WASHINGTON — Combating antimicrobial resistance — which kills about 36,000 people a year in the United States alone — not only requires a strong pipeline of new antimicrobial medicines and other products, but also preserving the effectiveness of those already in use, says a new congressionally mandated report from the National Academies of Sciences, Engineering, and Medicine. The report recommends ways to hold nursing homes, dialysis centers, and long-term care hospitals, in particular, accountable for appropriate use of antimicrobials.

Although antimicrobial resistance is most apparent in human medicine, the report says policymakers should consider the interconnectedness of human, animal, and environmental health — a One Health perspective.

Safe, effective antimicrobials are cornerstones of modern medicine as well as pandemic preparedness and response. As microbes know no borders, the United States’ program to counter resistant pathogens should be proportionate to the size and scope of the threat, says Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine. A program modeled after the President’s Emergency Plan for AIDS Relief may be best suited to addressing the global health challenge of antimicrobial resistance.

Currently, nursing homes, dialysis centers, and long-term care hospitals are potential hotspots for the emergence and spread of resistance. The Centers for Medicare and Medicaid Services (CMS) should require these facilities to have antimicrobial stewardship programs, the report recommends. Antimicrobial stewardship — use of the right drug, dose, and duration — should be included in the quality measures on Care Compare, a CMS website that publicizes quality data for patients and their caregivers.

Antimicrobial resistance occurs when microorganisms such as fungi, parasites, and bacteria evolve to become immune to the medicines used to treat them. The overuse and misuse of antimicrobial medicines contributes to this process. By recent estimates, between 0.91 million and 1.71 million people worldwide die from resistant infections every year. These infections can cost society in terms of increased hospitalization and expensive and extensive treatment, and through illness, disability, and loss of life.

“Numerous medical procedures — organ transplants, joint replacements, cancer treatment, and even safe childbirth — rely on effective antibiotics to prevent and treat infections in people’s most vulnerable moments. If we don’t make antimicrobial resistance a public health priority, we risk setting back gains in modern medicine,” said Guy Palmer, Regents Professor of Pathology and Infectious Diseases at Washington State University and chair of the committee that wrote the report. “As the ongoing COVID-19 pandemic has taught us, we must confront our vulnerability to pathogens in ways we haven’t before.”

Building a Pipeline of Novel Antimicrobials and Other Products

Antimicrobials are expensive to develop and do not sell well during their first years on the market. Some experts have proposed reward payments of $500 million to $2 billion for companies that bring new antimicrobials to market. But most antimicrobials approved for use recently offer little to no added clinical value over existing treatments. Before paying market entry rewards, the government needs to be sure it is rewarding an innovative product, says the report. A U.S. Department of Health and Human Services (HHS) intra-agency committee should establish criteria to identify antimicrobials that would truly be novel and useful, and fund studies to understand their optimal use.

The nature of resistance means there will be a constant need for new antimicrobials, as well as diagnostic tools to correctly target therapy and help reduce inappropriate antimicrobial use. The HHS should support outcomes research that can improve understanding of the true value of diagnostic testing, and help inform practice guidelines and payers’ reimbursement for testing, the report recommends. Automated diagnostic tests should be updated to reflect changes in pathogens’ susceptibility to drugs and to include new antimicrobials when possible.

There is also good evidence that vaccines can reduce antimicrobial use, which could help drive wider vaccine uptake, especially in low- and middle-income countries. The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health should provide supplemental funding to ongoing immunization trials, to better understand the usefulness of vaccines as a tool to mitigate antimicrobial resistance.

Animal Health Interventions

Humans and animals share an environment and interact in many ways, creating ample opportunity for microbes to pass between species. There is a need for animal vaccines that are affordable and easy to administer on farms. International cooperation, harmonized review, and a common application form could improve the reach of new animal vaccines.

Longer term, the Food and Drug Administration (FDA) Center for Veterinary Medicine should promote the use of electronic prescriptions, which would make it easier to track how veterinarians prescribe antimicrobials in both livestock and pets, which like food-producing animals, can harbor drug-resistant pathogens. FDA should also encourage farmers and veterinarians to share information about the dose, duration, and indication for antimicrobials used in animals.

Environmental Surveillance

Analyzing the places where contaminants enter water (for example, wastewater treatment plants) could help characterize the role of water as a conduit of resistance. The U.S. Environmental Protection Agency should provide guidance and funding to states for testing wastewater treatment plants for antimicrobial resistance traits and integrating these data with other surveillance networks. The agency is already working with CDC and HHS on surveillance for SARS-CoV-2 in wastewater; this provides a foundation to expand into surveillance for resistant pathogens, the report says.

The global response to antimicrobial resistance must also consider climate change. For example, extreme weather events may aggravate crowding and sanitation problems that cause infectious diseases, and drive demand for effective antimicrobial medicines.

A Future Role for the United States

The report recommends the systematic tracking of activities and outcomes of the goals outlined in the 2020–2025 National Action Plan for Combating Antibiotic-Resistant Bacteria. Congress should direct the Government Accountability Office to conduct biennial evaluations of federal agencies’ progress against these goals, and use this evaluation to suggest course corrections when necessary.

“When antimicrobial resistance develops anywhere, it is a threat to people around the world. Public spending on combating antimicrobial resistance is also an investment in global health security, pandemic preparedness, and the realization of a One Health effort that considers human, animal, and environmental health,” said Victor J. Dzau, president of the National Academy of Medicine. “We need a multifaceted approach that includes revitalizing the antibiotic pipeline, supporting stewardship, and bolstering surveillance, while also attacking root problems like water, sanitation, and hygiene. The U.S. has a real opportunity to use its depth in science and medicine for the global public benefit.”

The study — undertaken by the Committee on Examining the Long-Term Health and Economic Effects of Antimicrobial Resistance in the United States — was sponsored by the National Institute of Allergy and Infectious Diseases. The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.

Contact:
Stephanie Miceli, Media Relations Officer
Office of News and Public Information
202-334-2138; e-mail news@nas.edu

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