Journalist and Author
Constant readers — any of you who are Kindle users can now find SUPERBUG the blog in the Kindle store. I placed it there today; it may take 48 hours for it to propagate through the system.
SUPERBUG the book will of course be on Kindle as well, in March. Stay tuned!
Constant readers, my warmest greetings for Christmas or whatever winter holiday you celebrate! You are high on the list of the many gifts in my life. Thank you for gathering here and contributing to this truly international community of concern about antibiotic resistance.
I’ll be back early next week with news of two fascinating new studies. Snow-dusted (12″ and rising here) holiday wishes ’til then.
Constant readers, I don’t often ask you for anything — OK, I did ask you to consider an advance buy of SUPERBUG, but that’s a win-win for all of us, right?
But today I’m going to ask you for something, and I hope you’ll trust me that it, too, is a win-win all ’round.
ProMED Mail, the disease early-warning website and listserv of the International Society of Infectious Diseases, is having its annual fundathon. If you have any cash to spare, I would like you to consider making a small donation. Here’s why. Here on the net:
We value crowdsourcing. In the disease world, ProMED has been doing that longer and better than anyone. Their network of volunteer spotters — physicians, epidemiologists, animal-health experts, journalists and engaged citizens — has been running since 1994.
We value passion. ProMED has more than 30 expert editors, all significant researchers in their respective specialties, who comb through those crowdsourced reports to find them gems. They all have lives and more than full-time jobs already. And they don’t do this for glory: They don’t even attach their names to their pieces, just their initials. (Among ProMED aficionados, it’s a moment of insider glee to spot the initials and translate them to an important name.)
We value reach. ProMED has more than 57,000 subscribers, each of them a potential contributor, in 187 countries. It runs sub-lists of news with articles relevant to particular parts of the world, volunteer-translated into Portuguese, Spanish, Russian, and French (for West Africa), and also runs sublists in English of articles relevant to the Mekong Basin and to English-speaking East Africa.
More than anything, we value effectiveness — and as a subscriber since sometime in the 1990s, I can testify that ProMED delivers. The listserv is the primary reason that the government of China fessed up to the existence of the international epidemic of SARS in spring 2003, after attempting to conceal its burgeoning outbreak for almost six months. ProMED pried loose that admission simply by posting a note from within its network: a question from a pseudonymous man in southern China that was relayed to an acquaintance in northern California and then to an epidemiologist in Annapolis who sent it to ProMED. (That story is told in my book Beating Back the Devil, and you can read it in this excerpt here.)
That is the power of a network, and that’s why ProMED deserves our support.
Constant reader Pat Gardiner guided me to an enlightening post at the website of the agricultural magazine World Poultry that questions the routine use of antibiotics in food animals. It’s written by Wiebe van der Sluis, a Netherlands journalist from a farming background, founder of World Poultry and also the magazines Pig Progress and Poultry Processing.
The Netherlands, let’s recall, is the place where MRSA ST398 first emerged, and also the place where that livestock-MRSA strain has caused the most serious human cases and triggered the largest changes in hospital infection-control practices. In the Netherlands, swine farmers and veterinarians are considered serious infection risks because of their exposure to animals, and are pre-emptively isolated when they check into hospitals until they can be checked for MRSA colonization.
Van der Sluis takes seriously the tie between the use of antibiotics in animals and the emergence of MRSA:
Although most of the time MRSA is linked to pig production, it is also related to the veal and poultry industry. The industry, therefore, cannot shrug its shoulders and move on if nothing was wrong. In this case it would be wise to redefine the term prudent use of antibiotics. Time is up for those who use antibiotics to cover up bad management, poor housing conditions or insufficient health care. The standard rule should be: Do not use antibiotics unless there is a serious health issue and no other remedy applies. Veterinary practitioners, who usually authorise producers to use antibiotics, should also take responsibility and prevent unnecessary antibiotic use and the development of antibiotic resistance in animals and humans.
It’s unusual in the US context so hear someone so immersed in agriculture speak so candidly about antibiotic use. It’s refreshing.
Constant reader Pat Gardiner guided me to an enlightening post at the website of the agricultural magazine World Poultry that questions the routine use of antibiotics in food animals. It’s written by Wiebe van der Sluis, a Netherlands journalist from a farming background, founder of World Poultry and also the magazines Pig Progress and Poultry Processing.
The Netherlands, let’s recall, is the place where MRSA ST398 first emerged, and also the place where that livestock-MRSA strain has caused the most serious human cases and triggered the largest changes in hospital infection-control practices. In the Netherlands, swine farmers and veterinarians are considered serious infection risks because of their exposure to animals, and are pre-emptively isolated when they check into hospitals until they can be checked for MRSA colonization.
