Gathering Storm: Future Without Antibiotics Is Coming at Us

Heather Saunders MPH, RN, CIC: “I think [infection preventionists] really need to be aware of what the efforts are at their state health departments and how they can collaborate with those efforts. IPs need to also have their own surveillance systems in place. They need to know what they’re looking for.”

In 1900, the average life expectancy for a male born in that year in the United States was 46.3 years; for females it was 48.3 years, according to the Centers for Disease Control and Prevention (CDC). One of the horrible legacies of COVID-19 is that it decreased the average life expectancy for people born in the first half of 2020 by a full year. “Life expectancy at birth for males was 75.1 years in the first half of 2020, representing a decline of 1.2 years from 76.3 years in 2019. For females, life expectancy declined to 80.5 years, decreasing 0.9 year from 81.4 years in 2019,” the CDC notes. Still, for men the difference between a life expectancy of 46.3 years to 75.1 years—that’s a sizeable chunk of living. One of the things that made that possible was the introduction of antibiotics in 1945. This meant that infection was no longer the leading cause of death, as a study aptly titled “The Treasure Called Antibiotics” put it. Heather Saunders MPH, RN, CIC, the director of infection control at Johns Hopkins Office of Population Health, tells Infection Control Today® that we possibly face a future that’s as much without (effective) antibiotics as was our past. Saunders and other health care experts call the growing threat of antimicrobial pathogens the silent pandemic. She believes it’s getting worse, that “the COVID-19 pandemic might have accelerated the pace of antimicrobial resistance. This was a problem before COVID. But we’re seeing that it’s really a problem now.” What can be done? What can Saunders’s fellow infection preventionists do to beat back the silent pandemic?

Infection Control Today®: What have you found out so far in the research you’ve done for your upcoming article in Infection Control Today®?

Heather Saunders MPH, RN, CIC: This is a really important topic, I don’t think I can stress enough just how important this topic of antimicrobial resistance is. Let me start off with just a really startling statistic to really drive this point home. Currently, around the globe, we see around 700,000 deaths each year to drug resistance from bacterial infections, malaria—we’ve got HIV/AIDS, tuberculosis. But by 2050, public health experts predict that that number is going to be estimated to be somewhere around 10 million deaths annually to drug resistance. Ten million!

That’s surpassing the current number of worldwide deaths for the COVID-19 pandemic. We, of course, don’t want to make light of the pandemic right now. But, really, I just want to drive home for infection preventionists what an important topic this is. And as we think about this, we’re really far removed from the discovery of penicillin, right? None of us remember what it was like to not have antibiotics to treat infections. But we are moving into this era where not having antibiotics to treat infections that we take for granted, [not] being able to treat is going to be more of a reality. And some of our medical advances, things like joint replacements, chemotherapy, transplants; those are going to be things that are life or death situations that are not going to be possible without the antibiotics that we take for granted right now.

ICT®: It’s interesting. Whenever somebody says they wish they were born and lived in a different era, I ask: “So you mean before 1940?” Because that’s when penicillin came about.

Saunders: Right, exactly.

ICT®: Other health care experts that I’ve spoken to point out that the world-altering pathogens are viruses for the most part, such as COVID-19. And what you’re talking about are bacterial and fungal problems, right?

Saunders: Right, exactly. And you know, a lot of experts are referring to the rise of antimicrobial resistance as being the silent pandemic. Because for one, we’re not talking about this enough; about this issue of antimicrobial resistance. But also, sometimes, what we see is the transfer of these organisms from person to person, without our knowledge, so individuals being able to be colonized with these organisms that are antimicrobial resistant, that are fungal infections, or bacterial infections. And the more resistant they’re becoming, the harder it is to treat those infections. And they can cause a number of different infections. They can cause pneumonia. They can cause wound infections, urinary tract infections that lead to sepsis. And then we are running out of antibiotics to treat them. This is a huge issue that I think is really, like I said, accelerating. The pace in which we’re moving to this post-antibiotic era. Of course, respiratory infections are incredibly important. Viruses are incredibly important, as we’ve seen with the COVID-19 pandemic. But I think arguably equally important is this issue of antimicrobial resistance, and not having the antibiotics to treat some of these common infections that we’re so used to being able to treat right now.

ICT®: The CDC [Centers for Disease Control and Prevention] recently launched an effort to try to cut down on overprescribing of certain antibiotics at hospitals for certain conditions. Is that a good first step?

