Guest Host: Nia-Malika Henderson

Today the UN General Assembly is doing something it has done only four times before — they are addressing a global health issue. Like HIV, Ebola and chronic disease that has come before it, the topic generating high levels of concern now is antimicrobial resistance or superbugs. Since Penicillin was discovered in 1928, antibiotic resistance was understood — and feared. Fast forward: antibiotics save lives, but they are used too often which speeds up resistances and makes it harder, and sometimes impossible, to treat infections with the drugs at hand. Guest host Nia-Malika Henderson and our panel discuss the rise of superbugs and what to do about it.

Guests

  • Dr. Jesse Goodman Director of the Center on Medical Product Access, Safety and Stewardship and professor of medicine at the Georgetown University Medical Center; attending physician, MedStar Georgetown University Hospital and Washington DC VA Medical Center. He was formerly chief scientist for the Food and Drug Administration.
  • Ramanan Laxminarayan Director, Center for Disease Dynamics, Economics & Policy
  • Elizabeth Jungman Director, public health programs for Pew Charitable Trusts; she represents Pew as a member of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria
  • Lance Price Director, Antibiotic Resistance Action Center at The George Washington University

Transcript

  • 10:06:55

    MS. NIA-MALIKA HENDERSONThanks for joining us. I'm Nia-Malika Henderson of CNN sitting in for Diane Rehm. Diane will be back on Monday. Today, at the UN, world leaders will be addressing a topic of growing concern, antimicrobial resistance. To discuss the rise of superbugs and what we can do about it, I'm joined in the studio by Dr. Jesse Goodman of the Georgetown University Medical Center, Elizabeth Jungman of Pew Charitable Trusts. Joining us from New York City, Ramanan Laxminarayan of the Center of Disease Dynamics, Economics and Policy and Lance Price, director of Antibiotic Resistance Action Center at the George Washington University. Thank you all for being her with us today.

  • 10:07:40

    MS. NIA-MALIKA HENDERSONAnd we'll be taking your comments, questions throughout the hour. You can call us on 800-433-8850. Send us your email at drshow@wamu.org. Join us on Facebook or on Twitter. Ramanan, and I apologize for mispronouncing your name there. I want to start with you. Now, you're at the UN. I want you to describe for us the extent of the problem.

  • 10:08:09

    MR. RAMANAN LAXMINARAYANSure. So we've had antibiotics only for about 75 years and during that period of time, resistance has been growing slowly but surely. I'm sure a lot of your listeners have heard about resistance. But in the last 10 or 15 years, it's gotten to the point where we actually have infections that are not treatable with any available antibiotics. This is happening both in the United States and Europe, but also across the developing world and it's a matter of great seriousness.

  • 10:08:40

    MR. RAMANAN LAXMINARAYANThe people who are most at risk are newborns, you know, particularly with infections in developing countries and they don't have treatment options. And in the United States and North America, in general, the elderly who might require transplants, surgeries, all of these procedures that require effective antibiotics to ward off infection, their health is being compromised. So we are at a tipping point with respect to antimicrobial resistance.

  • 10:09:12

    MR. RAMANAN LAXMINARAYANThat's the reason why this issue is at the highest level of the global political arena today and I'm at the United Nations as a matter of fact where I’m just outside the room where the high level meeting is happening to adopt a resolution to tackle this problem at a global level.

  • 10:09:29

    HENDERSONAnd it's a complicated problem because antibiotics, of course, they save lives, but then, many still don't have access to them.

  • 10:09:36

    LAXMINARAYANThat's exactly correct. In fact, at the current time, there are probably more people around the world who are suffering because of a lack of access antibiotics. But that said, resistance itself is a barrier to access because imagine someone who's living in rural India, first time they get to use an antibiotic and guess what? They've never used an antibiotic before, but because everyone else has overused, misused antibiotics, that antibiotic no longer works for the bacteria that have learned how to become resistant.

  • 10:10:07

    LAXMINARAYANSo resistance itself is causing a lack of access. In rich countries, we can buy our way out of the problem, but in poor countries, we're really going to have a problem because people will die and are already dying because of the problem.

  • 10:10:19

    HENDERSONAnd Lance, you're also attending these meetings at the UN. Why is this a problem that needs a global solution?

  • 10:10:28

    MR. LANCE PRICEIt's a problem that needs a global solution, Nia-Malika, because it's -- these bacteria move around the world seamlessly. They've never -- bacteria have never been able to travel the world faster than they do today. They get on airplanes. They get on boats. They travel on food. They hitchhike on us and some of the worst superbugs, some of the worst drug-resistant bacteria are the kind that travel on us silently so they don't initially cause any symptoms.

  • 10:10:55

    MR. LANCE PRICEWe can carry them for days to even years before they cause an infection that's untreatable. And in the meantime, we can be sharing those with people. We can share them with, you know, our sick friends, our people whose immune systems are not as strong as ours and they can succumb to these drug resistant infections. So the drug resistant bacteria that evolves in one country because of the abuse of antibiotics or overuse of antibiotics, say, in livestock, can spread from animals to people and then from person to person and travel outside of that country and around the world.

  • 10:11:31

    HENDERSONAnd Dr. Goodman, I want to turn to you on this. What exactly is a superbug?

