What they are attempting to do. It is telling. They have no right. None. Good evening welcome my name is natalie draper. I am really excited when i was approached about speaking at the Library Mostly out of curiosity and as a teenager equal parts traumatized and fascinated. So here to discuss his book brandnew that has just been out superbugs thank you all for joining us tonight. [applause] thank you for coming out. Im excited to be here when i was working on this book researching and writing this when my wife was sitting across me at the dining room table she squinted her eyes i could tell she was deep in thought and she said of all the guys how did i end up with the yeast infection guy . Pe[laughter] thats what i spend my time focusing on his yeast infections that are difficult to treat that is one of the superbugs you may not always hear about so what i talk about is what our superbugs and where they came from and what we do about it and then i will open for discussion because i found people have a lot of questions about this topic. It is a fascinating topic so what i will try to do is clarify and also do a short reading what it is like to be a superbugs hunter because that is what i do. What is a superbugs . The traditional answer it is a drugresistant microbe that can be bacterium a fungus a parasite or even a virus some people say hiv is a superbugs and others would say not we should be strict that to drugresistant bacteria promoting the book i got an email afterward from a professor who said i really dont like the term superbug you should be difficulthe to treat infections i said thats not much of a book title and thats not what im talking about because many of the superbugs that i treat are hard to tree they may be resistant to many antibiotics onbut if they are susceptible to one, then we dont have a problem. This comes up quite a bit where somebody is referred to me with a urinary tract infection and e. Coli is in the year in which is a common cause but what comes along with that is a long list of all the antibiotics that it does not treated that will freak out wind as long as there is one that means it is s that means it is susceptible and not our for resistant you can treat it so i spend time figuring out what do you do if it is all resistant quests and that is the starting point for my book. I will do a little bit of reading so you know what its like to be in the room was somebody that has a superbug infection with no treatments. Then we will talk about what happened to him and where the whole field is going. My love to share the stories but also the scientist to come up with a cure for this. Just after dawn i felt the buzz i put down the coffee and glanced at my pager i am needed in the emergency w room. 2014 on a warm october day with a flurry of anxiety and excitement for after 11 years of training i accepted a position at new york presbyterian. On the Upper East Side of manhattan and the patient had just arrived with an infection that stomped the team in the er. One moment later i was standing before residence and was a stretcher mechanic from queens with dark green eyes and a tattoo on his shot in a large area of the bullet was infected looking at the jagged entry a student handed me a piece of paper the printout revealed the microbiological test my eyes would bolt affected with the new bacteria resistant to every antibiotic at my disposal except for one. Id only use that a few times in my career and never with good results because it was so outrageously toxic. Calista may kill bacteria but it destroys kidneys and other organs in the process leaving many patients with two options. Dialysis or death. Antibiotics proven so effective a short time ago were useless and if i wanted to save this mans life it was my only option. I shook my head and handed the paper back to the student. Not good. More than 20000 people die every year from antibiotic resistant infections and that pipeline is on the verge of drying up. Ii crouched to meet his eyes and picked my words. You have a severe infection. His gaze darted for me to those behind me. How severe . He took a deep breath and held it for a quick felt like an hourglass was flipped and now it was very hot paraguay took off my white coat and i said quite severe. I extended my arm to hold his hand but i caught myself i was not supposed to touch the patient without protection. Everybody out. Now. I will be right back. Just outside i put on a disposable down and purple gloves and return to the bedside alone. Its very hard to treat but not impossible. He was now breathing very quickly on the verge of hyperventilating he grasped where the bullet had entered bacteria was rapid the multiplying devouring muscle and bone. Will i lose it . In truth i was not sure only calista had the chance to destroy the infection but there were no guarantees. The last person died 12 hours after she received it before that died while receiving it. I dont think so as confidently as i could. I would have to summarize the nuance of the case they would need to take special precautions just to be in the same room with him. We will get you through this as his eyes began to water. We will