Attacking on Other Fronts
Regardless of what treatments may be used once bacteria have infected people, scientists and public health officials agree that one crucial step in developing an effective offense against the microbes must be the establishment of a strong surveillance system. The system should pinpoint resistance problems early, give clues as to why they are happening, and quickly provide critical information to public health officials worldwide. But no worldwide system is in place, and surveillance in the United States is uneven and has major problems, according to public health officials themselves.
Rosamund Williams, a bacteriologist who is coordinating the new Antimicrobial Resistance Monitoring Program for the World Health Organization (WHO), spoke openly at last summer’s Institute of Medicine forum about the outcome of the current lack of such a setup. “We know that we have a big problem with resistance to antimicrobial agents, but we don’t know how big it is,” she said. WHO is therefore starting a system that will attempt to strengthen the ability of laboratories within its 191 member countries to monitor resistance problems, build national reporting operations, and provide international coordination.
Even U.S. surveillance is spotty, David Bell, assistant to the director of the CDC’s National Center for Infectious Diseases, pointed out during the meeting. The CDC has several systems that collect different information from various sources. The systems monitor hospital-acquired infections, pathogens in food, tuberculosis, sexually transmitted diseases, malaria, and others. Managed-care organizations also run private surveillance systems, while networks of universities-with funding largely from the drug industry-oversee others. “One of the problems we have,” Bell said, “is that virtually none of these systems provides anywhere close to nationwide coverage.”
There are other problems, too. “We really need to know more than which drugs are becoming resistant to which bugs,” Bell said. “We need to know who are these patients with the resistant infections, and are they randomly distributed across a population group or do they fall into certain risk groups-for example, hospital patients, or people who travel abroad, or people who use a lot of antibiotics.”
Fred Tenover, chief of the CDC’s hospital-infections laboratory branch, said the resistance problem could be much worse than is already known because not all organisms are tested for resistance and some labs rely on improper testing methods. In one case last year, he said, 30 percent of the 2,100 labs looking for resistance in Streptococcus pneumoniae used the wrong test.
Effective treatments and strong surveillance systems that spread early warnings about resistant bacteria are still only part of a solution to fight drug-resistant bacteria. Public-health officials, doctors, and members of the drug industry also agree that preventing overuse of antibiotics is critical. “The more and more we use these antibiotics, the more selection we have, and these mutants will emerge,” says Stuart Levy, president-elect of the American Society for Microbiology. “There is inadequate physician, veterinarian, farmer, and patient education,” says Mitchell L. Cohen, director of the CDC’s division of bacterial and mycotic diseases. He says doctors admit to overusing antibiotics by 15 to 20 percent.
Doctors in managed-care settings, where pressures can mount to see high numbers of patients quickly, are among those who often over-prescribe antibiotics, says S. Michael Marcy, a Kaiser Foundation staff pediatrician and pediatrics professor at the University of Southern California and University of California at Los Angeles Schools of Medicine. Patients who don’t receive an antibiotic on the first visit and are convinced they need one often return-a problem for doctors at managed-care facilities that try to reduce return visits, according to Marcy. Patient satisfaction surveys also contribute to generous prescriptions for antibiotics: “Now, up to 30 percent of our salary will be determined by our satisfaction rating,” he says. The message becomes: give patients “what they want.”
In answer to the criticism of antibiotic overuse, some professional medical and scientific organizations have begun distributing brochures for patients and doctors on the proper use of antibiotics. “It would be much more powerful and effective,” urges Frederick Sparling, chair of the department of medicine at the University of North Carolina and president of the Infectious Diseases Society of America, if major professional organizations would all get behind one set of guidelines.
In the end, so many players exist in the saga of resistant microbes and their invasion of people that answering the question “Can we beat antibiotic resistance?” is impossible.
If scientists reveal the inner workings of all virulent microbes and design novel ways to overcome their drug resistance; doctors quit over-prescribing antibiotics and patients learn proper respect for the drugs; hospitals, nursing homes, and doctors’ offices adhere to strict infection-control policies; and a strong global surveillance system is established; then humans would seem to have the advantage.
Except that bacteria have a much longer track record at adapting and surviving than humans. And scientists, left to wonder what unknown paths of mutations lie ahead, say they aren’t willing to bet against the microbes. “I don’t think any of us will ever develop an agent [for which it is] totally impossible to have resistance,” says Zurenko of Pharmacia & Upjohn. “There are still a lot of imponderables,” points out Joshua Lederberg. Yet based on the recent level of activity in antibiotic-resistance research, he says, “At least some of the right people are paying close attention. That was not true a couple of years ago.” That, he says, is “progress.”