Second Opinion with Joan Lunden

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> Each year in the U.S., at least 2.8 million people are infected with antibiotic-resistant bacteria or fungi, and more than 35,000 people die as a result.

It's considered a slow-moving pandemic, and it is one of the most serious global public-health threats in this century.

Joining us today on "Second Opinion," primary-care physician Dr. Lou Papa from the University of Rochester Medical Center... >> Antibiotics should be used when you know that you have a bacteria -- not a virus -- that is causing your condition or your illness.

>> ...infectious disease specialist Dr. Ted Louie, also from the University of Rochester Medical Center... >> So as doctors, we have to be very choosy when we give antibiotics, and the other thing is the length of time.

>> ...Steven Roach from the Keep Antibiotics Working Coalition... >> We should only use antibiotics when we actually need them -- when you have a bacterial infection that you know is making the person, or in this case, the animal, sick.

>> ...and husband and wife George Semakula and Dr. Miriam Abu, who are here to tell their personal story.

>> All the antibiotics -- about 16 of them, like George said, were resistant to the disinfection.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

I thank you all for being with us today for this conversation.

George, I want to start with you.

I want to take you back to April of 2019.

You traveled to Tanzania for your mom's funeral, and I'm sorry for your loss, but tell us what happened when you were there.

>> Well, when I was there, after the funeral, the second day, when I was walking back around the city later, some people, they mugged me and they pushed me in the ditch, and they broke -- it was severe broken, my leg, left ankle, and I took a while before I got to the hospital.

And the bone was protruding.

>> Ugh.

>> And I was there at Kilimanjaro Christian Medical Centre, for like 10 days, then I got the opportunity to fly back to Durham, North Carolina, then went to Duke Hospital.

>> Let me just ask, Miriam, when this was going on, and he was, like, lying in a ditch with a broken ankle, where were you?

>> I was flying back to United States.

>> Oh!

>> So, after my mom-in-law's funeral, we were there for few days, then I had to come back to work, and as I was about to change to another plane in Amsterdam to come to North Carolina, that's when I noticed I had multiple calls from family members from Tanzania.

I called them back, and that's how I found out that George had been injured severely and he had broke his leg.

>> So, did you have your surgery, George, once you got back?

I think you went to Duke University.

Did they perform the surgery there?

>> Yeah, they did, multiple surgeries, like six surgeries, because they had to do the external fixation first.

And when they were doing that, they realized my leg was, like, infected so much, and they had to cut a lot of skin, so tried to find the medicine to cure the infection.

The medication, they tried like 16 of them.

It didn't work, so they had to -- I had to go to surgery every other day to clean it because... >> Wow.

>> ...the infection was spreading very rapid, yes.

>> Miriam, you have a medical background.

You're a doctor.

What were they telling you?

>> Well, the only information that I got when I was there -- Obviously, my role there was a patient's wife.

I was there as a patient's wife.

But, obviously, they knew that I was also a trained physician, and I was able to communicate to the doctors directly.

What they told me, the infection disease specialist -- that they had, you know, sent the samples for testing, and all the antibiotics -- about 16 of them, like George said, were resistant to the disinfection.

And that was very scary.

>> I want to just ask you, Lou, first of all, what causes an infection like this?

>> So, there's lots of things that can cause this infection, and actually, when I looked this over, he was infected with acinetobacter baumannii, which, when I was a medical student, a resident, was more of a tropical-type infection and you didn't see too much in the United States.

Now you see it a lot more in the United States.

>> Is that just because of world travel and everything?

>> Right, it's world travel, and also just because it's changed and it's morphed.

It can affect skin, blood, urine, lungs.

It has a wide range of infections that it can cause.

And, you know, bacteria and viruses, they're very ancient life forms, and their main mode of survival is adaptation.

Their main adaptation with us humans is to find a way around our antibiotics.

>> Remind us of when it is appropriate to use an antibiotic.

>> So, antibiotics should be used when you know that you have a bacteria -- not a virus -- that is causing your condition or your illness.

We have lots of bacteria in our lungs and in our mouth that are just there, that we don't -- they're just kind of living there.

