By ARJUN SRINIVASAN. MD and RAMANAN LAXMINARAYAN, PhD
Every few years there are reports of antibiotic resistant microbes that prompt a series of predictions about “the end of antibiotics.” It happened in the 90s with multi-drug resistant tuberculosis and then again earlier this decade with methicillin-resistant Staphylococcus aureus or MRSA. It’s happening again with carbapenem-resistant Enterobacteriaceae or CRE. Predictably, over time these bacteria have become resistant to more and more antibiotics. Almost just as predictably, they could be treated by a category of powerful antibiotics known as carbapenems – until now.
Today, 35 states have reported cases of CRE infection to the Centers for Disease Control and Prevention in Atlanta. And they are dangerous. In a recent study of almost 100 cases, more than a third of the patients died from the infection. The concern over these bacteria is compounded by the fact that there are no new antibiotics to treat them coming anytime soon. Most experts agree that even in the most optimistic scenario it will likely be about 10 years before effective new drugs are developed. A variety of efforts are being debated to speed the development of new antibiotics, but these discussions often overlook one critically important issue. One of the reasons our current antibiotics are losing their effectiveness is because we don’t use them properly. Studies have shown, repeatedly, that up to 50% of antibiotic prescriptions are either unnecessary or inappropriate – a statistic that is disappointingly consistent across both in-patient hospitals and out-patient clinics. Not only does this overuse reduce the effectiveness of our current antibiotics, it threatens the utility of any new antibiotics that come along in the future.
While we work on new antibiotics for the future, there is much that must be done right now to both preserve the lifespan of the antibiotics we currently have and to pave the way to ensure prolonged usefulness of new antibiotics that are developed. The most important immediate need is to reducing the overuse of these drugs. Reducing antibiotic over-use is good for society as a whole but it is also good for individual patients. A recent study showed that exposure to a carbapenem antibiotic was the single greatest risk factor for getting an infection with CRE, increasing the risk by 15-fold.
This week, the CDC and its partners have launched the “Get Smart for Healthcare” program to complement the existing “Get Smart: Know When Antibiotics Work” program. This is an expansion of CDC’s existing Get Smart programs targeting outpatient clinics and pediatricians offices to include hospitals and nursing homes. Promoting appropriate antibiotic use, as basic as it seems, can carry our drugs a great deal further.
It can be helpful to view antibiotics much like we view natural resources that benefit from concerted, coordinated conservation efforts. Conservation requires collaboration and recognition that individual actions have an impact on the common good. Reducing overuse means engaging everyone in the effort—for example, by urging the passage of innovative policies aimed at hospitals, other healthcare facilities, and even pharmaceutical companies, to encourage stewardship. By aligning incentives for hospitals and healthcare facilities to focus on infection control and prevention, we can reduce the prevalence of resistant infections that jump from healthcare facilities into the community. By motivating pharmaceutical companies to care about drug resistance, we can encourage them to stop overselling their drugs. Consumers also need to stop demanding antibiotics when they suffer from a viral infection.
We do need new antibiotics–urgently. But, in the meantime, we must focus on using the ones we already have in a sustainable fashion. Not only will this extend the utility of the drugs we have on the market today, but it will also ensure that drugs approved in the future will stay effective for longer periods.
It is easy to make frightening predictions about the end of antibiotics. It is harder but no less possible, to take definitive steps to ensure that such a day never comes. It is time for action.
Arjun Srinivasan, M.D., is Medical Director for the Center for Disease Control and Prevention’s “Get Smart for Healthcare” program and Associate Director for Healthcare-associated Infection Prevention Programs for CDC’s Division of Healthcare Quality Promotion.
Ramanan Laxminarayan, Ph.D., is the director of Extending the Cure, a project that examines policy solutions to the growing problem of antibiotic resistance. Extending the Cure is funded in part by the Robert Wood Johnson Foundation’s Pioneer Portfolio which powers ideas to transform health, seeking breakthroughs with the potential to generate significant health and social impact.
