Confronting Drug Resistance Requires Stewardship, Data Sharing—and Better Appreciation of the Microbiome
NEW ORLEANS, LA—Internationally-coordinated public health efforts, including better stewardship of antimicrobial drugs, is crucial to overcome the challenge of multidrug-resistant pathogenic bacteria—but so is a better appreciation of the importance of the healthy human microbiome, said U.S. Centers for Disease Control and Prevention (CDC) Director Tom Frieden, MD, in a plenary talk at IDWeek 2016.
“Truly, we face a scary situation,” Dr. Frieden said. “We need to act now because we cannot know with certainty that we'll have new and better drugs in the future. “
“Bacteria are very effective at evolving,” he said. “They outnumber us—and we had better outsmart them. They evolve to survive with natural selection. We need to use rigorous collection and analysis of data to hone our practices to stay ahead of bacteria. And the means by which our brains will outsmart their numbers is to use data.”
Confronting the challenge will require not just better sharing and analysis of data, but fundamental paradigm shifts, Dr. Frieden said. We need to think “outside the bacterial strain” and better appreciate the importance of our microbiome, he said.
“We really need to understand the ecology of bacteria,” he said. “One of the most startling studies I've seen in recent years was one of the first outbreaks we've identified that did not involve a clonal expansion of a strain of bacteria or a virus, but a plasmid-mediated outbreak in sinks and hoppers that had been colonized by multiple strains of bacteria.”
The bacteria were able to share pathogenic genes among one another within their biofilm ecosystem.
To effectively confront the emergence of multidrug resistance, we must also better understand and appreciate the importance of a healthy microbiome, he said.
In the past, clinicians and public health researchers focused almost exclusively on harmful bacterial infections instead of healthy and health-promoting commensal bacterial ecosystems.
“The metaphor of a war against bacteria is really misleading,” he said. Our microbiome involves a million bacterial genes—meaning that many times more genes are at work within our bodies than merely those found in the human genome.
“We don't have to go to the bottom of the ocean or to Mars to find unusual bacteria,” Dr. Frieden said. “They are within us. There are many more friendly than unfriendly bacteria around, and we disrupt them at our peril. ‘First, do no harm' applies to bacteria and the microbiome!”
A microbial-ecology approach to public health also requires “thinking outside of the hospital,” Dr. Frieden added.
“Healthcare facilities are not islands,” he explained. “Patients move and bacteria and infections move with them. Patients move around enormously between long-term acute care hospitals and long-term care facilities. We'll only make progress against drug-resistant and nosocomial infections if we get a handle on this. Even the best facility is in many ways at the mercy of the nursing home down the block.”
Facilities must work together and share data to protect their patients, Dr. Frieden said. “A coordinated approach will prevent infections and save lives.”
Globally and locally, the weakest link in the chain can determine outcomes, he cautioned. For example, the rise of multidrug-resistant tuberculosis (MTB) was a result of failures to properly treat patients and to prevent its spread in some regions and at some facilities, despite intensive public health efforts elsewhere.
“No program, no matter how well resourced, can treat multidrug-resistant TB faster than a bad program can create multidrug-resistant TB,” he said. “A blind spot anywhere is a vulnerability everywhere.”
A similar situation is now emerging around the world with drug-resistant gonorrhea, Dr. Frieden warned.
The United States has taken a lead role in funding improved public health lab capacity around the world and helping to foster an international culture of data sharing. “The U.S. is putting over a billion dollars into this over the next several years,” he noted.
There's still much to do right here in the U.S. “Seventy-five thousand Americans dying [annually] of infections picked up in the hospital is not an acceptable situation,” he said.
Turning the tide against antimicrobial-resistant bacteria will require four steps, Dr. Frieden said, including: finding strains faster and more completely in hospitals and nursing homes—as well as the community, and in animals and food; preventing drug resistance more thoroughly through stewardship programs that prevent unnecessary or overly-broad spectrum prescribing; halt the spread of these strains through surveillance, more whole-genome sequencing, reporting and information sharing between facilities, and outbreak control.
Last but not least in his list, is the need for more innovation, Dr. Frieden emphasized – such as finding ways to better leverage antibiotics, -omics, and our understanding of the microbiome.
“If you could, with a simple rapid test, know ‘bacteria or viral?' and ‘resistant or not?', you'd see much more appropriate prescribing,” he noted.
Congress increased funding for multidrug resistance work, starting in 2015. If that funding is sustained, Dr. Frieden predicted that over five years, 619,000 multidrug-resistant infections and 37,000 deaths will be averted, at a savings to the US health care system of $7.7 billion.
“We can save lives and save money,” he said.