Holding the Ground on Super Bugs

Antibiotic-resistant organisms—the so-called "super bugs"—may be gaining an upper hand if action is not taken very soon on the healthcare front.

At a hearing last week on antibiotic development, Rep. Henry Waxman (D-CA), chair of the House Energy and Commerce Committee, said that the goal both in the United States and abroad is that individuals keep on benefitting from life-saving treatments.

Providing that, though, can be tough. "By definition, this is an inherently difficult goal to achieve—after all, the very use of antibiotics leads to the development of pathogens that can no longer be treated by those antibiotics," Waxman said. In this case, rather than "use it or lose it," with antibiotics it is "use it and lose it."

The impact of these super bugs is being felt worldwide. In a report released Tuesday by the Washington, DC-based Center for Global Development, many international drug distribution programs were found to be creating drug resistance themselves—and endangering the lives they should be saving.

For instance, in nations with the highest use of antibiotics, 75% to 90% percent of Streptococcus pneumoniae strains were already drug resistant.

In many poorer countries, drug expenditures can range from 20% to 60% of total expenditure on health. When first line drugs fail, alternatives were more costly and require greater medical oversight: Curing one patient of extensively drug resistant tuberculosis costs the same as curing 200 patients with ordinary TB, the report notes.

"Drug resistance is a natural occurrence, but careless practices in drug supply and use are hastening it unnecessarily," the Center's Rachel Nugent, who led the group writing the report, said in a statement.

Back in the U.S., antibiotic resistance can be considered an economic burden on the healthcare system, too, Centers for Disease Control and Prevention Director Thomas Frieden, MD, told the House panel earlier this spring.

Resistant infections not only cost more to treat—but also can prolong healthcare use, Frieden said. For instance, in a 2008 study of medical costs for antibiotic resistant infections, it was estimated that infections in 188 patients at a single healthcare institution cost between $13.35 million and $18.75 million.

Unfortunately, as Frieden points out, infections caused by antibiotic-resistant bacteria—despite precautions taken—still remain an everyday occurrence in healthcare settings.

Antimicrobial resistance is a complex issue and addressing it will require "creativity and persistence," said Janet Woodcock, MD, director of the Food and Drug Administration's Center for Drug Evaluation Research, at the House hearing.

This will include, she said, developing new vaccines—"diminishing the need for antimicrobial treatment in the first place," Woodcock said. Prevention of infections through the use of vaccines has virtually eliminated or markedly decreased the problem of resistance in organisms such as Haemophilus influenzae type b, virtually eliminated in the U.S., but still a problem in other parts of the world, and Streptococcus pneumoniae, also known as pneumococcus.

Also, improved diagnostics will help curb overuse of antibiotics, she said, by allowing physicians to determine whether a patient has a bacterial infection and, if so, whether it is resistant to conventional antibiotics.

Educating providers—and patients—about the overuse of antibiotics has been important, said Sandra Fryhofer, MD, a member of the American Medical Association's Council on Science and Public Health. However, the use of antibiotics for the treatment of pediatric acute otitis media has not subsided despite the issuance of a watchful waiting guidance from the American Academy of Family Physicians and the American Academy of Pediatrics six years ago.

Unfortunately, the issue that will not go away is that new drugs that battle antibiotic resistance need to be created. Many pharmaceutical manufacturers, though, have been increasingly reluctant to move in such a direction because of high costs and low returns on investment.

Thus, "innovative incentives" must be developed, Fryhofer said, to foster “continued research and development of novel antibiotics to make sure that these important tools that combat infectious diseases remain available for future generations of physicians."

One AMA proposal, announced Wednesday at its annual meeting, is to educate the public about antibiotic resistance and to create incentives for manufacturers to develop 10 new antibiotics by 2020.

But will that be soon enough? Take the case of the new antibiotic linezolid—considered one of the few effective antibiotics to fight severe MRSA infections. However, in new research reported this month in the Journal of the American Medical Association, new cases have been reported already of linezolid resistant Staphylococcus aureus (LRSA) in Spain, Germany, Brazil, and even the U.S.

As far as super bugs are concerned, the fight continues.