Antibiotic Resistance: Medical and Public Health Directions

Steven Solomon, MD, FACP, FIDSA Global Public Health Consulting, LLC

Atlanta, GA

2016 Swine Education In-Service ConferenceSt. Louis, MO

September 28, 2016

Antibiotic Resistance (AR)

1. AR is a serious, global public health problem

2. Antibiotic use, in all settings and all circumstances, drives antibiotic resistance

3. Changing the way we use antibiotics, in all settings and all circumstances, requires changing the way we think about antibiotics

4. There are several concrete steps, some already underway, that can successfully address this problem in the next few years

1. AR is a serious, global public health problem

4

AR spreads at the speed of jet travel

Molton J S et al. Clin Infect Dis. 2013;56:1310-1318 5

Communication

AR: Bottom-line• Antibiotic resistance (AR) is the single most complex

problem in all of medicine and public health • The AR problem is rapidly worsening because:

• Antibiotics have been overused in all settings• Bacterial resistance spreads easily • Enough new antibiotics are not being developed • Current strategies for hospital infection prevention

and control are inadequate• Information systems for AR data are inadequate

2. Antibiotic use drives the development of antibiotic resistance

• All antibiotic use, in every setting and all circumstances, adds to the burden of antibiotic resistance, including human infections

• Antibiotics have been, and largely continue to be, overused in all settings

• Antibiotics disrupt the human microbiome, contributing to disease and accelerating transmission of AR bacteria and genes

The End Of Antibiotics?BY SHARON BEGLEY

Last week, at the annual meeting of the American Association for the Advancement of Science in San Francisco, microbiologist Alexander Tomasz of Rockefeller University warned that many common bacteria are evolving resistance to more and more antibiotics. As a result, we are facing "nothing short of a medical disaster." he said.

A longstanding problem

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December 8, 1955

A longstanding problem

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Timeline of antibiotic resistance:

Humans vs. Bacteria

3 billion years before present

Bacteria evolve antibiotics and resistance

Humans discover and use antibiotics

Present

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Antibiotics AR--The “Resistome”

People

Bacteria

Animals

Plants

Soil

Water

Air

The Black Box of AR Dynamics

3. Why antibiotics are overused and why we need to change the way we think

about them

George Herbert, 5th Earl of Carnarvon, 1866 – 1923

Howard Florey, 1898 –1968

Radcliffe Infirmary Hospital, Oxford, England, ~1940

Antibiotic use in hospitals

• 50% of all patients admitted to hospitals

receive an antibiotic at some time during

their hospital stay

• At any given time, two-thirds to three-

quarters of patients in hospital intensive care

units are receiving an antibiotic

Antibiotic prescribing per 1000 persons, US, 2011

Antibiotic overuse in human medicine: Variations in prescribing demonstrates overuse

Hicks. Clin Infect Dis. 2015;60:1308

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html;http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf

Stewardship

Dwindling therapeutic options: A decline in new antibiotics in recent years

New antibiotics approved by FDA,1980 - 2012

New drug classes discovered,1890 - present

Won S Y et al. Clin Infect Dis. 2011;53:532-540

CRE patients

Current infection control is inadequate:Infected and colonized patients move widely and easily

between healthcare settings

4. What can be done to control AR• Improve the way antibiotics are used, globally

• Antibiotic stewardship, optimal prescribing • International cooperation

• Prevent the spread of resistant bacteria and resistance genes• Improve infection control• Prevent infections

• Develop new antibiotics and diagnostic tests

Many Action Plans and Reports

Coordination

Improve the way antibiotics are usedAntimicrobial stewardship

Get better data on antibiotic use and make data available in usable ways

Mandate programs in hospitals; financial penaltiesOptimal prescribing

Improve knowledge of epidemiology and genomicsPersonalize the risks of antibiotic-prescribing: “Do

no harm” Antibiotic-related adverse events (side effects, allergies,

drug-drug interactions)

Disruption of the human microbiome

Grice, E. A. and J. A. Segre (2012). "The human microbiome: our second genome." Annu Rev Genomics Hum Genet 13: 151-170.

• 90% of all the cells

associated with the human

body; the other 10% are

human cells

• Disruption of the microbiome

leads to:

• Short-term and long-term

adverse events, including

C. difficile disease• Greater likelihood of

resistant infection

The human microbiome

Prevent the spread of resistant bacteria and resistance genes

Prevent infections and improve infection control Improve knowledge of epidemiology and genomics Get better data and make it available in usable ways Develop new prevention techniques Improve knowledge of environmental factors

Manufacturing effluents and waste water contamination

Take a One Health approach

Develop new antibiotics and diagnostic tests

• Study bacterial genomics and make data

available in most usable form

• Extend diagnostic networks and national and

international collaboration

• Solve the economic problem

Getting it done

•Metrics

•Measurement

•Communication

What to look for in AMR metrics and measurement over the next 10 years

•Lots of pilot testing and evaluation•More epidemiologic research •An increased focus on genomics•A focus on antibiotic prescribing and use data

•More data and better visualizations•More transparency

http://gis.cdc.gov/grasp/PSA/index.html; http://wwwn.cdc.gov/narmsnow/

State and

national AMR

data

Summary• There is a gradually growing crisis of antibiotic resistance that will

develop more slowly, but have far wider effects than usual media-driven high-profile outbreaks

• We need to know a lot more about the complex relationship between antibiotic use and how resistance emerges and spreads, but there is no debate about the need to improve antibiotic use in all settings

• We need to change our social and cultural perceptions of antibiotics by using 21st Century communication techniques and behavioral interventions to make those changes

• We need to further refine and widely disseminate new tools in information technology and genomics need to prevent infections and the spread of resistance

• We need a new economic model (or a lot of money) to develop new antibiotics and diagnostic tests

It was six men of Indostan,To learning much inclined, Who went to see the Elephant(Though all of them were blind), That each by observationMight satisfy his mind. ………..And so these men of IndostanDisputed loud and long, Each in his own opinionExceeding stiff and strong, Though each was partly in the right, And all were in the wrong! 

John Godfrey Saxe (1816-1887)

SteveSolomonMD@gmail.comGlobal Public Health Consulting, LLC

Thank you.