MUDr. Marek Štefan: Cooperation With Pharmacists Is Essential in Antibiotic Therapy

Why do so many physicians in general practice still rely so heavily on CRP when prescribing antibiotics? And what would be the ideal role of PCR testing in this context?

CRP testing in general practice or urgent care is a useful tool that can help reduce antibiotic prescriptions. However, results must always be interpreted in the context of the patient’s overall clinical picture and history, as false positives and negatives can occur. Elevated CRP levels usually indicate an ongoing bacterial infection, but the finding is not definitive—CRP may also rise in noninfectious inflammatory states or in more severe viral respiratory infections (such as COVID-19).

Etiological diagnosis using PCR remains the gold standard because it can confirm viral origin—for example, in respiratory infections—and thus eliminate unnecessary antibiotic use. However, in routine outpatient practice, PCR use is limited by cost and availability. More commonly, antigen tests are used to detect the most frequent viral (SARS-CoV-2, influenza virus) and bacterial (pyogenic streptococcus, mycoplasma) respiratory pathogens. A new test currently under investigation targets the protein MxA—a marker that can be considered a functional counterpart to CRP, as its levels rise in viral infections.

Should the prescribing of “Watch” category antibiotics be restricted in cases where they are not strictly indicated?

For basic orientation in antibiotic strategy, the AWaRe classification—often referred to as the “antibiotic traffic light”—is a useful tool.

The Access (green) group includes first-line antibiotics for common infections in both outpatient and hospital settings. Their use should be preferred, as they carry a lower risk of resistance development and are generally less toxic to the human body.

The Watch (orange) group includes higher-risk antibiotics that require cautious use. In hospitals, their administration should be supervised by an antibiotic stewardship center, while in outpatient settings, these drugs—such as fluoroquinolones, macrolides, and 2nd-generation cephalosporins—are still often prescribed inappropriately. One possible improvement in outpatient prescribing would be to limit the availability of these agents. Personally, I favor education and constructive feedback for both physicians and patients.

The Reserve (red) group comprises “last-resort” antibiotics, which can be used only after approval by an antibiotic stewardship center.

What conclusions did the KMINE congress reach about when and for whom to use reserve antibiotics?

In recent years, several new beta-lactam antibiotics have been approved (including ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, imipenem/relebactam, meropenem/vaborbactam, aztreonam/avibactam, and fosfomycin). These agents target various multidrug-resistant Gram-negative bacterial strains. They represent costly reserve therapies, indicated only in clearly defined cases where no other effective antibiotics are available.

The Nordic countries are often cited as a model for antibiotic stewardship. What lessons can we learn from their approach?

The Nordic countries maintain low levels of antibiotic resistance, largely due to their rational and restrained antibiotic use. Contributing factors include cultural attitudes, systematic education, unified clinical guidelines, and reliable access to first-line antibiotics. These experiences can serve as inspiration for us. Compared to other European countries, the Czech Republic ranks about mid-range in terms of resistance levels and outpatient antibiotic consumption, but our hospital antibiotic use remains among the highest in Europe—highlighting significant room for improvement.

How important is cooperation with clinical pharmacists or pharmacologists in antibiotic therapy?

Collaboration with them is absolutely crucial in modern medicine. It brings benefits across many areas—from individualized dosing based on therapeutic drug monitoring to managing drug interactions and choosing optimal formulations. This approach is essential not only in infectious diseases but across all medical specialties.

In our field, we most often monitor serum levels of vancomycin and aminoglycosides, and increasingly also beta-lactam antibiotics and other antimicrobial classes, including antivirals and antifungals.

Incorrect use of broad-spectrum antibiotics is associated with the risk of Clostridioides colitis. In what cases does this complication occur?

Clostridioides difficile colitis is a severe intestinal infection caused by disruption of the gut microbiota, typically following treatment with broad-spectrum antibiotics. The imbalance allows Clostridioides to overgrow and release toxins that damage the intestinal mucosa. The disease can take a severe course, and in the most extreme cases (toxic megacolon) may lead to colectomy or even death.

The highest-risk antibiotics include combination penicillins (such as amoxicillin/clavulanate), cephalosporins, clindamycin, and fluoroquinolones. In English, these are often summarized as the “4 C” antibiotics—co-amoxicillin, cephalosporins, clindamycin, ciprofloxacin. However, virtually any antibiotic has the potential to trigger C. difficile colitis. Treatment consists primarily of discontinuing the causative antibiotic (if possible), starting targeted therapy (vancomycin, fidaxomicin, metronidazole, or tigecycline), providing supportive care, and ensuring strict isolation, as the infection is highly contagious due to spores shed in stool.

What are the latest developments in antibiotic therapy?

Although the development of new antibiotics continues, it is important to recognize that bacteria will always have an advantage due to their ability to rapidly evolve resistance. A highly promising direction is bacteriophage therapy—using “cocktails” of bacteriophages, viruses that specifically infect and destroy pathogenic bacteria. This elegant approach offers targeted action and potentially lower toxicity compared to conventional antibiotics. Bacteriophage therapy may become a key component of the future fight against infections.

Editorial Team, Medscope.pro