Van der Sluis takes seriously the tie between the use of antibiotics in animals and the emergence of MRSA:
Although most of the time MRSA is linked to pig production, it is also related to the veal and poultry industry. The industry, therefore, cannot shrug its shoulders and move on if nothing was wrong. In this case it would be wise to redefine the term prudent use of antibiotics. Time is up for those who use antibiotics to cover up bad management, poor housing conditions or insufficient health care. The standard rule should be: Do not use antibiotics unless there is a serious health issue and no other remedy applies. Veterinary practitioners, who usually authorise producers to use antibiotics, should also take responsibility and prevent unnecessary antibiotic use and the development of antibiotic resistance in animals and humans.
It’s unusual in the US context so hear someone so immersed in agriculture speak so candidly about antibiotic use. It’s refreshing.
I’m thrilled today to present another guest blogger: Dr. Brad Spellberg, associate professor of medicine at the David Geffen School of Medicine at UCLA and author of the new book Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them (Prometheus Books). This new book is important reading for anyone concerned, as all of us are here, about the narrowing pipeline for new antibiotics against MRSA and other resistant pathogens. That pipeline problem is something Dr. Spellberg knows well: He is not only a practicing infectious-disease physician, but also a member of the Antimicrobial Availability Task Force of the Infectious Diseases Society of America, the specialty society that produced the “Bad Bugs” reports that I’ve posted on before.
Below, Dr. Spellberg thoughtfully answers some questions about the difficulties of treating resistant infections and of developing drugs to control them.
From your point of view as a practicing ID physician, why is it so difficult to prevent resistant infections?
It’s difficult to prevent all infections period. Not more difficult to prevent infections caused by resistant organisms than any other organisms. However, also difficult to prevent the spread of resistance among bacteria that are causing infections.
So, why is it difficult? People have this crazy belief that hospital acquired infections are the result of sloppy medicine. Not so. They are the result of very sick people with tremendously sophisticated levels of intensive medical care being delivered in a concentrated environment (i.e., a hospital). Crowd a bunch of sick people together with plastic catheters, mechanical ventilators, and nasty bacteria, and such infections are inevitable. What we are learning is that we have to go above and beyond normal to stop these infections from happening. Research is needed on how best to do this. It’s not as simple as people think.
You can’t stop the spread of the resistance itself. It is inevitable.
You say in Rising Plague that physician misuse and overuse of antibiotics is not the cause of antibiotic resistance. What do you consider the primary driver?
This is by far the biggest misperception among the public. Let’s start from first principles. Who invented antibiotics? Who invented antibiotic resistance? When were both invented?
Humans did NOT invent antibiotics. Bacteria did…about 2 billion years ago. And they invented antibiotic resistance at the same time. So, bacteria have been creating and defeating antibiotics for 20 million times longer than humans have even known that antibiotics exist (about 78 years, as the original sulfa compound was developed in late 1931 by Gerhard Domagk). Over the past 2 billion years, bacteria warring among themselves have learned to target virtually every targetable biochemical pathway with antibiotics, and have learned to create defense mechanisms to defeat virtually all such antibiotics. They are already resistant to drugs we haven’t even developed yet. It is bacteria that cause antibiotic resistance, not humans.
What humans do, is we apply natural selection when we use antibiotics. We kill off susceptible bacteria, leaving behind already resistant bacteria to replicate and spread their resistance genes.
This may seem like a subtle distinction: We don’t create antibiotic resistance, we just increase its rate of spread. But, from the perspective of effective response planning, this is a critical distinction. If inappropriate antibiotic use caused antibiotic resistance, all we would have to do to defeat resistance is never prescribe drugs inappropriately. Unfortunately, that won’t work. All antibiotic prescription, even appropriate antibiotic prescription, increases selective pressure, which increases the rate of spread of resistance.
Eliminating inappropriate antibiotic use, and always using antibiotics appropriately is indeed critical, because it will slow the spread of resistance, buying us time to develop new antibiotics. But if 100% of our efforts are focused on antibiotic conservation, all we will achieve is a slowing of the inevitable exhaustion of the antibiotic resource. What is needed is to marry antibiotic conservation with antibiotic restoration. That is, we need new drugs to be developed. Just conserving what we have is not enough.
Why are “antibiotic stewardship” policies not a sufficient remedy for controlling resistance?
See above. Stewardship leads to conservation. That is half the battle, but by itself it will only lead to a slowing of the inevitable exhaustion of the resource.
