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October 21, 2013

US needs to take action against 'nightmare' bacteria

Last spring, Arjun Srinivasan, an associate director of the Centers for Disease Control and Prevention, delivered a presentation to state health officials with some alarming information. Before the year 2000, he said, it was rare to find cases of bacteria resistant to carbapenems, a class of powerful, last-resort antibiotics. But by February 2013 they had been seen in almost every state. Srinivasan also briefed Thomas Frieden, director of the CDC. On March 5, Frieden issued a public warning about "nightmare" bacteria, a family of germs known as CREs. They can kill up to half the patients who get bloodstream infections from them, resist most or all antibiotics and spread resistance to other strains.

Last month, Frieden released a report estimating that at least 2 million Americans get infections each year that are resistant to antibiotics and that at least 23,000 people die as a result. Margaret Chan, director general of the World Health Organization, warned last year: "A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child's scratched knee could once again kill."

The words of Frieden and Chan ought to make our hair stand on end. But my reporting for the documentary "Hunting the Nightmare Bacteria," which is to air Tuesday on PBS's "Frontline," suggests that past warnings about antimicrobial resistance were largely discarded. This is not a threat that causes people to jump out of their chairs. It always seems to be someone else's problem, some other time.

We ought to snap out of our long complacency.

Alexander Fleming warned of resistance to penicillin in his 1945 Nobel Prize lecture. But after World War II, the "wonder drugs" seemed inexhaustible and their powers immensely potent, opening doors to new horizons in medicine. Infection no longer meant certain death. What could go wrong?

The answer came in dozens of reports, books and scientific reports warning that bacteria were developing resistance to antibiotics, in part because of careless overuse. In 1982, Marc Lapp published the book "Germs That Won't Die." A conference held in 1984 at the National Institutes of Health resulted in a study published three years later that noted "the consequence of microbial resistance is without boundaries and the spread of resistance genes has been tracked among countries throughout the world." Stuart B. Levy of Tufts University, a pioneer in researching resistance who had overseen the NIH study, published a book in 1992, "The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers." The Congressional Office of Technology Assessment weighed in with a massive report in 1995. Since then, there has been a stream of popular books and articles.

If Frieden is right, a public health crisis demands more than a business-as-usual approach in Washington. I found smart people at the CDC, NIH, the Food and Drug Administration and elsewhere all working on the resistance crisis, but it is almost impossible to find anyone at - or near - Cabinet-level who is leading the charge. I am told the main coordinating effort is an interagency task force created in 1999. It meets once a year.

Our indifference can't be chalked up to lack of evidence. Resistance is real.

But politically, there is no active constituency - no patient groups marching in the streets. We take antibiotics for a short period and then forget about them. And hospitals, which can be cauldrons for resistant bacteria, often remain silent about infections and outbreaks out of concern for adverse publicity and patient privacy. Yet another dimension of the crisis is that the economics of drug development have led major pharmaceutical firms to abandon research into new antibiotics while they pursue more lucrative therapies for chronic disease. The antibiotic pipeline is slowly drying up.

President Barack Obama ought to shake us out of this lethargy and appoint someone to tackle antimicrobial resistance across all fronts. The goals are clear: far more detailed, national data reporting; improved stewardship of existing antibiotics; and a major antibiotic drug discovery and development effort. We shouldn't expect government to do it all. This crisis will require truly broad collaboration, including scientists, clinicians, hospitals, regulators and the pharmaceutical industry. But government can light a spark and galvanize people toward a result that each could not achieve acting alone in the face of a real threat.

Antimicrobial resistance is driven by evolution, a relentless process. But we shouldn't throw up our hands. We do not have to return to the pre-antibiotic age. To sustain the wonder in wonder drugs, to find a way forward, a little leadership would go a long way.



 

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