AMR: On diagnosing illness, pharmaceutical companies, and global effects

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The United States may be the global leader in scientific research and medicine, but the nation and its patients are not immune to problems caused by antimicrobial resistance (AMR).

Despite advances in technology, especially in the COVID-19 pandemic, physicians may not be able to diagnose an infection quickly when a patient presents with an illness, said Priya Nori, MD, medical director of antimicrobial stewardship at the Montefiore Health System in the Bronx, New York. AMR can have an effect on illnesses that primary care physicians encounter routinely.

Finally, there are things the pharmaceutical industry could do around the world to ensure appropriate use of antibiotics. That is a factor because overuse drives the bacterial evolution that makes germs resistant to the drugs.

Nori spoke with Medical Economics to discuss AMR within the state of medicine as of late 2024 and early 2025. This transcript has been edited for length and clarity.

Medical Economics: Is there an easy and an effective way for clinicians to differentiate between infections that are caused by resistant and the nonresistant pathogens?

Priya Nori, MD
_{© Montefiore Health System}

Priya Nori, MD: Unfortunately, we're not quite there yet. We don't have point of care or readily available ambulatory testing for a lot of infections. We made a lot of progress during COVID in that we were able to develop point of care testing for things like COVID-19, influenza, RSV (respiratory syncytial virus) to be done kind of all at the same time. We've had Group A streptococcal antigen testing for a long time now to diagnose strep throat, and that has made a big difference in terms of getting antibiotics quickly into children for a potentially life-threatening condition. But there's still a lot of conditions that we can't pick up in the primary care setting. There's still a whole bunch of other respiratory viruses that we can't diagnose typically in that setting without a very, very expensive multiplex PCR (polymerase chain reaction) test, which picks up a whole bunch of other viruses. In case it's not group-based strep, or in case it's not flu or RSV or COVID, it can still be a whole bunch of other viruses, but we won't know yet, and that still leads to diagnostic uncertainty, which can lead to an unnecessary antibiotic script because you can't confirm, is this truly a virus or is this a bacteria? Even in the hospital setting, while we have made a lot of progress in terms of being able to diagnose antibiotic resistant infections, and usually that's done by checking for certain genetic elements that indicate that this is the antibiotic resistant bacteria, that's still not available in every single hospital. Those tests are used by big university hospitals, well-resourced places, but I would say the vast majority of hospitals in the U.S. and certainly outside the U.S. don't have access to those yet. They're still very expensive. They may lack the manpower to perform those tests. I do hope, though, that over the next decade, or even sooner, maybe over the next five years or so, that the cost of these tests will dramatically reduce and that they'll be more readily available to any hospital that wants to use them.

Medical Economics: Can you explain how AMR affects clinical outcomes in common infections that are seen in primary care, such as urinary tract infections or pneumonia?

Priya Nori, MD: Anytime you invoke antibiotic resistance, that complicates matters, that leads to more need for testing, that leads to potentially a need for hospitalization for patients to get the care that they need. And there is a body of evidence that shows that antibiotic resistant infections can be associated with increased morbidity and mortality, and this is because of delays, really, in diagnosing that drug resistance, the cause of drug resistance, the mechanisms, and then the proper antibiotics to give for that. Most of those antibiotics exist in hospitals, in the inpatient space. Most of them are intravenous. There's very few, actually, that are by mouth that we can give to somebody and maintain them at home. Often they require some kind of IV treatment. So you can imagine, if somebody's at home, they need IV antibiotics. That's a significant delay right there. They have to either come into the ER or come into an infusion center after a series of referrals and insurance clearances and X, Y and Z. It would be far easier to just prescribe an antibiotic to their pharmacy for them to start within a few hours. So that right there contributes to why they have poorer outcomes when they have antibiotic resistant infections. Even in the hospital when a patient is presenting with, let's say with gram negative sepsis, let's say E. Coli from a bad urinary tract infection. It's often a couple of days into the course before we're able to diagnose that and know and confirm that we've given the right antibiotics based on the resistance profile of that particular bacteria. All the while those first, let's say, 48 hours of their hospitalization, we're kind of guessing, we're making our best guess at that, that we're giving the right drugs, and often we give something very broad, so we can be sure to cover all the bases. When I say broad, I mean to cover a whole slew of different bacteria. But we still cannot confirm that till a few days into the hospitalization. Often we're correct with our antibiotic choice, and we would have covered the bacteria implicated. But every so often we're wrong, and we have to totally switch gears and say, oh, what you need is actually a drug that is more broad, newer, fancier, more expensive, potentially more toxic, and all of that. And so that those are the issues that contribute to an increased burden of morbidity and mortality with AMR.

Medical Economics: What role do pharmaceutical makers have in the development of antimicrobial resistance, and what role do they have in resolving this problem?

Priya Nori, MD: In the U.S., you cannot dispense in antibiotic without prescription from a health care provider. That's great, that is a basic principle of stewardship, and that is really working for us in Western countries where we have those laws in place. However, in a lot of lower and middle income countries, that is not the case. You can dispense antibiotics without a prescription from a nurse practitioner, PA, physician, et cetera. Pharmacies can just purchase them in bulk from wholesalers and sell them to patients. And in fact, I've experienced this myself when I go back to my parents’ homeland of India. So while that increases access for patients, what it does is, it creates a heck of a lot of antibiotic resistance in the community. And this antibiotic resistance circulates. It's in the municipal water supply, it's in wastewater, it can spread very easily all around the community, and that's exactly what we've seen happen. These same countries, with help from WHO and their central governments are now kind of cracking down on this. But a lot of the damage has been done, and so we'll have to see what happens, and we'll have to see if legislation and policy around AMR can move the needle in the positive direction in those countries.

So, you asked about the role of pharmaceutical companies. It's very complex. In the U.S., the role of the pharmaceutical companies in AMR, I don't think they're in the business of spreading AMR, per se, because of their practices. It's not that our markets are flooded with all these cheap, readily available antibiotics that patients can just get over the counter. It's good that they're not. What I'd like to see them do more, though, is invest in maybe smaller companies. So like a big pharma company, you name it, we have so many of them, they can really kind of adopt, take under their wing, a smaller biotech company who's working on AMR, knowing that, OK, if that small company develops a new drug to fight AMR, then my treatment for cancer will go further, because, in case that patient develops a complication, they can have this new antibiotic to treat their infection and continue to take this immunologic therapy for their cancer. That's just an example, but I think they have a role in making sure that not only are they creating new drugs for inflammatory conditions, for cancer, for weight loss, for diabetes, but they are kind of reserving, 10, 15% of their bottom line to also work on other things that society needs, that public health needs, like vaccines or drugs for antibiotic resistance. Outside the U.S. in other countries where there's their pharmaceutical big pharmaceutical industry, like in India and China, there's a lot to be done there, because those companies actually contribute a lot to local AMR, and this is because, you know, they flood the market with all these cheap drugs, there's less regulation, they're dispensed without prescriptions. All these pharmaceutical byproducts from the plants run off into wastewater, municipal water, and spread all, all around. So, a lot more can be done outside the U.S., I think when it comes to the contribution of these big pharmaceutical companies to worsening AMR. Likewise, I do think they can also work on new drugs to target antibiotic resistance and provide those to, you know, the rest of the world as well. So it's a complex, complex, but very, very interesting problem.