Furthermore, the initial calls for stewardship were made by people like Max Finland in the late 1940s and early 1950s. This is not a new call. It’s more than a half century old. It just doesn’t work very well. An analogy is the temptation to say that we don’t need condoms to stop the spread of STDs, we just need abstinence. It is true that abstinence will stop the spread of STDs. But, an abstinence-only policy just doesn’t work. You’ve got to have the condoms too. Well, stewardship, by itself, just hasn’t worked after more than 60 years of calls for it. It is too hard to change behavior, and the pressures on physicians not to be wrong about their patients’ illnesses is too great.
What do you consider the chief impediments to developing newer/better antibiotics?
The two major impediments are: 1) economic, and 2) regulatory.
The primary economic impediment is that antibiotics have a lower rate of return on investment than other classes of drugs. You make a lot more money back on your R&D investment if the drug is taken every day for the rest of the patient’s life (e.g. cholesterol, hypertension, dementia, arthritis) than if it is taken for 7 days and then the patient stops because he/she is cured.
The regulatory problem is a startling degree of confusion at the FDA regarding what types of clinical trials should be conducted ot lead to approval of new antibiotics. There has been a total rethinking of antibiotic clinical trials at the FDA over the past 5 years. Right now, companies don’t know what trials they are supposed to do to get drugs done, and increasingly the standards are calling for infeasible study designs that simply can’t be conducted. This revisionist thinking is being driven by statisticians who know nothing about clinical medicine or patient care. They are asking for things to be done that can’t be done to human beings. The balance of clinical and statistical concerns is totally out of whack, and must be restored if this problem is to be solved.
What types of policies are needed to kick-start development of new antibiotics?
Simple. Solutions follow the problems above.
For the economic problem, we need Congress to pass legislation that creates special economic incentives for companies to re-enter the antibiotic R&D market. The return on investment calculation must be changed. Antibiotics are a unique, critical public health need. Congress should recognize this. Examples of programs that would work include increase in funding to scientists (e.g. via NIH) who study bacterial resistance and antibiotic development. Increased small business grants to help translate basic science discoveries to lead compound antibiotics. Tax credits, guaranteed markets, patent extensions, and prizes to serve as pull strategies to help companies improve the return on investment for antibiotics.
For the regulatory problem, Congress needs to stop hammering the FDA into a state of paralysis, where fear permeates every decision to approve a drug. We should be encouraging a balance between statistical concerns and clinical concerns, and we need to restore a sense that the agency is regulating drugs used by physicians for patients, and that trials showing those drugs are safe and effective must be feasible to conduct and relevant to how the drugs will be used in clinical medicine after they are approved.
I’m thrilled today to present another guest blogger: Dr. Brad Spellberg, associate professor of medicine at the David Geffen School of Medicine at UCLA and author of the new book Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them (Prometheus Books). This new book is important reading for anyone concerned, as all of us are here, about the narrowing pipeline for new antibiotics against MRSA and other resistant pathogens. That pipeline problem is something Dr. Spellberg knows well: He is not only a practicing infectious-disease physician, but also a member of the Antimicrobial Availability Task Force of the Infectious Diseases Society of America, the specialty society that produced the “Bad Bugs” reports that I’ve posted on before.
Below, Dr. Spellberg thoughtfully answers some questions about the difficulties of treating resistant infections and of developing drugs to control them.
From your point of view as a practicing ID physician, why is it so difficult to prevent resistant infections?
It’s difficult to prevent all infections period. Not more difficult to prevent infections caused by resistant organisms than any other organisms. However, also difficult to prevent the spread of resistance among bacteria that are causing infections.
So, why is it difficult? People have this crazy belief that hospital acquired infections are the result of sloppy medicine. Not so. They are the result of very sick people with tremendously sophisticated levels of intensive medical care being delivered in a concentrated environment (i.e., a hospital). Crowd a bunch of sick people together with plastic catheters, mechanical ventilators, and nasty bacteria, and such infections are inevitable. What we are learning is that we have to go above and beyond normal to stop these infections from happening. Research is needed on how best to do this. It’s not as simple as people think.
You can’t stop the spread of the resistance itself. It is inevitable.
You say in Rising Plague that physician misuse and overuse of antibiotics is not the cause of antibiotic resistance. What do you consider the primary driver?
This is by far the biggest misperception among the public. Let’s start from first principles. Who invented antibiotics? Who invented antibiotic resistance? When were both invented?
