identical
microorganism from the lower airways is as high as 50%
[ 101. The higher the salivary and fecal concentrations
of methicillin-resistant Staphylococcus aureus (MRSA),
the higher the risk of its spread [ 111. In order to contain
a resistant mutant, a bacterial population of at least 10’
microorganisms is required [12]. Therefore, to prevent
overgrowth we must respect the microbial ecology of
normal flora and not use antibiotics which suppress
normal flora. We should only use agents that are active
against potential pathogens whilst sparing indigenous
physiologic flora. This sort of antibiotic is a narrow-
spectrum antibiotic by current definition, only active
against potential pathogens. Broad-spectrum antibiotics
kill both potential pathogens and also the normal flora.
Flucloxacillin is broader than cephradine, from an
ecological point ofview [13,14]. In addition to exerting
a selection pressure on MRSA, flucloxacillin may
promote concomitant overgrowth of MRSA and
encourage dissemination. It is not surprising that more
MRSA than ever are reported. Yet we continue to use
the so-called narrow-spectrum antibiotic flucloxacillin.
We believe that restoration of the microbial ecology
may be a prerequisite for the control of the emergence
of serious resistance problems. However, that approach
implies a careful withdrawal of popular antibiotics
such as (3-lactams and (3-lactamase inhibitors, fluoro-
quinolones and carbapenems known to have an impact
on the ecology. But do most patients need them?
Rick van Saene,
Sandy Fairclough,’
Andy Petros
Correspondence
*Department of Mechcal Microbiology,
University of Liverpool, Liverpool, UK;
2Department of Pharmacy,
Alder Hey Hospital;
Liverpool, UK;
3Paediatric Intensive Care Unit,
Great Ormond Street Hospital,
London, UK
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