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Scientists are hunting for genes that enable bacteria to become resistant to life-saving antibiotics

Disease-causing bacteria are becoming resistant to antibiotics more quickly than we’re discovering new ones.

From the muddy bottoms of deep ocean trenches to Komodo dragon blood, scientists have scoured Earth’s remote corners in search of molecules that could yield the world’s next antibiotic. They hope to discover powerful new medicines against which bacteria have not yet evolved defenses. It’s a high-stakes pursuit. Disease-causing bacteria are becoming resistant to antibiotics more quickly than we’re discovering new ones.

That’s a big problem for humans. Infections that throughout the 20th century became easy to treat because of antibiotics have today become deadly. In the United States alone, more than 2 million people each year are infected with bacteria that can’t be killed by the drugs that were meant to stop them. At least 23,000 of those people will die as a result of their infections.

“[I]n the antibiotic ‘arms race’ against bacteria, humanity is rarely ahead,” wrote a team of researchers headed by microbiologist Gautam Dantas in a recent review article. Dantas, an associate professor at Washington University in St. Louis, is trying to change that.

We can no longer outrun antibiotic resistance by simply mining nature for new compounds, Dantas explains. He and others now are tackling the problem head on – by hunting for the genes that enable bacteria to become resistant to life-saving medications. Finding and decoding these genes may provide fresh clues about how antibiotic resistance emerges – and how to shut it down.

Unearthing the antibiotic resistome

Antibiotics are chemical substances that kill or slow the growth of bacteria. They are often thought of in terms of their medicinal properties that stop infections in humans, but many bacteria in the environment naturally produce chemicals with antibiotic properties, too.

In fact, some of our most important antibiotic discoveries have come from microorganisms in the environment. Scientists isolated penicillin, the world’s first antibiotic, from a type of mold in 1928. Other antibiotic discoveries – including streptomycin, the first medical cure for tuberculosis – came from soil bacteria. In the span of a generation, people stopped dying from injuries and illnesses such as pneumonia, scarlet fever and syphilis.

(Graphic: U.S. Centers for Disease Control and Prevention)
(Graphic: U.S. Centers for Disease Control and Prevention)

Scientists aren’t exactly sure why bacteria started making antibiotics in the first place, but they’ve been at it for a long time – probably since around the time bacteria emerged about 3.5 billion years ago. And since they were essentially creating their own poison with the antibiotics, the bacteria needed an antidote. So, over time, they evolved a suite of antibiotic resistance mechanisms.

Researchers have found genes encoding antibiotic resistance just about everywhere they’ve looked in the environment – on fossils scraped from the walls of subterranean caves or buried beneath feet of permafrost, even in the healthy gut microbes of people in a Yanomami Amerindian village who have never had contact with modern medicine.

“It’s an ancient feature of virtually every microbial ecosystem on the planet,” says Dantas. Scientists call this collection of resistance-conferring genes the antibiotic resistome.

Dantas and other researchers have spent the past decade cataloguing the resistomes of various environments – soil, farm animals, wastewater treatment plants, even the human gut. A stark picture is beginning to emerge – they’ve found genes encoding resistance to our most important antibiotic medicines lurking nearly everywhere they looked.

Growing problem

If antibiotic resistance is ancient, why is it just becoming a problem for humans now?

“We’ve applied a very big stress to the natural system over the last couple of decades,” says Andrew Edwards, a microbiologist at Imperial College London.

Antibiotics are some of the most commonly prescribed medications on the planet. While there’s no doubt antibiotics can be life-saving, they’re also commonly misprescribed for minor ailments and illnesses that don’t respond to antibiotics, explains Edwards. In the United States alone, an estimated one in three antibiotic prescriptions isn’t necessary, according to the US Centers for Disease Control and Prevention.

Then there’s the use of antibiotics in farm animals. Some poultry and other livestock receive antibiotics in their feed. Low doses of antibiotics help them grow bigger on less food, cutting the cost of production. A US Food and Drug Administration report last year found that sales of medically important antibiotics for use in farm animals in the United States rose 26 percent between 2009 and 2015.

