Burden of Antibiotic Resistance: Stopping an Epidemic, Containing Cost
Burden of Antibiotic Resistance: Stopping an Epidemic, Containing Cost
Antibiotic resistance is exacting a high price in the US. In April 2011, the Centers for Disease Control (CDC) reported that antibiotic resistance accounted for approximately $20 billion in health care costs. Although there is a stronger push for new antibiotic agents to come to market, managed care is facing a steep price tag for these new, potentially life-saving treatments. Stewardship is key—with an aim toward decreasing course of treatment and increasing value.
The potential loss of life due to antibiotic resistance in the decades to come is staggering. Antibiotic-resistant germs and Clostridium difficile result in 23,000 deaths in the US and >2 million illnesses, according to the CDC. If steps are not taken to meet this crisis head-on, deaths caused by antibiotic resistance will exceed 10 million worldwide, more than that of cancer.
WHY THE PROBLEM EXISTS
At a recent Pharmacy Learning Network meeting in Washington, DC, infectious disease specialist James Lewis II, PharmD, addressed this issue.
Germs mutate rapidly. “The problem that we’ve seen is that the bugs don’t quit,” Dr Lewis said. “Meanwhile, big pharma has gotten out of antibiotic development,” Dr Lewis said.
The number of antimicrobial agents that have been developed has continuously decreased from the mid-1980s to 2012. For example, from 1983 to 1987, 16 antimicrobial agents were approved. However, from 2008 to 2012 only 3 drugs were approved.
“You’ve got a return on investment problem here,” Dr Lewis said. “Lipitor, in its last year on patent, did $12 billion globally. Our beloved pip-tazo [piperacillin/tazobactam], its last year on patent did $1 billion. So, if you’re the CEO of a major pharmaceutical company, which drug do you want to invest in?”
“When was the last time you saw a statin stewardship team?” Dr Lewis challenged. They do not exist. There are no pharmacists urging the health care team to consider the duration of care for statins nor do they warrant a national action plan.
A GROWING MOVEMENT
But there is one to address antibiotic resistance. In March 2015, the White House issued the National Action Plan for Combatting Antibiotic-Resistant Bacteria. The plan includes goals aimed at advancing the development of diagnostic tests, slowing the emergence of resistant bacteria, preventing the spread of infections, strengthening a national surveillance program, accelerating the research of new antibiotics, and improving international collaboration.
The FDA is offering an incentive for companies to return to the antibiotic development game. Drug companies are eligible for an expedited review process for the new antibiotics they develop.
Several newer antibiotic agents have hit the market. But they do not come with generic prices. Dalvance® (dalbavancin) and Orbactiv® (oritavancin) are only approved for skin and soft tissue infections. Estimated prices for the course of therapy of these two agents are:
• Dalbavancin: $4500 (approved May 23, 2014, an injectable administered via an IV).
• Oritavancin: $3300 (approved August 6, 2014, an injectable drug).
There is some good news for payers. Zyvox® (linezolid), indicated for some bacterial and skin infections and pneumonia, recently went off patent. What once cost $300 per day has dropped to $100 per day.
The interests of payers and health care providers focusing on antibiotic stewardship intersect when it comes to the question of duration of therapy. Shorter duration of therapy lowers the chance of antibiotic resistance and results in lower costs.
“One of the big pushes in stewardship is the durations of therapy for these indications,” Dr Lewis said. “I think that we’re way over-treating a lot of this stuff.”
Now, a number of studies have been done regarding duration of therapy. Many of them have shown that 5 to 7 days of therapy is as effective as the longer periods that have characterized antibiotic therapy. “The shorter duration is just as good as the long,” Dr Lewis said. “Stop the 14-day madness.”
Dr Lewis pointed to the need for health care providers to “start the right drug promptly at the right price for the right duration.” De-escalation, when possible is extremely important.
SYSTEM-WIDE COORDINATION
More coordination is needed. Patients move through the health care system, from facility to facility, but the coordination of care is lacking.
“You can be great at doing antibiotic stewardship, doing infection control, your core measures can look good, everybody in your hospital can wash these filthy beasts [hands] at every perfect opportunity, yet you still have a C. diff problem, you still have a CRE problem, you still have an MRSA problem,” Dr Lewis said. “Why? Because the nursing home down the street isn’t. These patients, as you all know, don’t stay in one place. They move. And not only do they move all over your hospital, they move all across the health care system.”
How many of you, Dr Lewis asked the audience, has had a patient transferred in from another facility only to discover 3 days later that they had C. diff, that they were colonized with MRSA, that they had Ecoli?
“One of the things that you’re going to see, hopefully, is a lot more integration,” Dr Lewis said. “You can’t be an island out there in the middle of all this mess. The mess is still going to get to you.”
Community-acquired infections have become the norm. The National Institute of Allergy and Infectious Disease (NIAID) estimates that 5% to 10% of all hospitalized patients acquire an infection.
