Essential strategies for winning the war on antimicrobial resistance
An estimated 39 million people could die globally by 2050 directly from one thing, if projections in a September Lancet study are accurate. It’s not COVID-19, swine flu or measles. Instead, it would be from antimicrobial resistance—the silent epidemic in healthcare.
“When we first had penicillin, back in the late 1930s, there was very little resistance, and penicillin would treat a lot of different types of infections,” says HealthTrust Physician Advisor William Sistrunk, M.D., an infectious disease specialist at Mercy Health. But bacteria have always evolved, trying their best to stay alive. And as antibiotic usage grows and bacteria mutate, those that remain develop resistance to different antibiotics.
“We can watch evolution happen under our noses in a matter of days with bacteria,” explains HealthTrust Physician Advisor S. Shaefer Spires, M.D., an infectious disease specialist at Infectious Disease Consultants in Georgia. “We watch natural selection happen all the time. It’s not a mystery how it happens. The ones that survive are resistant.”
The good news is antibiotic resistance requires energy from the bacteria and scaling back inappropriate use of antibiotics can help. “If you pull away the pressure of the antibiotics, organisms tend to revert to their normal state of not being so resistant,” Dr. Spires says. “But it’s not something that will ever go away—only something we hope to control. These infections are not very common, but they’re happening at an increasingly alarming rate.”
Realigning the economics
One way to fight this resistance is by creating new antibiotics directed at resistant bugs. But there are problems with this approach, with continued concern that governments and pharmaceutical companies are not making the needed investments in the research and discovery process. Incentives are misaligned. “Pharmaceutical companies generate revenue from increased volume,” says Tyler P. Stewart, PharmD, MPA, BCPS, Senior Director, Pharmacy Operations at Scion Health. The government, healthcare organizations and private industry must collaborate to incentivize research partnership. Any new treatments must be accessible to the healthcare system, from a supply chain and financial perspective, he says.
“Drug companies are willing to invest billions to make a lipid lowering drug or weight loss drug, because a lot of people will use them,” Dr. Spires says. But development is expensive and niche antibiotics given for short periods do not provide the same financial reward.
Research backs this up. The World Economic Forum estimated in October that an antibiotic drug development project profitability was $50 million, versus anticipated profitability of $1.15 billion for a musculoskeletal drug.
Antibiotics are usually given for short courses, says Dr. Spires, and they can become useless after several years due to resistance. They can also be restricted to specific scenarios, as they are in his facility. Due to internal policies, Dr. Spires only prescribes a specific antibiotic that fights the potentially deadly carbapenem bacteria once or twice a year, restricting its use for dire scenarios. With overutilization, resistance increases, rendering future usage ineffective. “The company making it will take forever to recoup their cost,” Dr. Spires says.
New antibiotics are coming out, but not enough to fully combat antimicrobial resistance. “We’re going to continue to see the bacteria mutate and develop resistance to those new drugs. It’s a self-fulfilling deal, where the more antibiotics we use, the more resistance we’ll see,” Dr. Sistrunk explains.
The World Health Organization (WHO) reports that only 13 antibiotics have received marketing authorization since 2017, each taking 10–15 years for development. Yet antimicrobial resistance can occur in two to three years.
Prioritizing antibiotic stewardship
Developing new antibiotics is just one tool in the kit. Antibiotic stewardship is another. In the U.S., more than a quarter of antibiotic prescriptions in emergency departments and clinics are unnecessary, per the Centers for Disease Control and Prevention (CDC). Scion’s stewardship program is built on core elements from the CDC and The Joint Commission. It includes systemwide metrics for ongoing education and evidence-based guideline implementation. Antibiotic stewardship is also built into Scion’s national quality strategy to bring accountability and visibility at every level, Stewart says.
➊ Prevent infections.
Preventing infections is a cornerstone element of stewardship, so making sure you’ve enacted hygiene practices like vaccine promotion and environmental cleanliness can significantly reduce healthcare-associated infections, and it extends far beyond clinicians and providers, Stewart says. “Everybody in the building in the healthcare system is vital to the process of ensuring we’re preventing infections.”
Improved diagnostic testing can also help prevent unnecessary antibiotic use. In hospitals, there’s always a concern that patients will come with a history of resistant organisms, and those patients should potentially be isolated to prevent spreading. “Highly resistant bacteria may be living on their skin,” Dr. Sistrunk explains. Providers and even family members should wear gloves and gowns when seeing this patient, especially if it’s known they have a resistant organism.
➋ Reduce unnecessary antibiotic usage.
Physicians must be prudent with antibiotic use, talking with patients when suspecting a viral infection and not routinely prescribing an antibiotic. Dr. Sistrunk says his health system shares data with the community about which viruses are currently common and updating providers so they can share this with patients presenting with an infection.
The biggest culprits to excessive antibiotic prescriptions are urinary tract infections (UTIs) and upper respiratory infections (URIs). UTIs, especially, are overtreated, says Dr. Spires. Patients who are confused are often treated with antibiotics for a UTI even if they have no lower urinary tract symptoms. “In post-menopausal women, over half will have a positive urine culture. That’s normal,” Dr. Spires adds.
URIs can be caused by allergies or a virus, but most end up getting antibiotics prescribed. Bacteria in other parts of the body can become resistant to the antibiotic. With a bacterial infection, Dr. Spires recommends treating it with the most focused, narrow-spectrum antibiotic for that bug, for the shortest duration possible.
➌ Spread the word.
Education about antimicrobial resistance and infection prevention, including the importance of routine hygiene are essential, says Dr. Sistrunk. This is especially important regarding elderly and young people, adds Stewart. “The elderly and young are more susceptible physically to significant adverse outcomes. Elderly patients typically have multiple comorbidities, and age is a risk factor for babies, who are more susceptible to adverse effects from infections,” he explains. Plus, there may be more limited options to treat these populations.
Vaccines are another stewardship method. Dr. Sistrunk shares that vaccine development and pediatric uptake against streptococcus pneumoniae starting several decades ago, for example, prevented illness and reduced related antibiotic usage. This resulted in slower antimicrobial resistance development.
The WHO reported that vaccines targeting 24 pathogens could lower the number of prescribed antibiotics 22% globally, the equivalent of 2.5 billion daily doses annually.
Looking forward
Legislation, including the 2012 GAIN Act and the 2016 21st Century CURES Act created some benefits for companies to develop new antibiotics, such as prolonged periods of trademark protection, says Dr. Spires. “We’re seeing some of the fruit of that legislation now.”
It’s not just a matter of mortality, but also quality of life, Dr. Spires adds. A new oral drug against carbapenem was recently approved, a potential game-changer for patients, he says. Intravenous (IV) administration requires either at-home or medical center infusion, frequent lab draws and additional infection risks.
As our population ages, the risk for these resistant organisms is increasing. Dr. Sistrunk is encouraged that the government and drug companies are increasing investments to address antimicrobial resistance. “But we still need to have more support to push the antibiotic research,” he adds. There are still bacteria resistant to all currently available antibiotics, and the community needs options with different mechanisms of action.
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