Visualizing the Threat Posed by Antibiotic Resistance

For the first time, researchers and policymakers can visually track the rise in “superbug” infections over time and identify regions of the country with rapidly spreading rates of resistance.

Researchers at Extending the Cure, a nonprofit project funded by the Robert Wood Johnson Foundation’s Pioneer Portfolio, have developed ResistanceMap—an online tool that tracks changes in resistance levels. These maps show us how the problem of antibiotic resistance has gotten worse–with some regions of the country experiencing a significant and worrying increase in drug- resistant microbes.

Infections like those caused by MRSA (methicillin-resistant Staphylococcus aureus) kill an estimated 100,000 people in the United States each year. Progress toward solving this emerging public health crisis has been slow, an important reason why the Robert Wood Johnson Foundation has funded this research through its Pioneer Portfolio. We share a common view that the best way to prevent an epidemic from occurring may lie in dramatically reframing how we approach the problem.

This is exactly what Extending the Cure has done with ResistanceMap, a web tool that presents scientific data in a user-friendly way, allowing policymakers and researchers to quickly identify regions in urgent need of better infection control, enhanced surveillance, more vigilant antibiotic stewardship, and comprehensive methods to curtail the spread of resistant microbes.

At the core of these maps are data on more than 5 million individual patient samples tested for resistance, or the ability to survive a treatment course with an antibiotic. The resulting maps show that resistance has risen sharply during the first decade of the 21st century.

They also highlight additional significant trends. Each year, tens of thousands of people are killed by Acinetobacter baumannii, which causes pneumonia and other health problems. This microbe now has the ability to evade a last-resort class of antibiotics called carbapenems. The map shows resistance rates in the U.S. have risen from under 5 percent in 2000 to nearly 40 percent in 2009, an eight-fold increase. In some cases, infections caused by this superbug are unstoppable.

That’s why tackling a superbug like Acinetobacter requires new thinking on an old problem. The Extending the Cure project started with a 2008 report that examined antibiotic resistance in a fundamentally different light. By approaching the problem as a natural resources economist might, the report argued that we could help turn the tide on superbugs by optimizing the effectiveness of a scarce societal good (antibiotics).  Taking such a perspective leads researchers to look upstream from the point of antibiotic use and consider issues related to the development, production, regulation and management of these drugs.  This is a dramatic break from usual approaches to drug resistance which emphasize infection control and greater government investment in new antibiotics to replace older, ineffective ones without altering incentives for how antibiotics are utilized.

At the time, this concept was well outside the established research paradigm. And, in fact, the concept emerged from a completely different field of study. However, through its Pioneer Portfolio, the Robert Wood Johnson Foundation serves as an incubator for ideas – like ResistanceMap — that have the ability to drive lasting change in health and health care.

With the launch of ResistanceMap, we have the ability not just to study the past but to peer into the future of resistance, accelerating our progress against superbugs—a crucial step if we are to stave off a major public health crisis.

John Lumpkin, M.D., M.P.H., is senior vice president and director of the Health Care Group at the Robert Wood Johnson Foundation in Princeton, N.J.

Ramanan Laxminarayan, Ph.D., is the director of Extending the Cure, a project that studies the growing problem of antibiotic resistance. Extending the Cure is funded in part by the Robert Wood Johnson Foundation’s Pioneer Portfolio.

18 replies »

  1. While over the counter antibiotics may be beneficial in low and middle income countries, it is not beneficial in America. We are finding that these foreigners are importing antibiotics from these countries and making business in America and many of these foreigners who may have AMR are in America and without health insurance and is causing America billions of dollars. GARP need to intervene and make better policies and have better surveillance on these OTC antibiotics.If we don’t take a stance now, globally we will be heading up the creek.

  2. Nikolay, yes self medication is a big problem but not just outside of US, it is also right in our back yard. Check your local corner stores and online sites such as ccheapantibioticsonline.com. It is frightening.