  • 10:11:36

    DR. JESSE GOODMANWell, I don't think anybody has a perfect definition for that, but it's a term that's really captured the imagination. And I think when we talk about it, we're talking about a bacteria that has genes and functions in a way to allow it to resist the effect, typically, of multiple antibiotics. And often, what we're calling superbugs are bacteria where there's only just one antibiotic left to treat it or even potentially we lose that antibiotic. It learns to become resistant to that and then we have something that, as was mentioned, may be not treatable with any available antibiotics.

  • 10:12:11

    DR. JESSE GOODMANAnd a big one we worry about now is what's called CRE. It's a long-term, it's carbapenem-resistant Enterobacteriaceae. These are resistant to what has been one of our most powerful classes of antibiotics, the carbapenems, and what's of tremendous concern in the last year is that we're now seeing spread of resistance genes which allow the bacteria to become competent to resist it, to what had been the antibiotic of last resort for treating CRE, an antibiotic called Colistin.

  • 10:12:47

    DR. JESSE GOODMANAnd that's really a place that ties this issue of animal antibiotic misuse to human health because it appears that the use of colistin in agriculture, particularly in Asia, has selected out resistance genes that have then spread around the world.

  • 10:13:05

    HENDERSONAnd Elizabeth Jungman, why the persistent overuse of antibiotics and the rise in resistance?

  • 10:13:16

    MS. ELIZABETH JUNGMANSo we've really begun to understand the effect of overprescribing of antibiotics on resistance and so, you know, if you keep antibiotic use stable over time, you're going to expect to see resistance develop. So it's really -- there's kind of an arms race, you can think of it that way, between the antibiotics that we're using to treat bacteria and the bacteria that they're designed to kill. And, you know, over time, those bacteria will develop resistance. And so you do see, you know, significant overuse in a number of settings.

  • 10:13:45

    MS. ELIZABETH JUNGMANSo you see it in human healthcare. You see it both in hospitals and in outpatient facilities. You also see it agricultural settings. And it's really important to control our use in all of those areas.

  • 10:13:54

    HENDERSONAnd Ramanan, how does this compare, what Elizabeth describes, how does that compare to what we see around the world, the developed world versus the developing world?

  • 10:14:07

    LAXMINARAYANRight. So we are seeing the spread the resistance, as Lance said, around the world. Notably, about six years ago, we had an emergence of a new strain called New Delhi Metallo-beta-lactamase. Now, the key words are New Delhi because -- and that bug was named that because it was first found in a patient who was believed to have been from New Delhi. That bug, which confers resistance to carbapenems, which is a very powerful class of antibiotics, is now in over 120 countries, including in many U.S. facilities.

  • 10:14:39

    LAXMINARAYANThis is just in the space of five or six and that's the speed at which these bugs spread. Now, the problem in the developing world is different also because when first line drugs fail, most of the folks living there who might be below the poverty line or generally don't have access to drugs can't afford second line drugs. So they pay with their lives. We're in a slightly better position in the United States where we can afford the second, third and the last line, last resort antibiotics.

  • 10:15:08

    LAXMINARAYANSo we might pay through higher healthcare costs and indeed, today, the antibiotics that you would get in a hospital are, you know, might cost hundreds maybe even thousands of dollars compared the cost of penicillin, which is, you know, a few cents a dose, which still works sometimes, but that is the escalation in the cost of dealing with infections. And you can think of antibiotics as sort of this global resource. Any of us can tap into the resource and we, you know, we might overuse it, but the consequence is then that there's less of that resource available to everyone else to use and we're slowly running out of this very precious resource.

  • 10:15:46

    HENDERSONAnd Dr. Goodman, I mean, is there any good news in terms of successes, in terms of changing practices in terms of the approach?

  • 10:15:55

    GOODMANWell, I think there is good news. In the, you know, the 20 years or so since I first worked on trying to attract attention to this issue and work within health systems to improve how antibiotics are used, there has been a revolution, in the last three or four years, of awareness and I think largely triggered by this "superbug" issue and the fear that there could be untreatable infections or health systems could fail, the recognition that it's a global problem, et cetera.

  • 10:16:24

    GOODMANSo we are seeing some positive signs. However, as CDC recently reported, even in the United States, antibiotic use in hospitals is not increasing so that's good news. However, we know that resistance and use of more advanced drugs, these more expensive broader spectrum drugs, has increased. So to keep pace with the situation, we keep -- even where we're not increasing antibiotic use, we're using more complex antibiotics.

  • 10:16:55

    GOODMANThe other thing that has gone on is, for example, most -- for our listeners, you know, colds, the flu don't respond to antibiotics. They don't need them. You shouldn't ask your doctor for them. Your doctor shouldn't give them to you for that. But what we're seeing is that in some areas where most of the problems are viral infections, like ear infections or otitis in children in the United States, that people are getting the message and parents are learning and pediatricians and other physicians are learning that not all of these children need antibiotics.

  • 10:17:25

    GOODMANSo we are seeing some improvements, but not of the degree needed to really slow this problem down.

  • 10:17:33

    HENDERSONComing up, more of our conversation on superbugs.

