The End of Antibiotics. Can We Come Back from the Brink?

The End of Antibiotics. Can We Come Back from the Brink?

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Tom Frieden CDCAntibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die.  Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report  on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.


Clinicians, health care facility leaders, public health leaders, agriculture leaders and farmers, policymakers, and patients all have key roles to play.
The FY 2015 President’s Budget requests $30 million for the CDC’s Detect and Protect Against Antibiotic Resistance Initiative (known as the AR Initiative), part of a broader CDC strategy to target investment and achieve measurable results in four core areas:

Detect and track patterns of antibiotic resistance.

A new five-region lab network, if funded, will speed up our ability to detect the most concerning resistance threats. The network would increase susceptibility testing for high priority bacteria and keep pace with rapidly mutating bacteria so labs are ready to respond to new threats as they emerge.

A new public data portal will show national trends as well as variations in rates of antibiotic prescribing and resistance among states and regions. An increase of $15 million in the FY 2015 President’s Budget for CDC’s National Healthcare Safety Network (NHSN) will allow full implementation of electronic tracking data from U.S. hospitals on antibiotic use and resistant bacteria.  (I’ll talk more about this in a future post.)

Respond to outbreaks involving antibiotic-resistant bacteria.

Enhanced information from hospitals and the new lab network will help detect outbreaks that might previously have gone unnoticed.  We’ll be able to better track the movement and evolution of bacteria, helping local and state responders better prepare for and stop outbreaks of antibiotic-resistant bacteria.

Prevent infections, prevent resistant bacteria from spreading, and improve antibiotic prescribing.

We’re establishing AR Prevention Collaboratives, groups of health care facilities around the country working together to implement best practices for inpatient antibiotic prescribing and preventing infections. Hospitals, long-term acute care hospitals, and nursing homes can all work together to protect patients from drug-resistant infections as patients move between medical facilities in a community.

They’ll scale up or extend the reach of interventions proven to reduce or stop antibiotic-resistant threats, improving antibiotic prescribing and stewardship programs and ultimately reduce antibiotic resistance.

Discover new antibiotics and new diagnostic tests for resistant bacteria.

Because antibiotic resistance occurs as part of the natural evolutionary process of bacteria, it can be slowed but not completely stopped. New antibiotics and therapies will always be needed to keep up with resistant bacteria, as will new tests to track the development of resistance.

To support these efforts, CDC will create a Resistance Bacteria Bank that will make drug-resistant samples available to diagnostic manufacturers, pharmaceutical companies, and biotech firms to develop new diagnostic tests and evaluate new antibiotic agents and therapies.

Exciting new molecular diagnostics may be able to determine if patients have an infection, and whether it is resistant, within hours instead of days, allowing treatment to be tailored to the patient’s particular infection.

With $30 million annual funding over the next five years, CDC’s AR Initiative could cut the deadliest resistant organism, CRE, in half, and also cut healthcare-associated C. difficile in half, saving at least 20,000 lives, preventing 150,000 hospitalizations, and cutting more than $2 billion in health care costs.

Other projected outcomes include a 30 percent reduction in healthcare-associated multidrug-resistant Pseudomonas; a 30 percent reduction in invasive MRSA; and a 25 percent reduction in MDR Salmonella infections.

Urgent action is needed now by everyone who manufactures, prescribes, or uses antibiotics. Drug development for new antibiotics and antifungals is necessary but not sufficient to deal with our antibiotic resistance threats.

Doctors and health care systems need to improve prescribing practices.  And patients need to recognize that there are both risks and benefits to antibiotics – more medicine isn’t best, the right medicine at the right time is best.

Consider this a down payment for our country to start tackling our biggest drug-resistant threats.  The actual funding needed to effectively address all of our drug-resistant threats will likely be many times this amount.

But with this type of significant public health investment, we can open a new chapter in the fight against resistance.

Tom Frieden, MD, MPH (@DrFriedenCDC) is Director of the Centers for Disease Control and Prevention.

