Whistling Past the Graveyard… Antibiotic Resistance

Whistling Past the Graveyard… Antibiotic Resistance

The Centers for Disease Control (CDC) recently released the report, “Antibiotic Resistance Threats in the United States, 2013” (hereafter, the “Report”) which announced that “antimicrobial resistance is one of our most serious health threats”.  The Report, which runs more than 100 pages, describes itself to be “a snapshot of the complex problem of antibiotic resistance today and the potentially catastrophic consequences of inaction”.  Its overriding purpose is “to increase awareness of the threat that antibiotic resistance poses and to encourage immediate action to address the threat.”

(Here’s the link if you’d like to take a closer look:  http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf)

We briefly interact with the Report in this post and urge you to seriously consider what we have to say.  In a nutshell, we think the CDC’s report has been way too long in coming, the warning and the sense of urgency are far too weak and, in the end, the effort may turn out to be too little, too late.

The Report is divided into three major sections.  Section 1 is titled, “The Threat of Antibiotic Resistance” (pp. 11-30); Section 2 is titled, “Fighting Back Against Antibiotic Resistance” (pp. 31-48); and, Section 3 is titled, “Current Antibiotic Resistance Threats in the United States, by Microorganism” (pp. 49-92).

Section 1:  “The Threat of Antibiotic Resistance”

According to the Report, the CDC estimates that in the United States, “more than two million people are sickened every year with antibiotic-resistant infections, with at least 23,000 dying as a result.”  The Report is then careful to point out that the estimates are based on conservative assumptions and are therefore likely to be “minimum estimates”.  Later, a more explicit admission, “the estimates provided in this report represent an underestimate of the total burden of bacterial resistant disease” and then a bit further into the Report, the frank statement, “the actual number of infections and the actual number of deaths…are certainly higher than the numbers provided in this report.”  So, bottom-line, the CDC has no idea how large the numbers might actually be. [emphasis ours]

In a section titled, “Gaps in Knowledge of Antibiotic Resistance” (pg. 27) there is the candid admission of the following:

  • “…We do not have a complete picture of the domestic incidence, prevalence, mortality, and cost of resistance.”
  • “Currently, there is no systematic international surveillance of Antibiotic Resistance Threats…”
  • “Data on Antibiotic Use in Human Healthcare and in Agriculture are not Systematically Collected…”
  • “Programs to Improve Antibiotic Prescribing are not Widely Used in the United States…”
  • Advanced Technologies “which can identify Antibiotic Resistance Threats much faster…are not being used as widely as necessary in the United States…”

In sum, the CDC not only admits that antimicrobial resistance is a serious health threat which presents potentially catastrophic consequences, it also seems to be saying here that, in addition to not knowing the actual numbers, we have no foggy idea how far-reaching the “SuperBug Effect” currently is!

Section 2:  “Fighting Back Against Antibiotic Resistance”

Section 2 describes what can be done to combat the growing threat of antibiotic resistance.  This is where the reader would expect to see the real meat of the Report, looking for the CDC to pull out its “big guns”, telling us what specifically needs to be done in order to win this ever-widening war.  So with great anticipation and a sense of hope we read on to discover the CDC’s Battle Plan, which is summed up in “four Core Actions that fight the spread of antibiotic resistance”:

Core Action #1 — Preventing Infections, Preventing the Spread of Resistance;
Core Action #2 — Tracking Resistance Patterns;
Core Action #3 — Antibiotic Stewardship: Improving Prescribing, Improving Use; and,
Core Action #4 — Developing New Antibiotics and Diagnostic Tests.

This, then, is the strategy: Preventing, Tracking, Prescribing, Developing.  Let’s take a closer look…

#1— Preventing Infections, Preventing the Spread of ResistanceWe are told at the outset, “There are many ways that drug-resistant infections can be prevented…”  And then the report addresses what the CDC can do/is doing about prevention in the healthcare setting (hospitals, nursing facilities, nursing homes, etc.) and in the community setting.  After admitting that “antibiotic resistance in healthcare settings is a significant threat to public health”, we’re ready to find out how, specifically, the CDC is working to prevent this growing problem.  For starters, we’re told the CDC has developed and is working to continually improve a system to track resistance and prescribing patterns at the national, regional and local levels.  Wait a minute.  “Tracking” and “Prescribing” have been listed separately as two of the four Core Actions.  Are we going around in circles here?  Maybe we need to be told more than once.  In any event, we’ll address these below.  We’re then told that to “help prevent infections, CDC conducts research to find new ways of preventing infections”!  This is making us dizzy.

