APHJ – Antibiotic Resistance with Sara Tomczyk

APHJ – Antibiotic Resistance with Sara Tomczyk


One of the greatest medical and public health breakthroughs of the 20th century was
the development of antibiotics. Antibiotics allowed us
to successfully treat myriads of infections
that had previously killed or seriously injured millions
of individuals. It led to expansion
of the pharmaceutical industry which developed newer
and more potent antibiotics and in countless ways,
it changed the way we practiced human
and animal medicine. However, bacteria are
quite hardy and adaptable. In the last 30 years,
we have seen an increase in the number of bacteria
that are immune or resistant to our antibiotics. We’ve also seen a decline
in the number of new antibiotics being
developed. This is literally
a deadly combination. In fact,
over 2 million infections and over 23,000 deaths occur
on an annual basis in the United States due to
antibiotic resistant organisms. Antibiotic resistance has become
a major public health problem– a problem few people know about. Because of that, we will talk
about antibiotic resistance on today’s episode
of “A Public Health Journal.” Please stay tuned. (man) Welcome to
“A Public Health Journal,” a program that explores
public health issues facing our society today and
tomorrow. The host of the show is
Dr. Ed Ehlinger, Commissioner of Health
for the state of Minnesota. “A Public Health Journal”
is sponsored by the Minnesota
Department of Health, and the
Hennepin County
Human Services and
Public Health
Department; all working together
towards the goal of healthy people
living in healthy communities. Welcome to “A Public Health
Journal.” Today we’re going to talk about
antibiotic resistant organisms. Our reliance on antibiotics to
keep us safe makes this decline in their
effectiveness of major concern. Antibiotic resistance has become
a major public health problem. Because of that, I’ve invited
Sara Tomczyk to join us to talk about this issue. Sara is a Preventive
Medicine Fellow at the Centers for Disease
Control and Prevention or CDC. She is currently working on a One Health Antibiotic
Stewardship Strategy at the Minnesota Department
of Health. Sara is an infectious disease
epidemiologist who has worked on outbreak investigations
in more than 10 countries across Africa, Southeast Asia,
and the Americas. Sara, welcome to our program.
Thank you for having me. Thank you for being here
in Minnesota to help us on this issue of antibiotic
resistance. So let’s start with some really
basic things. First of all,
what are antibiotics? Antibiotics are an important
public health tool; they’re an important treatment. Ever since the development
of penicillin, it’s essentially been
a miracle drug. It’s something that has allowed once killer infections
to be treated. It’s allowed us to prevent
infections in surgery
or in cancer treatment. And so it’s an incredibly
important piece of medicine. Although with any resource,
it’s also a precious resource. So it does, two things
that I think most people don’t realize, it treats
diseases once you get them, but it also prevents things. How is it used to prevent
disease? Right, so in terms
of prevention, I think 2 key examples of it
as I just mentioned, is in terms of surgery,
so once we go into surgery, it’s used as a prophylactic in terms of infection
prevention. And then also for also intensive
care unit medicines or in cancer treatment, etc. So most people would assume
that antibiotics are things that you take in pill form or
get an injection of penicillin in the good old days, but antibiotics are
more ubiquitous than that. Where else do we find
antibiotics. Right, yes, and they’re also
in our soaps, they’re also in our sprays, so when we’re
washing our hands you have antibiotics in the soap
to prevent infection, so you’re absolutely right,
you see it in a lot of products. And are those effective
in preventing disease? ‘Cause I understand that
sometimes soap without antibiotics in them are just as effective as soaps
with antibiotics. Yes, absolutely, so hand hygiene
is critical, but soaps without antibiotics
also does the trick in terms of infection
prevention. And antibiotics are used
not just for humans, they’re also used
for animals. Right? How are antibiotics used in veterinary medicine
and in agriculture? Yes, so just like humans get
sick, animals also get sick. And so antibiotics are
an important treatment an important public health tool
in veterinary medicine or in agriculture, on the farms. So this is another important use
of antibiotics as well. So do they again treat illnesses
and prevent illnesses just like used for humans? Right, so certainly
on the treatment side. It’s also used to prevent
antibiotics. There is some new legislation in
the works in the United States that will actually be providing
new rules on how we use antibiotics for prevention
of infections in animals to be judicious as possible, but they are used in both ways,
prevention and treatment. And has the use of antibiotics
increased since the 1940s when penicillin was created? Has there just been continued more and more use
of antibiotics? Yes, so we have seen
increasing trends of both overuse and misuse
of antibiotics. When you talk
about overuse and misuse,
what are you talking about? Right. And so actually,
