New Approaches To Winning The Fight Against ‘Superbugs’ by [email protected]
Ezekiel Emanuel on the fight against ‘superbugs’
When a Pennsylvania woman was recently found to carry a strain of E. coli that was resistant to colistin, an antibiotic of last resort, alarm bells went off in the medical community about the arrival of the first pan-drug resistant ‘superbug’ in the U.S. With few antibiotics in development, and doctors and patients continuing to overuse the drugs, the situation has become critical.
Ezekiel Emanuel, a renowned bioethicist who is vice provost for global initiatives and chair of the medical ethics and health policy department at the University of Pennsylvania, is offering two solutions: Require hospitals and outpatient clinics to join a government program that tracks antibiotics use, and offer a $2 billion prize to folks to develop new antibiotics.
He argues that the marketplace model – letting market forces boost the return on investment on antibiotics high enough to spur more development by drug companies – doesn’t work in this case and a new approach is needed. Emanuel, who is a medical doctor, also explains how hand sanitizers and other anti-bacterial products fit into the picture. He discussed his views in a recent op-ed piece in The Washington Post and also spoke about the issue on the [email protected] show that airs on SiriusXM Channel 111.
[email protected]: The case in Pennsylvania is bringing more focus on superbugs, but in terms of the severity of the situation, where does that sit?
Ezekiel Emanuel: In the case of this Pennsylvania woman, she had a gene that made her E. coli resistant to colistin, the antibiotic of last resort. In that context, this was newly found in human beings in the United States and a serious problem. But the bacteria she had was still resistant to at least one antibiotic, the carbapenem, a family of antibiotics. We didn’t have all the genes lined up in one bacteria.
What worries public health officials and medical people is when you get all those genes lined up in one bacteria and they’re resistant to colistin and carbapenems, then you really do have the superbug that everyone’s worried about because there’s not another antibiotic that will actually fight this infection. We’ll basically have thrown ourselves back into the 19th century where we didn’t have antibiotics for bacteria, and people died of these bacterial infections quite commonly.
That’s the horror scenario that people are worried about. Is that going to happen tomorrow? No. But is it almost inevitably going to happen in the next few years? Yes. And that’s what’s worrying everyone.
[email protected]: What is the probability of all of those genes lining up?
Emanuel: I can’t quantify what the modeling shows. But the fact that all those genes are circulating out there does mean it’s almost inevitably going to happen at some point. What we have is no antibiotics in isolation and very good infection control procedures, but that’s very different than having an antibiotic that can fight the infection. I think that’s what worries people.
“We’ll basically have thrown ourselves back into the 19th century where … people died of these bacterial infections quite commonly.”
[email protected]: That gets into one of the main themes of your piece in The Washington Post, which is that the medical community and maybe even the government need to consider what those next antibiotics are going to be.
Emanuel: We really have to attack these problems at two levels. One is to try to prevent bacteria from becoming antibiotic-resistant by using our antibiotics much, much more wisely than we have over the last 50 years.
The second is, we really do have to develop a lot of new antibiotics. Not just for a short period. We don’t have to go into a sprint mode. This is a long-term problem. Bacteria are constantly evolving. They will constantly evolve. We’ll get an antibiotic, they’ll find a way to be resistant, we’re going to have to get more antibiotics. This is a marathon for the rest of human existence to try to find more and more antibiotics.
Doctors have been, I would say, not as responsible as we should be on the use of antibiotics. We often use the wrong antibiotics; we use them in cases that are viral infections or in the cases of self-limited bacterial infections. We know from research by the Centers for Disease Control and Prevention as well as others that somewhere between 20% and 50% of antibiotic prescriptions, both in the hospital and in the outpatient setting, are either inappropriate or unnecessary.
We had a recent article in the Journal of the American Medical Association that showed one-third of antibiotic prescriptions out of physicians’ offices were inappropriate or unnecessary. It should be shocking.
[email protected]: How do you curb this unnecessary use of antibiotics? How do you police that?
Emanuel: It’s easier to police in a hospital because it’s a confined area and you really do have control over all those prescriptions much more directly. The CDC has developed this antibiotic stewardship program that starts with the leadership in the hospital as well as appointing someone, a pharmacist usually, to be the point person to oversee this.
It develops data and gives the data back to physicians about their own antibiotic prescription use and the resistance that they’re developing — someone independent reviews every antibiotic prescription. Those processes are well-defined and can be implemented by every hospital.
[email protected]: How prevalent are these programs?
Emanuel: I don’t know the percentage of hospitals that have adopted them, and that actually goes to the heart of my suggestion in the article I wrote, which is that we just have to make them mandatory. There is an easy way for the government to make them mandatory.
Government has rules called “the Requirements for Participation in Medicare.” If you’re a hospital and you get Medicare payments, there are certain things you have to do. This could be one of them. Antibiotic stewardship procedures have to be implemented in your hospital, and you have to report the results back to Medicare every year. It seems to me that’s something we ought to do. It’s good for patients, it’s good for the community, and it saves hospitals money, which means it saves all of us money.
“Is that going to happen tomorrow? No. But is it almost inevitably going to happen in the next few years? Yes.”
[email protected]: It’s almost a little bit like a job review for the doctors themselves. Obviously, a lot of doctors are so busy going from patient to patient, they probably don’t think about it a lot. But if you see on paper the percentage of times that you are diagnosing antibiotics, you can see firsthand whether there’s a problem.
Emanuel: I totally agree with you, and I think it actually uses the principles of behavioral economics to help doctors. It provides them with immediate information feedback, and typically, if you rank them or show them how they compare to their peers in this situation, you will get the bottom improving. And that’s really what we want to have happen.
[email protected]: But you say that now is as good a time as ever to try to do something like that and even advance what we have already because the medical community has made