Saunders: That’s definitely a great first step. Antimicrobial resistance and antibiotic stewardship go hand-in-hand. We need those antibiotics. Being smart about our use of antibiotics and making sure the prescribing of our antibiotics is judicious is incredibly important. What I think doesn’t get enough attention is the role that infection prevention and control plays in decreasing the rise of antimicrobial resistance or containing antimicrobial resistance. This is really a multilayered approach, just like we saw with the COVID pandemic. We have masks. We have social distancing. Staying home when you’re sick. There are lots of different layers to preventing and controlling infections. Antimicrobial resistance is definitely no different. Antibiotic stewardship is incredibly important. And we haven’t had a new class of antibiotics since 1981. We’ve really got to look to develop new classes of antibiotics. We’ve got to look to be really judicious with our use of antibiotics. But we’ve also got to look at those other layers. The other ways in which we can prevent and control [antimicrobial] resistance. And infection prevention and control is one piece of that puzzle,

ICT®: You’re an infection preventionists. In fact, you’re the director of an infection prevention department. Speaking to your fellow infection preventionists: What can they do to help this effort along?

Saunders: There are a lot of things that we can do as infection preventionists in the fight against antimicrobial resistance. A lot of what we’ve seen in the COVID pandemic, unfortunately, I think, has accelerated the spread of antimicrobial resistance. And there are things that we definitely can do to contain, prevent and control resistance right now. I think number one, like you mentioned, the CDC has launched a lot of different efforts. The government in partnership has a lot of different efforts to contain antimicrobial resistance through the state public health departments. IPs should be aware of what the state public health department is doing in containing antimicrobial resistance. Being a partner in that. Collaborating with them on their containment efforts. A lot of state public health departments are doing increased surveillance for some of these novel and targeted antimicrobial resistant organisms. I think IPs really need to be aware of what the efforts are at their state health departments and how they can collaborate with those efforts. IPs need to also have their own surveillance systems in place. They need to know what they’re looking for. And they need to know what their laboratories are doing to identify these organisms. Do they have the capability to identify Candida auris or carbapenem-resistant Enterobacterales? Knowing what your laboratory is doing and having your own surveillance systems in place to identify those organisms. The three “I’s”: identify, isolate and inform. We want to be able to identify with those surveillance systems. We want to make sure that we are isolating appropriately individuals that have antimicrobial resistance. And that we’re quickly informing our public health department so that we can act upon identified resistance, particularly some of the novel and targeted resistance that we’re seeing an increase in prevalence of. And then I think it’s back to the basics. It’s the basics of infection control. Really work to contain the horizontal transmission of some of these antimicrobial resistant bugs. So, hand hygiene, environmental cleaning, good use of personal protective equipment (PPE). Those are all really important parts of containing, preventing resistance. We’ve got to get back to the basics. After the COVID pandemic and all the changes we’ve experienced. Back to the basics of focusing on infection prevention and control measures like hand hygiene, environmental cleaning. Those are just a few of the different things that IPs can do. Also, knowledge is power. Informing ourselves of those organisms. How do they spread? What are the ones that are really being targeted by public health efforts? And containment and educating our health care workers. I cannot tell you how many physicians I’ve talked to who don't know what Candida auris is. And I think we need to be out there informing our health care workers about these organisms and the threat that they [pose] to our ability to use antibiotics in the future.

ICT®: Do you see a public/private effort coming to this? We see a little bit of that with the CDC. But more? Perhaps on the scale of what we did with the vaccines for COVID-19? Or will there have to be a calamity first, then that will happen?

Saunders: That is a really great point because you’re right, the development of new antibiotic classes is not profitable for pharmaceutical companies. It’s part of why we haven’t seen any new antibiotic classes since the 1980s. I think that policy is important here. Funding is important toward trying to develop new antibiotic classes for the treatment of drug resistant infections or infections in general. I think that developing public and private collaborations to be able to do that is one way in which we have an opportunity to further our fight against antimicrobial resistance. I can’t speak to any specific current policy that’s in the works, although I know that there are definitely people out there that are lobbying for funding and lobbying for such policies to be created so that we don’t have funding and profit as a barrier to the development of new [antibiotics].

