The following interview with Ramanan Laxminarayan, Director of CDDEP and its Extending the Cure project, originally appeared on the NewPublicHealth blog of the Robert Wood Johnson Foundation.
Get Smart about Antibiotics Week is an annual effort to coordinate efforts from the Centers for Disease Control and Prevention, state public health agencies and other partners on the importance of appropriate antibiotic use.
NewPublicHealth spoke with Ramanan Laxminarayan, executive director of the Robert Wood Johnson Foundation-funded program Extending the Cure, about this week s annual campaign and about new tools for better tracking of antibiotic use and resistance. Extending the Cure released new data today revealing a pattern of antibiotic overuse in parts of the U.S., particularly the Southeast. The five states with the highest antibiotic use in the nation are West Virginia, Kentucky, Tennessee, Louisiana and Alabama, but the maps show high antibiotic use in other parts of the country as well.
NewPublicHealth: A study was published in Pediatrics last week that found that there are perhaps ten million unnecessary pediatric antibiotic prescriptions written each year. Is that number surprising?
Ramanan Laxminarayan: I m not surprised by the large number, but the good news is that the situation may be getting better. The antibiotic prescription for otitis media [ear infection], which is the single most common condition for which antibiotics are prescribed in the U.S., has dropped. So that s the good news. Much more could be done to reduce antibiotic use, and one reason why it is has not gone forward with the same pace as it could have is because the CDC is woefully underfunded to carry out this task. But what they did do is to get the Get Smart campaign in full force, and they ve had a tremendous impact. You couldn t go to a pediatrician s office without seeing one of those pamphlets saying don t ask for antibiotics from the provider and at least some people got the message. What is missing right now is a sustained education message letting people know that antibiotics are a precious resource and we need to use them carefully.
NPH: What else might be keeping us from having a more dramatic decline in inappropriate antibiotics use in the outpatient setting?
Ramanan Laxminarayan: There s a sense of a social norm, which says it s okay for a mother or a father to ask for antibiotics, and it s okay for the doctor to write the prescription even when it s not needed. That scenario is socially considered okay just as much as if we were talking in a coffee shop 30 years ago and one or both of us would be smoking. In Scandinavian countries they have managed to get to a different social norm where it s neither okay to demand an antibiotic from your prescriber, nor is it really okay for the physician to willingly write a prescription for an antibiotic when it is not indicated. It s going to be a challenge, but certainly one that can be overcome to get from where we are to one where the norm is that we don t use antibiotics. It s been done with smoking in this country, no reason why it can t be done with antibiotics.
NPH: What else could be done on a policy level to address antibiotic resistance?
Ramanan Laxminarayan: An immediate policy lever is related to reducing infections in general. So, a stronger policy to reduce hospital infections would both reduce those infections as well as reduce the need for antibiotics, and that s an urgent need. A second priority is related to seasonal influenza vaccination. Our research shows that antibiotic prescribing for certain very powerful antibiotics spike every winter because of influenza. The cause of the fever may not be a bacterial infection but people go out and get an antibiotic anyway and that shows up as higher resistance in February, March and April. The worst months for resistance turn out to be those months because they follow on a winter of high antibiotic prescribing, which means that a second policy lever is really to push seasonal influenza vaccines to the public and to their providers.
NPH: How is this year s Get Smart About Antibiotics Week different from previous years?
Ramanan Laxminarayan: One initiative that s new for this year based on a paper that s in the British Medical Journal [BMJ Open] relates to how we measure antibiotic resistance and how we use that measurement to inform our understanding of where resistance is and what s causing it.
Because drug resistance is hard for people to understand and it all seems very complicated because there are so many kinds of bacteria, so many kinds of antibiotics, we ve created a composite measure, sort of like a Dow Jones for drug resistance. Just like you don t follow the stock market by just following one stock; it doesn t make sense to follow drug resistance based on single bug or resistance to single drugs. We call the new tool the drug resistance index.
NPH: How will the index be used?
Ramanan Laxminarayan: In any environment from a hospital up to the whole world the index lets us compare against categories of organisms to see where the problem really is and where drug development should be focused.
Just having an index might trigger better data selection because people now know that it feeds into something which is being reported on a regular basis, so it improves surveillance. Another outcome that it can point to is the need for specific new drugs in cases where the index is going up unabated because there are no new drugs in that area. It could even direct research and development priorities. And the index is a public health priority because it can identify how much attention should go to drug resistance relative to all of the other problems health departments have to deal with.
NPH: How do you expect the index to be received by the infectious disease and public health communities?
Ramanan Laxminarayan: Amongst the practitioners, it is being quite well received because they are struggling for ways to communicate to non-specialists the problem of resistance. But it s quite difficult to tell someone that Acinetobacter resistance to carbapenems is going up because that may mean little to them. Why is that particular bug important? Are those important drugs, and are they used very frequently? We think the practitioners are happy to have an aggregate measure that lets them communicate the overall trends in resistance.
Ramanan Laxminarayan: ResistanceMap is our web-based collection of interactive maps and data visualizations. The goal of the project is simple we want to paint an accurate picture of the spread of antibiotic resistance. We started working on the project last year, including only U.S. data. This September it was expanded to include data from other developed nations Canada and Europe.
The narrative of ResistanceMap is simple in that it traces resistance changes both over time and allows you to compare resistance in different regions. The objective is to focus attention on the problem of antibiotic resistance, and the feedback that we ve gotten so far is that this is a really unique resource out there so people have been very excited to be able to, for the first time, have the data all in one place. We ve heard from users that this is a really great way of highlighting some of the key trends, notably how the U.S. compares against other nations and also what some emerging and important trends in antibiotic resistance.
The map is being used at a fairly regular basis at pharmaceutical companies in showing how resistance trends are evolving over time. Another constituency is state health departments that are looking to see how well or poorly their particular states are doing relative to other states, and of course, a third constituency is the advocacy community, which is using these maps to show that this is an important problem that really ought to get focused on. So, for instance, the World Health Organization has a major report coming out in antibiotic resistance in a couple of months and that prominently highlights the ResistanceMap.
NPH: What else is new about the ResistanceMap?
Ramanan Laxminarayan: The second version of ResistanceMap differs from the first version in two important respects. The first version was like watching a movie you couldn t really control what you wanted to watch, it just showed you how resistance changed in each state over time. ResistanceMap 2.0 lets you have control over specific bugs and specific trends that you want to see over time. So it gives the user a lot more control to be able to visualize resistance.
Another aspect of ResistanceMap 2.0 is that it will soon have information also on antibiotic use in these different states. So one will be able to look at trends in resistance against trends in antibiotic use and infer how these might be correlated, which is critical because an important driver of resistance is the antibiotic use.