antibiotic-resistant bacteria of concern

The WHO just published a list of 12 bacterial families that they feel pose the greatest threat to human health (see http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/ ). These are considered the "priority pathogens", which should serve as a focus for research and development of new antibiotics. The most critical group includes multi-drug-resistant bacteria that pose a particular threat in hospitals, nursing homes, and among patients who require devices such as ventilators and blood catheters. These bacteria have become resistant to a large number of antibiotics including carbapenems and third-generation cephalosporins, the best available drugs for treating multidrug resistant bacteria. The 2nd and 3rd tier priorities include increasingly drug-resistant bacteria that can cause more common diseases such as gonorrhea and salmonella. The goal is to spur governments to incentivize basic science and advance research and development, both public and private sector, to invest in new antibiotic discovery. The list does not include tuberculosis, which does have increasing resistance, but is covered by other programs.

Priority 1: critical
1.       Acinetobacter baumanii, carbapenem-resistant
2.       Pseudomonas aeruginosa, carbapenem-resistant
3.       Enterobacteriaceae, carbapenem-resistant, ESBL-producing

priority 2: high
1.       Enterococcus faecium, vancomycin-resistant
2.       Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant
3.       Helicobacter pylori, clarithromycin-resistant  [see http://blogs.bmj.com/ebm/category/gi-h-pylori/​ for multiple blogs on H Pylori resistance and optimal treatment strategies]
4.       Campylobacter spp., fluoroquinolone-resistant
5.       Salmonellae, fluoroquinolone resistant
6.       Neisseria gonorrheae, cephalosporin-resistant, fluoroquinolone-resistant

priority 3: medium
1.       Streptococcus pneumoniae, penicillin-non-susceptible
2.       Haemophilus influenzae, ampicillin-resistant
3.       Shigella spp., fluoroquinolone-resistant

Commentary:
--this WHO publication follows others which have warned of scarily increasing bacterial antibiotic-resistance world-wide (eg, see http://gmodestmedblogs.blogspot.com/2014/05/who-report-on-antimicrobial-resistance.html )​
--the focus of this current publication is to spur on research and development of new antibiotics.  BUT, though not mentioned, the elephant in the room is that we need to decrease the future development and spread of antibiotic-resistant bacteria.   Some of this is decreasing the unnecessary use of antibiotics for nonbacterial illnesses (see prior blogs, as below, in the file: http://gmodestmedblogs.blogspot.com/search/label/antibiotic%20resistance   ). But the largest part of this has to do with industrial use of antibiotics in livestock, where antibiotics are used to increase the weight of animals and prevent infections largely in the setting of huge industrial farms, where there is great opportunity for sharing of pathogens. Although there are different estimates out there on the quantity of antibiotics used, one study by the Union of Concerned Scientists suggested that 24.6 million pounds of antimicrobials are used annually for nontherapeutic purposes in chickens, cattle, and swine vs 3.0 million pounds used for humans (see Landers TF. A review of antibiotic use in food animals: perspective, policy, and potential. Public Health Rep. 2012 Jan-Feb 127(1): 4.).  ie90% goes to animals....
--an additional issue is that drug companies have been loath to develop new antibiotics.  as for-profit organizations, they see much more income from life-long drugs, such as those for lipids, diabetes, etc (the gift that keeps on giving), vs those prescribed for just a 10-day course. (the apparent exception is for hepatitis c, where the meds are given for several months, these were new meds for a very serious and very common condition, and they were able to jack up the price independent of their actual costs of R&D). and, many of the drug-resistant bugs, at this point, are in areas of the world where there is not lots of money to be made (see http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1​ ) .  from the blog of 7/11/14: “at this point we really need new antibiotics developed. there have been no new class of antibiotics since 1987. issue is that the $$ is in chronic meds. even over-charging for antibiotics doesn’t help much if it’s for only a 10 day course.  and, will append below a previous blog  which shows that the vast majority of R&D by big pharma is for look-alike drugs and not for important break-throughs (though their arguments supporting the huge costs of drugs hinges on the expense of R&D)”
--so, bottom line, we do need new antibiotics to deal with the spread of these "superbugs". But we really do need to intensify internal pressure on clinicians to decrease antibiotic overprescribing and, especially, external pressure on industrial farming to dramatically decrease antibiotic usage.

