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Neonatal-Perinatal Infections: Are We Losing the Battle?
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Foreword Neonatal-Perinatal Infections: A r e We Lo s i ng t he Ba t t le ?
Lucky Jain, MD, MBA Editor
The December 3, 2014 edition of The New York Times1 carried an alarming story: “Superbugs Kill India’s Babies and Pose an Overseas Threat.” The article describes a deadly epidemic “that is quietly sweeping India and could have global implications.” Among its victims are “tens of thousands of newborns who are dying because oncemiraculous cures no longer work.” Bacterial infections in these newborns are resistant to most (if not all) of the antibiotics available for use in these areas. The result: 58,000 newborn deaths in 2013 from drug-resistant infections in India, far in excess of the nearly 24,000 or so annual newborn deaths in the United States from all causes combined.2 Similar trends, albeit not as striking, are being reported from many other countries as well. Multiple factors have contributed to this escalation of deaths from multi-drugresistant pathogens. First (and foremost) is the overuse of broad spectrum antibiotics. Clinicians working in affected areas feel compelled to use the most powerful antimicrobials available to them when working with sick patients at high risk of death or disability. However, prudent use of antimicrobials and true antimicrobial stewardship can help achieve the multiple goals of treating the infection, protecting the native microbiome, preventing emergence of resistant pathogens, and minimizing other risks associated with antibiotic overuse (Box 1).3,4 Antibiotic overprescribing is a huge problem in primary care given the large number of viral infections that do not require treatment but pose diagnostic challenges for busy practitioners.3 Multifaceted interventions are needed to reduce the overuse, including prohibition of the over-thecounter sale of antibiotics, use of antibiotic stewardship programs, use of rapid point-of-care tests, and audits/reporting of antibiotic usage patterns.3 There is more bad news: the lack of new antimicrobials that can treat tough infections is pretty daunting. The pipeline for antibiotics has a paucity of promising new
Clin Perinatol - (2015) -–http://dx.doi.org/10.1016/j.clp.2014.12.002 perinatology.theclinics.com 0095-5108/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
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Box 1 Risks associated with overuse of antibiotics Increased antimicrobial resistance Increased severity of infections Increase in length of disease and hospital stay Increase in risk of complications Increased mortality Increase in health care costs Increased risk of adverse effects of antibiotics Increased risk of rehospitalizations Increased medicalization of self-limiting infectious and noninfectious conditions Adapted from Llor C, Bjerrum L. Antimicobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:231; with permission.
candidates with the exception of small molecule antibiotics currently in development. Strategies being considered include revival of old antibiotics. For neonatologists, combinations such as ampicillin and gentamycin have withstood the test of time for initial sepsis treatment. Yet, clinicians often choose other combinations, sometimes to the detriment of the patient.5 There is also the need to better understand the antibiotic resistome and the factors that influence evolution of resistance genes along with the spread of mobile resistance elements.6 These and many other important issues related to perinatal infections have been extensively covered by the many authors recruited by Drs Smith and Benjamin. With renewed concern about bloodstream infections, necrotizing enterocolitis, and fungal and viral infections, this issue of the Clinics in Perinatology is very timely. In addition to the editors and contributing authors, I am grateful to the publishing staff at Elsevier, particularly Kerry Holland and Casey Jackson, for their support. I am also grateful to you, the readers, for your support of the Clinics in Perinatology and ongoing feedback about topics relevant to you. Lucky Jain, MD, MBA Department of Pediatrics Emory University School of Medicine and Children’s Healthcare of Atlanta 2015 Uppergate Drive Atlanta, GA 30322, USA E-mail address: [email protected] REFERENCES
1. Harris G. Superbugs kill India’s babies and pose an overseas threat. The New York Times 2014. 2. Gregory EC, MacDorman MF, Martin JA. Trends in fetal and perinatal mortality in the United States, 2006-2012. NCHS Data Brief 2014;169:1–7. 3. Llor C, Bjerrum L. Antimicobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:229–41.
Foreword
4. Brooks BD, Brooks AE. Therapeutic strategies to combat antibiotic resistance. Adv Drug Deliv Rev 2014;78C:14–27. 5. Clark RH, Bloom BT, Spitzer AR, et al. Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamycin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. Pediatrics 2006;117:67–74. 6. Perry JA, Westman EL, Wright GD. The antibiotic resistome: what’s new? Curr Opin Microbiol 2014;21:45–50.