just to lay a foundation, any type of antibiotic use
can lead to resistance, but in particular what we’re
concerned about, is when we use antibiotics,
when we’re talking about misuse, when we use antibiotics for
something that’s not bacteria, so something that it can’t
actually treat. And a good example of that is
your common cold or your cough. That is most likely always
caused by a virus and so when we take antibiotics
for our common cold, that’s not something
that is appropriate, it’s not something that will
treat a virus, antibiotics. And so that would be
a prime example of misuse. Now overuse is also similar
in the sense of we’re using too many antibiotics
to treat one infection. So it might be a bacterial
infection, but we’re using too many antibiotics
to treat that same infection. Now I’ve got a little map here
that shows antibiotic prescriptions
per 1,000 persons in the United States
according to states. It looks like antibiotics are used differently
throughout the country. Tell us a little bit about
what you see on this map. (Sara Tomczyk)
Yeah, so if you see, in terms of the darker colors on this
map, that’s where we see more antibiotic prescriptions
per 1,000 persons. And so certainly you see
in the southeast it’s a
little bit larger of a problem. But I think the bottom line is
that antibiotic use and misuse and overuse
is a problem in all states, I mean,
we can improve everywhere. You can see that Minnesota in particular
is sort of in the middle. There are certainly states that, they’re better than some states, but again, the bottom line is that we can improve
everywhere across the U.S. So does this mean that people
practice medicine differently or does this mean that there are
more infections in some parts of the country than in
other parts of the country, sort of the culture different
in different places? I think it’s multifactorial,
so it’s a combination. So we might see different
patterns of infections in different areas because
we also have different climates, we have different interactions
between people, and then it certainly,
there’s a cultural aspect too. So the public might seek
antibiotics in a different way or clinicians might prescribe
in a different way and that would be sort of
the cultural piece as well. Another thing to remember
if we’re looking at patterns of antibiotic-resistant
infections or antibiotic prescriptions, is
that we can also measure that in different
ways across the state. And so it’s important just to
remember back to the bottom line is that we can probably improve
in all areas on certain common goals, like I mentioned
in terms of trying to avoid antibiotics for something like
your common cold or your virus. The pharmaceutical industry is
a huge industry, and I think a lot of it has been
built up around antibiotics. Are there more and more
antibiotics available and more powerful antibiotics? So you know, I think
that it depends. I think there are– antibiotics
are still readily available at our primary clinic,
for example, for something like the common cold, but in terms of
the development of antibiotics, I think we’ve actually seen
not as many antibiotics being developed like penicillin
once was as a miracle drug. And so it’s a combination
in terms of goal-setting on the national level
for example, is that we want to get better antibiotic
prescribing, but we also want to encourage innovation and
development of new antibiotics. We talked a bunch about
antibiotics and now I want to talk about antibiotic
resistance, but we’ll have to do that in the next segment, ’cause
we’re going to take a break. We’ll be back,
right after this message. [man sneezes] [man sneezes] [man clears his throat] Welcome back, we’re talking
about antibiotic resistance with Sara Tomczyk, a preventive
medicine fellow from CDC working at the Minnesota
Department of Health. Sara, in the first part
we talked about antibiotics, what they are and how
they’re used and a little bit about some of their
inappropriate use, but let’s talk about
antibiotic resistance. What do we mean
when we’re talking about
antibiotic resistance? Right. And so like we said
earlier, antibiotics have been an incredibly important public
health tool and treatment. But like any resource, we need
to use them judiciously. And what we found
is with antibiotic use and in particular, antibiotic
misuse and antibiotic overuse, is that bacteria have changed. They’ve changed in a way
that has either reduced the effectiveness of antibiotic
drugs or they’ve eliminated the effectiveness of the drugs. And so that’s what we mean
when we say resistant bacteria. So what kind of organisms
are immune or resistant to antibiotics, things that we
thought well we had under good control,
and now all of a sudden we don’t have the tools
to treat them? So we’ve seen a range
of bacteria unfortunately, that have become resistant
to drugs. We have things like
our respiratory pathogens so bugs called streptococcus
pneumoniae or tuberculosis, we have sexually transmitted
diseases like gonorrhea, we also have our GI bugs so this can be
campylobacter or salmonella. So unfortunately, we’ve seen
quite a range of bacteria that has become resistant
to antibiotics. And in fact I’m wearing
a TB tie that says it’s antibiotic
resistant. So how does antibiotic
resistance develop? Is it just natural, kind of
