For Clinicians | Traveling With Medical Supplies

For Clinicians | Antibiotic Resistance in 2026

What Actually Changed Since You Trained

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed by Kristen Carpenter, PA-C — Clinical Advisory Board Member

Most of us were trained on a model of antibiotic resistance that’s about a decade out of date. Not wrong, exactly. Just no longer the whole picture. And three of the things we tell patients with the most confidence are the three things that have shifted the most.

This is a refresher, not an alarm. We’re going to walk through what’s updated in antibiotics in the last decade…where the resistance you treat at the bedside really comes from, why “finish the full course” stopped being the guidance, and what resistance actually is at the population level, because that last one is where the standby-antibiotic question finally gets a clean answer.

Where does the resistance you treat actually come from?

Let’s start with the scale, because the threat is a big deal. The GRAM study, now the gold-standard global model, attributes about 1.14 million deaths directly to resistant infections in 2021 and projects more than 39 million cumulative deaths from 2025 to 2050 if we hold the current course.¹ In the US, the CDC’s standing figure is more than 2.8 million resistant infections and over 35,000 deaths a year, and that’s before you count C. difficile.²

So the problem is real. The question is where this resistance comes from, and this is the first place the old model misleads. You’ve seen the figure that around 80% of antibiotics in this country go to animals. It’s true by volume. It’s also where most people stop, and stopping here is the mistake, because volume is not the same as the resistance you fight at the bedside.

Here’s the clearer way to hold it: agriculture matters most for the bacteria you get from food, and least for the resistant infections you actually admit. Farm use is a real driver of resistant foodborne enterics, the non-typhoidal Salmonella and Campylobacter that NARMS tracks across human, animal, and retail-meat isolates.³ It’s a minor player in the urgent threats that keep you up at night: CRE, C. diff, and drug-resistant gonorrhea are overwhelmingly driven by human prescribing and healthcare transmission.⁴

This isn’t a clean “humans, not farmers” story, and you should be wary of anyone selling it that way. Livestock-associated MRSA is real. The best transmission models still credit animal use with a modest share of human resistance, not none.⁵ But “modest and bug-specific” is the true shape of it, and it points stewardship attention back where it does the most good: the prescriptions written by people like us.

Does “finish the full course” still hold up?

For most common infections, no. This is the shift that surprises people most, because “always finish the course, even if you feel better” is something we’ve all said a thousand times, and we said it on the theory that stopping early breeds resistance. That rationale never had much evidence under it. A 2017 BMJ analysis said so in its title: the antibiotic course has had its day.⁶

What replaced it is the principle of shortest effective duration. A 2025 systematic review found that 85% of duration trials, 267 of 315, showed shorter courses were non-inferior to longer ones.⁷ IDSA’s 2025 complicated-UTI guideline moved the same direction, toward shorter treatment.⁸ The reasoning is plain: every extra day of antibiotic is another day of selection pressure on the patient’s own flora, with no added benefit once the infection is handled.

Three cautions so this doesn’t get oversold. First, and the one that matters most at the counter: shorter does not mean stop when you feel better, and it isn’t a blanket rule. Each shorter duration was validated in its own trial, for one specific infection, and the prescriber sets it for that indication. It tracks cure, not symptoms. Strep is the clean example: most patients feel fine inside a day, but the standard amoxicillin course still runs the full ten, because the goal is eradicating the organism and heading off rheumatic complications, not just clearing the sore throat. Second, the evidence is strongest for common, uncomplicated infections. Severe disease and resistant-organism infections are still under-studied, and “shorter” there is not yet settled. Third, the claim that holds up is that shorter courses are non-inferior for cure and reduce exposure. The further claim, that shorter courses demonstrably lower resistance, is plausible but weaker, and we shouldn’t state it as proven.

The practical translation for the counter: patients still follow the specific prescription in front of them. “Shorter is fine” is a guideline-level change in how we prescribe, not a license for patients to freelance the stopping point on their own.

What is resistance, actually?