--see http://gmodestmedblogs.blogspot.com/2016/09/sti-infection-therapy-who-guidelines.html   for a detailed blog about WHO guidelines for treatment of gonorrhea, chlamydia and syphilis in this era of  increasing antibiotic resistance, with reference to several other blogs on gonorrhea resistance
-- see http://gmodestmedblogs.blogspot.com/2016/06/more-superbugs.html  for blog on superbug colistin-resistant E coli
--see http://gmodestmedblogs.blogspot.com/2016/01/antibiotic-overprescribing-and-acute.html / and http://gmodestmedblogs.blogspot.com/2019/01/antibiotic-overprescribing-2-more.html  about the overprescription of antibiotics for nonbacterial conditions (eg URIs, acute rhinosinusitis, pharyngitis, bronchitis). the latter blog points out that the public outcry about antibiotic overuse in farming has led to some manufacturers decreasing antibiotic usage (eg Tyson intends to eliminate routine antibiotic use in chickens, Purdue and Pilgrim's Pride are decreasing antibiotic usage)
-see http://gmodestmedblogs.blogspot.com/2015/12/antibiotic-resistant-bugs-in-gut.html  for a small study of  mothers and kids, finding many excreted ciprofloxacin-resistant E coli, finding, among other things, that the length of hospital stay after birth correlated with cipro-resistance in infants' stools
--see http://gmodestmedblogs.blogspot.com/2015/11/longterm-microbiome-changes-with.html , which noted long-term microbiome changes with antibiotics
--see http://gmodestmedblogs.blogspot.com/2014/05/who-report-on-antimicrobial-resistance.html  for the US White House report on animicrobial resistance, along with targets for research (many being similar to WHO paper)

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

diabetes DPP-4 inhibitors and the risk of heart failure

the FDA just came out with a safety alert about 2 DPP-4 inhibitors and the increased risk of heart failure (released 04/05/2016)(see  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494252.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery ​ ). details: --saxagliptin and alogliptin were singled out because of 2 clinical trials in diabetic patients with heart disease. in each trial more patients taking these meds were hospitalized for heart failure vs those on placebo     --in the saxagliptin trial: 3.5% were hospitalized for heart failure (vs 2.8% on placebo). risk factors included prior heart failure or kidney disease     --in the alogliptin trial: 3.9% were hospitalized for heart failure (vs 3.3% on placebo) --recommendation by the FDA:     -- we should consider stopping these drugs if the patient develops heart failure -- i believe these trials (not cited specifically by the FDA) were the ones in the blog
Read more

cystatin c: better predictor of bad outcomes than creatinine

Image
  another article found significant discordance between creatinine and cystatin C in assessing renal function,  finding that the latter correlated most strongly with both renal and non-renal adverse clinical outcomes (see   ckd cystatin c better than creat AJKD2023  in  dropbox or doi: 10.1053/ j.ajkd.2023.04.002)   Details: -- 158,601 adults who were in the Stockholm Creatinine Measurements (SCREAM) project and had testing of creatinine and cystatin C on the same day during a healthcare encounter, from 2010-2018     -- >400,000 outpatient tests were done for both creatinine and cystatin C levels -- mean age 62, 48% female -- mean eGFR by creatinine (   eGFR cr ) 80; mean eGFR by cystatin C ( eGFR cys  ) 73 -- mean stage of renal insufficiency: 39%  eGFR cr   90+; 38%  eGFR cr  60-89; 12%  eGFR cr  45-59; 7.1%  eGFR cr  30-44; 3.2%  eGFR cr  15-29, 0.7%  eGFR cr  <15 -- mean urinary albumin-to-creat ratio: 12 mg/g -- comorbidities: hypertension 59%, diabetes 8%, coronary heart di
Read more

UPDATE: ASCVD risk factor critique

I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the current ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:              -- there is very clear evidence that there are many individual risk factors that are associated with increased risk of a cardi
Read more