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Dr. Jeanne Marrazzo is an infectious diseases physician with more than 25 years of experience. She is the C. Glenn Cobbs Endowed Chair in Infectious Diseases and director of the Division of Infectious Diseases at the University of Alabama at Birmingham, where she also co-directs the Center for AIDS Research. Dr. Marrazzo also serves as treasurer of the Infectious Diseases Society of America.

While largely unknown to the general public, antimicrobial resistance is a national and global health crisis. More than 2.8 million antimicrobial-resistant infections occur each year in the United States, and more than 35,000 people die as a result, according to the Centers for Disease Control & Prevention (CDC). The World Health Organization has referred to antimicrobial resistance as the “silent pandemic.” Meanwhile, drug development to adequately fight these pathogens has slowed in the United States. An infectious diseases physician provides insight into why antimicrobial resistance is the next health care nightmare.

Antibiotics have long been considered one of the big milestones in public health. Are we truly at risk of losing them?

Dr. Marrazzo: Antibiotics have unquestionably transformed how we care for patients and treat conditions that were once considered deadly. However, over-prescribing and improper use of antibiotic treatments over time have made drug-resistant bacteria more common and more dangerous, contributing to what health care professionals and scientists call antimicrobial resistance.

Bacteria that develop antimicrobial resistance are superpowered “bugs” that can cause fatal infection because our antibiotics can no longer effectively treat them, particularly for vulnerable communities such as people admitted in hospitals — people who are getting very common surgeries like knee replacements or caesarean sections, or cancer patients. Antimicrobial resistance is particularly dangerous to people residing in long-term care facilities and rehab centers. Increasingly, we’re seeing perfectly healthy people acquire resistant infections in their communities through common activities like sports or gardening.

What is the worst-case scenario?

Dr. Marrazzo: The nightmare scenario that keeps me up at night is something like this — a supercharged antibiotic resistant pathogen outbreak that makes its way through hospitals, intensive care units, and vulnerable communities. The potentially lethal pathogen then spreads through patients and health care workers, into nursing homes and long-term care facilities, and ultimately into the larger community as people unknowingly carry the pathogen. Antimicrobial resistant pathogens are more difficult to control through prevention measures, and staffing challenges and lack of PPE availability make widespread outbreaks inevitable. The public health and health care system are already at their breaking point from managing other outbreaks and infections. There is virtually no effective antibiotic treatment available, and there are not enough providers to support patients who crowd hospital beds.

This may sound very similar to our experience with Covid-19, but this antimicrobial resistance nightmare could be much, much worse. First, antibiotic resistant pathogens can have a much higher mortality rate. Second, hardly anyone is working to develop new antibiotics to treat these resistant infections. And third, once an antibiotic resistant pathogen takes root in a health care facility, it is very difficult to eliminate, and its presence, without effective antibiotics, can make it too risky to perform procedures like cancer chemotherapy, organ transplants, and other surgeries.

If an infection is resistant to one antibiotic, can doctors prescribe or use different antibiotics?

Dr. Marrazzo: Right now, we already see patients who are out of options because their infections are resistant to every available antibiotic.  There is no guarantee that we will have adequate treatments to limit the next outbreak given the state of the drug development pipeline. We are going to run out of effective antibiotics for more and more patients. There isn’t enough innovation or development of new antibiotics. As doctors we would do anything to help our patients — it is an incredibly frustrating and helpless feeling to not be able to do so because there aren’t enough drugs that work.

What effect did the Covid-19 pandemic have on antimicrobial resistance?

Dr. Marrazzo: Across the globe, Covid-19 caused more intensive care and antibiotic use, and any prolonged hospital stay increases the potential for hospital-acquired infections, which are increasingly antibiotic resistant. The CDC found that there was a 15% increase in antimicrobial-resistant infections and deaths during the first year of the pandemic, and almost half of those patients got the infection while in the hospital. A 2022 special report from the CDC concluded that antimicrobial-resistant infections have “become an even more prominent threat” as a direct result of the pandemic.

I think I speak for many provider colleagues when I say that treating patients with Covid-19 was emotionally and intellectually difficult in those early months. There is the dual heartbreak of treating patients who recovered from Covid-19 only to later die from an antimicrobial-resistant infection.

Covid-19 has also led to widespread provider burnout — everyone talks about the “great resignation” in every sector — in healthcare that means there aren’t enough infectious diseases experts to manage outbreaks and prevent infection.

What needs to be done?

Dr. Marrazzo: Infectious diseases specialists have consistently been the ones tamping down smaller outbreaks of antimicrobial resistant pathogens across hospitals and healthcare facilities regularly, but we are at a real turning point. There is an opportunity for legislators to stave off the nightmare scenario and help prepare the health care system for the future by bolstering the research and development pipeline.

The bipartisan Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act would encourage innovative drug development, improve the appropriate use of antibiotics, and ensure domestic availability of treatments when needed. This legislation, with input and approval from infectious diseases specialists, scientists, public health experts, and patients across the country, would lead to a more robust drug development pipeline by supporting biopharmaceutical companies that produce antibiotics and provide hospitals the resources they need to use antibiotics wisely to prevent resistance and ensure every patient can receive the best possible care.

Infectious diseases providers want to support our patients as best we can. We currently face a serious lack of tools to fight antimicrobial resistance, leaving us unable to help those with serious needs. The U.S. health care system may not be able to sustain another supercharged pathogenic outbreak. Congressional leaders must understand the gravity of this issue and act now to prevent a worst-case scenario.