Way Too Much of a Good Thing

STEVE SOLOMON, M.D., one of the federal officials leading the fight to slow the growth of bacteria that are resistant to antibiotics, is setting off alarm bells. Solomon, as director of the Office of Antimicrobial Resistance at the Centers for Disease Control and Prevention, says if we don't take certain steps to reduce the use of antibiotics, they will no longer work. Some hospitals and systems have strict antibiotic controls in place [see story, Page 50]. | Interviewed by Paul Barr

How did we get to this point?

SOLOMON: Antimicrobial resistance has been a problem since the discovery of antibiotics in the 1940s. The problem has continued to worsen. But at every step of the development of antimicrobial resistance, the development of new antibiotics has proceeded with such speed that for several decades it really wasn't something that we had to worry about. So, as resistance developed, we always were confident that there would be a new variety of antibiotic coming along that would treat these resistant strains. What's happened, in the last decade or so, is that there has been a dramatic reduction in the antibiotic development pipeline. So, as resistance has continued to develop, an inevitable process with bacteria, we now have fewer drugs to treat these resistant strains.

Why did the CDC issue a report on the subject now?

SOLOMON: In our report, we've identified three problems as being urgent. Those are carbapenum-resistant Enterobacteriaceae (CRE), cephalosporum-resistant gonorrhea and Clostridium difficile, which in itself is not a resistance problem but is a major source of illness and death, especially among hospitalized patients, and which is caused by the overuse of antibiotics and the prevention of which follows many of the same principles that we're using for antibiotic-resistance bacteria.

The timing of this report has to do with the urgency of these threats and the fact that we are right now at the last line of defense for treating these resistant bacteria. If that resistance develops, we are going to go over a cliff and fall back into the situation we were in during the pre-antibiotic era, when there were no treatments left for the very dangerous infections.

That sounds like a worst-case scenario. What is the best-case scenario?

SOLOMON: The best-case scenario is that we're successful in helping both medical professionals and consumers get on board with what we call our four core prevention strategies, our four core means of preventing antibiotic-resistance.

The first of those is to prevent infections and prevent the spread of resistance in hospitals and other health care settings. The second major way we prevent the growth of resistance is through tracking. We need to track these bacteria and the infections they cause at the local level, at the state level, regionally, nationally and internationally. The third part of the strategy for combating antimicrobial-resistance is improving antibiotic use — what many people call antibiotic stewardship. Clearly, antibiotics are overused; our information from a variety of studies is that in human medicine up to 50 percent of all antibiotic use is either unnecessary or it's prescribed in an inappropriate way. The fourth element in combating antimicrobial-resistance is the new development of antibiotics and diagnostic tests.

How do those four elements fit together?

SOLOMON: What we're hoping is that if people adopt those four strategies, there will be a dramatic reduction in the spread of antibiotic-resistance and a dramatic decrease in the number of infections they cause. If we can do the first three and slow down the incidence of infection, then the fourth one will kick in and we'll have time to develop new antibiotics and to develop those incentives.

But right now, resistance is spreading faster than our ability to develop new antibiotics. And so the best-case scenario is we have a dramatic reduction in spread, and we have the time to allow for new antibiotics to come to market.

What other organizations can get involved?

SOLOMON: You're getting right at the heart of why we've done this report. It's really to try to gain as much support as possible, from health care professionals, from organizations and from providers and provider organizations, hospitals, health systems, and everyone involved in health care, and consumers, who clearly have a role to play when they go to their doctors. In addition to giving health professionals better tools, we need to educate consumers, help them to understand that antibiotics are like any other drug.

Which departments of a hospital should be involved?

SOLOMON: Every department needs to be involved. Certainly the folks in the ward, certainly the folks in surgical areas, but everybody from central supply to laundry, top to bottom. Infection control, in general, involves everyone in every health care setting. It's everybody's job.

Are there any low-hanging fruit strategies that could have a quick effect without a lot of effort?

SOLOMON: Good hand hygiene is probably the No. 1 thing that will help in preventing the spread of all infections and all pathogens including the antimicrobial ones.

What makes the three on the urgent list different?

SOLOMON: The reason we've identified those three as urgent is because, in the case of CRE and gonorrhea, we are at the last line of defense. Already, many of the CRE are pan-resistant — they are resistant to every antibiotic that's available.

We certainly get reports from physicians with patients infected with some of these bacteria, and they have absolutely no antibiotics that will treat them. That leaves health care providers in a situation that is, in fact, comparable to the situation doctors faced before 1940 when the first antibiotics were developed.

For gonorrhea, the cephalosporins [a class of antibiotics] are the last line of defense. Gonorrhea is a disease caused by a bacterium that has had a tendency to quickly become resistant to whatever antibiotic is most commonly used against it. We're seeing the first evidence of emerging resistance to cephalosporins. If we lose the ability to treat gonorrhea with cephalosporins, that disease will spread and will cause the same sort of problems in fertility, serious infections similar to what we saw in the pre-antibiotic era.

Clostridium difficile itself is not resistant, but it causes hundreds of thousands of illnesses and more than 14,000 fatalities every year, and that's just looking at the infections that occur in hospitalized patients or that required hospitalization.

THE SOLOMON FILE

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Previous CDC experience includes as an officer in the Epidemic Intelligence Service with the Hospital Infections Program in the National Center for Infectious Diseases, and as deputy director of the Office of Healthcare Quality in the Office of the Assistant Secretary for Health in Health & Human Services.

EPIDEMIOLOGIC INSPIRATION

While an intern in a Washington, D.C., hospital, Solomon heard Stephen Thacker, M.D., a CDC official who died earlier this year, describe an effort to deal with the aftermath of a Legionnaires' disease outbreak in Philadelphia. Thacker's talk was so interesting, Solomon decided to get into epidemiology.

TIME & SPACE

Solomon recommends the movie "Gravity" starring Sandra Bullock and George Clooney. "I thought it was spectacular. One of the most amazing films I've ever seen," Solomon says. He has little time for much beyond his work at the CDC — "I'm kind of a workoholic," he admits. But he and his wife find time for their recently arrived grandchild. "It's very exciting."