The Persistence of Resistance And Some Reasons Why - Wired (blog)

Tuesday marked the start of the United States’ Get Smart About Antibiotics Week, an annual observance by the Centers for Disease Control and Prevention that tries to direct attention to the root causes of antibiotic resistance and possible fixes. (It is also European Antibiotic Awareness Day, and also the first day of Australia’s Antibiotic Awareness Week. I don’t know of other national observances; if you do, leave them in the comments!)

To mark the day and jump-start awareness, the CDC and a number of US medical and public-health organizations held press events. The observances and the policy statements that came from them were important â€" but reading between the lines, it is discouraging how much there is yet to do.

(By the way, constant readers: Sorry to be gone so long. Some challenges in the extended family of Casa Superbug; almost all better now, hope everything will be over by the weekend. Meanwhile…)

So first: The CDC released a statement, co-signed by 24 other organizations, that commits all the signers to pushing for a number of actions. Some are boilerplate, but some would make a significant difference to the worsening trend, if they could be achieved. Among them (quoting from the statement):

• To work towards optimizing antibiotic use through antibiotic stewardship programs and interventions…
• To improve surveillance for drug-resistant infections…
• To encourage the development of pharmaceutical products to combat antibiotic resistance, including new antibiotics or novel therapies, compounds to boost antibiotic effectiveness, diagnostics to better diagnose infections and their resistance characteristics, and vaccines…
• To work with regulatory, veterinary and industry partners to promote the judicious use of antibiotics in food animals…
• To reinforce the judicious use of antibiotics in agriculture by: limiting the use of medically important human antibiotics in food animals; supporting the use of such antibiotics in animals only for those uses that are considered necessary for assuring animal health; and having veterinary oversight for such antibiotics used in animals.

The signers include the American Academies of Pediatrics, Physician Assistants and Urgent Care Medicine; the American Society of Health System Pharmacists and the Society of Infectious Diseases Pharmacists; stalwarts on this issue, including the Alliance for the Prudent Use of Antibiotics, Robert Wood Johnson Foundation, Pew Charitable Trusts and Trust for America’s Health; and groups who are particularly concerned with resistant organisms in healthcare: the Association for Professionals in Infection Control and Epidemiology, Council of State and Territorial Epidemiologists and Society for Healthcare Epidemiology of America. (See the online version for the full list.)

But some other things released Tuesday, by yet more of the CDC’s partners, point to some significant hurdles to reducing antibiotic resistance.

First, the Center for Disease Dynamics, Economics and Policy â€" creators of the excellent online tool ResistanceMap, which tracks trends in drug resistance in particular organisms over time â€" released an analysis of US antibiotic-prescribing trends from 1999 to 2010.

On the good-news side, they found that antibiotic use â€" a driver of antibiotic resistance particularly when the use is for diseases that don’t respond to antibiotics â€" is dropping across the country, by 17 percent when averaged for all the states.

But on the not-good side, they found that the trend is far from uniform. In  Kentucky, Louisiana, Mississippi, North Dakota and West Virginia, antibiotic use either dropped so minimally that the change was  insignificant, or actually increased. Compare that to Colorado, Florida, Montana, Nevada, New Hampshire, Oregon, South Dakota and Vermont, where antibiotic use sank by as much as one-third over that same period.

Cutting the data another way: Per capita, people in Kentucky and West Virginia take twice as many antibiotics every year as people in New Hampshire or Colorado.

How can that be? There are clues embedded in yet another package of data released Tuesday, by the Pew Charitable Trusts. The data was assembled from the results of a poll of 1,004 US adults, followed by in-depth interviews with two focus groups. The poll found:

• 87 percent of Americans believe antibiotics are effective against bacterial infections
• but 36 percent believe they also are effective against viral infections;
• 47 percent of Americans believe taking antibiotics when they are not necessary reduces the effectiveness of the drugs for others
• but 39 percent think it makes no difference;
• 81 percent think “some diseases becoming resistant to antibiotics” is a problem
• but 42 percent think it is unlikely that an antibiotic-resistant illness will affect them or their family.

Thinking of the CDDEP map, I asked the folks at Pew whether these beliefs about resistance could be broken down geographically. They said no â€" but that the views could be correlated to levels of education, income and socio-economic status. If you mapped income and education in the US, the states that ranked among the lowest would coincide with the states on CDDEP’s map where antibiotic use remains high.

This stubborn persistence of high antibiotic use, causing or causing by these incorrect beliefs about antibiotic resistance, points up how far efforts such as Get Smart About Antibiotics have yet to go in creating real change. That is especially discouraging because, as revealed in additional data released Tuesday, resistance trends are worsening. In an additional analysis, CDDEP showed that multi-drug resistance increased by 30 percent in E. coli, the bacteria that cause most of the 8 million urinary tract infections in the United States each year â€" and the highest increases were among the same Southeastern states where antibiotics are being misused the most.

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