According to the CDC, more than 2.8 million antibiotic-resistant infections occur in the U.S. each year, resulting in 35,000 deaths. Antimicrobial resistance, or AMR, is a threat we need to take seriously, said Phyllis Arthur, vice president of Infectious Diseases & Emerging Science Policy at the Biotechnology Innovation Organization (BIO). We spoke to Arthur, who has spent nearly three decades working in the biopharmaceutical industry to fight infectious diseases, about what drives AMR, its impact on women's health, why it was exacerbated by the Covid-19 pandemic and how we can tackle it.
The transcript has been lightly edited for clarity and length.
What is antimicrobial resistance?
Antibiotics have been one of the most important medical innovations of our time. They have enabled our ability to do very complicated modern medicine.
But the use of antibiotics has also caused bacteria to change over time. Let's put it this way: To put it very, very simply … bacteria are kind of like roaches. The first dose of bug spray can kill a whole bunch, but the ones that survive reproduce, and whatever allows them to survive moves forward in its genetics.
This is called antimicrobial resistance, and it means that over time, the bacteria that were very susceptible to a new antibiotic on day one have evolved enough to escape being treated or affected by that antibiotic later on.
How does AMR impact women’s healthcare and everyday lives?
Women have a high number of medical interventions and therefore interact with the healthcare system as part of their lives. Some of these experiences, unfortunately, make women more susceptible to what we'll call opportunistic bacterial infections. For example, you could get a urinary tract infection that might be caused by a bacterium that is resistant to certain antibiotic treatments; you might have a C-section and then unfortunately get a hospital-acquired bacterial infection while you're recovering; or you might be gardening, nick your finger and get a methicillin-resistant staphylococcus aureus (MRSA).
An infection that previously could have been easily treated with antibiotics can become life-threatening because of AMR.
How has the Covid-19 pandemic affected AMR?
These types of public health emergencies often go together: You have a virus causing serious illness and hospitalization, and then you can also have opportunistic secondary infections driving increased antibiotic use, therefore potentially spurring resistance faster than in normal healthcare times.
A recent study of 148 hospitals in 17 states found a 24% increase in multi-drug-resistant infections associated with the surges in Covid-19 cases between March and September of 2020. That means a whole lot of people who were in the hospital with crushed immune systems from serious cases of Covid then became very sick from subsequent bacterial infections. The study estimates that one in eight hospitalized patients suffered from a secondary infection.
Another study found that 50% of the Covid patients who died had a consequent bacterial infection along with their Covid infection.
Why do we need to tackle AMR with urgency?
We need new antibiotics to battle bacteria as they evolve. Drug development normally is a seven- to 10-year exercise, and we already don't have the products we need today to treat resistant infections — let alone those of the future. We are already in a situation in which physicians have few, or zero, antibiotics that address certain resistant threats. We must spur and sustain innovative research and development now to adequately address — and stay ahead of — these serious and life-threatening infections.
We also must think of AMR as a pandemic and disaster preparedness problem that we can't put off solving.
How is AMR connected to pandemic and disaster preparedness?
You can have a pandemic virus like Covid-19, SARS (severe acute respiratory syndrome), MERS (Middle East respiratory syndrome) or the flu that causes an increase in hospitalizations and potentially an increase in secondary infections.
But you also have what we call all-hazards events: hurricanes, fires, mass shootings — events that cause people to be hurt and in the hospital for other reasons. These situations, and any other events involving mass hospitalizations, carry significant risk of secondary infections, including those from resistant bacteria.
As a result, we think of antibiotics as a product that absolutely must be constantly renewed for pandemic and disaster recovery. These critical products are part of our ability to get people well, get them out of the hospital, and keep them safe and healthy.
Why is it a challenge to bring new antibiotics to the market to deal with AMR?
Antibiotics have a unique marketplace situation. Because we want to make sure that these products don't get overused and drive up resistance, novel antibiotics to treat the most-threatening infections (particularly those products that you need in the hospital — the ones you would get through an IV) are held in reserve to treat only the sickest patients. That means that when a company develops a new antibiotic, they'll have a very limited amount of sales — even though those antibiotics are vital to our healthcare system. This has even led to some companies going bankrupt.
Some policies have been put forward to help give incentives to developers of new and novel antibiotics to, in essence, separate the idea of revenue and volume of product. How can we set up a market mechanism in which these companies can have some return on investment for making these products, rather than by selling an inappropriate amount of them?
There's also a different problem: Newer antibiotics are sometimes not used by hospitals because of barriers to adequate reimbursement of novel products. Current Medicare in-hospital payment discourages the use of new AMR medicines because hospitals will lose money — even in situations in which these medicines are clinically appropriate. This creates a barrier to patient access and contributes to the poor uptake of AMR medicines. Addressing this part of the problem has one goal: to make sure access is not an issue when a patient needs new and novel drugs, and ensure healthcare providers can give the right drug to the right patient at the right time.
What are some of the policies being considered to deal with AMR?
A bipartisan bill called the PASTEUR Act — it stands for Pioneering Anti-microbial Subscriptions To End Up-surging Resistance — has been introduced in both the House and the Senate. It proposes a government contract mechanism that would pay companies that develop novel antibiotics against the threats that have been outlined by the CDC to ensure availability of these medicines, thereby establishing an arrangement that partially separates revenue from the volume of product used. The bill also includes stewardship components to ensure that we don't overuse the new antibiotics.
The idea is not just to spur companies to make new products, but to also fix, to some degree, the broken way that the marketplace works for these types of innovative products.
Another piece of legislation is the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act, which would address reimbursement challenges for new antibiotics while requiring hospitals to monitor their use and report data to the CDC.
What can women do as patients and mothers to help stop AMR?
One of the most important things we can all do is be very acutely aware of when an antibiotic is the right product to use — and when it's not. If you have a urinary tract infection, your doctor may prescribe an antibiotic and, in some complicated cases, they may recommend the use of a novel one if the bacterial infection appears resistant to common antibiotics. But if you or a member of your family has a viral infection, don't take antibiotics "just in case." Similarly, don't ask the doctor for an antibiotic for your child if their healthcare provider says they have a viral infection.
Take antibiotics as prescribed, even if you're feeling better. If treatment stops too soon, the remaining bacteria may become resistant to the antibiotic. Do not skip doses, and don't take antibiotics prescribed for someone else.
Finally, take action to support policies that will make sure we have many more antibiotics coming in the near future. Talk to your legislator about why it's important, and share your own stories with legislators, if you or a family member has had any experience with a hard-to-treat infection. We all have a part to play in curbing AMR.
This resource has been created with support from BIO.