This is the shift that reframes the standby-antibiotic question, so it’s worth being precise. Resistance is not an individual phenomenon. A patient’s body does not “get used to” an antibiotic the way it might habituate to caffeine. Resistance happens at the level of bacterial populations: a drug applies selection pressure, the susceptible bugs die off, the resistant ones are left to multiply, and resistance genes move between bacteria on plasmids and other mobile elements.⁹ The patient is the environment. The bacteria are what changes.

If resistance were something a person develops, then holding antibiotics, or having taken them before, would be the hazard all by itself. It isn’t. The lever is use, and specifically inappropriate use: the wrong drug, the wrong indication, a subtherapeutic dose, treating something that was never bacterial.

One caution for credibility, because clinicians will think it: even appropriate, indicated use carries an ecological cost. It selects for resistance in bystander gut flora every time. The point is not that correct prescribing is free. It’s that the benefit outweighs the cost when the drug is right and the indication is real. Inappropriate use is all cost and no benefit. That’s the whole game.

So where do standby antibiotics fit?

We were trained to prescribe inside a closed system: one patient, one prescriber, one chart, one local pharmacy that knew about all three. Now patients get antibiotics through telehealth, mail-order, pharmacies abroad, and the leftover stashes in the cabinet, with or without us. So the real question isn’t whether people will have antibiotics on hand. It’s whether what they have is the right drug, for a real indication, with instructions. And the logic follows straight from the last section: if the lever is use, then keeping the right course on a shelf is not what drives resistance. Misuse is. Possession isn’t.

This isn’t a fringe idea, either. Advance provision is built into medicine everywhere access is the real constraint. Ships without a physician aboard are required to carry antibiotics for crew self-treatment under WHO and maritime labor conventions.¹⁰ Expedition medicine sends them along when evacuation is days out. The US government piloted home doxycycline “MedKits” for anthrax post-exposure.¹¹

No standby provision program has published resistance outcomes. The precedent is real and the logic holds, but we can’t cite a study proving our specific model is resistance-neutral. So the defensible ground is narrow on purpose, and we’d rather claim less and hold it firmly: standby antibiotics make sense where a patient can reliably recognize the problem and access is the binding constraint. Doxycycline for a tick bite or travel into tick country. The worked-up recurrent-UTI patient who knows her pattern. A disaster or remote setting where care is unreachable for days. Travel where the local drug supply is counterfeit or degraded, which is itself a resistance driver, so a quality-assured course carried in is the safer call, not the reckless one.¹²

Where it does not belong: the sore throat, the cough, the sinus pressure that’s viral the overwhelming majority of the time.

The safeguards that make it stewardship

What separates a standby course from a leftover stash isn’t the molecule. It’s everything wrapped around it. Done right, each of these is a stewardship lever. Together they’re the standard a standby program has to clear to count as stewardship at all, the bar we hold our own work to:

• Right drug, chosen deliberately: lead with WHO Access-group agents (amoxicillin-clavulanate, doxycycline, metronidazole) over Watch-group drugs that carry more collateral damage. The molecule is a stewardship decision before the box is ever opened.
• A documented indication: a specific condition the drug is matched to, not “antibiotics, just in case.”
• Clear dosing and the shortest effective duration, spelled out, so nobody is guessing or rationing.
• Explicit “when NOT to use this”: the criteria that point the patient back to care instead of to the kit. With no clinician at the moment of use, this written guidance carries the weight, so it has to be unambiguous.
• A path back to a clinician: these complement primary care, they don’t replace it. Use what’s on the shelf only when real care isn’t reachable.

That’s the standard, not a snapshot of any kit on the shelf today, ours included. The “when not to use” guidance is the piece we’re still building toward, because getting it unambiguous with no clinician in the room is the hardest part of the whole thing, and we’d rather name the bar than pretend we’ve already cleared it.

Charting the grey space

Right now, care is all-or-none. A patient either reaches a prescriber while it still matters, or they’re left with a leftover stash and a search bar. There’s no sanctioned middle: no clinician-built step that prepares someone for the few things they can reliably recognize, before access fails. That gap is where we work, and the category has a name we use on purpose: appropriate medical preparation. The right drug, a real indication, clear instructions for when to use it, prescribed ahead of the moment access disappears.

