Antibiotic Resistance: Back to the Future

In today's Pittsburgh Tribune Review is an article by Mike Wereschagin detailing the public health emergency posed by antimicrobial resistance. I was interviewed (alongside the leading voice on this topic, Dr. Brad Spellberg of UCLA!) for this important article and made a few points that included:

  • Alexander Fleming prophetically warned of this trend in the 1940s
  • In my own career, I have had to "treat" totally drug resistant infections and have seen patients succumb to their infections
  • The need to move from non-specific therapies such as broad spectrum antibiotics to targeted therapies such as bacteriophages and antibodies (which were the mainstay of treatment prior to the discovery of antimicrobials, see Arrowsmith)
  • Brian Potoski, a stellar infectious disease pharmacist and my colleague, makes the point about the danger of using antimicrobials for common viral infections (which is incorrectly done the majority of the time)

Adding to the information contained in this article, is a small piece I wrote detailing the Lancet Infectious Diseases report on the issue and their recommendations, which include exploring the "age-old" phage therapy."

 

Severe ARDS Centers

An important research study focused on the geographic characteristics of severe ARDS centers undertaken by UPMC's David Wallace (who was one of my CCM co-fellows) and colleagues is to be presented at the annual SCCM meeting in abstract form.

Wallace's study looks at the locations of hospitals equipped to care for individuals with severe ARDS based on variables such as their annual mechanical ventilation volume and capacity for ECMO. What Wallace found was that between 88 and 99.7% of the US population has access (via ground or helicopter) to a severe ARDS center within 2 hours.

This study provides essential underpinning to construct a national system of severe ARDS centers--similar to trauma, cardiac, stroke, transplant, and burn centers--which could prove crucial during an outbreak of a severe respiratory infection such as influenza, SARS, MERS, or an as yet emerged pathogen.

A few years ago, my colleagues and I developed a conceptual model to construct such a system. It is with research such as conducted by Dr. Wallace that such a system may, one day, become reality.

 

 

Interferon Free Therapy for Hepatitis C!

In the last few weeks the FDA approved two new antiviral agents for hepatitis C--a scourge that infects over 3 million Americans and is the leading cause for the need for liver transplantation. 

For years the standard treatment for hepatitis C virus had been a combination of two drugs, interferon via injection and ribavirin, taken for up 24- 48 weeks (depending on which genotype of hepatitis C virus is present). These medications had serious side effects including depression, anemia, and flu-like symptoms causing many individuals to stop treatment early. 

A few years ago, the landscape of hepatitis C changed with the approval of two new drugs to be used in combination with interferon and ribavirin in the treatment of the most common type (genotype 1) of hepatitis C. These protease inhibitors, boceprevir and telaprivir, have improved treatment response rates and can, in some instances, decrease the duration of treatment. Last month, the FDA approved simeprevir a once-daily protease inhibitor that can also be used in combination with interferon and ribavirin.

The 2nd drug the FDA  approved is sofosbuvir, a potential pathbreaking nucleotide analog.  The excitement over this drug stems from the fact that it can be administered in an interferon-free regimen, sparing patients months of dreadful side effects. Interferon-free regimens are restricted to genotype 2 and 3 infections. For genotype 1 infections, triple therapy with an interferon backbone remains the preferred treatment  because clinical trial data does not support the use of interferon-free regimens.

 

 

Tuberculosis on planes

Earlier this week there was a news story regarding a 2 hour US Airways flight between Texas and Arizona that carried an individual with tuberculosis on board. While the story made headlines, a few important points were missing from many news stories:

  • There has never been a confirmed case of TB transmitted via air travel
  • A trip of at least 5 hours duration is thought to confer risk
  • The air within a plane is filtered to such a degree that it is likely cleaner than the air in most buildings

A good resource for these kind of incidents is the WHO guidance on this topic.

Meningitis

Last night Dr. Lee Harrison of UPMC discussed meningococcal meningitis at the  Baltimore Tropical Medicine Club. Some highlights included the fact that the US is at an all-time low of meningococcal meningitis (despite the Princeton and UCSB outbreaks) and that serotype X (which there is no vaccine for) has been causing invasive disease in the meningitis belt in Africa. 

The Novartis serotype B vaccine, approved for use in the EU and Australia, is now being distributed to the Princeton University population in an investigational manner. It remains to be seen what the impact of his vaccine, for which no hard efficacy data is yet available, will be at Princeton and the rest of the world.