  • 10:20:02

    HENDERSONWelcome back. I'm Nia-Malika Henderson with CNN, sitting in for Diane Rehm. I'm joined today by Dr. Jesse Goodman, Elizabeth Jungman, Ramanan Laxminarayan and Lance Price. The topic is super-bugs. Elizabeth, I want to go to you on this. We were trying to talk about good news on this front, and you want to talk about policy changes.

  • 10:20:22

    JUNGMANSure, there's been some good news on the policy front, as well. As Jesse mentioned, there's been a lot of attention to this issue in the last, you know, two or three years, and that has translated into some positive policy change. So the Centers for Disease Control has put out guidance for hospitals and for long-term care facilities about what a good stewardship program looks like, so as folks really try to implement change, they've got some -- they've got some guidance to rely on.

  • 10:20:47

    JUNGMANThe Centers for -- the agency that covers the Medicare and Medicaid program, that runs the Medicare and Medicaid program, has put out a proposed rule that will require hospitals that want to participate in the Medicare program, which is pretty much everybody, to develop stewardship programs to be able to do that. So your Medicare dollars will then depend on your being able to develop a stewardship program.

  • 10:21:05

    JUNGMANAnd on the agricultural side, the Food and Drug Administration will have implemented a policy by the end of this year that will phase out the use of antibiotics for growth promotion, so that's when you're just using antibiotics to make animals grow faster or to gain more weight. So those uses will be phased out by the end of this year. So there have been some positive developments on the policy front, but of course more is needed.

  • 10:21:29

    HENDERSONAnd Lance, I wonder if you can pick up where Elizabeth is talking about the antibiotic use in farm animals. Why is this such an important part of this conversation? I think it might be a surprise to some people that they're being used in animals to promote growth.

  • 10:21:45

    PRICEWell first of all, it's the single greatest use of antibiotics globally, and that's true in the United States, as well. It's estimated that maybe as much as 80 percent of the antibiotics in the United States are being used for animal production. And, you know, and this new FDA rule is promising, but it's -- it's a baby step when we should be running towards our goal here. What's still allowed is for food animal producers to give animals antibiotics just to prevent diseases that are occurring because of the way we're raising them.

  • 10:22:16

    PRICESo in other words we're making animals sick by the way we're raising them, and then we're giving them antibiotics to try to treat those infections or prevent those infections. And so -- and what that does is that gives this fuel for these drug-resistant bacteria to grow in those animals, and then those bacteria can spread to us either through direct exposure to those animals through the environment or now through the food, as well.

  • 10:22:41

    PRICEAnd so -- and that's the problem. And what we see is that the BRICS nations, Brazil, Russia, India, China, South Africa, those countries that are developing very quickly, and as they develop, they're demanding more and more meat, they're also adopting our methods of industrial animal production and integrating these antibiotics to their feed.

  • 10:23:01

    PRICEAnd just last November we saw this first report of a new resistance gene that can jump from bacteria to bacteria, that codes for resistance to our last drug for treating these CREs that were mentioned earlier, this really important class of super-bugs. We have one drug left to treat them, and it turns out that the Chinese livestock producers were using that drug to, as the United States does, to promote growth of antibiotic, so promote growth of these animals, and then that led to the evolution of this new resistance gene that has now spread globally.

  • 10:23:37

    HENDERSONAnd Lance, you've got a paper that I think is coming out today about MRSA and how that can be food borne.

  • 10:23:44

    PRICEYeah, so this is -- this I think is really important because it underscores that what is true yesterday or was true yesterday may not be true tomorrow because these bacteria are continually evolving. So early on, when we first discovered livestock-associated MRSA, it seemed that the only people who were really at risk were the people that were directly exposed to the livestock animals themselves, so livestock producers, farmers, veterinarians and their families. So we see that direct spillover into the community. And it really is a threat to them, and we should care about them, as well.

  • 10:24:25

    PRICEBut we didn't see evidence of food borne transmission of this bacterium, but now we see that it's changed, it's evolved just slightly, and it appears to be -- it appears to have become better adapted to colonizing people. And those are the ones that we see clear evidence of food borne transmission with.

  • 10:24:45

    HENDERSONAnd Ramanan, what would you actually hope to see globally in regards to antibiotics -- antibiotics in livestock? We've talked here about how there are some new restrictions here in the U.S. in terms of giving antibiotics in terms of promoting growth. What would you like to see globally?

  • 10:25:03

    LAXMINARAYANSo the U.S. has only recently recognized that this is a problem that's worthy of broader attention. For many years, there was really no action on this. But consumer preferences have changed. I think many of your listeners now know that there is such a thing as antibiotic-free meat, ergo there must be meat in all the other -- antibiotics in all of the other meat, which means that, you know, the large fast food chains, everyone, is moving to -- to trying to source meat that is free of antibiotics.

  • 10:25:35

    LAXMINARAYANSo that pressure, which is now in the United States, that needs to translate into consumer education and that same pressure around the world. We can't mandate from the top up. It really is going to come through awareness that this is not a good way to raise meat around the world.

  • 10:25:48

    LAXMINARAYANAnother point I'd like to make here related to this is that all of these antibiotics that we're ingesting, and we're putting into -- into our animals, it's probably about 150,000 tons of it every year, it's all going out into the environment, which means that we are changing the microbial world in fundamental ways that we cannot even begin to understand.

