Doctors can help fight the superbug crisis, but they can’t do it alone

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It’s been half a century since a new antibiotic to treat CRAB, a drug-resistant bacterial infection, came to market.

Finally, there’s hope on the horizon. Earlier this year, scientists announced the discovery of a novel class of antibiotics that effectively treat CRAB, which is short for carbapenem-resistant Acinetobacter baumannii. This infection has been resistant to most available antibiotics until now, and for doctors and our patients, that’s been a significant challenge. CRAB causes serious infections of the lungs, brain and urinary tract and can lead to life-threatening conditions like pneumonia and meningitis.

That would be bad enough on its own, but at least 20 more pathogens – bacteria and fungi – have also become resistant to the drugs we have to treat them, also known as superbugs. They include gonorrhea and group A Streptococcus, the cause of strep throat. Most are steadily increasing in prevalence.

Kellie Wark, MD, MPH
_{© University of Kansas}

In the bigger picture, more than 2.8 million antimicrobial-resistant infections occur in the United States every year. Globally, according to an analysis in The Lancet, antibiotic-resistant bacteria cause approximately 1.27 million annual deaths and contribute to nearly 5 million. A United Nations report forecasted that if we continue on our current path, antimicrobial resistance could cause 10 million deaths per year worldwide by 2050.

Yet many doctors don’t need statistics to know that the superbug problem is growing, because we see it in our own practices. Eight years ago, I saw one or two CRAB cases a year. Now it’s once a week.

Before 2020, health care systems had made some progress in combating certain types of drug-resistant microbes. But COVID-19 erased those gains and contributed to a new spike in cases. That’s partly because in the early months of the pandemic, doctors prescribed antibiotics in hopes of helping patients when we didn’t yet know the nature of this new disease and whether secondary bacterial infections were contributing.

The progress lost against these pathogens is also partly due to the volume of patients that often overwhelmed hospitals, where people acquire infections even in the best of times. Patients on ventilators, as many were during the pandemic, are especially vulnerable. A study from the CDC found that drug-resistant hospital-acquired infections and deaths rose at least 15% in 2020. CRAB infections jumped nearly 80% that same year.

Antimicrobial resistance is taking a steep toll on patients, doctors, and the health care system as a whole. Difficult-to-treat infections land more patients in hospitals, often the only places they can get novel antibiotics intravenously, since the newest antimicrobials may not be covered by insurance in outpatient or rehab settings. But the multiweek stays required for treatment grow frustrating for patients and put strain on hospital resources once again.

As existing antibiotics lose effectiveness due to resistance, doctors are being forced to prescribe others that can come with severe side effects. For example, colistin is effective against gram-negative bacteria, which causes several kinds of dangerous infections. But colistin is also often considered a last resort antibiotic because it’s very toxic, particularly for the kidneys. It can impair renal function, which can cause patients to end up on dialysis for the rest of their lives.

If no antibiotic options remain in the case of a particularly nasty abscess or bone infection – a situation that’s becoming more common – doctors have no recourse but surgery to try to rid the infection at the source. This is eerily reminiscent of the preantibiotic days in what is now being referred to as the postantibiotic era.

There are ways we could alter our course. Even as physicians who are well aware that superbugs are a problem, the seriousness of the crisis isn’t always well known. That’s why we need to raise awareness within our own community. We also need to be exceedingly thoughtful about how we use the effective drugs we still have. Hospitals are required to have antibiotic stewardship programs to ensure we use the antimicrobial drugs in our arsenal appropriately to prevent pathogens from more rapidly developing resistance to their defenses. However, these programs vary in their capacity and some hospitals, especially in rural areas, lack staff with specific infectious diseases training to oversee them.

State governments, which oversee many aspects of public health, also play an important role. As lead of the antibiotic stewardship program at the Kansas Department of Health and Environment, I’ve been surveying the capacity of labs that test medical samples to identify multi-drug-resistant organisms.

We found that many labs don’t use methods that could differentiate between strains of the same fungus. For instance, about one-third of labs didn’t report identifying down to the species level of fungus when testing certain lab samples. That means they likely aren’t distinguishing between, say, relatively mild Candida albicans and drug-resistant Candida auris, which kills up to half of people it infects. Detecting Candida infections without identifying the particular species of the fungus could explain why 21 states – Kansas included – have not reported any cases of C auris.

States also need regulations to better monitor superbugs when patients are transferred between facilities. In Kansas, we recently rolled out a notification system that updates in real time so that clinicians know when they’re receiving a patient with a drug-resistant infection. Interfacility communication is key to appropriately caring for these patients while also protecting providers and other patients.

But to make a real difference in addressing antimicrobial resistance, we need action on the federal level. Breakthroughs like the new CRAB treatment, while promising, are not the norm today – and a potential treatment still has to go through the process of clinical trials and U.S. Food and Drug Administration (FDA) approval before it reaches patients. Even if it does, its future is uncertain.

For most medicines, developers can expect to recoup their investment in a successful new drug once it hits the market. But antimicrobials are unique. Since new antimicrobial drugs must be used sparingly in only the sickest patients, developers can’t earn a return with a traditional sales model based on the number of doses prescribed.

Because of this, start-ups that have tried to develop new antibiotics in recent years have struggled to stay afloat. Since 2013, eight new antibiotics developed by small companies earned FDA approval. But each of those companies has since declared bankruptcy or been forced to sell the business at a low valuation.

Fortunately, federal legislation to address this challenge already exists and is gaining momentum. The “Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act” would allow the government to invest in development of new antimicrobials targeting the most serious superbugs through a subscription-style model. Instead of paying per dose, the government would contract with companies to pay for access, however many doses were eventually used. The PASTEUR Act would also increase resources for antibiotic stewardship programs in rural critical-access hospitals and other health care facilities, providing clinicians with the support we need to monitor antibiotic use and beat back drug resistance.

The superbug crisis is gathering speed. But if we all play our role, there’s still time to turn it around.

Kellie Wark, MD, MPH, is an assistant professor in the Division of Infectious Diseases at the University of Kansas Medical Center.