Humans did NOT invent antibiotics. Bacteria did…about 2 billion years ago. And they invented antibiotic resistance at the same time. So, bacteria have been creating and defeating antibiotics for 20 million times longer than humans have even known that antibiotics exist (about 78 years, as the original sulfa compound was developed in late 1931 by Gerhard Domagk). Over the past 2 billion years, bacteria warring among themselves have learned to target virtually every targetable biochemical pathway with antibiotics, and have learned to create defense mechanisms to defeat virtually all such antibiotics. They are already resistant to drugs we haven’t even developed yet. It is bacteria that cause antibiotic resistance, not humans.
What humans do, is we apply natural selection when we use antibiotics. We kill off susceptible bacteria, leaving behind already resistant bacteria to replicate and spread their resistance genes.
This may seem like a subtle distinction: We don’t create antibiotic resistance, we just increase its rate of spread. But, from the perspective of effective response planning, this is a critical distinction. If inappropriate antibiotic use caused antibiotic resistance, all we would have to do to defeat resistance is never prescribe drugs inappropriately. Unfortunately, that won’t work. All antibiotic prescription, even appropriate antibiotic prescription, increases selective pressure, which increases the rate of spread of resistance.
Eliminating inappropriate antibiotic use, and always using antibiotics appropriately is indeed critical, because it will slow the spread of resistance, buying us time to develop new antibiotics. But if 100% of our efforts are focused on antibiotic conservation, all we will achieve is a slowing of the inevitable exhaustion of the antibiotic resource. What is needed is to marry antibiotic conservation with antibiotic restoration. That is, we need new drugs to be developed. Just conserving what we have is not enough.
Why are “antibiotic stewardship” policies not a sufficient remedy for controlling resistance?
See above. Stewardship leads to conservation. That is half the battle, but by itself it will only lead to a slowing of the inevitable exhaustion of the resource.
Furthermore, the initial calls for stewardship were made by people like Max Finland in the late 1940s and early 1950s. This is not a new call. It’s more than a half century old. It just doesn’t work very well. An analogy is the temptation to say that we don’t need condoms to stop the spread of STDs, we just need abstinence. It is true that abstinence will stop the spread of STDs. But, an abstinence-only policy just doesn’t work. You’ve got to have the condoms too. Well, stewardship, by itself, just hasn’t worked after more than 60 years of calls for it. It is too hard to change behavior, and the pressures on physicians not to be wrong about their patients’ illnesses is too great.
What do you consider the chief impediments to developing newer/better antibiotics?
The two major impediments are: 1) economic, and 2) regulatory.
The primary economic impediment is that antibiotics have a lower rate of return on investment than other classes of drugs. You make a lot more money back on your R&D investment if the drug is taken every day for the rest of the patient’s life (e.g. cholesterol, hypertension, dementia, arthritis) than if it is taken for 7 days and then the patient stops because he/she is cured.
The regulatory problem is a startling degree of confusion at the FDA regarding what types of clinical trials should be conducted ot lead to approval of new antibiotics. There has been a total rethinking of antibiotic clinical trials at the FDA over the past 5 years. Right now, companies don’t know what trials they are supposed to do to get drugs done, and increasingly the standards are calling for infeasible study designs that simply can’t be conducted. This revisionist thinking is being driven by statisticians who know nothing about clinical medicine or patient care. They are asking for things to be done that can’t be done to human beings. The balance of clinical and statistical concerns is totally out of whack, and must be restored if this problem is to be solved.
What types of policies are needed to kick-start development of new antibiotics?
Simple. Solutions follow the problems above.
For the economic problem, we need Congress to pass legislation that creates special economic incentives for companies to re-enter the antibiotic R&D market. The return on investment calculation must be changed. Antibiotics are a unique, critical public health need. Congress should recognize this. Examples of programs that would work include increase in funding to scientists (e.g. via NIH) who study bacterial resistance and antibiotic development. Increased small business grants to help translate basic science discoveries to lead compound antibiotics. Tax credits, guaranteed markets, patent extensions, and prizes to serve as pull strategies to help companies improve the return on investment for antibiotics.
For the regulatory problem, Congress needs to stop hammering the FDA into a state of paralysis, where fear permeates every decision to approve a drug. We should be encouraging a balance between statistical concerns and clinical concerns, and we need to restore a sense that the agency is regulating drugs used by physicians for patients, and that trials showing those drugs are safe and effective must be feasible to conduct and relevant to how the drugs will be used in clinical medicine after they are approved.
Constant readers: To my complete surprise, SUPERBUG is up on Amazon!
Mind you, the page is almost blank. The cover image has not been added; the flap copy hasn’t even been finalized; and my bio is out of date. (For an up-to-date bio, visit my Amazon author page, where posts from here will soon be mirrored.)
Nevertheless, there it is — and at a lovely pre-release deep discount (34%!) too.