Chicken being fed tetracycline as treatment for the intestinal infection colibacillosis. (Photo: Lucyin/Wikimedia Commons)
Chicken being fed tetracycline as treatment for the intestinal infection colibacillosis. (Photo: Lucyin/Wikimedia Commons)

Bacteria are really good at improvising their way out of trouble – it’s how they’ve survived on the planet for 3 billion years, explains Gerry Wright, a microbiologist at McMaster University in Ontario, Canada. “Each time we use an antibiotic, it creates the opportunity for that adapt-or-die dichotomy,” he says. Because bacteria are so bountiful, and they reproduce so quickly, it doesn’t take long for some to develop mutations that confer resistance and then, in the presence of the antibiotics, to dominate populations.

All of this use has resulted in an increase of antibiotic resistance genes in non-disease causing bacteria found in the environment. A 2010 study from the Netherlands reported that genes conferring resistance to some tetracyclines, a class of antibiotics, were 15 times greater in soil bacteria by 2008 than the 1970s.

Doctors discovered resistance to penicillin soon after the drug was introduced, but antibiotic resistance wasn’t initially appreciated as a problem, because new antibiotics were being discovered at a quick pace throughout the 1950s and 1960s (what some call the golden age of antibiotics). However, the problem soon became obvious as the rate of discovery of new antibiotics began to slow through the second half of the twentieth century, Edwards explains.

ID’ing environmental reservoirs

Finding resistance genes to medically important drugs in bacteria from a manure pit or a ball field isn’t the same as finding them in disease-causing bacteria in the hospital. Each day we’re bathed in a sea of microbes, and most don’t make us sick.

But bacteria can swap DNA. Some bacteria send packets of DNA into their environment. Others pick up and incorporate those packets into their own genetic material. It’s called horizontal gene transfer, and it’s what many bacteria do instead of sex to spread their genes.

A benign soil-dwelling microbe could theoretically lend its antibiotic resistance genes to a human pathogen in this way. Researchers have long suspected that disease-causing microorganisms could dip into environmental pools of antibiotic resistance, but experts weren’t sure whether this was actually happening at any meaningful rate.

In 2012, Dantas and colleagues showed for the first time that it was. They found soil microbes that shared a set of antibiotic resistance genes with human pathogens. Exchange of resistance genes between soil and clinic established soil as a key player in the network of pathogenic resistance, explains Dantas, though their research did not show the direction of the transfer – whether the genes moved from soil to pathogen or pathogen to soil.

Morten Sommer, a professor of bio-sustainability at the Technical University of Denmark, now is trying to understand which environmental reservoirs pose the most risk to human medicine.

“We want to know how and where that transfer to human pathogens is most likely to occur so we might be able to prevent the spread of resistance genes out of those environments,” says Sommer. He doesn’t have the answers yet, but he’s probing the antibiotic resistomes of soil, farm animals, wastewater treatment facilities and even the “good” bacteria of the human gut.

Finding a solution

Armed with a greater knowledge of the antibiotic resistome, scientists can devise new ways to counteract resistance to the drugs we already have and the antibiotics of the future.

Historically, humans have taken a reactive approach to antibiotic resistance — waiting to act until some superbug shows up in the clinic. Dantas and others now are taking a proactive approach. In May, Dantas along with several other Washington University researchers discovered a group of compounds produced by bacteria that could block resistance to tetracyclines by “gunking up” the cellular machinery some bacteria use to make the drugs ineffective. They’re now exploring whether these resistance-blocking compounds could be given together with existing antibiotics to help preserve their efficacy.

It’s just one example. Other researchers are using the resistome to come up with new combinations of antibiotics that could help slow the spread of multi-drug resistance, where bacteria are resistant to more than one antibiotic. In the antibiotic discovery pipeline, some new compounds make better candidates than others, but researchers often can’t weed out the duds until resistance shows up in the testing phase — a time-consuming and costly process. Understanding the likelihood of a rare genetic swap from one environment to another may help scientists save time and resources by predicting earlier which new compounds may be more or less susceptible to widespread resistance.

Dantas is hopeful about the possibilities, though none of it really matters if we don’t curtail our current antibiotic use, he points out. Antibiotic resistance is a fact of nature. It’s not going away unless bacteria go away (in which case we’d be gone too). There are steps we can take to stay ahead of it or even slow it, but “we have to protect the armamentarium if we want that shot,” he says.

This article was first published on Ensia.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

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Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the marketing team and not by the editorial staff.