occurring or is it because of the misuse,
or is it both? It’s both, so with every use
of antibiotics we have seen resistance,
what I should say is all antibiotic use can lead
to antibiotic resistance, but in particular, what we want
to try to address and what we want to try to improve is the
misuse and the overuse piece, because antibiotics are still
an important treatment and certainly a public health
tool to use, we just want to use them more appropriately
and more judiciously. Let’s take
an example– somebody’s got
a cold, you said you shouldn’t be using antibiotics
for a virus infection ’cause they’re not effective,
but a lot of people do. They say I’ve got a cold,
I’m going to go to the doctor
and get an antibiotic. They get an antibiotic– how
does that lead to resistance, ’cause they’re not effective
on the virus in the first place. How does that lead
to antibiotic resistance? So when we take an antibiotic
that is not going to treat something like a virus,
we essentially give time for the bacteria to change,
so to reduce it’s effectiveness or to reduce the effectiveness
of the drug or eliminate the effectiveness. The same goes with maybe not taking the full antibiotic
course. So maybe we do have a bacterial
infection and the doctor has prescribed
7 days of antibiotics, we start to feel better
in the middle and we stop, that’s another way that we have
given the time for the bacteria to potentially change
and become resistant. So when you say the overuse,
I mean treating for things that are not appropriate, can
you treat too long or too many? I know some organisms
use multiple drugs to treat it. Yeah, and so the other half
to remember– so on one hand we have something like your
common cold at the clinic, but then you also are obviously
treating infections at the hospital setting,
and so a lot of that depends on your diagnostic tools
and identifying the right bug, and that sometimes takes
a little time. And so clinicians may provide
different antibiotics to try to cover
that particular pathogen. And so sometimes they probably
provide too many antibiotics in an effort to be cautious,
but one way that we can work on improving antibiotic use
is also to improve diagnostics. So we give clinicians the tools to make better decisions
about antibiotic use. Are the antibiotics
used in animals the same as the antibiotics
used in humans? Yes, so there is some overlap. So there is some use
of antibiotics that are of human healthcare importance
in animals. So does the same thing hold
with animal use, overuse, used inappropriately,
does that then also not just affect the animals
but also effect humans? Yes, and so we kind of
have to see the big picture. So absolutely, in terms
of animal antibiotic use, we see inappropriate use
and overuse and that’s going to lead to resistant infections
within our animals itself, so that could be our pets
or on the farm in agriculture, and then maybe that resistant
infection is released through the waste
of the animals, maybe that gets into
our wastewater and maybe that’s also affecting
our human healthcare or it could be through food animals,
so what we’re eating as well. And so again,
it’s this big picture, kind of the circle of life in terms
of the interconnectedness between antibiotic use in both human healthcare
and animal healthcare. So is antibiotic resistance
a problem just in the United States, or is it
a worldwide phenomenon? It’s definitely global,
it needs to be a global effort because it is a global issue. This is reflected in a lot of
initiatives that are worldwide to address antibiotic
resistance, so promoting a collaboration between
countries, so not only nationally in different states,
but also within different countries,
and this is exemplified by the World Health Organization,
so WHO, and efforts that they’ve had to address antibiotic use
and antibiotic resistance. It’s also been
in the agriculture, in the food animal world
as well globally. So there’s a lot of groups
trying to bring people together to address this issue globally
as well. ‘Cause I understand
in some countries, you can get antibiotics
without a prescription, just go to a pharmacy
and get them, that must lead to huge problems
with antibiotic resistance. Yeah, so of course, there’s
a range of different challenges in different countries,
and so if you have a system that perhaps doesn’t have
as much regulation on how you get an antibiotic
or an antibiotic prescription, then that can lead
to different challenges in terms of antibiotic
resistance. So yes, we see it in different
countries in different ways. Another challenging piece
is how we measure it in different countries, ’cause
we don’t have the same type of surveillance system in every
state or every country and so it can sometimes also be hard
to just compare what is a problem
in different settings as well. And I know you’re doing
something called antibiotic stewardship,
and I want to talk about that and also this whole concept
of One Health, which we’ll get into, but first we need
to take another little break. We’ll be back
right after this message. Heart, what’s goin’ on? I’m leavin’. Why? What did I do? Not enough. You constantly ignore me,
you barely eat anything healthy, you’re half as active
as you used to be; the pressure is
just too much. I quit. Okay, I get it.
