This World War II advertisement informs the soldiers about a new “wonder drug” that can cure gonorrhea. The disease is one of many diseases — including the infamous “superbugs” — now showing resistance to all modern medicines. Photo courtesy of the National Library of Medicine.
Here are three good reasons the nickname “superbug” doesn’t cut it anymore for the drug-resistant crop of bacteria showing up in U.S. hospitals under the more formal title Carbapenem-resistant Enterobacteriaceae:
- They kill about half the people they attack
- They’ve appeared in at least 42 states
- And their resistance to drugs has quadrupled in the last decade or so
That’s why Dr. Tom Frieden — director of the Centers for Disease Control and Prevention — came up with another name: “Nightmare bacteria.”
Pretty startling language from the head of the CDC. But Frieden told reporters recently that the hype is justified. “Our strongest antibiotics don’t work and patients are left with potentially untreatable infections,” he said.
Before panicking, here’s a caution: these germs aren’t very common. For the moment, they’re confined mostly to inpatient health care facilities. And while the exact scope of the problem isn’t known — largely because medical facilities in most states aren’t required to track and report the number of CRE infections and deaths — the CDC estimates that only 4 percent of U.S. hospitals and 18 percent of long-term acute care centers had a patient with CRE in the first half of 2012.
That’s why Frieden stressed that if the proper steps are taken, “we now have a window of opportunity to prevent its further spread.”
The same is true for a number of other germs that seem to be growing more indestructible against modern medicine by the year.
If nothing is done, CDC officials warn that a “post-antibiotic era” may be around the corner — an era in which diseases commonly cured today with a few pills could once again run rampant. And it may be closer than most people realize.
“It’s not something that’s theoretical,” said Dr. Arjun Srinivasan, associate Director for Healthcare Associated Infection Prevention Programs at the CDC. “It’s not a statement that someday, we might encounter bacteria that are resistant to all antibiotics. That day is here. And it really calls upon us to take action now.”
Srinivasan joined PBS NewsHour last week to discuss the CDC’s latest findings on antibiotic-resistant infections — including gonorrhea and tuberculosis — and what Americans should be doing to protect themselves.
Dr. Srinivasan, thank you so much for joining us. Let’s cut right to the chase: How concerned should Americans be? Is this a crisis in the making?
Dr. Srinivasan: I think crisis is probably not too strong a word for it. A number of factors add up here.
Antibiotic resistance writ large is a huge and global issue. It is a challenge in America. It’s a challenge in every country in the world — in both our health care facilities and also out in the community. We are reaching a situation where we are running out of effective antibiotics to treat a host of different infections. We talk about resistance in malaria, in tuberculosis, in gonorrhea, in Methicillin-resistant Staph aureus, or MRSA, and most recently in these Carbapenem-resistant Enterobacteriaceae. So it’s really a far-reaching and global problem. And it’s something that is going to impact many, many people all over the world.
Dr. Frieden called this a ‘nightmare’ for public health. How, specifically, is that the case?
Dr. Srinivasan: It is absolutely a nightmare scenario. The prospect of having bacterial infections that we can’t treat with antibiotics is indeed a nightmare. It has the potential to undo so much of the progress that we’ve made in medicine. A lot of the medical advances that we enjoy today are directly dependent on our ability to treat infections that patients might develop. For example, organ transplants, cancer chemotherapy, bone marrow transplants and a host of the other treatments that we give people for rheumatoid arthritis — all of these treatments have the undesirable effect of weakening a patient’s immune system, which means that all of them put patients at high risk for infection. We can offer people these treatments because we can treat infections, for the most part, that the patient is likely to develop as a result. So if we lose the ability to effectively treat those infections, we will lose the ability to safely offer people many of the modern medical advantages and advances that we take for granted every day.
What’s happening to make these bacteria resistant to the antibiotics we use?
Srinivasan: Bacteria always develop resistance to antibiotics. They’ve been doing that since the dawn of time. And that’s because they have numbers on their sides. There are trillions of them. And over time, with exposure to antibiotics — and sometimes even without exposure to antibiotics — they will randomly develop mutations that might confer resistance to the antibiotics that we use. And so this is something that we know is going to happen and can never stop. So you will always have a need to have new antibiotics, because we know that bacteria eventually are going to develop resistance.
But some of the other factors that are promoting this problem are the ability of these bacteria to spread, particularly within health care settings. So you might have one patient who has a resistant infection. But if we don’t do a good job of controlling infections within our hospitals and nursing homes and clinics, those bacteria can spread to other patients.
And another contributing factor is, of course, the overuse of antibiotics that we see in the United States and indeed around the world. If you look at studies that have been done, they show you that across the board, in hospitals and nursing homes and outpatient clinics, up to half of all the antibiotics that we use are either not needed at all or we’re using them incorrectly. So there’s a tremendous overuse of antibiotics that’s also fueling this antibiotic resistance.
Which resistant infection is the CDC most worried about at the moment?
Srinivasan: We’re worried about all of them. The one that we are really sounding the alarms about is Carbapenem-resistant Enterobacteriaceae, or CRE, and one of the reasons that we’re so particularly concerned about this one is that it really is that nightmare scenario where there are very limited treatment options and for some of them, there are, in fact, no treatment options.
So this CRE really does take us into the post-antibiotic era. It’s not something that’s theoretical. It’s not a statement that some day, we might encounter bacteria that are resistant to all antibiotics. That day is here. We are encountering infections with these CRE that are resistant to all antibiotics. And it really calls upon us to take action now.
What’s the risk that someone who contracts CRE will die?
