In a recent 2017 report from the Centers for Disease control (CDC), an alarming medical case was reported: “the Washoe County Health District in Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-antibiotic-resistant bacteria that was resistant to all available antimicrobial drugs. The patient was placed in a single room under contact isolation precautions.
The patient had a history of recent hospitalization outside the United States in India.” She unfortunately died from this drug resistant bacteria. The CDC estimates that drug-resistant bacteria cause two million illnesses and approximately 23,000 deaths each year in the United States alone (1).
The death of this Nevada woman in August of 2016, and highlighted in the CDC report, represents an opportunity for us to re-examine the answer to our Great Courses Lecture 24, titled: The hunt for the next pandemic. In the lecture, I assimilate the knowledge covered in the preceding course material to challenge the Great Courses audience to determine what the next pandemic will be. The possibilities include bacterial and viral threats, and include the multiple drug resistant bacteria, “New Delhi” strain, resistant to all antibiotics, which was the cause of the patient’s death. Lecture 6 discusses antibiotics and mechanisms of antibiotic resistance.
What this should remind the Great Courses audience is that diseases can cross continents within 24 hours. In the Infectious Disease course we discuss the arrival into the U.S. of SARS, MERS, and EBOLA- all deadly viruses- making the threat of infectious disease pandemics a reality in the US. More recently, the spread and invasion of ZIKA virus in Florida provides us with another reminder of newly emerging infectious diseases, which will take time to fully understand.
Returning to our main topic regarding antibiotic resistance, it is important to point out that when individuals take antibiotics, it is not just an individual decision to take them. We have an expanded social responsibility to take them only when needed, and to take them as prescribed, in order to prevent emerging antibiotic resistance.
In 2014 President Obama issued Executive Order #13676 to combat antibiotic resistant bacteria. In March of 2015, a comprehensive plan entitled the National Plan for Combating Antibiotic Resistance was released. It was intended to provide a roadmap to navigating the nation regarding the challenge of increasing antibiotic resistant bacteria. This will form the basis for the rest of our discussion on antibiotic resistance. The goals of his 5 year national action plan are to:
The plan lays out specific milestones for achieving the action plan goals. It also introduces the concept of “One Health”- that disease and antibiotic resistance can arise in humans, animals, and the environment, and these are all intertwined. You might be surprised to know that 75% of all antibiotic use is in veterinary medicine. Over the past 50 years efforts to curb antibiotic use as growth promotors in animals has been challenging. Recently, however, bill HR-1552-the Preservation of Antibiotics for Medical Treatment Act of 2015, has been passed that is moving towards accomplishing this goal. This phases out the use of antibiotics in veterinary medicine for non- routine disease control. (3)
Another goal contained in plan is to develop rapid diagnostic “point of care” tests to distinguish between bacterial infections where antibiotics might be useful, and viral ones where they are not. Antibiotics are still prescribed for 65% of primary care visits for presumptive bacterial respiratory infections, but only 10-15 % of the time are they actually bacterial. Imagine going to your medical provider and having such a test available in their office to avoid overprescribing of unnecessary and potentially harmful antibiotics that may have detrimental side effects?
Imagine going to your medical provider and having such a test available in their office to avoid overprescribing of unnecessary and potentially harmful antibiotics that may have detrimental side effects?
Efforts to accomplish goal #1 to slow the emergence of antibiotic resistant bacteria include the concept of “antibiotic stewardship”. This means responsible use of antibiotics. Programs within hospitals have existed for the past 15 years, including my job at the University of Wisconsin to monitor antibiotic use. Nearly 50% of patients entering hospitals receive one or more antibiotics, but after review, nearly 50% of that antibiotic use was deemed “un-necessary”. For the first time, the government’s Center for Medicare Services requires all hospitals that receive re-imbursement from Medicare to have a hospital antibiotic stewardship program!
The CDC also announced in the fall of 2016 (4) that healthcare systems need to establish outpatient antibiotic stewardship programs to reduce inappropriate antibiotic prescribing, such as the overuse for respiratory infections. While the CDC had an existing program known as “Get Smart” about antibiotics for nearly 20 years, the program has had limited national success in its implementation. With the announcement this fall proclaiming goals for outpatient antibiotic stewardship, the plan is to “get smart, and get tough” on outpatient antibiotic use, and make sure it is necessary.
In summary, we now have a moral obligation to use antibiotics more wisely than ever before for many reasons. They are only beneficial under some circumstances, and have real risks of side effects. From a societal perspective, inappropriate utilization is leading to “superbugs” and a possible return to the pre-antibiotic era, where we will have no drugs to treat the pathogens. I sincerely hope you will give antibiotic utilization serious consideration in the future.
Dr. Barry Fox is a Clinical Professor of Infectious Disease at the University of Wisconsin School of Medicine and Public Health.
His lecture series An Introduction to Infectious Diseases is now available to stream on The Great Courses Plus.
1 Chen L, Todd R, Kiehlbauch J, Walters M, Kallen A. Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016. MMWR Morb Mortal Wkly Rep 2017;66:33. DOI: http://dx.doi.org/10.15585/mmwr.mm6601a7.