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this guys picture is funny 🙂
WOW! We had our first case of CRE this summer and no one knew what to do in our facility July 2012.
Great post and very intriguing information. What alternatives are possible if microbes become resistant the best antibiotics available today?
Antibiotic resistance is increasing health-care costs as well as the sufferings for humans. Indiscriminate use of antibiotics,may it in hospitals or in other clinics should be avoided. If present trend of Antibiotic resistance continues, we may become sort of effective antibiotics one day.
While we constantly hear of the overuse of antibiotics, it is now a standard of care that healthy women having healthy babies are given IV antibiotics 45 to 60 minutes prior to delivery. This is to decrease the incidence of incisional infections, but it is exposing the unborn child to unnecessary antibiotics prior to the first breath of life. The surgical suites, instruments and the surgeons themselves need to take more caution with the sterile field rather than subject healthy babies to antibiotics. The physicians need to “heal thyself” on this topic.
I agree with antibiotic usage being stopped in corporate agriculture.
By the way, the strain of MRSA aquired in the hospital is a different strain of MRSA that is community-acquired. Although with time, this will probably also change.
Thank you very much for the interesting and informative post.
It is a little sad and scary, Oh..
I have read your information.I like it.It would be interesting to see if the syndromic surveillance facility of certified emrs could be used to automatically track antibiotic use and resistance.
One day they will understand you.
Scary topic, as we have so little control over the overall use of antibiotics.
With 80% of the anti-biotics being produced getting fed to livestock so that they can be kept in the deplorable and obscene concentration camp conditions found on factory farms and at confined animal feeding operations (CAFOs), how can any discussion of bacterial (or viral) resistance completely avoid mentioning this elephant sitting on our heads? Instead, we should wish for a “market-based” solution to what is obviously a simple Darwinian evolutionary pressure for selection? Just make drugs more expensive so that only the rich can afford to use them? Give me a break!
First step, the only one that would be significant, is to outlaw the use of routine anti-biotic feeds. As the terrestrial environment and oceans fill up with our synthetic chemicals, many scientists postulate that this will only increase widespread selective pressure on organisms to evolve resistance. Funny how this has been a looming problem for the past 30-40 years. Yet the corporate animal conglomerates continue to pump out their contaminated products, including billions of pounds of anti-biotic contaminated manure. At this point, only a radical change can possibly have an impact.
When the system is broken, isn’t it time to try something bold, instead of more band aids and duct tape?
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This is a great analysis of the issues. The Alliance for the Prudent Use of Antibiotics (www.apua.org) recently addressed several of these concerns and provided suggestions to the Transatlantic Task Force on Antibmicrobial Resistance (TATFAR), including the need to:
1)Develop and publicize a concrete “emergency action plan”
2)Ensure surveillance systems to monitor antibiotic use and resistance
3)Reduce antibiotic misuse on the farm
4)Research funding and incentives to promote novel products, and to reclassify antibiotics as a special class of drugs
Organization collaboration will be key in accomplishing these activities.
does bacteria now mutate that they become resistant to Anti Bacterial/Anti Biotic
I think you are serious about this, even I also. And we have to take any action on this case.
Great Article!
You have written nice article and I agree with you that We need new antibiotics.
It would be interesting to see if the syndromic surveillance facility of certified emrs could be used to automatically track antibiotic use and resistance.
This is an interesting topic. It’s a continuous and constant battle.
*completely. I fail.
Your article complete ignores the use of antibiotics in corporate agriculture. You fail.
You make to mention of farm use of antibiotics which from the Danish experience has been shown to be the cause of much resistance which is then passed to humans.
The Danish have severely restricted farm use of antibiotics and as a result have seen resistance to antibiotics drop precipitously. They also have an extensive monitoring program which tracks farm and human use of antibiotics and resistance.
Severely restricting farm use of antibiotics would go a long way towards preserving the usefulness of current antibiotics.