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40 Comments on "The End of Antibiotics. Can We Come Back from the Brink?"


Member
Today 3:00 pm

This is a great website and it is very helpful to us.

Guest
Mar 8, 2015

Resistance to antibiotics has always been a worrying issue for years. The race to find new alternatives is a bit complex to handle as long as prescribing habits don’t change for good… and we all know this is probably the weakest link.

Guest
Oct 14, 2014

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Guest
Sep 29, 2014

We know about C-Diff but only because a family friend who’s a nurse told us about it. No doctor or nurse that was treating either of us talked to us about it. It seems that educating people about C-Diff during antibiotic treatment would be a given.

Guest
Sep 29, 2014

As a patient, discuss with your prescriber the role antibiotics might play in treating your current illness. Encourage your family and friends to use antibiotics wisely and to remember simple and effective germ-fighting steps such as hand washing.

Guest
Sep 23, 2014

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Aug 23, 2014

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Catherine Nichols Pogorzelski
Jul 1, 2014

Tom Frieden: So by all accounts, an ENT prescribing post-surgical Levaquin PLUS methylprednisolones TWICE, during the post-surgical period, would be deviating from “standard of care, initiating tendinopathies”

Would this have set up an on-going Staph Aureus, Moraxella Catarrhalis and Klebsiella Oxytoca Pneumonia situation into 2014 and beyond, in an immune-compromised patient (Lyme, Babesia and b. Burgdoferi and hypogammaglobulinemia)

Guest
Jun 29, 2014

SCIP and the Joint Commission now mandate stopping prophylactic antibiotics for surgery after 24 hours. Doesn’t this practice risk INCREASING the number of resistant organisms that survive? After all, we always tell patients to finish their full dose of oral antibiotics for that reason–because of the risk that the less resistant ones will be the only ones killed off, leaving the resistant organisms to thrive.

Would it make more sense to REDUCE the amount of prophylactic antibiotics that are given for clean cases not involving implants? And investigate the wisdom of continuing prophylactic antibiotics LONGER than 24 hours for clean cases with implants or clean-contaminated cases such as bowel resection, especially in patients who are diabetic or have other risk factors for infection?

It seems to me that this “quality measure”, like so many others, is too general and at the same time too rigid. So many problems such as postop wound infections don’t seem to be getting any better. More of “The Dark Side of Quality”–the flaws in the quality quest. See http://wp.me/p2bC3h-g7

Guest

It is important to note that the data on prophylactic antibiotics given to reduce the risk of surgical site infections demonstrates that the most important time to give the antibiotics is prior to the incision. There is not evidence that continuing prophylactic antibiotics beyond the surgery provides any additional benefit. Hence, the recommendations that prophylactic antibiotics be stopped within 24 hours after the procedure.

As you point out, it is important to ensure that prophylactic antibiotics are giving only before procedures where they are recommended. More data on the use of antibiotics for preventing infections after surgery would certainly help identify the most effective strategies in various patient populations.

Guest
Kathy Shreck
May 15, 2014

I don’t think most people realize how urgent it is to get all of this under control. My husband and I had heard the term MRSA. But like most people it was something that was out there but we didn’t give it much thought. I became sick in April 2013 and ended up in the hospital for months, several weeks of that in a coma. I had somehow gotten MRSA in my lungs. I had no outwardly cuts or sores, nothing to indicate something like that was wrong, but I had gone to an ER for a migraine three days before. My family was told I likely would not make it but I did and I left the hospital as a double amputee. I know that sounds terrible but knowing all the things that could have happened I feel very lucky! About two months after coming home my husband got MRSA in his arm; he did have a very tiny scratch where the MRSA occurred. He was treated successfully but he has gotten it again in the exact same place, this time there was no outward wound of any kind. He just finished the antibiotics but that’s two huge rounds of antibiotic treatment for him in less than six months. When he got MRSA the first time, they insisted on treating me as well. They explained it as “just in case”. Knowing what I know now I would not take the antibiotics but we were still in shock at that point and so terrified of what we felt like we couldn’t get away from.

