« Paging Dr. Mom: Beco... | Main | FP Salaries Increasi... »

Tuesday Jun 14, 2016

Arrival of Superbug Highlights Need for New Antibiotics, New Approach

Reports in the mainstream media are finally catching up to what the medical literature has been saying for months: We have bacteria that have developed or acquired resistance to all available antibiotics.

One strain of gram-negative, urinary-tract-infecting bacteria is now resistant to colistin, a drug of last resort for many multidrug-resistant organisms.

More than 50,000 health care-associated Pseudomonas aeruginosa infections occur each year, according to the CDC. Roughly 13 percent of these are multidrug-resistant.

There are already limits on which antibiotics work on different types of bacteria. For some infections, only one or two classes of antibiotics proved effective against them in the first place, so developing resistance to existing drugs can be easier than it sounds. Multiple mechanisms can confer resistance to antibiotics, whether via enzymes that break down the drug, pumps that remove it from the bacterial cell or some that are as yet unknown.

And once a mechanism exists, passing it on to other species is relatively easy. Several bacteria can transfer genetic material in the form of plasmids, which then confer resistance in the receptive bacterium. Replication going forward includes the plasmid, meaning the genetic offspring of that single bacterium all carry that resistance. Other bacteria may develop novel mutations that make them different enough that the medications meant to combat them no longer find the expected target and cannot work as designed.

So we as scientists and physicians try different medication targets or different combinations of medications to overcome the resistance mechanics, and the bacteria continue to develop new defenses.

The arms race escalates daily.

If you think that such a doomsday scenario would have the pharmaceutical industry scrambling to prioritize the development of new antibiotics, think again.

A Reuters article that broke the news of the superbug(uk.reuters.com) in Pennsylvania put it this way: "Many drugmakers have been reluctant to spend the money needed to develop new antibiotics, preferring to use their resources on medicines for cancer and rare diseases that command very high prices and lead to much larger profits."

In fact, dozens of pharmaceutical companies signed a declaration in January calling for government incentives to support the development of new antibiotics.

I initially considered writing this post as an open letter to the pharmaceutical industry, encouraging manufacturers to urgently do something about this problem. But the more I thought about it, the more I came to realize that was not the right plan. The idea that a single company or industry might be able to fix this problem alone makes the scientist in me cringe. This problem extends far beyond one group or industry. At some level, we are all to blame.

Thus, here's an open letter to all of us -- pharmaceutical companies, physicians and patients:

The recent recognition that a bacterium resistant to all known antibiotics caused infection in a patient in Pennsylvania catalyzed discussion about the problem of antibiotic resistance. But this isn't a new problem.

We've been fighting this battle for decades, and we as humans are losing.

Hospitals and physician groups develop infection control teams and protocols for dealing with infectious diseases. Governing bodies mandate hand-washing and isolation protocols. Policy statements about appropriate antibiotic use appear in major medical publications. And yet, we still see the growing threat of antibiotic resistance.

We need a new strategy -- a new way of looking at this problem. Education is good. Mandating infection control is good, too. But throwing money and time at the problem is not the only answer. This is not just about profit or loss. This is not about shareholders or investors or bottom lines. This isn't about ensuring CEO bonuses. This battle is not about one group or industry "fixing" the problem.

This is about the greater good and preserving lives. This is about using science to protect and serve all of humanity. Everyone involved in infection care and control must work together, each doing their part. No one gets a pass.

We physicians and allied health professionals can continue to educate ourselves and our patients(familydoctor.org) about using existing treatments appropriately. We must end the strongly ingrained habits of inappropriate antibiotic use and work to improve our diagnostic skills and testing. We can work together to build the body of knowledge about infectious diseases and appropriate use of antibiotics. No more caving to the whims of the consumer or doing what we've always done.

Instead, we must follow validated medical evidence. Whether in the inpatient or outpatient setting, we need to be good stewards, using our tools appropriately and implementing plans that ensure proper use of existing medications. We can teach our patients why we do what we do and what the appropriate practices entail. We can spread the word about infection control procedures that work, not just anecdotally, but with hard scientific evidence. And where that evidence does not exist, we should continue to study the problem.

Patients must learn to trust that evidence in the face of discomfort, especially for problems that are often improperly treated with antibiotics at patient request. We can help by re-educating everyone about safe and smart use of antibiotics for appropriate situations. We need a cultural shift away from the mindset of "I have to have a pill to get better" and toward appropriate use of antibiotics in established cases of bacterial infection. No more antibiotics for viral upper respiratory infections.

Each of us -- only one bacterial infection away from becoming a patient -- should do our part to encourage patient stewardship, as well. Take the full prescription of antibiotics, even if you begin to feel better. Throw away unused medications if there are leftover pills, and avoid the temptation to use leftover pills to treat future illness.

The pharmaceutical industry can continue working to discover novel medications and formulations. Innovation, while difficult, is necessary. Every year, the major companies look at hundreds if not thousands of compounds, searching for "the next big thing." Our society will benefit from companies devoting a larger portion of their substantial resources to the discovery of the next class of antibiotics.

Even better, drug manufacturers can continue to seek out novel mechanisms of action that don't allow for resistance. Give our immune system a new tool. Find a way to target specific species without adversely affecting noninfective species. I'll wager the profits from such a discovery will pay off monetarily in the long run, and the dividends in human lives saved will be immeasurable.

It's easy to wait for someone else to do it. Avoiding the challenge is safer for the bottom line and for patient satisfaction scores, but this path leads to debility and death. No matter what we do, we cannot just cross our fingers and hope this problem goes away. It won't. And lives are at stake.

We can fight back against this common enemy, but we must work together. We must seek answers to the hard questions and be willing and ready to change if the scientific evidence dictates it. And we must always, always keep going.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert(twitter.com).

Posted at 03:25PM Jun 14, 2016 by Gerry Tolbert, M.D.

« Paging Dr. Mom: Beco... | Main | FP Salaries Increasi... »


Subscribe to receive e-mail notifications when the blog is updated.



Leader Voices Blog - A Forum for AAFP Leaders and Members

FPs on the Front Lines


The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.