  • 10:26:11

    LAXMINARAYANWe've got to remember that there are far more microbes in the world than there are humans. In fact, there are 10 bacteria for every human cell, even inside our own body. We live in a microbial world, and this is planetary change at a grand scale, and this can't continue because we're essentially disadvantaging ourselves with respect to the bacteria.

  • 10:26:32

    LAXMINARAYANSo I would hope that all sub-therapeutic use of antibiotics is phased out across the world in five to 10 years. We call for that in a science editorial about a month ago. We think that countries that know how to do this, particularly in Europe, now increasingly in the United States, have a responsibility to help these producers and countries in, you know, Brazil, Russia, India, China, South Africa, to figure out how to raise meat without antibiotics.

  • 10:27:04

    LAXMINARAYANI think everyone's well-being is at stake, and we really need to share knowledge and expertise on how to do this.

  • 10:27:09

    HENDERSONElizabeth, you want to jump in?

  • 10:27:09

    JUNGMANSure, so Ramanan's actually absolutely right about needing to phase out unnecessary uses of antibiotics in animals, and I think that both that and Lance's study point out just another aspect of this, which is that we really don't know a lot about what's happening in animal agriculture. We have a lot of data about how antibiotics are being used in human health care settings. Every time an outpatient physician writes a prescription, we know that they wrote a prescription for that antibiotic.

  • 10:27:36

    JUNGMANWe have data systems that can track antibiotic use in hospitals, but we don't have that same level of surveillance in animal agriculture. And so, you know, as we -- as we see these emerging pathogens like Lance is describing, and Pew also just recently put out a report about emerging pathogens in animals, we really need to make sure that we've got good surveillance systems so that we can detect that as emerging, and we need to make sure that we've got the right capacity in state and local laboratories to be able to act quickly when those -- those emerge.

  • 10:28:05

    HENDERSONDoctor?

  • 10:28:07

    GOODMANYou know, one thing I'd like to add that I think we can do, while totally agreeing with this transition in agriculture for multiple reasons to reduce antibiotic use, you know, improve animal welfare, reduce risk to humans, I would like to point out that there is something different about Colistin, which both Lance and I talked about. This antibiotic, you know, when we treat patients at my university hospital, at other hospitals, with very serious, life-threatening infections or newborns throughout the world who might have CRE, we need this antibiotic.

  • 10:28:39

    GOODMANIt is being used in animal husbandry now, I do not believe in the U.S., but I believe...

  • 10:28:43

    LAXMINARAYANNot in the U.S.

  • 10:28:44

    GOODMANBut I believe that this should be globally banned immediately. I think that is something, if the U.N. and others want to take it up, that could be done. If -- if we keep exerting more pressure to select bacteria resistant to that antibiotic, you know, we have a big -- very big short-term problem.

  • 10:29:04

    GOODMANThe one other point I wanted to make is this isn't just a problem in hospitals, and it's abstract for -- should be abstract for people because they're going around healthy, thinking it doesn't affect them. Right now we have gonorrhea throughout the world that is increasingly drug-resistant. In this country now, when we treat gonorrhea, we have to treat with an injection and an oral antibiotic. That's just a really abysmal situation, and we face the prospect of a common, community-spread sexual transmitted disease becoming extremely antibiotic-resistant and difficult to treat.

  • 10:29:37

    HENDERSONAnd what about the development of new antibiotics, Elizabeth?

  • 10:29:42

    JUNGMANThat's exactly where I was hoping to go because there are actually only three drugs in the pipeline right now that would treat drug-resistant gonorrhea, and given that about one out of five drugs, at best, that make it into clinical development will actually get onto the market, that's a really disturbing statistic.

  • 10:29:56

    HENDERSONAnd why so few in terms of the development of new antibiotics?

  • 10:30:02

    JUNGMANThere are a lot of challenges to antibiotic drug development. There are a number of scientific challenges, so, you know, the low-hanging fruit has been picked. And so we really -- we are -- right now all of the antibiotics that we are using are variations on antibiotics that were discovered 1984 or earlier, so the mid-'80s or earlier. So we really haven't seen, you know, truly novel antibiotics in a very long time.

  • 10:30:23

    JUNGMANThere are some real scientific challenges to that. There are also, you know, there are some regulatory barriers, so there's some room for Congress to be helpful there. And then there's also economic challenges with encouraging pharmaceutical companies to engage in this.

  • 10:30:38

    HENDERSONTo develop. We've got an email from Dan in Arlington, Texas. He's an emergency room physician. He says he sees examples of antibiotic misuse daily. Physicians know not to prescribe antibiotics for viral infections, but patients demand them, and physician pay and employment is now linked closely to patient satisfaction surveys. If a physician does the wrong thing and prescribes improperly, she is rewarded with higher pay and continued employment. If a physician does the right thing, she gets less money and may get fired. This -- there's no incentive to prescribe properly. Dr. Goodman, do you want to talk about that a bit?