We're looking for bacteria that are pathogenic, and it's really important that the -- You want to make sure your reason for antibiotics are out of indication, not frustration -- that you make sure that it's that they are the cause of the disease and that the antibiotic's gonna alter the course of that condition.

>> So, I want to talk about that more, but I just have to ask, Miriam, they found, finally, an antibiotic, right?

But it wasn't approved?

Tell us about it.

>> Yes.

So, this was an investigational medication.

I believe it was being tested in Japan at that time.

It wasn't approved by FDA yet in the United States, and how we found out -- the fellow that was working with this infectious specialist, Dr. Fowler at Duke, told us about it the first time, that she was looking into this investigational medication, but it is in Japan.

She will see if she'll be able to get approved for it to come to Duke to be used as compassionate use.

>> I want to ask you, Dr. Louie, why are we seeing bacteria more and more becoming resistant?

>> So, as Dr. Papa had said, as a group, physicians and patients, we tend to use antibiotics too much.

So why is that?

For example, when you go to the doctor's and you have cold symptoms, oftentimes this is a virus, not a bacterial infection.

>> Yeah.

>> If you come in with a sore throat, sometimes it's a strep throat, but oftentimes it's a virus.

So as doctors, we have to be very choosy when we give antibiotics, and the other thing is the length of time.

If we can treat certain infections for shorter time rather than longer time, that's advantageous.

>> But the more antibiotics are used, we see them, what, like within four or five years, you start seeing that resistance again?

>> Yeah.

So ever since -- One of the earlier antibiotics was penicillin, so within 10 years, there was quite a lot of resistance, and every antibiotic subsequent to that, within 5 years, 10 years, you develop resistance, and as Dr. Papa alluded to, the bacteria adapt very easily.

They're very cunning.

So, let's say if you give antibiotics, and what'll happen is some of the bacteria will have mutations, and you're gonna kill out all the "normal" bacteria... >> Yeah.

>> ...and what remains are the ones with mutations, and they have different mechanisms for resistance, as Dr. Papa had alluded to.

>> Well, you know, it's scary 'cause we're so dependant on antibiotics to be able to be the cure-all.

Are there certain people who are more at risk, or this can happen to anyone?

>> Everybody.

Everybody.

>> It can happen to anyone.

>> There's a misconception which I hear from patients a lot -- "I'm resistant to the antibiotic.

I can't get that antibiotic 'cause it doesn't work for me."

And that's a big misconception.

The antibiotic has nothing to do with you.

The antibiotic is all about you being the host, alright?

And all that bacteria wants to do is replicate and mutate more inside of you, and it's doing damage in the process.

So the antibiotic resistance develops with the bacteria.

You have nothing to do with it.

So when patients say, "I can't take that antibiotic, it didn't work last time, I'm resistant to it," it doesn't apply.

>> So it's actually the bacteria.

>> It's the bacteria.

>> It's figuring out how to be resistant... >> Exactly.

>> ...to the antibiotic.

>> And it's a problem, because we want to address antibiotic infections very quickly, especially if they're serious.

You know, there's certain... >> Sure.

>> ...quality criteria where you want to get an antibiotic in quickly if somebody is very seriously infected.

But, realistically, depending on the study you look at, in the outpatient setting, 50% to 80% have antibiotics -- 50% to 80% are overprescribed.

>> 50% to 80%?

And a lot of this is because patients come in and they want... >> Right.

>> ...the antibiotic.

>> And on us doctors, too.

Us doctors, too, want to keep our patients happy.

Again, like I said, they get frustrated being ill. >> So, now, I want to bring Steve in, because there's another kind of pathway that's going on at the same time, and that's our food chain.

When we go food shopping, sometimes we see that little label that says "Antibiotic free."

I guess it's really in meats and dairy products.

Steve, this is your field.

Why are farm animals given antibiotics so regularly?

>> I think it's interesting, because both Dr. Papa and Dr. Louie mentioned how we should only use antibiotics when we actually need them -- when you have a bacterial infection that you know is making the person, or in this case, the animal, sick.

But what we have in the U.S. is we have a system where we've really gotten used to using antibiotics in animals that aren't sick, don't have any diagnosed illness, but in the past, a lot of it was we found that you could, if you gave them antibiotics, they would grow more quickly.

