The United Nations General Assembly’s first high-level meeting on antimicrobial resistance (AMR) in 2016 was a pivotal moment, highlighting the scope and urgency of this public health crisis. The meeting energized leaders in the fight against AMR in the United States and around the world, and many nations—including ours—have taken action to slow the spread of deadly drug-resistant infections. But as world leaders prepare to gather for the second high-level meeting on AMR on Sept. 26, the fight is far from over. Resistant infections are on the rise since the COVID-19 pandemic—and are now on track to lower global life expectancy by nearly two years over the next decade. So, there is more that our nation’s leaders can and must do to protect public health and save lives.
As antibiotic-resistant bacteria continue to spread, the antibiotic pipeline is not producing new and effective drugs to keep pace with patient needs. According to the most recent analysis from the World Health Organization, there are only four truly innovative antibiotics in development worldwide with the potential to treat the most dangerous resistant pathogens. Considering that, historically, only 1 in 5 infectious disease drugs that enter clinical trials make it to market, the odds of getting any of these new medicines to patients are grim. Four novel antibiotics are simply not sufficient to meet the magnitude of the problem. Not even close.
But Congress can take a major step toward fixing this shortage of new drugs by passing the bipartisan PASTEUR Act this year. The bill would incentivize the development of innovative, high-priority antibiotics by committing to pay for new drugs based on their value to public health rather than by volume prescribed. This “pay for success” approach, which has been called for by numerous commissions, reports, coalitions, experts, and organizations—including The Pew Charitable Trusts—brings some predictability and stability to a fundamentally broken antibiotics market that pharmaceutical companies have largely abandoned in favor of more profitable drugs, by providing funds only for drugs that address a currently unmet public health need and earn approval from the Food and Drug Administration.
Economic incentive models similar to the PASTEUR Act have been successfully piloted in the United Kingdom and Sweden, and Japan has created a similar program to support development of antibiotics that target key pathogens. And while these steps are encouraging, a few pilot projects will not suffice to remedy a worldwide problem this difficult—and this threatening to public health. That’s why such efforts must be scaled up, with incentives big enough to make antimicrobial drug development a winner in the market. And passing the PASTEUR Act will be a meaningful next step toward that critical goal.
In addition to developing new drugs, the U.S. needs to be doing more to make sure that existing antibiotics work for as long as possible. This is not as easy as it sounds—because the unfortunate reality is that every time antibiotics are used, bacteria have an opportunity to learn, evolve, and eventually outsmart the drugs designed to conquer them. So it’s critical that antibiotics are used only when necessary, to limit the opportunities for bacteria to develop strategies to evade them and become what are known as “superbugs.”
That’s where stewardship programs come in.
Antibiotic stewardship programs help reduce the misuse of antibiotics, improve patient outcomes, lower health care costs, and slow the emergence of resistance. These are all big wins. And there has been significant progress in improving and expanding stewardship programs in U.S. hospitals over the last few years. Now it’s time to expand these efforts to include outpatient health care settings, such as doctor’s offices, urgent care, and community health centers, where the bulk of U.S. antibiotic prescribing takes place.
At the federal level, the Centers for Medicare & Medicaid Services should incorporate antibiotic use metrics, such as the Antibiotic Utilization for Respiratory Conditions measure, into their core criteria that are used to assess the quality of care provided to children and adults under Medicaid. These core measures help states to better understand how they perform on health care quality and to prioritize issues—such as antibiotic stewardship—that may be in need of additional investment and support. State Medicaid agencies and private payers can include stewardship in their quality improvement programs—providing clinicians with data on their prescribing practices and incentivizing improvements in the care they provide. Nongovernmental stakeholders, such as health systems, can also broaden their antibiotic stewardship programs to include outpatient care rather than focusing them primarily on inpatient care.
Ultimately, ensuring that antibiotics are used appropriately in all settings is essential for protecting lives today—and in the future. But it cannot be done in isolation. Preserving available antibiotics, especially in outpatient settings, requires action from a range of stakeholders at the federal, state, and local levels.
One of COVID-19’s many lessons is that waiting until a pandemic hits is not a productive or cost-effective way to protect Americans from public health threats. Health experts have been warning for decades that the threat of antimicrobial resistance is growing, and the likely emergence of more and increasingly dangerous resistant superbugs is real.
This complex threat requires a comprehensive and multipronged response; drug development incentives and stewardship programs are crucial, but still are not enough to combat AMR. Much more needs to be done. Funding basic science at the National Institutes of Health, early-stage research and development of diagnostics and nontraditional antibacterial treatments through the Biomedical Advanced Research and Development Authority and CARB-X, and disease surveillance supported by the Centers for Disease Control and Prevention would be a good start. And while many private sector initiatives and public-private partnerships are contributing important work in the fight against superbugs, federal commitment and funding still play a critical role.
So, as global leaders come together to tackle the persistent menace of drug-resistant infections, U.S. policymakers have clear opportunities to meaningfully address AMR. By passing the PASTEUR Act and supporting efforts to preserve currently available antibiotics, Congress can continue the progress that’s already been made and reinvigorate momentum for the fight against AMR. It’s time for the United States to signal to the rest of the world that it refuses to let deadly pathogens go untreated—and let another dangerous pandemic take hold.
David Hyun, M.D., directs The Pew Charitable Trusts’ antibiotic resistance project and state health solutions project. Rachel Zetts, M.P.H. in public health, works on The Pew Charitable Trusts’ antibiotic resistance project and state health solutions project.