  • 10:31:16

    GOODMANWell, I think, you know, it's critical to hear the views of people like Dan who are on the ground dealing with this issue day in, day out. I deal with it in my clinics, too. That is true, there should -- you know, there are problems. When physicians are ranked in certain ways, and those measurements are inexact or sort of global, there can be tremendous problems. So we need to also look at the -- for example if you're going to look at patient satisfaction as one measure, you should also look at whether antibiotics are being prescribed inappropriately as another measure.

  • 10:31:50

    GOODMANYou know, patient satisfaction is important. The other thing is patients and the public, and that's why your show is so important here and all this consciousness-raising. They need to view this differently and realize, as Elizabeth said, that when you get an antibiotic, it's not harmless. It changes the world inside your body. It changes those bacteria. It can cause allergies. It can cause C. diff., an intestinal infection that can be serious.

  • 10:32:14

    GOODMANSo it's not free to use antibiotics, and we should only use them when we need them, and patients need to become more attuned to their health providers, could be a nurse, could be a physician, explaining to them why if they don't need it, they don't. So I totally agree with that comment.

  • 10:32:33

    HENDERSONI'm Nia-Malika Henderson with CNN. You're listening to the Diane Rehm Show. If you'd like to join us, call 1-800-433-8850, or send an email to drshow@wamu.org. And you can also find us on Facebook or send us a tweet. I want to go to a call now, and this is about C. diff., and it's Elsa from Grand Rapids, Michigan. Elsa from Grand Rapids, Michigan, you're on the air.

  • 10:33:05

    ELSAHi there.

  • 10:33:06

    HENDERSONAnd your question?

  • 10:33:09

    ELSAI just have a story to tell. Six months ago to the day, I went in for a scheduled C-section. I got antibiotics, you know, for the surgery, nine hours later went in for internal bleeding, got another round of antibiotics. During my pregnancy I had a sinus infection and was antibiotics. I'm 37, healthy. Two days later, went home, came back with fever. They were puzzled. They couldn't believe it. They said maybe it was the perfect storm of being immunocompromised during pregnancy, three rounds of antibiotics, and that was it.

  • 10:33:41

    ELSAUnfortunately I didn't respond to the standard (unintelligible) the other one starts with a V.

  • 10:33:48

    GOODMANVancomycin.

  • 10:33:49

    ELSASo I kept trying to go home because I had my babies there, and I kept coming back. Finally after transfusions and all sorts of things, severe colitis, my stomach severely swollen and painful and lots of incontinence, you're constantly very, very sick, they put me on a PICC line, and I got all my nutrients that way and finally got better. I was in the hospital on and off for a month.

  • 10:34:14

    HENDERSONDr. Goodman?

  • 10:34:18

    GOODMANWell, you've describe a story, which I think all our listeners need to pay attention to, which again reinforces what I just said, that, you know, while antibiotics are often lifesaving drugs, and many people in the world don't get them when they need them, even when you need them they can cause side effects and certainly again when you don't need them. The issue here with C. diff. is -- raises a lot of very interesting questions. There are some patients, C. diff. can be quite severe, you can get it after almost minimal antibiotic exposure. It's more typical after more prolonged.

  • 10:34:53

    GOODMANAnd sometimes the standard treatments, which are antibiotics that kill this bacteria, C. diff., and C. diff. overgrows, it's usually there in small amounts, and then it grows like crazy when antibiotics inhibit your normal bacteria and makes you sick, this is an area that's brought up a whole other area of science called the microbiome, and there is actually a new treatment for C. diff., which is to restore your healthy bacteria to your intestines.

  • 10:35:19

    GOODMANAnd this can be done in a variety of ways. People have heard of fecal transplants, which sounds kind of gross, but essentially that's the most primitive, simple form. You take the bacteria from a healthy person's intestines, and you essentially give it to a person with C. diff. It's highly effective, and now numerous scientists and companies are developing things like pill forms of normal flora.

  • 10:35:44

    GOODMANSo a whole new area of preventing and treating infectious diseases is to restore your body's normal flora, get rid of those drug-resistant and nasty bugs, and I think this is a very promising area of treatment and prevention.

  • 10:35:57

    HENDERSONAnd what do you think? I mean, Elsa went in, she had a C-section, a lot of women get C-sections. In terms of a person going into a hospital, what sort of information or questions should they be armed with when they're going in?

  • 10:36:12

    GOODMANWell, I think this isn't just -- it's a great question, and it's not just important with respect to antibiotics but all of health care and patient safety. And I would view antibiotics as a patient safety issue. You know, when you need them, they're great, and you should get them. When you don't, they're potentially harmful.

  • 10:36:26

    GOODMANSo I think with respect to her always asking why you're getting a treatment, if you really need it, is part of what you can do as a patient. We do know that preventive antibiotics for surgery can save lives and reduce infections. But we also know that you only have to give them for 24 hours or so around the time of surgery.

  • 10:36:47

    GOODMANSo one of the quality measures that we and others try to encourage in surgery is to just be sure those are very brief courses. Now it sounds like her situation was complex. She may have needed additional antibiotics. Her treatment may have been totally appropriate, and she just was one of those unfortunate people who got bad C. diff. As I mentioned, luckily if it doesn't respond to antibiotics, we now have additional treatments.

  • 10:37:14

    HENDERSONComing up, your calls and questions. Please stay tuned.

