Superbugs and Superproblems

Bacterial farm

Thomas Frieden, director of the US Centers for Disease Control, warns “nightmare bacteria” with a “fatality rate as high as 50 percent” and a high resistance to antibiotics could soon become a public health crisis. A coordinated international effort to prevent that outcome is imperative.

He was referring to carbapenem-resistant Enterobacteriaceae, commonly referred to as CREs, which are normally found in human intestines. As discussed by this primer issued by the CDC, these bacteria have been known to spread outside the intestines and cause infections—something that usually happens in nursing homes intensive care units, and rehabilitation centers, and usually affects elderly patients and/or those with compromised immune systems. Many of these patients are receiving care that includes having their skin breached with IVs, ports and catheters, which help in the spread of CREs.

CRE infections can be life-threatening, and as indicated by their name, cannot be treated even with carbapenem, which is a class of antibiotics that is used only when other antibiotics have failed, and which must be administered in hospitals, oftentimes intravenously. Even worse, Frieden points out, there is a way for CREs to spread their resistance to antibiotics to other bacteria, which may mean that a host of infections once considered easily curable might require hospitalization and intensive treatments to avoid patient deaths.

Frieden and the CDC tell us that we have “a limited window of opportunity” to do something about CREs. While CREs are currently confined to hospital and other care settings in the United States, the worry is that they may spread to the general population. If that happens, we will be in trouble, as CREs can be very hard to detect. Additionally, as the Wired story I linked to in this paragraph points out, we have to worry not just about CREs, but also other carbapenem-resistant bacteria that are not Enterobacteriaceae. The story references this finding on carbapenem-resistant Acinetobacter baumannii, which over the past fourteen years has become eight times less susceptible to carbapenem treatments. These superbugs, along with CREs, can pose a severe risk to the general population.

The crisis is international in scope, with CREs having come to the United States from other countries. In addition to carbapenem-resistant bacteria, another international threat comes in the form of a severe outbreak of drug-resistant tuberculosis, which could ravage the populations of developing countries—especially given the widespread presence of HIV/AIDS in those countries—and which could cause a significant health crisis if spread to Europe and the United States. As the National Post report points out, HIV co-infection helps facilitate the spread of drug-resistant tuberculosis strains, thus magnifying the number of deaths that can result from tuberculosis.

Adding to the problem is the fact that—as Megan McArdle points out—“antibiotics aren’t profitable. The regulatory hurdles are high, and if you clear them, you get . . . doctors thanking you kindly, and then putting your new product on the shelf as a reserve for when some other antibiotic fails.  By the time they haul it out, the patent may be nearing expiration.” And yes, there’s more bad news. McArdle directs us to the thoughts of Derek Lowe, who tells us that even if the market gets fixed, nothing much might happen because “no amount of cash will keep resistant bacteria from being the hard targets that they are.”

Given the profound public health consequences, government action to incentivize development of more effective antibiotics is essential.. McArdle has some good ideas on this issue, including treating antibiotics as “an exhaustible source” and being more conservative in their prescription and use, and creating financial incentives for conservation. Another might involve having government purchase antibiotics with price based in the quality of the antibiotic. Other ideas promulgated by McArdle involve creating incentives for hospitals to engage in more robust protocols for infection control.

We may also need governmental cooperation with pharmaceutical companies and price supports for those companies be contemplated by the government in order to provide a strong financial incentive to engage in vigorous (and costly) research and development in order to come up with new classes of antibiotics. I do not come to this position lightly; I don’t usually like having government tilt the market in so pronounced a fashion. But the fact of the matter is that unless the pharmaceutical supply is replenished soon, superbugs and the infections they cause may spread rapidly and may severely diminish the quality of life of millions of people.

Because the threat posed by superbugs is of an international scale, it requires an international response. This is why the CDC must partner with similar organizations around the world in order to work to confine the spread of superbugs. That partnership should include efforts to establish the implementation of proper protocols in as many hospitals, care centers, and rehabilitation facilities around the world as possible. These protocols should include vigorous hand-washing for all doctors and nurses every time they treat a patient, the instant removal of ports, catheters and if necessary and possible, IVs from patients suspected of having superbugs, and constant vigilance and surveillance of at-risk patients. Also, an individual patient afflicted with superbugs should be treated by a dedicated medical team that works only with that patient, so as not to spread the infection to other care facility residents. The more widely best practices are followed throughout the world, the better our chances of controlling the spread of superbugs.

Finally, it would be helpful if the Obama administration would work to restore money for the President’s Emergency Plan for AIDS Relief, or PEPFAR. As Christian Caryl writes—and as President Obama himself stated in his State of the Union Address this year—PEPFAR makes possible the realization of “the promise of an AIDS-free generation.” And yet, as Caryl notes, the Obama administration is actually proposing to cut PEPFAR. This is a blow not only to fighting HIV/AIDS and helping foster AIDS prevention, it is also a blow to the effort to fight superbugs; recall that HIV co-infection helps in the spread of drug-resistant tuberculosis. The more effectively we fight HIV/AIDS, the better our chances of controlling the spread of drug-resistant tuberculosis, and possibly other superbugs. The administration’s cuts in PEPFAR will only serve to exacerbate the superbug crisis.

We are at a perilous crossroads when it comes to fighting superbugs, and the consequences for the entire world can be dire if we fail. Combating superbugs will take an international effort on multiple fronts. It is reassuring to know that we have “a limited window of opportunity,” but the key word in that phrase is “limited.” If we do not take advantage of the time we have in order to fight the spread of superbugs, we could soon find ourselves living in a very different world from the one that we have become accustomed to. And we won’t like that world one bit.

Pejman Yousefzadeh is an attorney in the Chicago area. He writes on law and public policy at his eponymous blog.

Photo credit: Wikipedia