ICT®: Everybody, even the public, knows about wearing a mask, hand hygiene, social distancing. Now, are those the three things that will IPs will have to, A, do, and, B, monitor and keep track of among their fellow health care professionals? Or am I missing something? Is there a fourth or a fifth step when it comes to antimicrobial resistance?

Saunders: You hit the nail on the head definitely with hand hygiene. And then I think the use of personal protective equipment. Making sure that we’re placing these individuals on the appropriate transmission-based precautions that we’re monitoring. The adherence to those precautions and the use of PPE. Environmental cleaning is also really a big important one, and it kind of depends on the organism. That is why it is so important for us to know our bugs, if you will. Candida auris…. Those are very environmental organisms, and they love the environmental reservoir, just waiting for somebody to come along who hasn’t washed their hands prior to patient contact. I think environmental cleaning is another big important piece. And Candida auris happens to be pretty hardy and a little bit resistant to some of our common disinfectants. It’s important to know that. Important to know that if you have a patient with Candida auris that we should be using bleach, or bleach-based products, or something that is on that EPA’s [Environmental Protection Agency’s] list of agents effective against Candida auris. It’s going to be really important for us to know those organisms. We know the prevention measures that work well. But, you know, the tried-and-true measures like hand hygiene, good use of PPE, environmental cleaning; those are definitely ones we want to focus on, be able to monitor and educating our health care workers about the effectiveness of those in the prevention of infections.

ICT®: What about systemic changes in hospitals? How they function, and how infection prevention functions within a hospital system. Do you see changes coming with that in terms of this problem?

Saunders: That’s a really good question. I think that this is a multi-disciplinary issue. What I would love to continue seeing is the infection prevention and control departments collaborating with other disciplines across the hospital’s leadership. Making leadership aware of this issue. Environmental cleaning; making them aware of this issue. That department playing a role in the prevention and control of infections. They definitely have a part in monitoring environmental cleaning. They can take a part in fluorescent gel monitoring, ATP [adenosine triphosphate] monitoring. They play a part in that. Physicians play a part in it. Making this a multi-disciplinary effort. And if that is not already the case? The infection prevention and control department would love to see that that become more of a common thing in the fight against antimicrobial resistance.

ICT®: Is there something that I neglected to ask you that you think is pertinent to the subject matter that you would like to add?

Saunders: I’m really excited about this article [I’m writing for ICT®]. And I think, we’ll definitely chock it full of tips and things that IPs should be aware of. I think it’s also important that IPs be aware that a lot of experts talk about how the COVID-19 pandemic might have accelerated the pace of antimicrobial resistance. This was a problem before COVID. But we’re seeing that it’s really a problem now. We’re seeing more regional outbreaks. More regional increases in some of the novel and targeted antimicrobial resistant organisms like some of the carbapenemases producing organisms. Candida auris, for example. The CDC has a tracking website. They track some of the novel and targeted resistant [organisms]. A lot of public health departments do that as well. And a lot of areas of at least our country, the United States, is seeing some increases in antimicrobial resistant organisms. Some of us have a theory, the hypothesis being that the COVID-19 pandemic somewhat accelerated the pace of resistance for a couple of different reasons. One reason being that we used more antimicrobials. We did a lot more just-in-case prescribing during the COVID pandemic. I’m prescribing antibiotics for possible infections secondary to COVID-19. Again, in the very beginning, we weren't sure how to treat this thing. We were throwing the kitchen sink at it. That is one way in which that could have happened. Supply and demand increased for hand hygiene products, disinfection products, PPE. And in a lot of those we saw shortages, especially last spring. And that could have led to decreases in compliance with good PPE use, hand hygiene, good disinfectant—cleaning and disinfection—and that could have also contributed. And we focused a lot on health care worker safety and not so much maybe on the horizontal transmission between patients. Trying to prevent that horizontal transmission. We were really focused on health care worker safety as we should be, as we should have been. But potentially that hyper-focus sometimes in one specific area around one specific infection, sometimes will lead to other infections [being overlooked] from not having that focus and antimicrobial resistance could have been one of those. And then we saw increased health care-associated infections. And among some of those health care-associated infections there could have been antimicrobial resistant infections. Those are just a few of the hypotheses out there as to how or why we might be seeing such a rise after the COVID-19 pandemic. But I think that this really highlights that it is an issue that IPs need to be focusing on right now in their institutions. Need to be understanding better and working together to find ways to prevent and control resistance.

This interview has been edited for clarity and length.