Just please, don’t leave. I’ll do better. Okay.
But remember, if I go– you go. (woman) Listen to your heart.
Don’t let it quit on you. Uncontrolled high blood pressure
could lead to stroke, heart attack or death. Get yours to a healthy range
before it is too late. Welcome back, we’re talking
about antibiotic resistance and we’ll be talking about
antibiotic stewardship and a concept of One Health
with Sara Tomczyk from the Minnesota Department
of Health. So we talked about antibiotics,
the problems we have with antibiotics, you’re working
on something called antibiotic stewardship,
what does that mean? Antibiotic stewardship
is a term we use often in human healthcare, and so
this is, essentially it can be a coordinated set
of interventions that are meant to improve antibiotic
prescribing for antibiotic use. So it’s not that complicated
a definition, in fact, if you just think about
the word, we all want to be good stewards of antibiotic use. But when we say an antibiotic
stewardship program, for example,
this might be a hospital or a healthcare facility program
that is intended to improve antibiotic prescribing and
prevent resistant infections. So what kind of things
would they do to do that? So it could be something
as simple as different staff trainings or training
for healthcare professionals, or it can be something that
we’ve seen actually a lot of success with, something called
electronic decision support. So this might be something
that’s worked into electronic medical records
that could be prompts to remind the clinician of what
might be the appropriate drug, dose, duration, time period,
and things like that. But there’s actually a range
of different interventions. They’ve also looked at things
like posters in the clinic for the public to see
and the professionals to be reminded of,
and so it’s been quite a range
of different things. So are the pharmacists
engaged in this in addition to the physicians and nurses
who are prescribing? Yes, it’s absolutely, and it
needs to be, multidisciplinary. So part of these antibiotic
stewardship programs include both your physicians,
your nurses, your nurse practitioners,
your physician assistants, but essentially your pharmacist
as well, and so the pharmacist can be an incredibly important
support for all clinicians in terms of providing
recommendations on the right drug, the right
dose, the right duration, or providing a review
of the antibiotics prescribed maybe in the last month
at a particular facility. Do clinicians really realize
how big of a problem this is? You know, there’s a lot going
on, for example, in Minnesota. There’s a lot of facilities
and a lot of clinicians acknowledging the problem
of antibiotic resistance and acknowledging the need to
improve antibiotic prescribing. But I also think we certainly
have room to improve as well and continue to promote
awareness on the issue. Yeah, ’cause aren’t we sort of
running out of antibiotics and the bugs are continuously
changing. This could be a huge problem
for us down the road. So I think it’s also appropriate
to label it as an urgent public health
threat, so it’s absolutely something
that we need attention on. You know it’s not, it’s funny,
it’s called an emerging public health threat,
but antibiotic resistance is not something that’s new
’cause we’ve seen it since the development
of penicillin for example, but what’s exciting is that
we’ve just started to see more impetus
and people coming together and trying to push for this
important issue because again, it’s an urgent
public health threat and something
that we need to address now so that years down the road
we’re not in a situation where we don’t have anything
to treat infections. This is really a problem
for all of us, that’s what gets into this whole idea
of One Health. I’ve got a slide here, a graphic
that I’d like to have you talk about, what is One Health
and how does this bring all of us into better use
of antibiotics, antibiotic stewardship
across the board? (Sara Tomczyk) Right,
so One Health is a concept that essentially acknowledges
that the human healthcare and the animal healthcare and the health of our environment
are all interconnected. ‘Cause like we talked about
earlier, antibiotic use can lead to antibiotic resistant
infections in humans and in animals and then
resistant infections can be spread between animals
and humans, and then the antibiotics can be disposed
of into our environment, or we find antibiotic resistance
in our environment that might also spread to humans
and animals for example. So again, it’s this big picture
and it’s showing how each of these pieces
are related. So if we get antibiotic use
in animals and humans, we flush it down the toilet,
