OP-ED

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

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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chris
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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.

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Lensa Dunia
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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.

VIEW RUMAH
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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.

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Catherine Nichols Pogorzelski
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Catherine Nichols Pogorzelski

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)

Karen Sibert MD
Guest

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… Read more »

Tom Frieden, MD, MPH
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… Read more »

Kathy Shreck
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Kathy Shreck

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… Read more »

Andre De Lorenzi
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Andre De Lorenzi

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… Read more »

Medical Victory Strategist
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Medical Victory Strategist

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… Read more »

Andre De Lorenzi
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Andre De Lorenzi

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,… Read more »

Tom Frieden, MD, MPH
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.

Dr. Val
Guest

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.

LeoHolmMD
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LeoHolmMD

So not a single bullet point on stopping factory farms from dumping tonnage of antibiotics into animals for the sole purpose of growth and profit? This could be undone overnight. Why hasn’t the CDC done this already? This is not about “sick” animals. This is about routine antibiotic use to combat squalid conditions, and fattening animals. Would the CDC like to address the NIH funding or drug company dereliction in this matter? We have about 30 medicines so that someone doesn’t have to go pee-pee too much, but no new antibiotics? Would the CDC like to address formulary restrictions which… Read more »

Peter1
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Peter1

“So not a single bullet point on stopping factory farms from dumping tonnage of antibiotics into animals for the sole purpose of growth and profit? This could be undone overnight. Why hasn’t the CDC done this already?”

The CDC has no power with agriculture, the FDA as a little more;
http://www.fda.gov/forconsumers/consumerupdates/ucm378100.htm