This complements primary care, it does not replace it, and for anything outside that narrow band the answer is still a clinician. If you’d rather not prescribe in this space yourself, you can send patients to us at Jase.com. 

The bottom line

The model most of us trained on is about a decade out of date. Resistance is ecological, driven by how antibiotics are used, not by who keeps them on a shelf. Agriculture owns the foodborne bugs; human prescribing owns the ones we admit. Shorter courses are the standard now for common infections. And a well-chosen standby antibiotic, with a real indication and clear instructions, belongs inside stewardship, not outside it.

We’re building this in the open, and what you see in the office and at the counter sharpens it.

Sources

1. Naghavi M et al. (GBD 2021 Antimicrobial Resistance Collaborators). Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. The Lancet, 16 September 2024. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01867-1/fulltext
2. CDC. Antimicrobial Resistance Facts and Stats (2019 AR Threats Report baseline: more than 2.8 million resistant infections and over 35,000 deaths a year; with C. difficile, more than 3 million infections and 48,000 deaths). https://www.cdc.gov/antimicrobial-resistance/data-research/facts-stats/index.html
3. CDC, FDA, and USDA. National Antimicrobial Resistance Monitoring System (NARMS): tracks Salmonella and Campylobacter across human, retail-meat, and food-animal isolates. https://www.cdc.gov/narms/about/index.html
4. CDC. Antibiotic Resistance Threats in the United States, 2019 (CRE, C. difficile, and drug-resistant N. gonorrhoeae driven predominantly by human prescribing and healthcare transmission). https://www.cdc.gov/antimicrobial-resistance/data-research/threats/index.html
5. Booton RD et al. One Health drivers of antibacterial resistance: quantifying the relative impacts of human, animal, and environmental use and transmission. One Health, 2021 (Thailand model: eliminating animal use yields a modest reduction in human resistant colonization). https://www.sciencedirect.com/science/article/pii/S2352771421000100 — and Tang KL et al. Restricting the use of antibiotics in food-producing animals and its associations with antibiotic resistance: a systematic review and meta-analysis. The Lancet Planetary Health, 2017 (about 24% lower resistance in humans with restriction, concentrated in people with direct animal contact). https://www.thelancet.com/journals/lancet/article/PIIS2542-5196(17)30141-9/fulltext
6. Llewelyn MJ et al. The antibiotic course has had its day. BMJ, 2017;358:j3418. https://www.bmj.com/content/358/bmj.j3418
7. Mo Y, Tan WC, Cooper BS. Antibiotic duration for common bacterial infections: a systematic review. JAC-Antimicrobial Resistance, 2025;7(1):dlae215 (85%, 267 of 315 trials, found shorter courses non-inferior). https://academic.oup.com/jacamr/article/7/1/dlae215
8. Infectious Diseases Society of America. 2025 Guidance on the Management and Treatment of Complicated Urinary Tract Infections (shorter antibiotic courses for clinically improving patients). https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/
9. CDC. About Antimicrobial Resistance (resistance as population-level selection pressure plus horizontal gene transfer, not individual habituation). https://www.cdc.gov/antimicrobial-resistance/about/index.html
10. WHO, ILO, and IMO. International Medical Guide for Ships, and ILO Maritime Labour Convention, 2006 (ships must carry a medicine chest, medical guide, and required medicines, including antibiotics, for self-treatment without a physician aboard). https://imo-epublications.org/content/books/9789241547208
11. Institute of Medicine. Prepositioning Antibiotics for Anthrax (home doxycycline MedKits; Minneapolis–St. Paul postal pilot, 2008). https://www.ncbi.nlm.nih.gov/books/NBK190049/
12. Hall RM et al. Substandard and falsified antibiotics: neglected drivers of antimicrobial resistance? (subtherapeutic dosing from degraded or falsified product selects for resistance). https://pmc.ncbi.nlm.nih.gov/articles/PMC9394205/