Dr. Paul Pottinger: How to stop the superbug crisis

By Dr. Paul Pottinger

Another silent killer is lurking in our community, and it’s not COVID-19.

The threat is antimicrobial resistance – better known as an onslaught of “superbugs.” These are bacteria and fungi that can no longer be treated with existing antimicrobial drugs.

Between 2017 and 2019, Washington state authorities uncovered 77 infections from the drug-resistant bacteria CRAB (Carbapenem-resistant Acinetobacter baumannii) inside its health care facilities. In Spokane County in 2020, there were nearly 58 drug-resistant staph infections, MRSA (Methicillin-resistant Staphylococcus aureas), per 100,000 hospitalized people. That’s higher than the state average of 45 per 100,000. Both rates are considerably higher than the most recent national data, less than 3 per 100,000 in 2016.

This is not just a local problem. Superbug infections kill more than 35,000 people a year nationwide, and could kill up to 10 million people annually by 2050 if we fail to take action, according to the World Health Organization.

As an infectious diseases specialist at the University of Washington, I’ve lost patients because of a lack of effective antibiotics and other antimicrobial medicines. Antimicrobials have saved countless lives, but they are not keeping up with resistance. This is because when a bacterium or fungus is exposed repeatedly to a drug designed to kill it, it may evolve into a hardier version of itself. These superbug infections can be especially dangerous in hospitals.

We urgently need solutions. Thankfully, there are ways we can stop this looming threat.

One step is better antimicrobial stewardship. Medical professionals should be cautious in how we use antimicrobials to treat infections. Every health care facility is mandated to have an antimicrobial stewardship program with sufficient staff and resources to help guide clinicians, like we do at UW Medicine.

Members of the public can help, in part by washing their hands with plain soap and water to prevent the spread of infection. According to the CDC, hand sanitizer is a suitable alternative when water isn’t readily available.

But, better management of existing drugs and everyday handwashing – while essential – can only take us so far. We also need new medicines – and we’re not getting them quickly enough. The last entirely new class of antimicrobials came to market years ago.

Part of the challenge is that antimicrobials are used differently than most other drugs. Prescribing a medicine to one patient usually has no impact on whether it will work on others. But because any use of an antimicrobial can help the bug improve its defenses and make it more difficult to treat in the rest of the population, antimicrobials must be used sparingly, and only when they are needed.

This limited use clashes with the funding model for developing new medicines. Drug discovery relies heavily on private investment. It costs around $1.58 billion to develop a single new antibiotic, according to a 2017 estimate published in Health Policy. And to keep investment going, companies expect a decent-sized market for their product. When a drug needs to be used sparingly, that market isn’t big enough.

Because of this dynamic, many of the biggest drug makers have left the antimicrobial business, and several smaller biotech companies that took a shot have gone out of business.

Consider Achaogen. It worked for more than 15 years to develop a new antibiotic, plazomicin, which made it all the way through FDA approval. But in the end, even though the novel product addressed unmet needs, the company was unable to stay viable due to the broken marketplace for antimicrobials. The company went bankrupt in 2019.

One solution would be a payment model that aligns the business of developing novel antimicrobial products with the needs of public health. We should look to digital subscription platforms. If you get Netflix, the company makes the same amount of money no matter how much or how little you watch. Likewise, the government could provide drug developers a set payment for appropriate access to new antimicrobials, regardless of how many doses are eventually used. This guaranteed return on investment would incentivize companies to continuously invent, without fear of going out of business.

Britain introduced a program along these lines in 2020 that is now coming online. U.S. lawmakers are working on legislation called the Pasteur Act that would launch such a program here.

Reform is urgently needed. Failing to meet the superbug threat will only cost more each year, both in financial terms and in lives lost. As we emerge from one pandemic, we can see another one coming. The time to act is now.

Paul S. Pottinger, MD, is a professor of infectious diseases at the University of Washington School of Medicine and co-director of the University of Washington Medical Center Montlake’s Antimicrobial Stewardship Program.