The Hidden Epidemic: Tackling Antimicrobial Resistance

When choosing a hospital, most people consider treatment success rates, doctor specialties, and insurance coverage. What people do not generally consider, however, is the possibility that a hospital could inadvertently infect its own patients with additional illnesses. In the worst cases, these illnesses can be nearly impossible to treat and can even become deadly. Such is the typical case of Candida auris, a new and proliferant fungal infection that is drawing attention to the growing problem of antimicrobial resistance.

First discovered in 2009, C. auris has now been documented on every continent. Since 2013, the United States has seen 587 confirmed infections, primarily concentrated in Chicago, New York City, and New Jersey. The New York Times reported that 50 percent of residents in some Chicago nursing homes carry C. auris, though not all who are exposed to it become sick. That statistic is especially worrying when considering the vulnerability of the elderly; along with infants, diabetics, and autoimmune patients, they are among the most susceptible to infection. Nearly half of all patients who contract C. auris die within ninety days.

The scope and severity of infections are a result of the shocking resiliency of C. auris. Around 90 percent of C. auris strains are resistant to at least one antifungal drug. Just last month the Centers for Disease Control and Prevention (CDC) announced the first United States cases of C. auris found to be resistant to all known antifungals. Hospitals with outbreaks have found eradicating them difficult, time-consuming, and dangerous for both patients and staff. Mount Sinai Hospital in New York City resorted to tearing out floor and ceiling tiles from an infected patient’s room to eliminate the fungus. The Royal Brompton Hospital in London closed its Intensive Care Unit for eleven days following an outbreak. Hospital Universitari i Politècnic La Fe of Spain had eighty-five confirmed cases, and like Mount Sinai, Royal Brompton, and Chicago’s Northwestern Memorial Hospital (one confirmed fatal case), it made no public announcement.

The alarming case of C. auris highlights the dangers of a growing global epidemic: infectious bacteria and fungi that have developed resistance to commonly used antimicrobial agents. The United States alone sees 2 million infections annually that are resistant to at least first-line antimicrobials, leading to 162,000 deaths and costing the healthcare system an estimated $20 billion. These statistics likely do not even capture the full picture. Patients who contract C. auris and other bugs are often already sick with another illness, making identifying new cases difficult. Additionally, healthcare facilities with known cases may not want to disclose them for fear of scaring off prospective patients.

The problem of antimicrobial resistance will grow exponentially in coming years if current overuse of antibiotics and antifungal agents continues. Doctors often prescribe antibiotics to patients with generic and relatively mild symptoms “just in case” because doing so is cheaper than performing diagnostic tests. This approach may be effective in killing the majority of bacterial infections, but it promotes the proliferation of the surviving resistant strains. In the case of fungal infections, which now have global mortality rates greater than cancer and malaria, medicine may not be the only culprit. Recent research supports a link between the use of antifungal azoles in agriculture to azole-resistant fungal infections in humans. These practices, if left unaltered, will lead to an estimated 10 million deaths from antimicrobial resistant infections worldwide in the year 2050, with a cost of $100 trillion.

Despite the looming threat of a massive global epidemic, governments, health care providers, and pharmaceutical companies consistently fail to prioritize solutions to the antimicrobial resistance problem. Only 1.2 percent of the grant funds distributed by the National Institutes of Health are currently allocated toward antimicrobial resistance research. Of the $38 billion in venture capital spent on pharmaceutical research and development from 2003 to 2013, only $1.8 billion was spent on drugs to combat new resistant strains of infectious bacteria and fungi. Current incentives for all parties involved align to promote reckless overuse of existing antimicrobials and to discourage the development of new ones.

In the case of a negative externality like the current C. auris crisis, the responsibility falls to the government to regulate the culpable industries. Groups such as the Patient Safety Action Network and Health Watch USA have advocated for greater transparency from hospitals in the case of an outbreak of C. auris. Though this may sound like a good first step, plans that emphasize transparency above all else could do more harm than good.

Hospitals would likely be very reluctant to disclose any outbreaks to the government if that meant public exposure and the possibility of widespread panic. CDC efforts to track the spread and incidence of the fungus nationwide would be compromised, which is why the CDC currently protects hospital anonymity in its reports. More importantly, requiring full transparency could prompt the use of unstandardized and possibly inadequate eradication methods to cover up cases. Public fear of contracting C. auris could also discourage sick or injured individuals from seeking necessary care.

Any policy to mitigate the C. auris problem should address the root causes of all antimicrobial resistance. In developing countries, investments in vaccination and basic sanitation will help to prevent the spread of communicable diseases that require antimicrobials for treatment. In developed countries like the United States, a comprehensive solution has to properly incentivize farmers, doctors, insurance companies, and researchers by convincing them that they all have a stake in combating antimicrobial resistance.

To reduce agricultural overuse, stricter labeling guidelines have been suggested for products grown with antimicrobials. However, the fight over labeling genetically modified organisms (GMOs) has revealed that labeling may not actually deter consumers—mandatory labels may induce positive perceptions of GMOs by increasing perceived transparency regarding their use. Regulation should instead outlaw the use of antibiotics that are considered last-resort for humans as preventative measures for livestock. Manufacturers that produce antimicrobials and the farmers that use them must also be held to a minimum standard of environmental contamination prevention by the FDA.

Interventions in the medical industry are more complicated, but there are several common-sense changes to be made. Insurers that cover prescription antimicrobials should be required to cover diagnostic tests for microbe-caused illnesses. Doctors should also be required to administer these tests before prescribing antimicrobials to ensure that they are only used when absolutely necessary. Some medical providers have begun taking steps on their own through the implementation of internal antibiotic stewardship programs—which may require preauthorization for the prescription of antibiotics by an outside board, or limit the use of diagnostic tests with high false-positive rates—but these need to be standardized, scaled up, and enforced to affect the entire medical community.

To inform the implementation of these measures and suggest new ones, a new body of research must emerge surrounding antimicrobial resistance. Government grants should flow toward projects that promise solutions, whether they focus on improved medical diagnostics, methods of containment for agricultural antimicrobials, or the development of new drugs that could be effective against resistant infections. A study on antimicrobial resistance funded by the British government suggests a “pay or play” system for pharmaceutical companies: either they work to develop new drugs to address the resistance crisis or they pay a fee that governments can then use to fund antimicrobial resistance research. Another solution that could augment or replace a “pay or play” system involves rewards for pharmaceutical companies that invent effective new treatments to resistant infections.

Awareness is now growing among the medical community about C. auris and how to address an outbreak, and hopefully, new drugs will soon eradicate it for good. However, if the underlying problem of antimicrobial resistance is not addressed soon, C. auris will not be the last “superbug” to terrorize doctors and patients. A hidden epidemic of drug-resistant infections is fast approaching, and the world is woefully unprepared. Government policymakers need to work in conjunction with the medical community to proactively respond to this rising public health crisis.

The image featured with this article is in the public domain and is not subject to copyright law. The original was taken by Master Sgt. Jeffrey Allen and can be found here.