To its credit, the CDC does have published guidelines for healthcare workers to keep them from spreading pathogens from one patient to another, from one room to another, etc.  This includes things like changing gloves between patients, frequent hand washing, use of hand sanitizers, etc.  This is all well and good.  And, to be sure, it’s critically important these routines are carefully practiced in healthcare settings.  But this is basically theme and variation on the hand hygiene pioneered by Semmelweis while working in the Great Hospital in Vienna back in the 1840s.  As important as hand washing may be, we were kind of hoping the CDC was going to give us something more, something new here.

As for preventing the spread of antibiotic resistance in the community setting, we’re again told about “Tracking” and “Prescribing”, with the comment, “These activities are similar to the strategies used in medical settings…”  After admitting the “…spread of infection in the community is a significant challenge” and that “many prevention interventions are used”, the Report offers four examples from “the many”: Contact Tracing; Vaccination; Treatment Guidelines; and, Promotion of Safe Sex.  These are all important but, once again, we found ourselves asking, “This is all you got?”  Contact Tracing (where people who have had contact with someone who puts them at risk for infection are tracked down and evaluated for possible treatment) is an important practice but the reality is that it requires a significant amount of extra manpower, more than most healthcare facilities can muster or afford.  Vaccinations for drug-resistant microbes hardly even exist and the probability of seeing any significant developments and increases in their numbers is remote.  Treatment Guidelines can hardly apply to anything outside the healthcare setting.  Once the patient walks out the door and out into the community, this category is, for the most part, irrelevant.  And, as for Promotion of Safe Sex, that is a measure primarily specific to sexually transmitted diseases and will do little to restrain the spread of the burgeoning number of drug-resistant pathogens which are spread by other means.  Once again, the Report provides us with little consolation.

The Report goes on to include a subsection, “CDC’s Work to Prevent Antibiotic Resistance in Food” which is basically a re-hash of a portion of the CDC’s “Retail Meat Report” issued by the National Antimicrobial Resistance Monitoring System (NARMS) earlier in the year.  The report is alarming as it documents the presence and continuing spread of drug resistant and multi-drug resistant bacteria present in meat cases in grocery stores all over the country.  Suggest you read our post, “Drug Resistant Microbes in Meat at Your Local Grocery Store?” which takes a critical look at this NARMS Report and will explain to you why we warn, “Before you bite into that piece of chicken, hamburger, or pork chop, you should think twice.  You may be getting more than you paid for…”  You can read our evaluation and critique of the NARMS Report by clicking here.  Also, to get a better understanding of what’s behind this growing problem, please read the section, “How Did This Happen?” in the Bio/Tech News Special Report, “Superbugs: The Coming Deadly Global Pandemic”.

#2— Tracking Resistance Patterns The goal here is one of conducting the equivalent of military surveillance.  You want to know where the enemy is, how many troops are on the ground, what kind of weaponry you will be facing, etc.  Tracking is important in the War Against Superbugs.  We commend the CDC in its multi-faceted effort to keep an eye on developments in this area.  It’s important that we know what they are, where they are and what kind of resistance we’re up against.  At that point, we are better prepared to engage the battle.  But this all assumes, of course, that we have the kind of weapons that will enable us to overcome the enemy.  As we’ve already mentioned, we long ago sounded the alarm about our dwindling antibiotic arsenal (see the Bio/Tech News Special Report, “Superbugs: The Coming Deadly Global Pandemic”, the Section titled, “And the Cavalry Isn’t Coming”).

Below, in Core Action #4 (“Developing New Antibiotics and Diagnostic Tests”) the CDC openly admits what we have warned for years: we have less and less to offer when it comes to the real firepower we are going to need to win this coming war.

