COMMENTARY

This 'Slowly Evolving Crisis' Needs Attention

Paul G. Auwaerter, MD

Disclosures

August 28, 2020

This transcript has been edited for clarity.

Hello. I'm Paul Auwaerter with Medscape Infectious Diseases and the Johns Hopkins University School of Medicine.

The pandemic and coronavirus are top of mind not only among our infectious diseases profession but globally. However, some attention is being paid to collateral issues such as decreased immunization in children, which might lead to increased contagious diseases (eg, measles or chicken pox), elective surgeries that have been delayed, and people not seeking out healthcare.

Antimicrobial resistance, something that the World Health Organization has declared a serious global threat (and which worried me probably the most in 2009), has not gotten as much attention, but it is still worth thinking about because this is a slowly evolving crisis that really hasn't captured the attention of our politicians.

There are some important aspects that I want to highlight.

Little Structure in Antimicrobial Stewardship

First, what do clinicians think about antimicrobial resistance and stewardship issues? Open Forum Infectious Diseases published the results of a survey of primary care doctors, and 94% — a healthy percentage — acknowledged antimicrobial resistance as problematic.

Yet, when asked if they think it's a problem in their individual practice, more than half said no. And 60% mentioned that their prescribing habits are better than those of their peers, so perhaps they don't feel that they're contributing to any such problem.

Although antimicrobial resistance has been mostly focused in the hospital or in hospitalized patients, who often have the most resistant pathogens, it's thought that the global or the total burden of antibiotics that are prescribed — the tonnage — probably correlates greatly. This probably reflects prescribing practices in general.

For example, northern European countries have some of the lowest rates, whereas southern European countries and southern parts of the United States tend to have higher rates of antimicrobial prescribing in general.

At least in hospital, there's been much attention in recent years. The Centers for Medicare & Medicaid Services requires that participating hospitals have an antimicrobial stewardship program. Certain states, such as California, have passed state laws, but there's still little structure in the outpatient and ambulatory care world. Indeed, most feel that they would need some help in trying to understand how to achieve best practices and preserve the antimicrobials we have.

Keeping Drug Development Alive

On the other hand, the federal government and others have done a lot in the past few years, much spurred by the Infectious Diseases Society of America's 10 x '20 Initiative — that is, 10 new antimicrobials by the year 2020. And here we are. We've actually exceeded that because the US Department of Health and Human Services and agencies such as BARDA, the Biomedical Advanced Research and Development Authority, have funded research and development.

We have new antibiotics that do target pathogens that are troublesome, such as Pseudomonas, Acinetobacter, and carbapenem-producing organisms. We have drugs such as plazomicin, meropenem, relebactam.

However, many of the small antimicrobial companies have fallen on tough times. Sales have not been able to support the companies once the R&D funds have run out.

I was encouraged by the announcement this summer that the World Health Organization, in partnership with three pharmaceutical companies (Roche, Merck, and Johnson & Johnson) have put together a $1 billion fund to sort of be a Band-Aid or a bridge for over 36 small companies to try to keep them afloat.

This is marvelous. I think it's great to try to keep this space active so that we still have not only the drugs available but also the companies and the brains that go into getting these drugs developed and/or distributed. We need not only public health officials, researchers, and pharmaceutical executives, but also politicians to recognize the need for different strategies.

Indeed, a recent article by Paul Ambrose and his colleagues highlight why things are not working. A variety of strategies have been thought about to figure out why antibiotics don't fit the typical capitalistic pharmaceutical marketplace. Once we have great drugs, we tend to reserve them for special uses.

We need to figure out other mechanisms. There is too much to go into right now, but briefly, people have talked about patent extensions or awards for qualified medications that target pathogens in a unique way that would counterbalance the lack of profit from sales.

These are innovative ideas, but they haven't found much traction among politicians who use tax dollars. But they remain top of mind for many people in our profession.

This antimicrobial rescue fund — AMR Action Fund is its formal name — is very important and speaks to the fact that there's recognition by the big players in the field as to how important this is. Hopefully, others will follow.

Thanks for listening. I hope everyone is staying safe.

Paul G. Auwaerter, MD, is a professor of medicine at the Johns Hopkins University School of Medicine and clinical director of the Division of Infectious Diseases. His areas of clinical expertise include Lyme disease, Epstein-Barr virus, and fever of unknown origin. He has been a Medscape contributor since 2008.

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