I had plans to roll out news about the book over the next two months, but this has scooped me, a bit. So here’s the first bit of news, which you’ll see confirmed on the Amazon page: We finally decided on a subtitle. So the full title of the book now is:
Here’s something else this scoops me on: the release date. SUPERBUG will be published on March 23, 2010.
And here’s an important detail: My own experience with Amazon orders has been that pre-orders are not only discounted — they also move out from Amazon very quickly as release date approaches. So if you’d like to get a copy of SUPERBUG into your hand as soon as can be, a pre-order is one sure way to do it. (Plus, it makes my publisher happy.)
$17.16, folks. 34% off! How can you go wrong?
Via the Fresno Business Journal and the Torrance Daily Breeze come reports of a new study by California’s Office of Statewide Health Planning and Development: Known MRSA cases in the state’s hospitals increased four-fold between 1999 and 2007, from 13,000 to 52,000 cases per year.
From the Torrance paper:
The good news is that the percentage of people who die of MRSA has decreased, from about 35 percent in 1999 to 24 percent in 2007. The raw number of deaths, however, more than doubled to about 12,500. (Byline: Melissa Evans)
From the Fresno paper (no byline):
Fresno, Kings, Madera and Tulare counties were among 38 counties in California that had 61 to 80% of patients with staph infections.
Only one county, Sierra, fared worse. Eight-one to 100% of patients ended up with staph infections in that county’s hospitals.
In 1999, Kings and Madera counties were in the 0 to 20% range and Fresno and Tulare counties were in the 21 to 40% range.
100%??
Via the Fresno Business Journal and the Torrance Daily Breeze come reports of a new study by California’s Office of Statewide Health Planning and Development: Known MRSA cases in the state’s hospitals increased four-fold between 1999 and 2007, from 13,000 to 52,000 cases per year.
From the Torrance paper:
The good news is that the percentage of people who die of MRSA has decreased, from about 35 percent in 1999 to 24 percent in 2007. The raw number of deaths, however, more than doubled to about 12,500. (Byline: Melissa Evans)
From the Fresno paper (no byline):
Fresno, Kings, Madera and Tulare counties were among 38 counties in California that had 61 to 80% of patients with staph infections.
Only one county, Sierra, fared worse. Eight-one to 100% of patients ended up with staph infections in that county’s hospitals.
In 1999, Kings and Madera counties were in the 0 to 20% range and Fresno and Tulare counties were in the 21 to 40% range.
100%??
It’s been 10 years since the publication of the pathbreaking Institute of Medicine report, “To Err is Human,” which for the first time focused policy attention on medical errors. The Interdisciplinary Nursing Quality Research Initiative has been running a two-week special series of posts to mark the occasion, and they very kindly asked me to contribute.
Here’s a link to my guest-post, “Hospital Error Rates — Still a Long Way To Go,” looking at a recent paper and editorial in the Journal of the American Medical Association that reported very discouraging results in rates of infections in ICUs worldwide. (And, umm, yes, that is what I look like.)
While you’re there, please take a look also at another guest post by my good friend Nancy Shute, former staff writer and now blogger for US News & World Report, who discusses the difficulty of speaking up as a patient, based on her own experience in the hospital last summer. It’s very worth a read.
It’s been 10 years since the publication of the pathbreaking Institute of Medicine report, “To Err is Human,” which for the first time focused policy attention on medical errors. The Interdisciplinary Nursing Quality Research Initiative has been running a two-week special series of posts to mark the occasion, and they very kindly asked me to contribute.
Here’s a link to my guest-post, “Hospital Error Rates — Still a Long Way To Go,” looking at a recent paper and editorial in the Journal of the American Medical Association that reported very discouraging results in rates of infections in ICUs worldwide. (And, umm, yes, that is what I look like.)
While you’re there, please take a look also at another guest post by my good friend Nancy Shute, former staff writer and now blogger for US News & World Report, who discusses the difficulty of speaking up as a patient, based on her own experience in the hospital last summer. It’s very worth a read.
The New England Journal of Medicine has been running an open-access blog on H1N1 flu, and they’ve put up a post on when to give antibiotics to prevent secondary bacterial pneumonia, including MRSA pneumonia, in flu patients.
There’s a table of key clinical points to consider, and these important points are made:
For the child or adult admitted to a hospital intensive care unit in respiratory distress, we believe that empirical initial therapy with broad-spectrum antibiotics to include coverage for MRSA, as well as Streptococcus pneumoniae and other common respiratory pathogens, is appropriate.