#3— Antibiotic Stewardship: Improving Prescribing, Improving Use.  Tracking also involves keeping an eye on antibiotic prescribing, what drugs are being prescribed and which are being prescribed the most often in different parts of the country.  The Report notes that Vancomycin was the most commonly-used antibiotic, overall.  Which on its face is disconcerting since Vancomycin is one of the drugs “of last resort” because of its track record of efficacy in treating multiple, drug-resistant infectious agents.  Vancomycin is one of the drugs which needs to be kept in our last line of defense.  We’re already seeing the rise of VRSA (Vancomycin resistant Staphylococcus aureus) and VRE (Vancomycin resistant Enterococcus).  Once widespread resistance to this drug develops, we’ll be perilously close to having run out of “magic bullets” (the moniker originally and optimistically used to describe the first antibiotics).  It won’t then be long before we might as well start throwing rocks.

Overprescribing and careless prescribing of antibiotics has been common practice in our healthcare system.  In the long run, this proves to be a constant stimulus to various bacteria and other pathogens to develop a means of defense.  The more and the more often these bugs are challenged, the more rapidly they find ways to more effectively resist.  For a fascinating read on how they do this, check out the Bio/Tech News Special Report, “Superbugs: The Coming Deadly Global Pandemic” (see the Sections, “How Did This Happen?” and, “A Continuing Conversation”).   The CDC’s goal is to raise the awareness level that taking more care when prescribing can help slow down the pace of growing resistance.

The Report is actually quite frank here when it says, “Antibiotics are a limited resource.  The more that antibiotics are used today, the less likely they will still be effective in the future.”  Kudos to the CDC to the extent they can change these long-standing, potentially dangerous prescribing habits in the healthcare setting.  However, the Catch-22 here is that according to the CDC, reducing the amount of antibiotic prescriptions can help prevent infections.  But the problem is that infections exist and they need to be treated.  Every time you treat with antibiotics the risk of resistance or development of resistance or, worse yet, development of increased resistance is always there.  We understand the sentiment and endorse the practice of responsible prescribing but this is no answer for the long run.  We are already facing significant breaches in our lines of defense.  It’s only a matter of time…

#4— Developing New Antibiotics and Diagnostic Tests.

“This threat is extensive and worrisome.  We are already seeing infections that can’t be treated by any of the antibiotics currently at our disposal. The bacteria are constantly evolving and mutating. They develop resistance to the antibiotics, and the pharmaceutical companies have to come up with new antibiotics. But the output of antibiotics has slowed considerably.”  — Dr. Steve Solomon, Director of the CDC’s Office of Antimicrobial Resistance.

On page 28 of the Report, the CDC provides an interesting and informative historical timeline, showing dates when specific antibiotics were introduced and when resistance to these antibiotics was first officially identified.  As the timeline makes very clear, bacterial drug resistance has been with us since the beginning of the “Antibiotic Era”.  Even back in the days when Penicillin was introduced to the general population (1943), a penicillin-resistant Staphylococcus had already shown up (1940).  Since the beginning, it has only been a matter of time, often quite a short time that drug resistance develops among pathogenic micro-organisms.  So, problem number one is that just about as fast as we can come up with new “magic bullets”, the Superbugs figure out a way to defend against them.

Problem number two is depicted by a graph on page 44 of the Report, captioned, “Tomorrow’s Antibiotics: The Drug Pipeline” (see below).  The X axis is a timeline for the past three decades.  The Y axis is the number of new antibacterial drug approvals over this timeframe.  The graph demonstrates how dramatically the number of new antibiotics has decreased.  We have supplied a trend line here just to help make the point.

number of antibacterial new drug application nda

Section 3:  “Current Antibiotic Resistance Threats in the United States, by Microorganism”

Section 3 provides summaries of the drug-resistant bacteria (and one fungus, Candida) mentioned in the Report and prioritizes each into one of three, threat-level categories: “Urgent, Serious, and Concerning”.  It also includes specific applications of the above-mentioned four “Core Actions” which are or should be taken, so far as CDC is concerned.  You might find it interesting to compare these summaries with those we provided in the Special Report of the Bio/Tech News, “Superbugs: The Coming Deadly Global Pandemic” in the section, “A Rogues Gallery of Superbugs” (page 4).

