ICPs at the heart’ of fed drug resistance plan

"Unless antibiotic resistance problems are detected as they emerge — and actions are taken quickly to contain them — the world may soon be faced with previously treatable diseases which have again become untreatable, as in the pre-antibiotic era."

— Federal Draft Plan to Combat Antibiotic Resistance

The Centers for Disease Control and Prevention and several other federal agencies have drafted an ambitious plan to preserve the efficacy of antibiotics, addressing a host of issues from agricultural use to research needs. (See editor’s note on p. 110 for information on availability of the draft). Though finalization of the draft will raise "the devil in the details" in many broadly defined areas, it is clear the plan will rely heavily on infection control professionals and health care epidemiologists to track and prevent drug-resistant pathogens, says David Bell, MD, co-chairman of the federal task force that developed the draft and assistant to the director at the CDC center for infectious diseases.

"All of this — the surveillance, prevention, and control [aspects] — have to be built on local efforts," Bell tells Hospital Infection Control. "We’ve learned even from our [prior] efforts to improve antibiotic use that it’s not just a matter of handing out national guidelines. It’s a matter of local [clinicians] looking at national guidelines and saying, Here’s how we’re going to implement them in our health care system; here’s how we’re going to manage our patients.’ The infection control professional is going to be at the heart of this."

The draft is essentially a blueprint for future interaction by the CDC, the Food and Drug Administration, the National Institutes of Health, and several other federal agencies. It calls for a national system for antibiotic resistance surveillance that would include drug susceptibility data and patterns of antimicrobial use. (See action priorities, above.) The idea is to accomplish that goal as much as possible by linking existing surveillance and laboratory capabilities. "I don’t think anybody wants to invent some totally new structure," Bell says. "It’s going to be mostly a matter of coordinating and, to some extent, standardizing what we have. There are a lot of gaps that can be filled."

The draft plan calls for prevention and control of drug-resistant infections by promoting the prudent use of antimicrobial drugs, improving diagnostic testing, and increasing vaccine use. "Reduced infection transmission will be addressed through public health campaigns that promote vaccination and hygienic practices such as hand hygiene and safe food handling," the draft states. Infection control in health care settings will be enhanced by developing new interventions based on rapid diagnosis, improved understanding of the factors that promote cross-infection, and modified medical devices or procedures, according to the plan.

"All of these aspects have to be combined into an integrated program," Bell says. "No one single aspect will work. You can’t just do one thing or even two things. It has to be a package, and one of the priority items in the plan is to support what we call demonstration projects’ in various areas around the country to learn how to assemble this package most effectively."

If such demonstration projects show that antimicrobial resistance patterns can be lowered, might there be federal funding forthcoming to implement such programs nationally?

"The short answer is yes," Bell says. "We’ve already actually started to support some of these local programs. For example, the [CDC] hospital infections program has its Centers of Excellence. We also have awarded funds to states and other groups, but we need to do more of this. We need to learn which packages work and implement them on a wider scale."

That means it ultimately may depend on Congress to provide funding if the nation is to preserve antibiotic efficacy, which is eroding in the face of drug misuse and overuse in virtually every class of antimicrobials. "I can’t speculate on specific funding, but we know that there is bipartisan support [and] interest in Congress on antimicrobial resistance," Bell says. "We’ve received letters from Senators and Congressmen asking about drug-resistance issues and expressing interest, and this comes from both Republicans and Democrats. That is a good sign."

Ending the logjam in agriculture

The draft follows another recent FDA "framework" document underscoring that the agency is considering new regulations on antibiotic use in agriculture. "The FDA [involvement] has the potential to break the logjam of 30 years of argument between the public health and human medicine folks and the agriculture/veterinary folks," Bell says. "They have not explicitly taken into account safety in terms of antimicrobial resistance with infections in humans in the past. That’s one thing they’re now doing."

For example, there is mounting evidence that agricultural use of a drug called virginiamycin in chickens may contribute to human resistance to quinupristin/dalfopristin (Synercid), a new drug used for resistant pathogens like vancomycin-resistant enterococci. "It’s in the same antibiotic class, and so there’s cross-resistance," Bell says, adding that a CDC study found quinupristin/ dalfopristin-resistant pathogens in 59% of chickens bought in grocery stores in five states. "The presumption is that this is related to virginiamycin as a growth promoter in these chickens," he says.

From animals to humans

By consuming animals, humans can acquire their resistant pathogens over time, either through undercooked meat or cross-transmission from uncooked to cooked meat, he notes. One problem is that antibiotic resistance linked to agriculture use may not surface in humans for years, and it is difficult to withdraw an approved drug, he adds. "The real breakthrough [in the federal plan] is that they would require post-approval monitoring and make decisions post-approval based on surveillance of drug resistance in both humans and animals," Bell says.

There is little argument about the use of antibiotics to treat sick animals, but massive doses for "growth promotion" are the questionable practice that may be most affected. The National Research Council estimated in 1998 that the average weekly meat bill for a family of four would increase by only 75 cents if no growth-promoting antibiotics were used on farm animals. "And we’re not even advocating no growth promotants at all," Bell says. "We’re simply concerned about some of them that are also used in human medicine and could select for resistance. When an antibiotic valuable in human medicine is proposed for use on the farm, we are a little uncomfortable because we know that there is the potential for resistance to develop and then brought back to humans. And we also know that the FDA has trouble withdrawing the approval once it’s made."

(Editor’s note: The federal draft guidelines have been posted for review and comment by Aug. 5, 2000, at www.cdc.gov/drugresistance/action plan.)