By Danyale Kellogg*
Antibiotics and other antimicrobials are critical features of modern medicine that have made many common infections with once-high mortality rates more inconvenient than they are deadly. Yet, as antimicrobial resistance (AMR) rises globally, the risk of losing some or all these treatments is also growing. Antimicrobials are essential to treating certain common illnesses, stopping infections in populations like cancer and surgery patients, and, depending on the agent in question, responding to bioterror or biowarfare attacks. As such, AMR poses major threats to global health, international development, and national security. To combat this threat, the United States must pass legislation aimed at monitoring antimicrobial prescriptions and incentivizing research and development of new drugs.
Antimicrobials is a category that includes antibiotics, antivirals, antifungals, and antiparasitics, while AMR describes a disease-causing microbe’s developed ability to survive exposure to previously effective medications. While development of resistance is a natural biological process, it has been accelerated by factors such as overuse and misuse of antimicrobials, particularly antibiotics, globally. This overuse is not even particular to humans as the use of antibiotics to promote livestock growth has accelerated resistance development.
Sir Alexander Fleming’s 1928 discovery of penicillin, the first broad-spectrum antibiotic, revolutionized medicine. In his 1945 Nobel Lecture, Fleming and his team warned of the speed at which bacteria could develop resistance to penicillin, particularly if it was underdosed or over-prescribed. This had already happened at the time as Abraham and Chain reported a strain of penicillin-resistant E. coli in 1940. Furthermore, scientists identified at least four strains of resistant staph by 1942. This trend has continued over the past several decades and there are now several drug-resistant microbes affecting humans, including strains of malaria, tuberculosis, and even gonorrhea, the second most commonly reported infection in the United States.
According to the Centers for Disease Control (CDC), at least 2.8 million people in the United States contract antibiotic-resistant infections and upwards of 35,000 die from those infections annually. Globally, an estimated 700,000 a year die from these infections, but this number could rise to 10 million annually according to the United Nations. AMR also does untold amounts of damage to national economies and healthcare systems thanks to prolonged and more intensive hospital stays and corresponding reductions in healthcare worker productivity. The CDC estimates that the national cost to treat infections caused by six of the most critical multi-drug resistant germs alone is upwards of $4.6 billion in the United States, on top of the lives lost to this problem. All of this has the potential to become catastrophic when adding to the weight on an already incredibly inefficient healthcare system.
Despite these issues, production of new antibiotics has effectively stalled. Beginning in the 1980s, newly discovered antibiotics were generally not broad-spectrum and could only treat very specific types of infections, making them less profitable for pharmaceutical companies and stifling private sector research. Today, just four major pharmaceutical companies in the United States still have dedicated antibiotics divisions. This has led to major shortages, including Pfizer’s national shortage of Penicillin G procaine (a common treatment for congenital syphilis) in the late 2010s. Worse yet, this problem has led to multi-drug resistant bacteria, or so called “superbugs,” which can make existing health crises, like the COVID-19 pandemic, much worse and threaten progress in fighting ongoing epidemics.
There are three key ways the United States can begin to tackle the challenges AMR and stalled antimicrobial research create. The first is by considering the establishment of a national antimicrobial prescription tracking system, similar to those used to track prescriptions of controlled substances. Though the United States does have the National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS), NARMS tracks the antimicrobial susceptibility of intestinal bacteria in ill patients, retail meats, and livestock. It does not track prescriptions. The CDC also routinely analyzes antimicrobial prescription data to determine if interventions are necessary, but it is not as stringent as the systems for controlled substance prescriptions, despite the equal if not greater risk AMR poses to health security. Such a system would be a massive undertaking, but the severity of this threat might warrant such actions.
Second, passage of the Pioneering Antimicrobial Subscriptions to End Upsurging Resistance Act, or PASTEUR Act, is necessary to better ensure more comprehensive government attention to this problem and to promote long-term solutions to combatting AMR. The bipartisan PASTEUR Act would, among other things, form a federal Committee on Critical Need Antimicrobials, incentivize production of novel antimicrobials targeted at existing multi-drug resistant microbes using a delinked system to provide upfront incentives to manufacturers, and improve the CDC National Healthcare Safety Network to better collect AMR data.
Finally, educational institutions should implement curricula that promote good antimicrobial stewardship. Establishing best practices and the critical need to appropriately prescribe antimicrobials early in medical and allied health education will help reduce misuse and over-prescription. This has been affirmed by the University of Pennsylvania and is supported by experts across allied health, including medicine, pharmacy, and nursing.
While these three steps will not end the threat of AMR in totality, they will provide long-term monitoring and improve awareness so that it is less likely the vital, lifesaving benefits of antimicrobials will not be effectively lost. Other looming health crises, including the threat of future pandemics, will be made much worse if there are no longer effective antimicrobials. The threat of returning to a world where there are not reliable treatments for hospital and common infections is too great to even entertain; immediate action is needed to divert potential disaster.
*Danyale Kellogg is an MIA student at Texas A&M University and will begin her PhD in Biodefense in the fall of 2021 at George Mason University. Her research interests include East Asian security, American grand strategy, infectious diseases, health security, and defense policy.
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