Extending the Age of Antibiotics

In May 2018455845163_53212d73f0_k5, it was discovered that a patient in the U.S. had contracted a strain of bacteria that was resistant to the strongest of antibiotics, a characteristic known as antimicrobial resistance (AMR). This condition can result in previously harmless and treatable infections becoming deadly “superbugs.” Reactions to this announcement ranged from paranoid to nonchalant, as this is not the first time that a superbug has been discovered in the U.S.  However, observers at least agree that something has to be done to combat the rise of AMR, a stance researchers have held for years.

Antibiotics are part of a larger family of medicines labeled as antimicrobials, substances that possess the ability to disrupt life on the microscopic scale. They occupy a unique niche in the health care system. Since their inception into clinical protocols, antibiotics have been an effective medicine to treat and prevent many infections. But as their popularity of use grew, AMR grew as well. There is a Catch-22 with antibiotics: they are highly effective, but possess a diminishing marginal return for treatment. Due to the ability of bacteria to evolve and develop defenses, a type of antibiotic that worked before might not work again. The very definition of AMR. While no one factor is to blame, common culprits are the over-prescription of antibiotics by physicians and the under development of antibiotics by pharmaceutical companies.

The Centers for Medicare and Medicaid Services (CMS) has sought a way to combat two of the largest sources for AMR: over-prescription and patient misuse. On June 16, CMS announced a proposed rule that includes provisions which make payments to hospitals contingent on the establishment of programs that monitor antibiotic use. These programs would have to comply with certain standards, including the creation of antibiotic stewardship programs, accountability of physicians, and the monitoring of patient consumption. The provisions in these programs were established last year, but had merely been presented as suggestions. While the policies in the stewardship programs are designed to drastically reduce the over-prescription and patient misuse in hospital settings, they would have little effect in other health care institutions.

While the CMS rule prevents the misuse of current antibiotics, clinicians still face a reduced pool of effective antibiotics. In the past, as antibiotics became ineffective, they were replaced by newly developed ones. But in the past 20 years, the number of new antibiotics has sharply fallen. One of the primary reasons being that antibiotics are not as lucrative as treatments for other conditions such as cancer and diabetes. In January 2016, 80+ pharmaceutical and diagnostic companies called for an increase in the development of new antibiotics, and resolved that the way to do so was with new economic models and incentives for production. Most of their proposals involve altering the pricing systems and instituting safeguards for conservation. The hope is that incentives will encourage the production of new, effective antibiotics.

The biggest mistake in the fight against AMR would be in only adopting one measure to control for one of the instigators. Efforts are certainly needed to prevent the over-prescription, while strides must be made in the research and development of new antibiotics. If you are on a boat that has a leak and is filling with water, you have two options: plug the leak or bale the water. Why not both?