My family is not normal. We wear Ebola-grade protective suits to our kids’ elementary school career days, send holiday cards featuring our vaccination snapshots from the year and include stops to public health landmarks during summer vacations. We fill the time on road trips answering kid questions about different deadly diseases and have a full collection of plush toys representing smallpox, cholera, polio and many other pathogens.
So it wasn’t off-brand for us to spend a recent dinner conversation debating a hot topic: “What’s scarier – a new pandemic virus or a world without antibiotics?” The two titans of microbiology – the virus and the bacterium – took center stage alongside sheet-pan chicken to create a memorable family exchange.
Most American dinner discussions do not include hypothetical microbial doomsday scenarios. But how we prepare for the next pandemic and prevent the erosion of effective antibiotics are pressing issues. In many ways, they are interlinked.
Covid-19 brought public health into the spotlight and underscored the role of public-private partnerships to meet new disease threats. Vaccine R&D is enjoying a renaissance, buoyed by steady investment by major pharmaceutical companies over the past two decades and the viability of new start-ups. The application of mRNA and other new technologies offer the kind of innovative power required to meet the challenge of future viral threats, especially if matched with political will and new models for global coordination. Perhaps there is cause for a little optimism that we will be better prepared for the next pandemic.
Unfortunately, the same urgency does not exist to solve the looming specter of antimicrobial resistance (AMR). Since the discovery of penicillin almost a century ago, antibiotics have been in the league of vaccines and clean water as the most important public health interventions in history. Yet, with rampant overuse in our food systems, over-prescription for patients and poor waste management practices, the potential for dangerous bacteria to develop resistance to antibiotics increases each year.
Several programs have been established to catalyze research investments in next-generation antibiotics. Antimicrobial research grants from organizations ranging from the National Institutes of Health (NIH), Biomedical Advanced Research and Development Authority (BARDA) and the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) have helped close the gap. In the U.S., several lawmakers drafted the bipartisan PASTEUR Act to create a new model for pharmaceutical industry investment in the development of new antibiotics, but it died in committee last year following criticism that the private sector participants would not deliver the level of product innovation to justify billions of dollars in taxpayer funding.
The current pipeline for truly innovative antibiotics remains worryingly thin. In the past five years, only 12 antibiotics have been approved. That might seem okay if it didn’t mask a failure to deliver breakthrough products: 10 of the dozen new antibiotics belong to existing classes with established mechanisms of antimicrobial resistance and only one, cefiderocol, protected against all gram-negative bacteria on the WHO list of priority pathogens. As of 2021, only 27 new antibiotics against priority pathogens were in clinical stages of development – a drop from 31 products only four years earlier. The number of new candidates in the preclinical stage of development remains stagnant.
For millions of patients facing the frightening possibility of untreatable infections, we need to move with greater urgency to bolster innovation and improve responsible use for existing antibiotics. Already, nearly 1.3 million people around the world die each year from AMR, a number that exceeds higher-profile diseases such as HIV or malaria and is expected to rise to 10 million annually within the next few decades.
Beyond the health implications, the economic imperative to counter antimicrobial resistance is stark: the global cost of AMR is expected to exceed $100 trillion by 2050. There are some important steps that can be taken by governments, drug makers and healthcare providers.
Antimicrobial resistance is not an American problem; it is a threat shared by every country. As such, we should be looking at ways to allocate funding to the entities that can ensure the best application of research takes place. In the U.S., BARDA, NIH and CARB-X need more resources and channels to collaborate more extensively with similar grant entities around the world.
The PASTEUR Act should be resuscitated in the current Congress with renewed emphasis on incentivizing participating pharmaceutical companies to develop innovative antibiotics with new mechanisms of action. To help make the case to policymakers of all stripes, organizations like the Center for Strategic International Studies and Chatham House have excellent track records for framing health imperatives to the right audiences in terms that help prompt action.
Beyond policy and research actions, healthcare provider and patient education on the responsible use of antibiotics should be a priority in every country. This is the responsibility of governments, drugmakers, health systems, individual healthcare providers, even patients and consumers. Infections are scary business, but we need a more effective way of educating people along the entire prescription decision chain to ensure antibiotic potency remains strong.
And that connects back to vaccines. One clear way to reduce our use of antibiotics is to increase vaccination against many of the pathogens that create an opening for bacterial infections. Pursuing this goal, improving AMR-related education and expanding the pipeline of innovative antibiotics give us a shot at avoiding a bleak future where we are defenseless against invisible enemies.