  • 10:40:01

    HENDERSONWelcome back. I'm Nia-Malika Henderson with CNN, sitting in for Diane Rehm. Joining me today, Dr. Jesse Goodman, Elizabeth Jungman, Ramanan Laxminarayan, and Lance Price. Elizabeth, I want to go to you on this. We were talking about Elsa's case in Grand Rapids, Michigan. She went in, she had a C-section. She had to get antibiotics to get a C-section. Talk about the fact that a lot of these procedures that you would have to do if you go into the hospital, you have to get antibiotics.

  • 10:40:33

    JUNGMANThat's really important to understand. The advent of antibiotics has transformed medical care and there are a lot of procedures that we take for granted today, like the C-section, like cancer chemotherapy, minor surgeries that wouldn't be possible if we couldn't control infection through antibiotics. So, the risk of resistance is not just the risk of getting ill or dying from a bacterial infection, but it also really changes the way we'd have to think about Medicare -- medical care if we didn't have antibiotics.

  • 10:41:01

    HENDERSONDr. Goodman.

  • 10:41:01

    GOODMANYeah, totally agree. This is a key tool we rely on for modern medicine. Transplantation, cancer chemotherapy, et cetera. And certainly, you know, throughout the world for safe trial birth, pre-term kids. Treatment of pneumonia, et cetera. We need these drugs. I would point out another way to protect antibiotics and reduce their use is through prevention. Using vaccines that can prevent diseases that otherwise would be treated with antibiotics. We now have wonderful vaccines against pneumonia and meningitis and we need to be sure everyone in the world has access to those.

  • 10:41:37

    GOODMANAnd that people with access use them. Also, what we call infection control. You know, we, you know hear very much during flu season emphasize wash your hands. Avoid spreading flu, cover your cough, avoid spreading it around the community. But in hospitals and health care facilities, hand washing, careful environmental cleaning, it's amazing how difficult this is to ensure in the healthcare environment. But this is a very simple, cheap way to prevent spread of infections and protect patients.

  • 10:42:08

    GOODMANAnd in much of the world, there problems, even having access to things like soap and disinfectants.

  • 10:42:14

    HENDERSONThe hand gel that everybody uses here.

  • 10:42:15

    GOODMANYeah, so, you know, that's an area we can go without lots of fancy new antibiotics is to improve infection control globally. We need those new antibiotics, but we also need to apply the things we know work now. And that everyone should have access to.

  • 10:42:30

    HENDERSONWe've got an email from Mary Joe. She asks, is there any possibility of fighting antibiotic resistant infections with immunotherapy similar to the way it is used to fight cancer. Lance, I wonder if you could address that?

  • 10:42:47

    PRICEWell, I mean, I think you can -- there's things called vaccines, right? So, we've known about these for a long time and unfortunately, there was this sort of, hopefully, a temporarily wave against them. But there, you're actually stimulating the immune system to produce antibodies that would prevent you from becoming infected with specific bacteria. I mean, that's, that's the ideal situation, right? Preventing it rather than having to treat it. But there's a lot of other new therapeutics and we already talked about -- or, or potential therapeutics.

  • 10:43:19

    PRICEWe can use bacteria, good bacteria to fight bad bacteria. So pro-biotics, I think, were just at the front edge of a new pro-biotic era with the human micro-biome research that's going on. We're learning what are good bacteria, what are bad and then how to make them -- how to, how to manipulate the good ones to fight the bad. We can use these viruses that infect bacteria. There's lots of different things we can try. But if you don't mind, I'd like to come back to this issue of Colistin because I think it's such an important example.

  • 10:43:55

    PRICEColistin, you know, the fact that we are so desperate to use Colistin as a sign of this horrible situation. Colistin is a toxic drug. It's bad for the patient, but we are -- it's toxic to the kidneys and to the neurologic system. And, but we're so desperate we're willing to accept that collateral damage to save the patient. And so, I think, you know, when I hear people calling for a global ban on Colistin, I agree, but I think that that's still a little too limited. We need to have a systematic global change on how antibiotics are used in livestock production.

  • 10:44:35

    PRICEAnd we need better leadership from the FDA, I'd say. We need -- we need the FDA to come out and ban the sub-therapeutic use of all important antibiotics in human medicine and animals.

  • 10:44:49

    HENDERSONWe've got an email from Sue. She says she uses the natural antibacterial wipes from the health food store to clean her kitchen and bathroom. She wants to know if she should stop using that. And if so, what should she use instead?

  • 10:45:06

    GOODMANWell, it's, you know, it's hard to know, without knowing exactly what's in them. I think there's never been anything proven to be better than good strong soap and water for cleaning up. And, you know, I think beyond that, personal preference as to what that product is is reasonable. What we do know is that some of these products, which are said to contain anti-bacterials, you know, many of them were recently taken off the market by FDA because of two concerns. One is they don't work any better than the normal soap and water.

  • 10:45:39

    GOODMANAnd the other is possible toxicity to people. And then, finally, the issue of possibly selecting resistant organisms. So, I would focus on soap and water. The alcohol-based hand washes are also probably both safe and effective generally, though not for (word?)

  • 10:45:59

    HENDERSONElizabeth.