For the previously healthy child or adult with influenza who requires admission to a community hospital and has features that suggest a secondary pneumonia (Table 1), we would recommend empirical treatment with a drug such as intravenous second- or third-generation cephalosporin, after an effort has been made to prove the association with influenza and to get adequate lower respiratory tract specimens for Gram’s stain and bacterial culture.
If the Gram’s stain suggests the presence of staphylococci or if there is a rapidly progressive or necrotizing pneumonia, an additional antimicrobial agent to cover MRSA is appropriate. …
We do not believe that initial coverage for MRSA is indicated in all patients who are thought to have secondary bacterial pneumonia.
So, to recap:
For anyone concerned about pneumonia in the aftermath of H1N1, this is worth bookmarking.
The New England Journal of Medicine has been running an open-access blog on H1N1 flu, and they’ve put up a post on when to give antibiotics to prevent secondary bacterial pneumonia, including MRSA pneumonia, in flu patients.
There’s a table of key clinical points to consider, and these important points are made:
For the child or adult admitted to a hospital intensive care unit in respiratory distress, we believe that empirical initial therapy with broad-spectrum antibiotics to include coverage for MRSA, as well as Streptococcus pneumoniae and other common respiratory pathogens, is appropriate.
For the previously healthy child or adult with influenza who requires admission to a community hospital and has features that suggest a secondary pneumonia (Table 1), we would recommend empirical treatment with a drug such as intravenous second- or third-generation cephalosporin, after an effort has been made to prove the association with influenza and to get adequate lower respiratory tract specimens for Gram’s stain and bacterial culture.
If the Gram’s stain suggests the presence of staphylococci or if there is a rapidly progressive or necrotizing pneumonia, an additional antimicrobial agent to cover MRSA is appropriate. …
We do not believe that initial coverage for MRSA is indicated in all patients who are thought to have secondary bacterial pneumonia.
So, to recap:
For anyone concerned about pneumonia in the aftermath of H1N1, this is worth bookmarking.
Folks: On Wednesday 2 December, at 9:30 a.m. EST, Rep. Louise Slaughter (D-NY) will host a Congressional briefing about antibiotic use in food animals. As a reminder, Rep. Slaughter is an MPH and Congress’s only microbiologist, and the chief sponsor of PAMTA, the Preservation of Antibiotics for Medical Treatment Act that proposes restricting antibiotic use in animals to therapeutic uses under the guidance of a veterinarian and phases out “growth promotion” with sub-therapeutic doses, which consumes millions of pounds of antibiotics every year, many of them close analogs to human drugs.
Appearing at the briefing along with Rep. Slaughter are leaders of efforts that have produced an important string of reports on antibiotic overuse — the Pew Commission on Industrial Farm Animal Production and the Extending the Cure project of Resources for the Future:
Here’s a post explaining the importance of this issue from the blog of the Center for a Livable Future, a Johns Hopkins University research group that has produced some of the most mportant papers on leakage of antibiotic-resistant bacteria and antibiotic residues from CAFOs (“confined” or “concentrated” “animal-feeding operations” — very, very large-scale farms). And here’s some video on the issue from last summer from Lou Dobbs Tonight.
Because the event Wednesday is an informational briefing, not a hearing, I can’t find any link for a live webcast. (I’ll update if I find one.) But the hearing will be live-tweeted by the staff of the Center for a Livable Future (@LivableFuture) at the hashtag #CLF09. BLOGGERS: They will take tweeted questions toward the end of the hearing, ~10:45 a.m. — use the hashtag.
Folks: On Wednesday 2 December, at 9:30 a.m. EST, Rep. Louise Slaughter (D-NY) will host a Congressional briefing about antibiotic use in food animals. As a reminder, Rep. Slaughter is an MPH and Congress’s only microbiologist, and the chief sponsor of PAMTA, the Preservation of Antibiotics for Medical Treatment Act that proposes restricting antibiotic use in animals to therapeutic uses under the guidance of a veterinarian and phases out “growth promotion” with sub-therapeutic doses, which consumes millions of pounds of antibiotics every year, many of them close analogs to human drugs.
Appearing at the briefing along with Rep. Slaughter are leaders of efforts that have produced an important string of reports on antibiotic overuse — the Pew Commission on Industrial Farm Animal Production and the Extending the Cure project of Resources for the Future:
Here’s a post explaining the importance of this issue from the blog of the Center for a Livable Future, a Johns Hopkins University research group that has produced some of the most mportant papers on leakage of antibiotic-resistant bacteria and antibiotic residues from CAFOs (“confined” or “concentrated” “animal-feeding operations” — very, very large-scale farms). And here’s some video on the issue from last summer from Lou Dobbs Tonight.
