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Superbug Threat

By Ramanan Laxminarayan and Mark Plotkin

The Washington Post
Tuesday, November 4, 2003; Page A25

Every day in the United States, 100 men, women and children -- 40,000 or more every year -- die from infections caused by bacteria that are resistant to antibiotics. The number, which is larger than the number who die from AIDS, may actually be higher, because many deaths, particularly those of elderly patients suffering myriad problems, may in reality stem from these "superbugs."

The situation is already serious. It threatens to become worse -- much worse. We have to be ready before that happens because, if it does -- perhaps naturally, perhaps as the result of a terrorist attack -- it could be too late to prevent an outbreak of pandemic proportions.

Unquestionably medicine's greatest success during the past 60 years has been the discovery and use of antibiotics. The use of these "miracle" drugs -- which kill bacteria that once routinely killed us -- has lulled us into a false sense of security. Antibiotics have become the foundation of modern medicine. They are an essential ingredient not only in combating disease but also in transplanting organs -- heart, kidney, liver and others -- as well as surgery of all kinds. Without antibiotics, few surgeries would be "routine" because of the constant threat of death from infection.

The bacteria that were neutralized by antibiotics, however, did not disappear. Like other living organisms, they have responded to the challenge and adapted. Now medicine is encountering deadly new strains of bacteria that resist powerful antibiotics. Some strains already have appeared that are immune to all existing antibiotics.

Why are our miracle drugs failing us? One reason -- well documented -- is that we have used them too often, to treat infections and conditions that more often than not could be defeated by the body's immune system without medical intervention. Another reason is that antibiotics have become omnipresent, in our food and water supply, as farmers feed them to cattle and poultry and spray them on crops. As we ingest them in low doses, bacteria become familiar with them and mutate to protect themselves.

According to the Centers for Disease Control and Prevention, 2 million patients in American hospitals each year are infected during their hospital stays. Of these 90,000 die; in 70 percent of the cases, the bacteria that kill them are resistant to at least one commonly used antibiotic.

For years the last line of defense against many bacteria has been the powerful antibiotic vancomycin. Two cases already have been reported of potentially lethal Staphylococcus aureus infections that vancomycin could not cure -- a frightening portent of what the future might hold. The superbugs seem to be getting stronger, and doing so faster.

Obviously, the first thing that needs to be done is to reduce the use of antibiotics, saving them for situations in which they are absolutely necessary. Another obvious measure would be to clean up our hospitals, which are widely recognized as havens for drug-resistant bacteria. Too many health care workers fail to wash their hands -- properly or at all -- between seeing each patient. The failure to do so is a major cause of the transmission of superbugs from one patient to another.

These are positive steps, but they alone are insufficient. We are in desperate need of new antibiotics and other drugs to treat infections. Few drug companies are developing new antibiotics, and most of these are closely related to existing drugs. Hence, they are theoretically less likely to baffle bacteria very long.

What we need and what we are not getting -- and under present circumstances will not get -- are entirely new types of antibiotics with characteristics unknown to the new strains of bacteria lying in wait.

Adherents of the market approach will argue that if the need is there, the market will respond. Unfortunately, no.

First of all, drug companies are investing in items that promise big returns, such as Viagra and Celebrex. Of the roughly $26.4 billion spent on pharmaceutical research and development two years ago, only 14 percent, or roughly $3.7 billion, went to research on infectious diseases, including vaccines and HIV drugs. A very small part of that amount was for antibiotics, and even then most spending was on knockoffs of existing antibiotics.

Second, pharmaceutical companies are interested in developing drugs for widespread, not limited, use. And their experience with government intervention in the case of Cipro after the anthrax attacks in 2001 -- when the federal government effectively seized existing inventories and dictated a price -- does not encourage them to develop new drugs.

The need is too critical to wait for a market response. This situation clearly requires government intervention to encourage drug companies to undertake research and development of a whole new series of antibiotics to provide the fullest possible array of weapons to fight bacteria and to slow the inevitable resistance that will follow.

The precise manner of incentive -- whether it be subsidies, price guarantees or extension of patents on other, more profitable drugs -- is a matter for the political process to work out.

In the absence of that kind of initiative, however, the question will be not whether we will be confronted by a new plague, but when.

Ramanan Laxminarayan is a fellow at Resources for the Future and editor of "Battling Resistance to Antibiotics and Pesticides: An Economic Approach." Mark Plotkin is co-author (with Michael Shnayerson) of "The Killers Within -- The Deadly Rise of Drug-Resistant Bacteria" and president of the Amazon Conservation Team.

© 2003 The Washington Post Company

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