  • 10:46:00

    JUNGMANI don't really have a lot to add to that.

  • 10:46:02

    HENDERSONRight.

  • 10:46:03

    JUNGMANI think, you know, you...

  • 10:46:04

    HENDERSONIn this -- I'm going to go to this caller. Spencer. Spencer from Oklahoma City, Oklahoma. You are on the air with Diane Rehm.

  • 10:46:14

    SPENCERHi, yes, hi yes, my question -- I'm a big fan of the show, is just -- I think it was just covered, but I was curious about if we could still use this biological vector we're starting to see in modern cancer treatments to kind of attack these superbugs along that axis. Or if there are any other, aside from of course the (unintelligible) that your panel already talked about. Any other ways that we can use to, at least slow these resistances that are starting to show up.

  • 10:46:37

    HENDERSONDr. Goodman.

  • 10:46:38

    GOODMANYeah, it's, it's a great question. As Dr. Price said, the main immune therapy we have against bacteria are vaccines. Okay, which generate, can generate an effective immune response. But that doesn't mean we completely understand the immune response to all organisms. For example, we don't mount a very effective immune response to tuberculosis. Which is why it's such a challenge to treat. So, in areas like that, there's room for improved understanding of the immune system and can we make the human immune system work better?

  • 10:47:09

    GOODMANBut the cancer analogy is not exact, because the defect in cancer is somewhat different than the defect in infectious disease. The other thing Dr. Price mentioned, viruses to fight bacteria, is a fascinating area. There are these viruses called bacteriophages. They recognize a signal kind of bacteria, and basically, lice it. There are a lot of complex issues around using these, but 50 years ago, they were in very common use. 60 years ago in Europe and in Russia. And they probably can have some clinical utility and the European Union is sponsoring one such study of those products now and several small biotech companies are looking at them.

  • 10:47:52

    HENDERSONWe're going to go to Laura, who's in Claremore, Oklahoma. Laura, you are on the air with the Diane Rehm Show.

  • 10:48:01

    LAURAHi, thank you for taking my call. Kind of a question, comment. My husband is a large animal veterinarian of almost 50 years. And during that time, we moved from an eastern area to the mid-west here. And were shocked when we saw producers have access to antibiotics over the counter. And in more recent years, online, so the problem being also the traveling drug salesman who provide them with that. None of it's under veterinary care. The animals are given large amounts of antibiotics or undertreated for days and amount.

  • 10:48:47

    LAURAAnd either way, they end up in the food chain. If you have a sick cow, she's taken to the sale and dumped. So, my question is, that seems to me a very large piece of the problem that I'm not hearing discussed. This online and over the counter access and traveling drug sales people.

  • 10:49:07

    HENDERSONGreat question, Laura. Who wants to take that? Elizabeth?

  • 10:49:10

    JUNGMANSure, I'm happy to take that on. So, you know, I think you're going to see that there are some producers who've really made great strides in this area and are really getting it right. There's a lot more to be done. There have been recent rule changes that do bring most antibiotic use under veterinary supervision. And so, that is certainly a step in the right direction. But one thing that, you know, I think is important is for -- you know, we as consumers can be looking out for those products that make responsible use of antibiotics.

  • 10:49:41

    JUNGMANThat doesn't necessarily mean no use. But that means encouraging producers to develop products, creating a market demand for products that, you know, use antibiotics only when they're necessary for legitimate prevention purposes and for treatment of sick animals.

  • 10:49:57

    HENDERSONI think which goes to -- we've got an email from Bill. He says, should antibiotics be the standard of care for all bacterial infections? He's heard that some countries do not automatically treat strep throat, as an example, with antibiotics. And this sounds like what you're suggesting for treating animals, even. Not necessarily going to the antibiotic.

  • 10:50:20

    GOODMANWell, that's, you know, I think one of the things we face in clinical medicine is that, you know, as we've heard, you have a normal microbiome. You have bacteria living on your skin and inside your body all the time without causing problems. But -- and those kinds of things are not infections and shouldn't be treated. Okay. But strep throat, you know, if it's a certain kind of strep, is a serious infection. It can be associated, untreated, with rheumatic fever, which in much of the world, is a major cause of heart disease. And require valvular -- valve replacements and surgery which many people don't have access to.

  • 10:50:59

    GOODMANSo this is a case where that is an infection which actually does need treatment. Now, it doesn't need treatment with complicated antibiotics. It can be treated with penicillin.

  • 10:51:09

    HENDERSONElizabeth, you want to jump in?

  • 10:51:11

    JUNGMANSure, so the Center for Disease Control and Pugh recently partnered on some work that's relevant here. Where we took a look at antibiotic prescribing from doctors' offices and really tried to understand, what are physicians prescribing antibiotics for? And we learned from that work that one out of every three prescriptions in doctors' office is an inappropriate or unnecessary use of an antibiotic. And really got some detail about what was driving that. A lot of that is these upper respiratory infections, so about 44 percent of the antibiotics prescribed are for those types of infections.

  • 10:51:42

    JUNGMANAnd about half of those are unnecessary. So, you know, as Jesse mentioned, there are, certainly, there are absolutely legitimate uses of antibiotics for upper respiratory illnesses. But there's a lot of misuse going on there too.