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Foreword Neonatal-Perinatal Infections: A r e We Lo s i ng t he Ba t t le ?
Lucky Jain, MD, MBA Editor
The December 3, 2014 edition of The New York Times1 carried an alarming story: “Superbugs Kill India’s Babies and Pose an Overseas Threat.” The article describes a deadly epidemic “that is quietly sweeping India and could have global implications.” Among its victims are “tens of thousands of newborns who are dying because oncemiraculous cures no longer work.” Bacterial infections in these newborns are resistant to most (if not all) of the antibiotics available for use in these areas. The result: 58,000 newborn deaths in 2013 from drug-resistant infections in India, far in excess of the nearly 24,000 or so annual newborn deaths in the United States from all causes combined.2 Similar trends, albeit not as striking, are being reported from many other countries as well. Multiple factors have contributed to this escalation of deaths from multi-drugresistant pathogens. First (and foremost) is the overuse of broad spectrum antibiotics. Clinicians working in affected areas feel compelled to use the most powerful antimicrobials available to them when working with sick patients at high risk of death or disability. However, prudent use of antimicrobials and true antimicrobial stewardship can help achieve the multiple goals of treating the infection, protecting the native microbiome, preventing emergence of resistant pathogens, and minimizing other risks associated with antibiotic overuse (Box 1).3,4 Antibiotic overprescribing is a huge problem in primary care given the large number of viral infections that do not require treatment but pose diagnostic challenges for busy practitioners.3 Multifaceted interventions are needed to reduce the overuse, including prohibition of the over-thecounter sale of antibiotics, use of antibiotic stewardship programs, use of rapid point-of-care tests, and audits/reporting of antibiotic usage patterns.3 There is more bad news: the lack of new antimicrobials that can treat tough infections is pretty daunting. The pipeline for antibiotics has a paucity of promising new
Clin Perinatol - (2015) -–http://dx.doi.org/10.1016/j.clp.2014.12.002 perinatology.theclinics.com 0095-5108/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
ii
Foreword
Box 1 Risks associated with overuse of antibiotics Increased antimicrobial resistance Increased severity of infections Increase in length of disease and hospital stay Increase in risk of complications Increased mortality Increase in health care costs Increased risk of adverse effects of antibiotics Increased risk of rehospitalizations Increased medicalization of self-limiting infectious and noninfectious conditions Adapted from Llor C, Bjerrum L. Antimicobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:231; with permission.
candidates with the exception of small molecule antibiotics currently in development. Strategies being considered include revival of old antibiotics. For neonatologists, combinations such as ampicillin and gentamycin have withstood the test of time for initial sepsis treatment. Yet, clinicians often choose other combinations, sometimes to the detriment of the patient.5 There is also the need to better understand the antibiotic resistome and the factors that influence evolution of resistance genes along with the spread of mobile resistance elements.6 These and many other important issues related to perinatal infections have been extensively covered by the many authors recruited by Drs Smith and Benjamin. With renewed concern about bloodstream infections, necrotizing enterocolitis, and fungal and viral infections, this issue of the Clinics in Perinatology is very timely. In addition to the editors and contributing authors, I am grateful to the publishing staff at Elsevier, particularly Kerry Holland and Casey Jackson, for their support. I am also grateful to you, the readers, for your support of the Clinics in Perinatology and ongoing feedback about topics relevant to you. Lucky Jain, MD, MBA Department of Pediatrics Emory University School of Medicine and Children’s Healthcare of Atlanta 2015 Uppergate Drive Atlanta, GA 30322, USA E-mail address: [email protected] REFERENCES
1. Harris G. Superbugs kill India’s babies and pose an overseas threat. The New York Times 2014. 2. Gregory EC, MacDorman MF, Martin JA. Trends in fetal and perinatal mortality in the United States, 2006-2012. NCHS Data Brief 2014;169:1–7. 3. Llor C, Bjerrum L. Antimicobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:229–41.
Foreword
4. Brooks BD, Brooks AE. Therapeutic strategies to combat antibiotic resistance. Adv Drug Deliv Rev 2014;78C:14–27. 5. Clark RH, Bloom BT, Spitzer AR, et al. Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamycin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. Pediatrics 2006;117:67–74. 6. Perry JA, Westman EL, Wright GD. The antibiotic resistome: what’s new? Curr Opin Microbiol 2014;21:45–50.
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