Sabtu, 23 Oktober 2010

Been down so long...

being down don't bother me.  Having spent a few days here in Vancouver, I'm reminded of a paper published earlier this year out of British Columbia.  Gill et al, reported in CID results of a large 5422 person cohort of HIV+ patients with resistance testing during 1996-2008.  They described a drastic decrease in the incidence of new cases of HIV-1 drug resistance with the incidence rate of any newly detected resistance falling 12-fold from 1.73 cases per 100 person-months of therapy in 1997 to 0.13 cases per 100 person-months in 2008. I have posted Figure 1B below from the paper which shows declines in resistance to the major antiretroviral classes (PI, NRTI, NNRTI).

Isn't that amazing?  Wouldn't it be great if we could see the same thing in MDR-Gram negative bacterial pathogens?  Of course this won't happen, or at least won't anytime soon. Why would that be?  I think there are multiple reasons, but I think the major reason is that NIH and numerous other sources are funding HIV research to a much larger degree than anti-bacterial resistance research.  At the NIH, the funding disparity may be as high as 80 times.  In conversations, I've heard that NIH anti-bacterial resistance funding may be as low as $40 million/year compared to $3.2 billion/year for HIV research.  This comparison likely underestimates the disparity since pharmaceutical companies spend many multiples more on HIV antiretrovirals, because they are used chronically by patients over many decades.

I want to be clear that I'm not in favor of reducing what is spent on HIV research nor am I in favor of shifting funding from one infection to another.  Clearly that would be foolish and short-sighted as HIV AND antibacterial resistance are both problems of the next century. What I want to highlight is what can be accomplished with proper scientific inquiry, which is lacking in the "absence of evidenced-based medicine research" that exists in HAI prevention and antibacterial therapeutic choice.  Trip Gulick from Cornell mentioned yesterday at IDSA that there are now 10,000 possible 3-drug combinations of ART. Wouldn't it be great if we had similar choices and studies to utilize when we select antibiotics and duration of therapy for common bacterial infections. Quite frankly, you just get what you pay for.

I've been waiting 15 years for the tipping point, when we wake up and realize that bacterial resistance is a true public health emergency. However, I am increasingly concerned that we aren't waking up and responding in time.  Unfunded legislative mandates may make us feel like we're responding, but they will not solve much. We need to invest in our public health infrastructure and anti-bacterial discovery.  I just hope it's not too late.  What will surgery be like without effective antibiotics? We don't need to end up there if we follow the model put forth by the NIH and the cadre of investigators that have responded tirelessly to the challenge of HIV.  Let's face the antibacterial resistance challenge before it's too late.

Reference: Gill VS et al. Clin Infect Dis 2010

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