Now, for the antibiotics that are similar to the ones we used in humans, we got rid of that practice in the U.S. in 2017.

But we still allow farms to give antibiotics to animals in their feed or in water that -- when you anticipate they'll be sick.

And there's several factors that we use it.

Like, in cattle, instead of having most of the beef cattle that we raise eating grass for their whole life, we actually move them to big feed lots, and when you move them and mix them together, then they're gonna get respiratory disease.

But we also give them a diet that's high in grains, and that's not healthy for them, and because of that, they tend to get liver abscesses, so then we give -- you know, most cattle that are on feed are given tylosin, which is a macrolide antibiotic which the World Health Organization considers critically important, for pretty much the whole time they're on feed to reduce these liver abscesses.

So we do things that we know are going to cause some problems... >> Yeah.

>> ...and then instead of waiting until we have sick animals, we go ahead and give them widespread antibiotics, and the result is about 2/3s of antibiotics sold in the U.S. go into our animals, not into sick people.

>> So, we create the problem by taking them off the grass and putting them in the feed lot and giving them the corn, and then we have to give them the medicine to make sure they don't get sick.

Is the -- I mean, would the answer be, if we're having problems with the antibiotics that are being used, maybe to create a different antibiotic?

>> Yeah, well, I'm sure the doctors can talk about it, too.

We really don't have enough antibiotics.

It's kind of like the rate of creating new antibiotics is much slower than the rate that we're developing antibiotic resistance.

And that doesn't mean that we shouldn't use antibiotics to treat sick animals or treat sick people, but we really do need to be much more careful about how we're using them, so we really need to conserve the ones we have.

>> So, within the medical industry, Dr. Louie, there is something called "antibiotic stewardship."

What is that, and how does that work?

>> Sure.

So, antibiotic stewardship became popular about 10, 12 years ago, and what it is, is in each hospital, you have, usually or typically, an infectious disease doctor and a pharmacist, and you will review the use of antibiotics.

So the goal is, "Are we using antibiotics appropriately?

Is the dosage correct, is the antibiotic correct, and the length of time correct?"

So, you would be surprised at how many "opportunities" we have to what we call de-escalate.

So, patient comes into the emergency room, they're sick.

Of course you put them on lots of antibiotics.

So, sometimes, you're put on two antibiotics, sometimes three.

If I'm there, I may suggest one or two.

Of course, the ER is concerned that the patient will not do well, so they are very aggressive up front.

So at that point, if the patient does well, we can de-escalate antibiotics.

So now we have a diagnosis, a few days later, we have test results back, we have a specific bacteria we can target, so we should give a narrow-spectrum antibiotic instead of the broad spectrum we started out with.

And sometimes people are slow to do that.

>> But we see the resistance happening at a much faster rate.

What's the answer to that?

>> So, there's still a lot of work to be done.

I mean, so, let me give you some examples.

And I think that our whole practice style has to change.

So, I think, 20 years ago, 10 years ago, we tended to give much longer course of antibiotics.

So, for example, pneumonia, we often treated for 10 days, 14 days.

>> Yeah.

>> You probably remember that.

>> Oh, yeah.

>> And nowadays, you know, we encourage people to treat for five days, seven days, and that hasn't completely caught on, so we still have a lot of education to do, even among our peers.

>> Agreed.

>> But that five to seven days is effective?

>> Yes.

Absolutely.

>> Oh, yeah.

It's just as effective.

>> So we really didn't need to do it for the 10 to 14 days?

>> That's right.

>> But what happen is, patients have this connection to the antibiotic.

Not only do they get rid of the organism, but they feel better.

And if they're not feeling better quick enough, they want to be on antibiotics longer, and the problem is, there's not really a stewardship in the outpatient setting, where a lot of... >> Oh.

>> ...you see this issue because it's not as centralized as it is in the hospital.

So, there's multiple pharmacies use multiple practices, so it makes it a little bit more difficult to do something like that, and it's really on the physician and the patient to be the stewards.

>> Steve talked about the fact that we don't have that many antibiotics.

Why -- I mean, we see new drugs come in on the market all the time.

Why aren't there more antibiotics coming on the market?

