Scott Gottlieb, M.D.
Researchers working at the Centers for Disease Control and Prevention reported this month that nearly 19,000 Americans died in 2005 from MRSA, and about 95,000 were infected. Doctors have been reporting for years that MRSA was cropping up with alarming frequency. The same is true for other bacteria. In Rochester, N.Y., doctors recently reported nine children stricken with a strain of the bacteria that causes ear infections--streptococcus pneumonia--that was resistant to all 18 antibiotics commonly used to treat the condition.
The real news isn't that these bugs exist, but how woefully unprepared we are to deal with them. As we make progress in fields like cancer, we are taking a U-turn on bacteria. Despite advances in drug development, the bugs have increased their IQ nearly as fast as research, outwitting our medicines. Efforts have turned to preventing bacterial spread and clamping down on antibiotic prescribing.
Only 13 new antibiotics are in development inside big drug companies, compared to an average of 60 more than a decade ago.
There's no question that poor hospital hygiene, overuse--and sometimes misuse--of antibiotics contribute to educating bugs at our expense. But preventative efforts alone won't solve our bacterial challenges. What we need most are better diagnostic tests and new medicines.
This is high-stakes science, but the pipeline isn't promising. Since 1998, just 10 new antibiotics have been approved by the the Food and Drug Administration, only two of which work in fundamentally new ways. Only 13 new antibiotics are in development inside big drug companies, compared to an average of 60 more than a decade ago. Since leaving the FDA this year as its deputy commissioner, I've advised a few biopharma firms making antibiotics and the venture investors supporting them. Regrettably, however, many big drug makers have followed the lead of Eli Lilly, a pharmaceutical company that once pioneered antibiotics, only to exit the business entirely.
The problem? There's not a lot of payoff for developing drugs aimed at infections. First, they last only days, or at most weeks, limiting sales. And the better the drug, the more likely doctors and hospitals are to keep it on the shelf as a last resort. Most hospitals require that doctors get special approval to prescribe the best new antibiotics. In that regard, what's good for public health isn't necessarily good for antibiotic development.
Capricious regulation is another problem, adding to uncertainty and, in turn, the cost of development. For drugs targeted to many common bacterial ailments, the FDA historically required so-called non-inferiority trials. This meant a new antibiotic needed to prove it was generally no worse than existing treatments in order to win regulatory approval. Otherwise, conducting trials to prove a new antibiotic was better than a sugar-pill placebo--or superior to existing drugs--would require huge trials and, in some cases, was simply unethical if it meant asking patients with potentially serious infections to risk treatment by placebo.
That changed just last year when a handful of FDA reviewers became miffed that companies would get drugs approved through these non-inferiority trials without proving the new drugs were better than older medicines, and then market the new drugs for broad upper respiratory indications. The reviewers brought their complaints to Congress, which has since leaned on the FDA, at one point asking the Government Accountability Office--staffed with lawyers and policy analysts--to opine on the nuanced scientific question of non-inferiority trial design. The political intrigue has pushed the FDA to raise its approval bar in some areas, jettisoning the non-inferiority approach for some ailments while leaving a mess of uncertainty for many others.
So how do we surmount these obstacles to get the drugs and diagnostic tests we need to stay ahead of aggressive bacteria like MRSA?
First, we need to recognize that developing drugs aimed at super bugs is not an ordinary pharmaceutical business, and requires unique incentives. If public-health policies compel doctors to hold the best new antibiotics in reserve, we need to compensate with incentives for developing those niche drugs.
One way would be to clarify the rules under the 1983 Orphan Drug Act to include drugs that target resistant bugs. That law provides special incentives for drugs that treat rare diseases, including patent protections and streamlined regulatory review. The FDA needs to create better opportunities for companies to target not only conditions--such as pneumonia or skin infection--but also specific bacteria, like multi-drug resistant staph.
The FDA's guidance on other aspects of antibiotic drug development is similarly murky due, in part, to fluid standards. Congress recently had to write into law a demand that the FDA produce guidance on antibiotics for acute exacerbations of chronic bronchitis and acute bacterial sinusitis (finally released yesterday). Merely issuing documents doesn't guarantee clarity, and one of the FDA's recent documents on an aspect of antibiotic development ran several pages, saying little.
The FDA should collaborate with the Infectious Disease Society of America (IDSA) to develop meaningful guidelines that provide clear pathways to new drug development. The IDSA's credible voice could also buttress the FDA against the maneuvering of a handful of staff who take their views to politicians when they lose internal scientific debates.
Finally, we badly need better tools for rapidly detecting resistant infections in blood, even screens for bacterial genes. Today it can sometimes take days to discover that a patient is infected with a resistant bug. If there were better diagnostics--similar to the "rapid" strep test--bacterial infections could be distinguished early and doctors could treat patients with confidence. Drug companies could also more easily develop drugs targeted to specific bugs, conducting clinical studies aimed at specific pathogens, and making sure the right patients got the right drug early in the course of their illness, when drugs can make the most difference.
But the diagnostics business has been a lower-margin affair for many years, steering product developers into other fields. There are complicated reasons for this, but Medicare has systematically tried to drive down prices for diagnostic tests, often refusing to pay for new tests altogether. In turn, the big companies that make the tests committed a fundamental mistake early on, by adopting a strategy of charging lower prices for the throw-away test kits and premium prices for the platforms they run on--a reverse of the old razor-blade model.
The big diagnostic companies figured they would make most of their money off the platforms. They're regretting that now. The strategy may have worked if they had continued to innovate, but now many of the best ideas for new tests are coming out of small firms that have little ability to sell their own big platforms, and a hard time premium pricing diagnostic tests in a market conditioned by the big firms to expect cheap razor blades.
Most existing antibiotics are as old as the earth, screened out of nature where they resided, doing battle with bugs for centuries. We need to accelerate this evolution in our laboratories. Public policy mistakes are partly to blame for creating this inhospitable environment for new development, and it will take a concerted effort to improve it. The only sure way to stay ahead of bacterial evolution is by escalating this arms race.
Scott Gottlieb, M.D., is a resident fellow at AEI.