  • 10:51:54

    HENDERSONI'm Nia-Malika Henderson with CNN. You're listening to the Diane Rehm Show. And I want to take it back to what's going on today at the U.N. and ask you, Ramanan, what could come out of this UN meeting today?

  • 10:52:13

    LAXMINARAYANSo, the UN meeting does a few things. First, it signals at a very high level that this is important, important for all countries. I suspect that for many Presidents and Prime Ministers, this is the first time they're going to be really hearing about antibiotic resistance as serious problem. And will probably focus their attention on this when they go back. The second is that countries are going to have to commit to doing very specific actions. That's what the resolution calls for. It means reducing inappropriate use of antibiotics in humans and animals.

  • 10:52:45

    LAXMINARAYANIt means, you know, making sure that public health vaccines, infection control are strengthened. It means investing in new tools, diagnostics and vaccines and alternatives to antibiotics as well. Now, all of these are just words at the end of the day. And UN resolutions, you know, there are plenty of these, and, you know, many of these don't necessarily follow up into action. It is now incumbent upon, you know, all of us who are interested in this issue and know that it's a serious challenge to use this as the first step and as a vehicle for moving this forward.

  • 10:53:19

    LAXMINARAYANI think we're only scratching the surface, even now with the serious problem that we have, of what could potentially happen with drug resistance. You know, fortunately, many of the antibiotics that we have, we have 200 or so antibiotics, they still work. But they, you know, obviously, that effectiveness is going down every day over time. And it's important for the world to act together. A single country misusing antibiotics at a large scale can create resistant pathogens that could be a problem for everyone else, even if they have not created that resistant pathogen.

  • 10:53:51

    LAXMINARAYANSo, in a sense, this is like climate change. We're all in it together and, you know, at the UN, there are no do-overs. So, if we lose this opportunity, at this stage, to take this resolution and make sure that countries are taking action, including here in the United States, I think we would have really missed an opportunity and we would be denying our children, our grandchildren of this valuable medical drug that frankly people don't realize, we've only had antibiotics for about 70 years.

  • 10:54:21

    LAXMINARAYANSo, you know, our parents' generation or our generations might be the only ones to have lived fully in the era of antibiotics. And that's what we're trying to protect.

  • 10:54:30

    HENDERSONRamanan, I wonder, is there a global leader, kind of a model country in terms of how they're dealing with this issue? Or is everybody playing catch up?

  • 10:54:39

    LAXMINARAYANWell, countries in Scandinavia, Norway, Sweden, the Netherlands, they have, they have very good models for first, you know, when someone shows up at a doctor's office, not giving them an antibiotic right away. Saying, wait for a few days. Making sure that people who come into hospitals are checked for resistant pathogens before they're allowed into the facilities. There are models, but the problem is that these models are at very small scale. I mean, these countries are all, you know, in fact, most of them are smaller than the city of New York.

  • 10:55:10

    LAXMINARAYANAnd how we translate what they're able to do with two dozen facilities into the United States, for instance, where we have more than 6,000 facilities, is really a challenge. Health systems are very different in different countries. You know, it's easier to do in a system where there's command and control. There's a single person who operates the entire health system and they get to dictate what actually happens with the respect infection control. We don't have that here. We don't have that in many other countries.

  • 10:55:39

    LAXMINARAYANAnd we have to -- we have to encourage, cajole, we have to move people along to recognize that infection control is important, that reducing antimicrobial use is important. And on the animal side, again, the capacities are vastly varying. You know, even in the US, some manufacturers now have the capacity to raise meat without antibiotics. Many others don't, and certainly, that capacity doesn't exist across, you know, much of the developing world. So because the abilities are so different across countries, a single model in a single country does not apply everywhere. And although it's a global problem, the solutions have to be local.

  • 10:56:21

    HENDERSONOkay, and Elizabeth, what should we be looking for? I mean, is there news that you're expecting out of the UN? Or is there news that you're expecting out of the FDA or anything like that in the coming months or years even?

  • 10:56:34

    JUNGMANCertainly follow up is what it's all about here.

  • 10:56:36

    HENDERSONYeah.

  • 10:56:37

    JUNGMANSo the UN resolution is only going to be as valuable as the follow up, but as Ramanan points out, this is a real opportunity for public health leaders across the world and here in the US to take this and really make it actionable moving forward. And this is the kind of high level commitment that can give public health leaders the kind of encouragement they need to, to, you know, make this a priority issue.

  • 10:57:01

    HENDERSONDr. Goodman.

  • 10:57:01

    GOODMANYeah, and I would just add that this awareness of leadership is tremendous, but we can also all act locally. We're bringing together doctors and providers around here to do a better job of how we prescribe. Listeners can change their ideas about demanding antibiotics. And as one of the other speakers said, it was consumer demand for meat raised by antibiotics that largely has pushed this. So, not only us as leaders, but all of you as people out there can help solve this problem.

  • 10:57:30

    HENDERSONThank you so much, Dr. Goodman. I'm Nia-Malika Henderson with CNN, sitting in for Diane Rehm. Thanks to our guests, Dr. Goodman, Elizabeth Jungman, Ramanan Laxminarayan and Lance Price. Thanks so much for listening.

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