>> We are in a subscription-based pharmaceutical world, and what I mean by that is -- >> Well, yeah, what does that mean?

>> So, most drugs that we have now are for chronic diseases, where patients are getting them repeatedly and there's a high margin with them.

Antibiotics have just gotten an even shorter course, so there's not a wide margin for the pharmaceutical industry to step in, and in fact, one of the things that concerned me about all of this is that the pipeline is terrible and that even the stuff they're looking at is not any new technology -- it's the same old, same old.

There's no innovation.

>> And there's no innovation and no one at the top level -- Go ahead, Doctor.

>> So, if you think about it, if you have a medicine that prevents heart disease, people are gonna be taking it for many, many years every day, so of course it's a big profit-maker.

>> Okay.

Yes.

>> So antibiotics, if you have me telling you, "No, seven days, that's it," or, "Five days, that's it," then who's gonna develop the new products?

So, we tried very hard.

We tried to get the CDC to help support this, and they have to some extent, but it's a very hard task to get antibiotics developed.

>> Is that -- Is it the CDC's role in this, or NIH, or the FDA?

Like...?

>> They're trying to step in to try to get, you know, our kind of capitalistic model -- And this is really a worldwide problem.

It's not unique to the United States.

In some respects, in other countries, it's a lot worse.

>> Just because of that profit -- inability to have a profit?

>> It's even worse, right?

There's countries -- and correct me if I'm wrong, Dr. Louie -- where you can literally buy antibiotics over the counter like you buy Tylenol.

>> Really?

Okay.

>> And that contributes -- I mean, we alluded to before that we have -- and you had said, also -- infections travel throughout the world.

>> Yeah.

>> So we have very resistant bacteria, say, from -- there are some examples from India, for example, and there you can get antibiotics very readily without going to see a doctor.

You go to your pharmacist and you'll get antibiotics.

So, certain areas of the world, it is very easy to get, so therefore they have resistant organisms, and people travel.

>> Yeah.

>> People fly to India, people fly to elsewhere, and they come back and forth with these infectious diseases.

>> And here we are talking about how can we limit the use, a stewardship program in hospitals, hopefully in doctors' offices, and yet what you're describing is the antithesis to that.

>> That's right.

>> Bacteria don't have passports, so they can go anywhere.

So it really has to be a worldwide -- I mean, that's why the WHO really steps in on this.

It has to be a worldwide effort.

You can do a great job in one country, but if you have an airport or a port, you know, it makes it only a half try.

>> Steve, let me go back to you, because what steps could be taken in your realm to try to bring this under control?

>> Yeah, so, I think it was interesting again to hear the discussion about the duration of use, and in animals, you know, you all are talking about 14 days.

We could actually have animal... prescriptions or durations of use that are 28 days, and for some of the drugs -- actually about 1/3 of the products in animal feed -- there's no duration at all.

You could use it for the whole life of the animal legally.

>> Wow.

>> It's approved for that kind of use.

So one of the things FDA in the U.S. is trying to do is to get those durations shorter.

Now, so far, their current proposal pretty much leaves it up to the veterinarian to decide, so it's kind of not doing a whole lot, and we've suggested that they at least put a cap on it, saying if you're gonna use it for longer than 21 days, then you should have to have the vet go back and look at the animals and make sure they're getting it.

And part of that problem is that you're giving to animals where there aren't clinical signs, so if you're preventing a disease, you can't actually see whether it's working.

>> Right.

>> What can we do?

I mean, let's not -- Leave a little bit of the onus on us as patients.

>> Right.

So, part of it is, you know, especially for your primary-care doctor, you trust your primary-care doctor, and it makes it a little bit easier now because, with the electronic medical record, there's easier communication.

If the doctor says you don't need an antibiotic, don't demand one.

I mean, there's some disturbing statistics that show that 1 out of 5 patients will switch doctors if they don't get the drug they want.

>> Yeah.

I've seen that, yeah.

>> And most of that is antibiotics.

So trust your doctor.

Have open lines of communication so that if you worsen, you can address it.

And another thing is 1 out of 3 -- This was another survey, and 1 out of 3 individuals have taken a drug they've had in their cabinet, either theirs or somebody else's, and the vast majority of time, it's somebody else's.

