San Francisco Chronicle
COVID reignited a bacterial menace
As the threat from COVID-19 has decreased and we look toward the possibility of it entering an endemic state, there is an urgent need to address a dangerous legacy from that dark time: the catastrophic threat of the diminishing effectiveness of antibiotics.
According to the Centers for Disease Control and Prevention, the significant progress that the U.S. made in reducing antibiotic-resistant bacterial infections in hospitals prior to COVID-19 evaporated during the pandemic. This was due in large part to the more widespread prescribing of antibiotics and reduced attention to controlling the spread of resistant bacterial infections in hospitals to focus on controlling COVID-19.
In 2017, the CDC found that deaths from antimicrobial-resistant infections had reduced by 18 percent overall and by nearly 30 percent in hospitals, thanks to investments and a focus on infection prevention and control efforts. However, when COVID-19 cases increased in hospitals in 2020, so did antibiotic use. A study by the World Health Organization showed that from March 2020 to October 2020, almost 80 percent of patients hospitalized with COVID-19 received an antibiotic, although only 8 percent had documented infection. Overprescribing antibiotics is a major contributor to antibiotic resistance.
Dramatic reversals of progress in controlling resistance have also been seen in community settings. In 2020, rates of tuberculosis increased globally for the first time in over a decade. Gonorrhea infection rates also soared as public health programs and resources devoted to controlling sexually transmitted infections gave way to efforts to control COVID-19. Even worse was the emergence and spread of strains of tuberculosis, gonorrhea and health care-associated infections that were resistant to not just one, but multiple antibiotics, some to the point of being untreatable.
Globally, nearly 5 million deaths each year are linked to using ineffective antibiotics or to the lack of access to antibiotics for severely ill people. A threat assessment from the CDC in 2019 reported more than 2.8 million antibioticresistant infections in the United States and more than 35,000 deaths linked to resistance. That translates to one new antibiotic-resistant infection in the United States every 11 seconds.
Antibiotic resistance is sometimes called “the hidden pandemic,” but it is certainly not hidden to anyone who spends time in a hospital or to any parent whose child is suffering from their third ear infection in a year. Bacterial resistance is one of the greatest health challenges of our time, and more people are going to die if we don’t get back on track and fight back more effectively.
The deployment of antibiotics in the 1940s marked a new era in medicine. For the first time, humans had an effective weapon against deadly bacterial infections. But these new miracle drugs came with a warning about the risk of bacterial resistance if they were overused; this warning came from none other than Sir Alexander Fleming, the discoverer of penicillin.
How right he was. The bugs fought back. They evolved both through changes in their own genetic makeup and by acquiring from other bacteria the genetic information that enables them to become resistant. Bacteria have learned to adapt quickly to those things that cause them harm.
The primary driver behind the increase in bacterial resistance is misuse and overuse of antibiotics: in human and veterinary medicine, in agriculture and food animal production, and in aquaculture (think of farm-raised salmon). Physicians that reach for the prescription pad “just to be on the safe side” and don’t run a diagnostic test to guide their therapeutic choices (including when antibiotics are unnecessary) are a key issue.
For too long, the barrier to prescribing antibiotics was low because antibiotics were perceived as helpful and typically harmless. That is hardly the case. Adverse drug events from taking antibiotics can send people to emergency rooms with anything from mild to life-threatening symptoms. More importantly, antibiotic use predisposes people to infection with highly virulent, toxin-producing bacterium known as Clostridioides difficile, or more simply “C. diff.” C. diff can infect the bowel, causing symptoms that range from mild diarrhea to life-threatening colitis. Infection develops after taking a course of antibiotics when the “good bacteria” in the bowel are eliminated.
For serious bacterial infections, the benefits of antibiotics clearly outweigh the risks, but we certainly cannot ignore the risks. We cannot continue to give useless antibiotics for viral infections, like common colds, or “just to be on the safe side.” We all need to become good antibiotic stewards to preserve these precious resources. Two easy-to-adopt changes could help prevent antibiotic overuse:
Greater investment in diagnostic tools
Using diagnostic tests reduces the guesswork that can contribute to antibiotic misuse. For example, PCR-based diagnostic tests can identify multiple pathogens from a single specimen and can deliver results more quickly and affordably (often in one hour or less) than conventional culture methods that may take two or three days or even weeks to get an answer. Getting an accurate answer quickly helps physicians decide if an antibiotic is needed, and if so, which one.
Increased education and awareness for physicians and patients
Patients and their caregivers need to do their part by recognizing that antibiotics are not always the best approach to treating their illness. When prescribed an antibiotic, patients should ask their health care provider to explain why they need an antibiotic and if the physician performed a diagnostic test to guide the choice of the antibiotic. On the other hand, if they are told by their physician that they don’t need antibiotics, perhaps because they have a viral infection, patients shouldn’t press the doctor for antibiotics. It may well cause them more harm than good.
We cannot let the setbacks, such as those during the COVID-19 pandemic, become permanent. The use of diagnostic testing, responsible antibiotic use and stewardship, patient and provider education, and investment in the next generation of antibiotics all play a critical role in stemming this public health crisis.
We cannot wait another 30 years to take action against a problem that threatens all of us today.
Bacterial resistance is one of the greatest health challenges of our time, and more people are going to die if we don’t get back on track and fight back more effectively.
Fred Tenover is vice president for scientific affairs at Cepheid. Prior to joining Cepheid, he served for 18 years at the Centers for Disease Control and Prevention as associate director for laboratory science in the Division of Healthcare Quality Promotion.