What’s Needed in Second National Action Plan for Combating Superbugs

The United States released its first National Action Plan for Combating Antibiotic-Resistant Bacteria in March 2015 in response to the growing threat from what are commonly known as superbugs. By setting ambitious goals and prioritizing interventions, the five-year plan spurred significant achievements.

Much work remains to be done, however, as federal officials consider what to include in a second national action plan, expected later this year. According to recent data from the Centers for Disease Control and Prevention, Americans confront almost 3 million antibiotic-resistant infections each year, and more than 35,000 die as a result.

The continued threat posed by these superbugs requires a multipronged and well-coordinated response. Pew has identified key priorities that should be included in the updated plan. In the coming years, stakeholders including government agencies, health care providers, researchers, drug companies, farmers, and veterinarians should strive to:

Improve antibiotic use in all settings.

The more antibiotics are used—in any setting—the less effective they become. To help slow the emergence of resistance, the 2015 action plan called for major improvements in the way antibiotics are used through significant, nationwide reductions in inappropriate prescriptions for people and through improved antibiotic stewardship on farms.

In recent years, there have been significant advances in reducing inappropriate antibiotic use in human health care. For example, CDC created Core Elements of Stewardship for different types of health care facilities, which have been pivotal to progress. And, today, stewardship programs are required in the vast majority of hospitals and long-term care facilities. The next national action plan should focus on improving the quality of existing hospital stewardship programs while also promoting more widespread implementation of stewardship in doctor’s offices and other outpatient settings.

And when it comes to improving how antibiotics are used for food-producing animals, perhaps the most significant step forward since 2015 has been full implementation of the Food and Drug Administration’s Guidance for Industry 213, which prohibits the use of medically important antibiotics for growth promotion and requires veterinary oversight of antibiotics administered through animal feed and water. Still, other types of injudicious uses of these drugs persist.

The next action plan should incorporate the goals of FDA’s own 2018 five-year plan, which called for  establishing veterinary oversight of  injectable antibiotics and steps to ensure that all antibiotic drug labels meet FDA’s judicious use guidelines. For example, all labels should have clear limits on how long an antibiotic may be used. The plan also should set clear expectations for producers to implement stewardship programs that are aligned with the consensus-driven framework established in 2018, the result of an effort led by The Pew Charitable Trusts and the Farm Foundation.

Increase collection, measurement, and reporting of antibiotic use and resistance data.

More comprehensive data are needed to help policymakers track trends, refine priorities, and target interventions to reduce unnecessary antibiotic use and to prevent and control the spread of resistance. Availability of antibiotic use data from some health care settings enabled CDC and Pew to set data-driven national reduction targets in 2016 to help guide interventions. However, the country has yet to achieve the original action plan’s goal that the vast majority of hospitals report antibiotic use and resistance to CDC’s National Healthcare Safety Network.

In animal agriculture, significant gaps remain in understanding how antibiotics are used and why. The new plan should incorporate objectives from FDA’s five-year plan related to enhanced monitoring of resistance and antibiotic use in animals, including improvements to the National Antimicrobial Resistance Monitoring System. The plan also should call for metrics to assess meaningful progress in food animal antibiotic use, as well as implementation of a biomass adjustment—a method that uses animal population estimates to contextualize antibiotic sales data.

Develop new antibiotics and alternatives.

Because bacteria constantly evolve to resist antibiotics they come into contact with, new drugs and nonantibiotic strategies to address diseases will always be needed. The first action plan included a goal to develop more new antibiotics and nontraditional therapies, and some progress has been made on this front. Six new antibiotic candidates have made it to market since 2015, thanks in part to development funding from the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator.

According to a recent assessment from the World Health Organization, however, these drugs are not the new types needed to overcome resistance. Further, in recent  years, the major pharmaceutical companies have largely ended their antibiotic research and development programs, and multiple smaller antibiotic companies have filed for bankruptcy. Those remaining in the field are struggling to stay afloat. 

The next action plan should call for federal incentives to reward companies that develop urgently needed antibiotics that can treat the most dangerous superbug infections. The plan also should incorporate FDA’s five-year plan goal to spur development of alternatives to antibiotics for food animals.

Measure and evaluate national action plan effectiveness.

To maximize its impact, the next national action plan should include clear benchmarks and metrics to evaluate progress.

The country’s concerted efforts to combat resistant bacteria since 2015 have made a difference, but federal agencies, health care facilities, farmers, veterinarians, scientists, and other stakeholders need to continue the fight to keep ahead of this ever-evolving public health threat. The next national action plan will be crucial to guiding these efforts and protecting the health of every American.

Kathy Talkington directs The Pew Charitable Trusts’ antibiotic resistance project.