Antibiotic resistance — the tab comes due
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This past week, the maladies I treated in my patients amounted to a run in with the “most wanted” list of infectious disease. The unique severity of these infectious can often be traced back to an increasingly common source: antibiotic resistance. Antibiotics have been commonly used in hospitals to prevent and treat bacterial infections since the 1940s when Howard Florey and Ernst Chain transformed penicillin, discovered by Alexander Fleming in 1928, into an actual medicine. 

This week, the United Nations is recognizing the scale of the problem by inviting medical experts like myself to explore solutions in a rare urgent meeting. This alarm is warranted. The toll of this crisis will only increase if important steps are not taken now to halt its spread.

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Antibiotic resistance occurs when bacteria adjust in response to the use of these medicines, making infections harder to treat. This poses major problems for patients, doctors, and the practice of modern medicine as we know it. Also referred to as antimicrobial resistance, it currently cuts short approximately 750,000 lives per year, and is estimated to kill 10 million people across the globe by 2050. This death rate will dwarf road traffic accidents and even cancer, and the financial cost is estimated to total between $60 and $100 trillion.

Antimicrobial resistance is a basic fact of nature. It occurs irrespective of the presence of humans and has even been noted in underground cave-dwelling bacteria that have never encountered civilization. But humans have accelerated this process to such an extent that antibiotics used to treat infections are increasingly threatened with obsolescence. The problem is exacerbated by the fact that the number of newly discovered antibiotics is dwindling.

This problem reached a grim milestone in May of this year when, for the first time in the U.S., doctors treated a patient in Pennsylvania infected with a bacteria that harbored a transmissible form of resistance to a last resort antibiotic. Centers for Disease Control and Prevention Director Tom Frieden responded appropriately when he declared that this development could signify “the end of the road” for antibiotics.

Such a scenario threatens to return modern medicine to the pre-penicillin era in which Dr. Fleming practiced. In those times, a simple laceration could mean death, and modern procedures like organ transplantation, coronary bypass surgery, and prosthetic joint replacements were the fantastic stuff of scientific fiction.

Luckily, those days are behind us. In the short span of several decades, however, humans have injudiciously used antibiotics, squandering the value of these miraculous innovations. Inappropriate use of antibiotics comes about in a number of ways, ranging from a patient who demands an antibiotic for the nagging cold symptoms they just can’t kick, to the physician who seeks to avoid patient complaints or hedge his diagnostic uncertainty with an antibiotic prescription. This practice slowly takes a toll of the efficacy of these drugs, and today we are stuck with a tab of resistance that cannot be paid.

The problem is especially acute in the nation’s hospitals, where infections like E.coli and methicillin resistant Staphylococcus aureus (MRSA) are now harrowing everyday challenges for doctors like me. If a patient experiencing resistance survives their infection, they can spread the problem further by contracting more and more drug-resistant infections and possibly spreading them to other patients. This pattern adds to the burden of healthcare associated infections that plague our hospitals and nursing homes.

There are a number of things we can do as a nation to help contain this problem, which truly threatens the foundation of modern medicine. The solution starts with restoring basic trust in the doctor-patient relationship. Patients should stop demanding antibiotics for conditions that their healthcare provider says do not require an antibiotic.

Physicians, despite time-constraints, should make every effort to explain why antibiotics aren’t warranted, and be confident in their decisions. Administrators must realize the importance of this effort and fully support it. Hospitals and healthcare facilities should encourage accurate and confident diagnoses to minimize the amount of antibiotics prescribed “just in case.”

To accomplish this, they must empower physicians by deploying sophisticated viral testing at the point-of-care for illnesses such as influenza, as well as tests for biomarkers consistent with bacterial (as opposed to viral) infections. With these tools at hand, physicians will become better stewards of antibiotics. Healthcare facilities themselves must also do their part by developing formal antibiotic stewardship programs that employ surveillance, feedback, and continuous improvement with their institutional use of antibiotics.  

Coupled to these short-term solutions, new medications are desperately needed. While several more traditional antibiotics may trickle out of the development pipeline in the future, they will in turn, face the same prospect of resistance. This type of arms race with bacteria cannot be won with conventional methods. Supporting innovation will be essential. We must move beyond the overuse of antibiotics and spur innovation in products such as antibodies, novel vaccines, viruses that attack bacteria (bacteriophages), and those that harness the knowledge of the human microbiome.

If human lifespans are to increase, and if modern breakthroughs like organ transplantation are to continue to proliferate and evolve, physicians must be able to abate the risk of bacterial infection that will undoubtedly accompany such advances. Fleming’s heroic 20th Century discovery unrecognizably transformed that century’s medical care in a few short decades. Now we must marshal 21st century resources to ensure that the progress that revolutionized the treatment of infectious disease is not squandered.

Dr. Adalja is a board-certified infectious disease physician. Follow him on Twitter @AmeshAA and read his blog at www.trackingzebra.com


 

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