We understand the need to prioritize these bugs; there is good reason to do so.  However, and as we said in an earlier post on this blog (“Superbugs: Don’t Miss the Big Picture!”), focusing on individual pathogens like this can leave “the false impression that hospitals and other healthcare settings are concerned with having to deal with only one particular strain of Superbug at a time.  The battle is far greater than this, however.  We are not involved in a war with a particular strain of either MRSA, or Pseudomonas aeruginosa, or Enterococcus faecium, or Clostridium difficile, or E. coli, or Salmonella, or Acinetobacter baumannii, or Stenotrophomonas maltophilia, or Mycobacterium tuberculosis, etc.  Instead, and we can’t possibly emphasize this strongly enough, we are now engaged in a war with all of these multiple microbial adversaries simultaneously and the battlefield is now worldwide.  When you enter a hospital or other healthcare setting these days, you should assume that any number of these different pathogens may be present, each strain having the potential to cause serious harm.”

A Final Word

For by wise counsel you shall wage your war; victory depends on having many advisers.
— Proverbs 24:6

Earlier in this post, we said “we think the CDC’s report has been way too long in coming, the warning and the sense of urgency are far too weak and, in the end, the effort may turn out to be too little, too late.”  Hopefully, you can now understand why we said this.

According to CDC Director, Dr. Tom Frieden, MD, MPH, “Antimicrobial resistance is one of our most serious health threats. Infections from resistant bacteria are now too common, and some pathogens have even become resistant to multiple types or classes of antibiotics.”  That’s about as strong and urgent as the Report gets.

In a recent post in the Bio/Tech News, we pointed out that, “…in the early 1990s, we wrote a Special Report concerning the emergence of Multi-Drug Resistant Tuberculosis.  Since then, we have continued to keep a wary eye on developments within the burgeoning, and now, quite frankly, scary realm of Multi-Drug Resistant pathogens (which we have nicknamed “MDR Superbugs”).”  We were concerned twenty years ago.  Two to three years ago, that concern had grown to the place that we felt compelled to sound the alarm.  The CDC should have pre-empted us in this, in our opinion. Instead, they’ve been whistling past the graveyard.

Assuming that you want to emerge from a conflict victorious, warfare requires creative thinking and commitment on the part of those who are responsible for waging it.  Since the last century, this has become especially the case since the warfare has turned from conventional to unconventional and asymmetric, where the strategy and tactics employed by combatants differs significantly.

As we have been learning the painful lesson globally, you can’t use outmoded, conventional strategies and tactics to fight and conquer a resilient and highly committed enemy who uses the asymmetric, unconventional strategies of guerilla warfare, insurgency, terrorism, etc.

The same holds true as we find ourselves in a war with ever-increasing hordes of invisible, deadly microbes which have found ways to ride into town with the ability to disarm and disable the best conventional weapons we can muster.  The operative term here is “conventional”.  The problem here is that we have not been thinking unconventionally.  The process and development of antibiotics has been fundamentally the same since the early part of the twentieth century.  Find a particular chemical compound that is, for the moment at least, toxic to certain bacteria and then douse them with it, hopefully without at the same time killing the patient as one of the side effects.  Modern medicine has been in the same rut, operating from the same basic assumptions and techniques for nearly 100 years now.  And, ironically, our antiquated and obsolete approach has yielded the unintended consequences of stimulating and training new strains of pathogenic Superbugs.

The bottom line here is that we need to abandon the mindset which is now getting us nowhere fast and we need to start thinking about this problem in a different, unconventional way.  We can tell you about a number of possibilities.  If you want to read about one approach which offers what we think is some genuine hope, please read through the Special Report of the Bio/Tech News, “Superbugs: The Coming Deadly Global Pandemic”.  You can access this report FREE of charge by clicking here.

 

One thought on “Whistling Past the Graveyard… Antibiotic Resistance

Comments are closed.

Comments are closed.