Patients need to be educated so they know when to say no to antibiotics. They also need to know that they must complete the treatment if they start it and not just until they feel better. The general public needs education in the proper use of antibiotics.

We know about C-Diff but only because a family friend who’s a nurse told us about it. No doctor or nurse that was treating either of us talked to us about it. It seems that educating people about C-Diff during antibiotic treatment would be a given.

We live in Arkansas in a small resort town, tourism is the main industry. The doctors here told us that at least 1/3 of the people in our town would test positive for MRSA and that we can get it going to Walmart or Kroger but that we couldn’t give it to each other. It’s all very confusing.

I’m glad to see the government getting involved. I hope that the medical community and the public can be educated and that the answers can be found. What can I do to help?

Guest
Andre De Lorenzi
May 10, 2014

Dear Dr. Frieden , congratulations on your initiative, always acting in the fight against antimicrobial resistance. However, I am working in infection control in Rio de Janeiro for over 15 years. These measures suggested by the CDC, while very effective when put into practice, do not seem to be sufficient in our reality. I believe that the issue should be discussed with the entire society, even to try to define the extent to which we must fight desperately for maintaining a life that often has come to its natural end. The intensive care units remain overcrowded with chronic patients with multiple invasive devices and exposed to several episodes of infections by resistant germs.
I think it will be needed more radical attitudes, such as rethinking the architecture of intensive care units or even the very existence of these units. We may have to deal with critical patients in public wards, taking to them the necessary equipment and specialized health professionals. ICUs as they are now are true incubators of resistance. Moreover we should consider developing vaccines against bacteria, because, to my knowledge, very little has been invested in this particular activity.
Thank you very much for the opportunity.
Best regards ,
Andre De Lorenzi

Guest
Medical Victory Strategist
May 24, 2014

Dr. De Lorenzi,

My sense is that you have identified the true problem: outbreaks of antibiotic-resistant bacteria are not being tracked back to ambulatory pediatric health clinics that overprescribe antibiotics for colds and ear infections. They are coming out of ICUs like the ones for which you do infection control in Rio de Janeiro. In one or more of the URLs I supply above Dr. Paul Ewald describes the reasons.

The CDC is a jewel in the crown of American Medicine. When an outbreak of antibiotic-resistant bacteria hit a Florida long-term acute-care hospital, the CDC rushed to the rescue:

http://www.cdc.gov/hai/state-based/pdfs/HAIpreventionStories_FL_CRE.pdf

“Florida Stops Outbreak of Carbapenem-Resistant Enterobacteriaceae”

Note the similarity between the measures employed and those Israel used in similar facilities in the same situation:

http://www.michigan.gov/documents/mdch/Israeli_Experience_with_CRE_-_Marchaim_403295_7.pdf

“CRE Epidemiology-Global & Israeli Perspectives–Assaf Harofeh Medical Center Infection Control and Prevention Unit”

Interesting (to me anyway), there was no discussion of antibiotic prescribing practices in the Israeli paper, and in the CDC’s fact sheet on the Florida CRE emergency they said:

“What We Learned

• Spread of CRE can be reduced through tracking CRE and targeting prevention practices to patients who are colonized or infected with CRE.

• Critical strategies to stop CRE spread include: quickly detecting patients with CRE, separating patients with and without CRE and dedicating nursing staff and equipment to each group. Facilities must ensure constant adherence to isolation and hand hygiene practices to protect patients and save lives.

• Reducing CRE within and across healthcare facilities will require a regional public health approach.”

Now, we Medical Victory Strategists are always for the development of decisive new weapons. In the battle against mankind’s oldest and most-remorseless enemies, the only thing better than a new antibiotic that is to staphylococcus aureus what the atom bomb was to enemy cities, is a new antibiotic that is more like a hydrogen bomb (with the precision of our latest-generation guided missiles, of course). For saving individual patients who have already developed sepsis, “Rambomycin” (to invent a name) will be essential, and all measures to speed its development should be taken.