  3. It isn’t just self-medicating or using antibiotics for the wrong ailments (such as cold viruses) that’s a problem, it’s patients not taking the full course of antibiotics prescribed but instead quitting when they feel better allowing the microbes left behind to get resistant. Also, I notice that no one has mentioned the Indian reservations in this country. Many are much like developing countries. One of the Indian reservations I worked on has a huge MRSA problem that goes back years.

  4. Thank you for the reference! I see how ResistanceMap fits nicely with the last recommendation in your report. It would be great to have all sorts of tools in doctor offices and elsewhere to forge an attitude of personal responsibility. As consumers we often miss the link between individual actions and the collective costs they impose. The iphone asthma app is a really good example we can follow to educate the public about drug resistance.

    I also like your recommendation for improving physician training, which is another part of the drug resistance equation. We recently released a policy brief that summarizes the effectiveness of physician-based educational interventions to reduce antibiotic misuse. It’s available on our website:

  5. “Can this tool help inform the development of new approaches to drug resistance?”

    We believe that measuring and communicating the scale of the problem to larger audiences is essential to developing adequate policy solutions. Regional health authorities are more likely to act if there is broad public awareness that there are high rates of resistance and antibiotic overuse in the community.

    And while surveillance systems have been in place for years and drug resistance has gotten a lot of attention in research circles, there has been little effort to inform the public. A lot of the media information focuses on MRSA and other “superbugs”, and tends to be sensationalistic and incomplete. With ResistanceMap, we are hoping to give a simple but accurate idea of resistance development by using nationally representative time series data

  6. This is incredible! I’m trying to think of a way it can be made into “installation art” in primary care offices as a reminder of the impacts of our actions. Our report offers five categories of compelling recommendations that are supported by provocative examples of how to translate data into useful forms such as yours that encourage action at http://www.hopestreetgroup.org/docs/DOC-2367 .

  7. Thank you for your comments on behalf of CDDEP staff that works on the maps. Feel free to visit our website and sign up for our newsletter at http://www.cddep.org

    Some of the planned updates on ResistanceMap include visualizations on more pathogens and antibiotics, a more interactive interface, outpatient use data and maps on other regions of the world.

  8. Thanks for pointing that out, we definitely acknowledge antibiotic use is underresearched. You might be aware of this, but the Pew Trusts have done a lot of work in the area, including a technical paper on the link between antibiotic resistance and industrial farming http://www.saveantibiotics.org/resources/CommissionHealthTechnicalPaper.pdf

    You can find out more about their project and campaign to restrict farm use here: http://www.saveantibiotics.org/ourwork.html

  9. As part of our Global Antibiotic Resistance Partnership project, we hope to draw attention to the problem of resistance in developing countries, where the issue is not just overuse, but also access to drugs. A situation analysis for India will be released soon. We are also collecting data on prescribing patterns in New Delhi hospitals and doing a lot of other work on site in India.

    You can have a look at GARP country reports that have already been released at http://www.resistancestrategies.org/

    Also, registration is now open for the 1st Global Forum on Bacterial Infections: Balancing Treatment Access and Antibiotic Resistance | http://www.globalbacteria.org

  10. Overuse due to self-medication is a big problem, especially outside the US. Even when antibiotics are not sold over the counter we have inappropriate use because outpatients demand a prescription and hospitals use broad-spectrum agents as a cheaper form of infection control. In addition to putting maps of outpatient use in the future, we are currently organizing a chart review study with the CDC that will look at use patterns in several hospitals.

  11. I notice you don’t mention the use of abx in agribusiness.

  12. Was just asked by a colleague re prescribing antibiotics for irritable bowel syndrome, another opportunity to throw antibiotics at another disease breeding resistant organisms to attack the rest of us.

  13. Part of the problem is that many people take antibiotics without the doctor’s prescription. This only makes the microbes stronger. And when they transfer those to other people, it would be harder to treat. I hope we can educate these people trying to self medicate.