We are on the cusp of a dire era in human medicine — a time when antibiotics are ineffective against many bacterial infections. It’s hard to imagine a world where we can no longer count on antibiotics to cure even common infections, but that’s where we are headed if we don’t dramatically change our course. And that’s why two of the world’s premiere health organizations, the U.S. Centers for the Disease Control and Prevention and the World Health Organization, are focused on educating health workers, the agricultural sector, policy makers and everyday citizens on the dangers of antibiotic resistance through Antibiotics Awareness Week campaigns in mid-November.
In some ways, the post-antibiotic era has already arrived. In late 2015, we witnessed the alarming discovery of mcr-1, a gene that can jump between bacteria and make them resistant to colistin -- a drug that has become our last hope for treating people infected with some of the most dangerous superbugs. It is believed that this resistance gene originated from the heavy use of colistin in livestock. Since its discovery, the gene and its derivatives have been found in people and animals around the world. Then in early 2017, a woman in Nevada died of an infection that resisted every antibiotic that doctors used to treat her. Testing later showed that her infection had been resistant to 26 different antibiotics -- a truly post-antibiotic infection.
These stories received strong media attention, but as with so many crises, once it left the news cycle, most of us assumed that the problem had been contained. That’s far from the truth. In reality, cases like these are becoming increasingly common, and there are very few new antibiotics in the development pipeline that can rescue us from broadly resistant bacteria. But new drugs are not the only solution to the superbug problem. Like climate change, there are no silver bullets, but there many strategies that, if used together, can help us avert this public health disaster.
Among the most promising tools in the global fight against antibiotic resistance are diagnostic tests. These tests can help healthcare professionals figure out exactly what they are treating, before they write a prescription. Is it a viral infection (against which antibiotics are powerless) or is it bacterial? If it’s bacterial, which antibiotics will work best? Diagnostic tests can help clinicians answer questions like these and eliminate a lot of guesswork and a lot of unnecessary antibiotic prescriptions.
Today antibiotics are rarely prescribed based on a definitive diagnosis. In many cases, clinicians prescribe antibiotics based on an immediate assessment of the patient and professional judgment (i.e., educated guess). As a result, patients frequently are given antibiotics that are unnecessary or ineffective. It has been estimated that at least 30% of antibiotics prescribed in the United States are unnecessary, and that percentage is even higher in other parts of the world. If we use rapid diagnostic tests, clinicians will be able to provide an accurate diagnosis and thereby reduce unnecessary prescriptions, improve outcomes and increase patient satisfaction.
This is why it is important that insurance companies properly reimburse the healthcare community for using diagnostic tests. These devices are integral to the long-term interest of improving patient care and helping to slow the emergence of untreatable superbugs. Unfortunately, short-term thinking and the low cost of antibiotics favors the status quo, guess-and-treat system. In the short run, it makes sense that insurers would rather pay the cheaper option. But in the long run, we all lose if this is our default option. As infections increasingly fail to respond to antibiotics, treatment gets more complicated and expensive, workdays, productivity and wages are lost, and worse, people die.
Time is not on our side. Without urgent action, it is estimated that by 2050, ten million people will die every year from drug resistant infections resulting in 2% to 3.5% reduction in the gross domestic product and up to $100 trillion in lost global economic productivity.
With Antibiotics Awareness Week (November 13-19) quickly approaching, we have to refocus and find ways to encourage the use of diagnostics in the fight against superbugs. There have been some hopeful developments with the creation of multimillion dollar prizes for new diagnostic tests, but these are not enough. Few companies will invest the money necessary to bring such tools to market if they are unsure if the tests will be used and clinicians will be reluctant to use them if insurance companies are unwilling to reimburse the costs. We have to bring together public health experts, diagnostic companies, Insurance companies, healthcare professionals and policymakers to find ways to incentivize the use of existing diagnostic tests and encourage the creation of new ones that can be used within the short span of an outpatient visit. If we’re going to avoid a world where untreatable bacterial infections are the new norm, we have to take the long view and use all the tools that we have at our disposal, including diagnostics.