Sreenivasan: It depends on a number of different factors, including which type of infection and a lot of issues with the type of patient. For example, studies in this country and in others have shown that nearly half of patients who get a bloodstream infection with the CRE will die.
These CRE “superbugs” you’ve mentioned are contracted mostly by sick people in the hospital. But infections like antibiotic resistant gonorrhea seem like they could spread far more easily in the general population — should people be more concerned?
Sreenivasan: Antibiotic resistant gonorrhea is a major concern and it is indeed not one confined to health care facilities. It’s out in the community. And it can be spread fairly readily. The challenge that we face is that we are running out of the first-line treatment options that we like to use. And in particular, we’re running out of many of the oral treatment options that we have been able to use. Which means that as we run out of those oral agents, people might need intravenous therapy for treatment of simple gonorrhea infections that in the past could have been treated with an oral antibiotic. This is now being seen in the United States.
Let’s look at another disease Americans don’t typically worry about these days, at least not within U.S. borders: tuberculosis. There’s a strain circulating now that’s “extensively resistant” to all drugs. How concerned is the CDC about that? Could this become a major problem for the U.S. again?
Sreenivasan: That’s another major concern. It’s certainly something that is more of an issue in other countries than it is the United States, but we really believe that resistance anywhere is resistance everywhere. A pathogen that’s drug-resistant in any country anywhere in the world is a short plane ride away from being here in the United States. And the challenge with tuberculosis is that it’s very transmissible. And so if you do begin to develop cases, there’s a high potential that those cases can spread to other people. So it’s one that we are working on closely with folks in other countries to better understand and figure out ways to control that.
You used a term earlier that many health officials are using with great urgency at the moment — “post-antibiotic era.” What exactly does that mean? And what repercussions could that have for patients?
Srinivasan: We use that term post-antibiotic era to compare what could be coming to the pre-antibiotic era. There was a time in medicine when we didn’t have antibiotics — and a lot of people sometimes forget that that time wasn’t that long ago. Antibiotics really came onto the medical scene in the 1940s and 50s. Before that, when patients developed infections, they either healed themselves or they didn’t and there’s not much we can do to influence that outcome. And then we entered the era of having antibiotics and all of a sudden, the mortalities from infections plummeted. We were able to effectively treat the vast, vast majority of common infections that people develop.
When we talk about the post-antibiotic era, we’re talking about a time that basically takes us back into time. Back to a time when people developed infections and we as clinicians could do nothing but stand by the bedside and hope that the patient would be able to fight the infection themselves because we had nothing to offer them in terms of treatment. It has major implications for our ability to practice medicine.
All of this begs the question: How much research is being done into new types of antibiotics?
Srinivasan: There is research being done into new antibiotics. I think a lot more research needs to be done and this is a case where no one group should be working independently to lead that development. This is a case where academic partners, the government, drug companies — all of these groups should be working effectively together.
Developing antibiotics is a very difficult prospect. A lot of people who are very knowledgeable about antibiotic development have said that the “easy” — not that any of them are easy — but the easier antibiotics have all been developed. The new antibiotics that we need to develop are going to be much more challenging than the ones we developed in the past. And so it’s going to take a coordinated and concerted effort on behalf of a variety of different experts in these areas to develop new antibiotics and bring them to our patients.
That being the case, how long will these new antibiotics take to hit the market?
Srinivasan: My understanding is that the antibiotics in the works will take a while to develop. I think there are a few agents that are farther along than others. But I think that most experts in this field would agree that it’s likely to be many years before we have a new antibiotic to treat some of these infections. And particularly what they’re usually referring to is completely new antibiotics. Not simply a variation on a current theme but a truly new antibiotic that’s going to be effective against some of these very resistant pathogens we’re seeing today, like CRE.
So what preventive measures is the CDC currently pursuing to stop potential upcoming deaths?
Srinivasan: Our preventive strategies with effect to antibiotic resistance really fall into three broad categories. One is monitoring and tracking. It’s important that we better understand where these resistant bacteria are, who is likely to get these infections with resistant bacteria and what factors might be driving that resistance. And to accomplish that, the CDC is very engaged in what we call ‘surveillance’ or ‘monitoring’ of these resistant infections.
The other area where CDC is very focused is in trying to prevent the spread of these infections, particularly within our health care facilities. It’s a concept we call ‘infection control.’ And CDC develops guidelines and recommendations for how health care facilities can safely care for patients and minimize the risks of these types of resistant bacteria spreading within our hospitals, our nursing homes and our clinics.
And the last area where CDC is very focused is trying to work with partners and work with clinicians to figure out how we can improve the use of antibiotics so that we can slow the development of antibiotic resistance.
One way to do that is to slow down the use of antibiotics. Patients are often told not to overuse them. Is that more of a precaution for keeping individual resistance to antibiotics in control — or is it mostly helpful for the population as a whole, in terms of staving off the development of these resistant microorganisms in the first place?
Srinivasan: It’s really both. What we found is that when a patient takes an antibiotic that they don’t need, they are exposed to the side effects of the antibiotic without getting any benefit from it. Antibiotics have potential side effects, including allergic reactions and severe diarrhea in some cases. If you don’t need an antibiotic, you’re taking a medicine that has risks and you’re accruing no benefit from it. There was also a study recently that showed that if you take a course of antibiotics, you are significantly more likely down the road to develop an infection with a drug resistant bacteria.
And of course there are the societal issues, as well. We know that the overuse of antibiotics helps breed resistant bacteria more quickly, which can be spread among other patients. So improving the use of antibiotics will not only have benefits to society but important benefits to individual patients.
Interesting information to consider. Dr. Srinivasan, thank you so much for being with us.
Srinivasan: Thank you for having me.