it gets into the water supply, rivers and streams,
can that actually lead to antibiotic resistance
development? Yes, and so that’s
the interesting part about looking at this
in terms of a One Health lens because that’s also
a very important part that sometimes gets
neglected. So the disposal of our
antibiotics or the antibiotics that might come out
in our fecal waste or when we go to the bathroom, that could
get into our environment, into our wastewater
and that could potentially lead to other resistant infections
in humans again. Certainly the healthcare field
is worried about antibiotic resistance,
are the environmental folks and agriculture also worried
about resistance? Yes, so here in Minnesota
we have some very prestigious environmental scientists
that are looking at some of these questions in terms
of on the chemistry side how do antibiotics degrade
in the environment or on the wastewater management,
how can we treat our water to prevent antibiotics,
the presence of antibiotics or antibiotic resistance,
and then also on what is the proper disposal. So this is the public awareness
piece on how do we dispose of our antibiotics
appropriately so that we’re not flushing them
down the toilet and we’re taking them
to the pharmacy and trying to promote
better disposal. So on the environment side,
absolutely. On the animal side
there’s also a lot going on. They’re very active in terms
of groups in agriculture, for example,
with quality assurance or certification programs
to promote better stewardship
as well within those settings, so there’s a lot going on, we
have a lot of room to improve, but there are
existing activities. So I suspect the Centers for
Disease Control and Prevention, CDC and FDA and USDA,
all of these federal agencies, are they all engaged
in antibiotic resistance? Absolutely, so actually in 2015,
the White House released a national action plan
on antibiotic resistance and groups like the CDC, FDA,
USDA, are all coming together and working closely
with the government on this. And we’ve seen support from both
sides of the political aisle, for example, as well
in this important issue. And CDC for example,
is doing some great things in terms of promoting the goals
of that national action plan, but also in terms of awareness,
they have something called Get Smart About Antibiotics
Week. And this is every year
in November, Minnesota participated
this year. There’s a lot of exciting
components, it’s meant to raise the awareness of this urgent
public health issue, and how can we prevent it, how can we
promote better antibiotic use through different healthcare
professional trainings, or through different public
awareness campaigns, etc.? So they have a lot going on,
same with FDA, they’re working to improve how antibiotics
are used in agriculture and veterinary medicine,
and USDA in terms of also thinking about data collection,
how do we measure on the farm for example, antibiotic use
or antibiotic resistance? Sara, this has been fascinating,
a huge public health issue, things I don’t think most people
worry about, but it’s something we all have
to worry about. Thanks for
bringing that message here.
(Sara) Thank you for having me. I’ll be back
with a closing comment
right after this message. [man sneezes] [man sneezes] [man clears his throat] One of the greatest
public health achievements of the 20th Century
was the decline in deaths due to infectious diseases. As you can see from this graph,
the rate has dropped from 800 deaths per thousand
in the population in 1900 to under 50 in the year 2000. But what is also striking is
that most of the drop occurred prior to the introduction
of penicillin in the 1940s. That means that all of
the other control measures like improvements in the sanitation
of drinking water and wastewater along with improved hygiene
were incredibly powerful. Certainly, the advent
of antibiotics was a great addition
to our armamentarium of infectious disease-fighting
tools but, as we see the decline in their effectiveness,
we must redouble our efforts to implement and support
the other public health sanitary practices that continue
to be effective. We need to invest in basic
public health in addition to research on the development
of new antibiotics. What’s also dramatic in this
graph is the spike in deaths in 1918 due to the Spanish Flu
pandemic. The threat of pandemic flu is
always present and because flu cannot be treated by antibiotics
we must be sure to also maintain our preparedness
for such an outbreak. The bugs of the world never rest
so we can’t either. That’s all for today.
Thanks for watching. I hope you can
join us again next time
on “A Public Health Journal.”

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