CDC and Canada Issue New Reports on Antibiotic Resistant Infections: Is a Black Swan Coming?

Suppose we had a problem that kills one person in the United States every 15 minutes, day in and day out, 24/7/365? We actually have several. Traffic accidents fall into that range. Gun-related violence, including suicides, does as well. Breast cancer deaths are about 15% higher. But another cause also kills like this: Someone in the U.S. dies from an antibiotic-resistant (AR) infection every 15 minutes. Remarkably, someone is newly infected every 11 seconds.

The impact of this AR threat is vividly reported in the first new report on Antibiotic Resistance Threats in the United States released by the U.S. Centers for Disease Control and Prevention (CDC) since 2013. Although it shows some improvement in deaths, the report underscores the continued threat of antibiotic resistance in the United States. Divided into categories of urgent, serious and concerning threats and a watch list, the pathogen summaries in the 148-page report will keep you awake at night.

According to the report, more than 2.8 million antibiotic-resistant infections occur in the U.S. each year, and more than 35,000 people die as a result, yielding the “one death every 15 minutes” statistic. In addition, 223,900 cases of Clostridioides difficile occurred in 2017 and at least 12,800 people died. Combining those two mortality figures brings the annual death toll to 47,800 people.

To give these numbers some perspective, the U.S. had 36,560 highway fatalities in 2018. Another 39,773 people died from gun-related injuries (including suicides) in the U.S. during 2017, the last full year with data available. U.S. breast cancer deaths in 2017 were a little higher at 40,600. But the CDC mortality figures for AR infections may not reflect the extent of the AR problem. According to USA Today, researchers at Washington University School of Medicine say as many as 162,000 Americans may die from AR infections annually—a rate roughly four times the figures above.

The good news is that the CDC’s reported annual deaths from drug-resistant bacteria and fungi have declined 18% since 2013, excluding the deaths from C. difficile.  The CDC says this shows U.S. efforts—preventing infections, stopping spread of bacteria and fungi, and improving use of antibiotics in humans, animals, and the environment—are working, especially in hospitals.

The bad news is the CDC says the burden of antibiotic-resistance threats in the United States has been greater than initially understood.  As the report says, “Untreatable or pan-resistant infections are no longer a future threat—they are a reality.” The CDC is particularly concerned about rising resistant infections in the community. These increasing infections put more people at risk and make spread more difficult to identify and contain. They also threaten the progress made to protect patients in healthcare facilities. The emergence and spread of new forms of resistance also continues to alarm CDC experts, especially resistance shared among germs through genetic mobile elements where antibiotic-resistant germs share their resistance genes with other germs and can make them untreatable.

The CDC’s concern is echoed in a new report released this month by the Public Health Agency of Canada. Written by a panel of professionals assembled by the Council of Canadian Academies, the report, When Antibiotics Fail, projects that AR infections will cost Canada 396,000 lives, $120 billion in hospital expenses and $388 billion in gross domestic product over the next three decades. That’s a simple average of about 13,200 deaths per year, but Canada’s population is about 12% of the United States’. If you adjust for the population difference, this would translate to annual average equivalent deaths of more than 100,000 per year in the U.S. "This is almost as big, if not bigger, than climate change in a sense because this is directly impacting people. The numbers are just staggering," Brett Finlay, a University of British Columbia microbiology professor who chaired the panel, said in an interview reported by Laura Kane in The Canadian Press. "It's going to change the world," Finlay says. "We all go to hospitals and we all get infections."

The Canadian report also suggests AR may disproportionately affect socio-economic groups more at risk of AR infection, such as Indigenous, low-income and homeless people, as well as those who travel to developing countries. "Discrimination may be targeted at those with resistant infections or deemed to be at risk of infection," the report warns.

Comparing the AR infection issue to other medical and social problems may be helpful in spotlighting the size of the relative mortality and efforts at improvements, but it’s also misleading about the true extent of the risk. Deaths from motor vehicle accidents, gun-related violence and even breast cancer may ebb and flow over time but are unlikely to register dramatic increases. Deaths from AR infections could explode overnight if antibiotic resistance spreads to aggressive strains of bacteria or fungi that infect larger segments of the population. The CDC understands this and is attempting to monitor these risks. But the report fails to show whether we could respond effectively to such a Black Swan event and what the consequences of our lack of adequate preparation would be. Even without such a seminal event, over time the relentless spread of resistance could overwhelm the effectiveness of our remaining arsenal of antibiotics.

As we think about America’s social and political priorities, we need to remember this one. How we respond could prove to be a matter of life or death. At a minimum, we need to increase public awareness of this problem and continue to ratchet up pressure on hospitals and other medical care facilities to reduce AR. We must increase efforts to reduce unnecessary antibiotic use in humans and in animals. But prevention, containment, and antibiotic stewardship will only go so far. As much as the national political conversation on both sides has turned against Big Pharma, we also need to recognize that providing incentives for new antibiotic and other treatments for AR infections is not just important—it’s essential to our continued survival. As the CDC report makes clear, the development pipeline is long. Since 1990, 78% of drug companies have cut back on antibiotic research due to development challenges, and that’s before recent political threats to fix drug prices or seize drug patents. Many experts, including at the CDC, believe we are already in a “post-antibiotic era,” which means we must also fund more government and private research into alternative solutions such as vaccines, microbiome management and genetic and molecular engineering. For a good overview, see this report from The Pew Charitable Trusts.