But by the time doctors fall back to using Rambomycin, some patient is going to be really, really sick. So your point about rethinking the very *existence* of facilities that answer to the description Dr. Ewald gives of breeding grounds for MDR bacteria is well-taken. CDC’s actions in the Florida crisis were designed to take a facility that was such a breeding/transmission ground and make it into one that was not. The Israelis went farther and looked at their larger system of rotating very sick people from long-term care facilities to long-term intensive medicine facilities and back.

As for vaccines, absolutely. In:

http://www.pbs.org/wgbh/evolution/library/01/6/text_pop/l_016_06.html

Dr. Ewald discusses the development and use of vaccines not just to protect us humans, but to “domesticate” our microbial enemies.

Another issue we will have with “Rambomycin” is whether we let it be used in health care facilities that don’t follow Dr. Freiden’s guidelines. Of special concern are those outside the United States, to which CDC’s writ does not reach. Consider this article from little more than a year ago:

http://blogs.wsj.com/indiarealtime/2013/04/23/india-has-lost-superbug-war/

“India ‘Has Lost’ Superbug War”

Do we dare allow our “last-ditch” antibiotics to be exported to places where we risk that they will be beaten by the germs due to inadequate infection-control procedures?

Guest
Andre De Lorenzi
Jun 10, 2014

Dear Dr. “Victory Medical Strategist”
My previous comment was referring to a global problem that affects all countries regardless of economic or social situation and, in particular, the intensive care units. Since I graduated in medicine I’ve been watching and trying to follow all CDC recommendations related to hospital infection control. Actually the whole world knows the CDC is a global authority on health and its actions goes well beyond American borders. It is true that the reality of the underprivileged countries does not always allow that optimal measures are adopted in full. However, when we talk about hospital infection, we are referring to organisms that are on this planet for billions of years before our arrival, and possibly will remain here after our departure or extinction. So, I believe that we should approach the subject in a scientific manner and also philosophically, questioning even our limit when facing the terminal phase of human life.
I wonder if in a future not so distant, we may have to deliver the latest technology and medical knowledge to critically ill patients where they are, rather than gather them into a single unit where the transmission of resistant germs would be more likely, even if we adopt all necessary precautions.
Regarding your “rambomycin” it will always be very welcome and should, like all other antibiotics, be used wisely.
In your last paragraph you wrote:
“Do we dare allow our last-ditch antibiotics to be exported to places where we risk that they will be beaten by the germs due to inadequate infection-control procedures?”
This thought bothered me a lot, especially being in the 21st century. This kind of questioning, about denying access to scientific progress that can save human lives, besides being impractical, would be unethical and contrary to the UNESCO Universal Declaration on Bioethics and Human Rights.
http://unesdoc.unesco.org/images/0014/001461/146180e.pdf

Guest

As always, an interesting conversation.

Thank you for your comments on new drug development and antibiotic use in agriculture. Bacteria learn in a very short time how to outsmart antibiotics, and new drugs are years away. Making new antibiotics is both expensive and difficult. However, even when new drugs arrive, their effectiveness will quickly disappear if the prescribing and use doesn’t improve. We need to be doing a better job of improving appropriate use of antibiotics in all sectors – humans and animals.

Guest
May 7, 2014

Antibiotic resistant bacteria are indeed as terrifying as Dr. Freiden describes. In addition to his suggestions, I would favor policy changes that incentivize the development of new drugs to combat these super bugs. The Orphan Drug Act was instrumental in getting pharmaceutical and biologic companies to invest in targeted cures for rare diseases. A similar act (including things like patent extensions and FDA drug approval fast-tracking) for anti-microbial products/medicines could be very helpful and don’t cost tax payers anything.