Because the event Wednesday is an informational briefing, not a hearing, I can’t find any link for a live webcast. (I’ll update if I find one.) But the hearing will be live-tweeted by the staff of the Center for a Livable Future (@LivableFuture) at the hashtag #CLF09. BLOGGERS: They will take tweeted questions toward the end of the hearing, ~10:45 a.m. — use the hashtag.
We’ve talked before about the shrinking number of drugs available to treat MRSA and about the challenges of getting new drugs to market. Well, it’s not just a problem in the United States.
A new report from the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMEA) — that’s the CDC and the FDA of the European Union — analyzes the bench-to-market “pipeline” of new drug development in the EU and finds… not good news. Out of 167 antibacterial agents that are somewhere in the pipeline of development, only 15 look likely to improve treatment of resistant organisms over drugs that already exist — and 10 of those 15 are in early-stage trials and will not come to market anytime soon.
That leaves 5 potential new drugs, for an epidemic of antibiotic resistance that, just in the EU, causes 25,000 deaths and $1.5 billion Euros ($2.27 billion) in extra healthcare spending each year.
(Within that epidemic of resistance, by the way, the single most common organism is MRSA.)
It’s worth understanding how the agencies conducted their analysis. When we look for new drugs to treat resistant organisms, we ideally need several things:
Here’s what the EU pipeline looks like:
If you’re wondering whether you should be depressed, the answer is Yes.
… it is unclear if any of these identified agents will ever reach the market, and if they do, they may be indicated for use in a very limited range of infections.
The agencies call for a concerted government effort to turn this around, and ask for quick action because it takes years to get drugs through the pipeline:
…a European and global strategy to address this serious problem is urgently needed, and measures that spur new antibacterial drug development need to be put in place.
This echoes a call that has already been made in this country by the Infectious Diseases Society of America, which has asked for changes in incentives to drug-makers, and has backed what’s known as the STAAR Act (STrategies to Address Antimicrobial Resistance). With this latest EU report — which comes on the heels of a US-ER agreement to work cooperatively on resistance — the IDSA is asking for an international commitment to bringing forth 10 new drugs in 10 years, what they are calling 10 x ’20.
We’ve talked before about the shrinking number of drugs available to treat MRSA and about the challenges of getting new drugs to market. Well, it’s not just a problem in the United States.
A new report from the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMEA) — that’s the CDC and the FDA of the European Union — analyzes the bench-to-market “pipeline” of new drug development in the EU and finds… not good news. Out of 167 antibacterial agents that are somewhere in the pipeline of development, only 15 look likely to improve treatment of resistant organisms over drugs that already exist — and 10 of those 15 are in early-stage trials and will not come to market anytime soon.
That leaves 5 potential new drugs, for an epidemic of antibiotic resistance that, just in the EU, causes 25,000 deaths and $1.5 billion Euros ($2.27 billion) in extra healthcare spending each year.
(Within that epidemic of resistance, by the way, the single most common organism is MRSA.)
It’s worth understanding how the agencies conducted their analysis. When we look for new drugs to treat resistant organisms, we ideally need several things:
Here’s what the EU pipeline looks like:
If you’re wondering whether you should be depressed, the answer is Yes.
… it is unclear if any of these identified agents will ever reach the market, and if they do, they may be indicated for use in a very limited range of infections.
The agencies call for a concerted government effort to turn this around, and ask for quick action because it takes years to get drugs through the pipeline:
…a European and global strategy to address this serious problem is urgently needed, and measures that spur new antibacterial drug development need to be put in place.
This echoes a call that has already been made in this country by the Infectious Diseases Society of America, which has asked for changes in incentives to drug-makers, and has backed what’s known as the STAAR Act (STrategies to Address Antimicrobial Resistance). With this latest EU report — which comes on the heels of a US-ER agreement to work cooperatively on resistance — the IDSA is asking for an international commitment to bringing forth 10 new drugs in 10 years, what they are calling 10 x ’20.
It’s not very likely that people will be eating much pork today — OK, maybe some pancetta in the Brussels sprouts — and that’s good, because there’s lots of news today about MRSA in pigs.
(In fact, there’s a ton of news just this week. Make it stop.)
The European Food Safety Authority has published a long-awaited, European Union-wide survey looking for the presence of MRSA in pigs. Here’s the key points: Investigators found MRSA on 1 out of 4 farms where pigs were being raised and in 17 of the 24 EU states. (Two non-member states were included in the analysis.)