And that's even scarier, because you don't know what you're taking or why or for what indication.

You just think, "It's an antibiotic, I get better," and you take it.

And I think, you know, thinking about kind of the health equity thing, even with regards to some of the -- you know, some of our poorer segments of society, we really do need a global stewardship program... >> Yeah.

>> ...and we need a pipeline of new drugs, and we need some way that if we're going to address the food chain issues, that it doesn't continue to hamper or hamstring, you know, the family farmer against some of the big conglomerates.

You know, how do we keep that equal?

I know it's a big, tall order, but I think to really get it right worldwide, pretty much everybody in this world has these same issues.

>> So it's got to happen on two fronts, on a medical front and the food chain.

Dr. Louie?

>> And you had said, "Who is responsible -- FDA, CDC, WHO?"

>> Yeah.

>> The answer is everybody, so that goes from doctors, patients, hospitals, pharmacists, and large organizations -- government, FDA, CDC.

It's everybody together.

>> What would the world be like without antibiotics?

>> So, we go back to, yes, antibiotics are extremely valuable.

We've seen people who would die years ago, they live, and they live long, productive lives, so it's extremely important.

But we should think of it as a resource, a valuable resource that we have to conserve for future generations.

>> And remember, at the turn of the last century, before we had antibiotics... >> Yeah.

>> ...infections was one of the leading causes of death, and the life expectancy was in the mid-40s.

So a world without antibiotics would be terrifying.

>> Yeah, really terrifying.

So, I mean, let's talk about also some of just the other things that we, the people, can do.

You've talked to me about this.

If people would just use better hand hygiene... >> Exactly.

>> Talk about some of those... >> That's a very good point, Joan.

>> ...everyday things, without buying any medication, that we can do.

>> That's exactly right.

It's amazing how much hand washing -- We've seen during this pandemic, right?

>> Yeah.

>> In hospital infections, in office infections, infections in our own homes, we've seen them all plummet.

Why?

Well, we're wearing masks, but we're also washing our hands.

It has a huge impact.

It's such a simple thing to do, and proper hand-washing technique is a huge thing.

That's a very good point, Joan.

>> And there's other instances of resistant bacteria that are very easy to transfer from person to person.

So, Lou, I'm sure you've treated MRSA skin abscesses.

>> Absolutely.

I never used to, 10 years ago, as an outpatient setting, but they're at least half or more of my skin infections now.

Methicillin-resistant Staphylococcus aureus.

>> That's a pretty startling difference.

>> It is, but it gets at what Dr. Louie's talking about, is how quickly they adapt, how quickly they spread.

They have a billion-year head start on us.

They have an evolutionary billion-year head start on us.

They know how to survive.

And all they need is us to do it.

>> So, I want to just close here with George, because we all want to know, how are you feeling, George?

>> Well, thank God, now I'm feeling better, and it took me a while to heal because the bones were really in bad shape.

They pinned -- They put in -- The bones...

The bone -- You know, some parts of the bone were lost completely, so the bone had to grow afresh, you know?

So it took like two years... >> Wow.

>> Wow.

>> ...to completely heal.

Yes.

But for now, I'm doing better.

I'm doing very good.

>> Well, so, and how about you, wife?

How about you, Miriam?

Like, you've got the medical background.

Going through this whole experience, what have you taken away from it?

>> I feel this global antibiotic stewardship is very important, and I can attest, yes, in Tanzania, people buy antibiotics without a prescription.

I mean, I was, like, shaking my head when the doctor said that.

Yeah, it's completely true, so I think, yeah, we need to be very careful.

>> So we need to protect -- Maybe we do have to -- Maybe the WHO really does have to get involved, 'cause when you hear what's going on in other countries, as long as we just keep overusing them, letting people buy them off the shelf of a pharmacy... >> Yeah.

>> ...I don't know how you get this under control.

>> As they call it, it's a slow-moving pandemic.

>> Wow.

Alright.

George, I hope you do well.

Miriam, thank you.

Steve, thanks, and, Dr. Louie and Dr. Papa, thank you so much.

I also want to thank all of our medical advisors, who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And, of course, to all of you at home watching, thank you for joining us.

From all of us here at "Second Opinion," we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

>> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.