Strictly speaking, this is not a survey of MRSA in pigs; the study samples not the pigs themselves, but the dust in pig-raising sheds. The sites were 1,421 breeding farms and 3,176 farms where pig are raised to slaughter age. By far the most common strain was MRSA ST398, though other strains were detected, including some known human strains. The prevalence in various countries went from a low of 0 to as high as 46% of farms. (Highest, in descending order: Spain, Germany, Belgium, Italy, Portugal. The Netherlands, where St398 was first identified, had a prevalence of 12.8%. Countries reporting no MRSA: Bulgaria, Cyprus, Denmark, Estonia, Finland, Hungary, Ireland, Latvia. Lithuania, Luxembourg, Sweden, the United Kingdom, Norway and Switzerland.)
The report closes by recommending comprehensive monitoring of pigs for MRSA, as well as monitoring of poultry and cattle.
About the potential of ST398 crossing to humans, it has this to say:
In humans, colonisation with MRSA ST398 originating from pigs has been identified as an occupational health risk for farmers and veterinarians and their families. Although MRSA ST398 represents only a small proportion of the total number of reports of human MRSA infections in the EU… in some countries with a low prevalence of human MRSA infection, CC398 is a major contributor to the overall MRSA burden.
In most cases, colonisation with MRSA ST398 in humans is not associated with disease, although clinical cases associated with MRSA ST398 have been reported. MRSA ST398 can be introduced into hospitals via colonised farmers and other persons in a region with intensive pig farming. Therefore, MRSA ST398 may add substantially to the MRSA introduced in health care settings. However, it seems that the capacity for dissemination in humans (patient-to-patient transmission) of livestock-origin MRSA, in particular ST398, is lower as compared to hospital-associated MRSA).
… Food may be contaminated by MRSA (including ST398), however there is currently no evidence for increased risk of human colonisation or infection following contact or consumption of food contaminated by ST398 both in the community and in hospital.
Britain’s Soil Association, which pressed for the study to be done, has released a statement quoting the food safety agency warning that the testing method may have underestimated MRSA’s presence on farms, and warning that if ST398 is not yet in England, it is certainly soon to arrive. Germany’s Federal Institute for Risk Assessment also released a statement, admitting that ST398 in German pig stocks is “widespread.”
The report is here, executive summary here, and press release here. All well worth reading.
Via Emerging Infectious Diseases comes the full version of a piece of research I posted on in September that was presented at the London conference Methicillin-resistant Staphylococci in Animals: Veterinary and Public Health Implications. A new MRSA variant — not ST398 — has been spotted in pigs in China.
Luca Guardabassi and Arshnee Moodley of the University of Copenhagen and Margie O’Donoghue, Jeff Ho, and Maureen Boost of the Hong Kong Polytechnic University report that they found a pig-adapted MRSA strain in 16 of 100 pig carcasses collected at 2 wet markets in Hong Kong. By multi-locus sequence typing, the strain is ST9, previously found in pigs in France; by PFGE, they fall into categories that tend to carry the community-strain cassettes SCCmec IV and V.
Here’s the bad news: This strain possesses resistance factors that resemble human hospital-associated MRSA more than they do ST398.
Twelve isolates displayed a typical multiple resistance pattern, including resistance to chloramphenicol, ciprofloxacin, clindamycin, cotrimoxazole, erythromycin, gentamicin, and tetracyline. The remaining 4 isolates were additionally resistant to fusidic acid. … All isolates were negative for Panton-Valentine leukocidin and susceptible to vancomycin and linezolid.
The further bad news, of course, is that this is being found in Hong Kong, adjacent to China, which is the world’s single largest producer of pork, raising tens of millions of tons of pig meat per year. Most of the pigs sold in Hong Kong come from the Chinese mainland, not from the SAR. Pig surveillance for MRSA in China is practically non-existent (which is not much of a criticism since it does not exist in the United States, either). A human infection with ST9 has already been recorded in Guangzhou, the province adjacent to Hong Kong.
The question, for this strain as for all MRSA strains in pigs, is what is its zoonotic potential? Here again, the news is not good. According to Maureen Boost, who presented this research at the London conference, the isolates were obtained by the researchers from intact heads from butchered pigs; the researchers took the snouts to the lab and and swabbed them there. Pig snout happens to be a desirable meat in China; it is bought in markets, taken home and made into soup. Boiling in broth would probably kill MRSA bacteria — but home butchering of a pig snout could pass the bug on to the human cutting it up, or to that human’s kitchen environment, long before the snout ever got into the pot.
The cite is: Guardabassi L, O’Donoghue M, Moodley A, Ho J, Boost M. Novel lineage methicillin-resistant Staphylococcus aureus, Hong Kong. Emerg Infect Dis. 2009 Dec. DOI: 10.3201/eid1512.090378