pick where the for the room and remove my gown and gloves and address the team. Start calista. One of the residents frowned. That we vigorously washed our hands and movedhe on to the next patient. I will pause there to say this is what it is really like to have these conversations with patients. I started the book this way because i felt that so much of the conversationn around drugresistant bacteria and superbugs take place at 30000 feet talking about policy proposals or over prescription of antibiotics and the issues that cause the epidemic but have not addressed what it is really like for the patients in the book is full of stories that not only deal with these infections but suddenly ask to be a part of the Clinical Trial. That is what my book is about. Just starting out as a young faculty membert s i was invited to be the Principal Investigator on the Clinical Trial that could treat superbugsat. The book is about the approaching patients who are affected and scared and nervous and if they are willing to try a new and unproven drug that had never been usedve before. New york presbyterian is the top hospital in new york 16 years in a row and they pride themselves on its reputation. I found our hospital does not carry many antibiotics that were just approved by the fda. Your hospital almost certainly doesnt either. This is part of what the book is about. Why is that . We hear about drugresistant bacteria and fungi and then we find success with the fda approving a new drug. That doesnt go to the shelves of your hospital or your doctor knows how to prescriber it ort that it will ever reach you. I was flabbergasted. Why . What is the reason . More importantly, what is this mean for future Drug Development . One thing that people dont recognize there is a Formulary Committee at each hospital they decide what drugs to add or which ones they will not use. They are able to buy in bulk based on making specific deals. At my hospital we use love for ofloxacin but not its sister drug but some coming out are so expensive that the farmers loan the pharmacies in the hospitals cannot afford to useim them. I thought this was a fascinating conundrum and my book is about a new antibiotic that was approved by the fda may 2014 and did not go anywhere. I didnt go to my hospital or any in my community. The reason is the company wanted to charge thousands and thousands of dollars for a single dose. The hospital said we cannot afford that. That will break the budget. Where they have that same conversation of cancer or cardiovascular drugs i am not privy to that but we certainly seem to have the best drugs forie the other conditions but with infections we seem to be not dropping the ball but willing to not stock the latest antibiotics you can look at those approved last year thats almost certainly are not in your local hospital because it cost so much money in the and the question is why . It isnt that the pharmaceutical companies are greedy, but to get a drug approved by the fda typically takes ten years and 1 billion to go through phase one and two and three Clinical Trial. If youre developing a drug for high Blood Pressure or high cholesterol, it will be worth it because that is a drug they will prescribe and say take this every day for the rest of your life. He will take it a lot. With the antibiotic short courses, doctors are very stingy to prescribe them even the best new drug will wear out the welcome when the bacteria mutates. So we have companies that say its not worth it to be in the antibiotic game now there is a lot of talk how to fix it. That is what my book is about not only to address the Patient Perspective but what about everybody else . You may not now but someday you might and where is the pipeline of new drugs going toto be . What will he have available . Aof great example is a drug plays all mice and it took a company years and tens of millions of dollars to get a finally approved by the fda last year and then they filed for bankruptcy last month. The reason is its not a blanket approval. You can now use it for any condition it is very specific it was approved for the uti it was banking on the bloodstream infection so now that i can make a difference if it survives or not. If you are a small start up you cannot absorb that kind of decision. So now we look at the larger pharmaceutical companies who will hopefully save us. That is a scary prospect especially if we see a trial going on in oklahoma with Johnson Johnson that intentionally misled people to use opiates in ways that were harmful. The pharmaceutical industry over the last 75 years has been our partner to make antibiotics. Now we have a model of how drugs come to you is now breaking and that model is the federal Government Funds scientists we will cut it by 3 percent if you promise to invest in a legally binding contract to invest profits into antibiotics that is the push incentive that would incentivize them to do something they may not but there is a pull incentive to say if you take the risk to get the new drug approved and it does, right now you get five and seven years of exclusivity we will make it 25 so nobody can challenge her c patent. No generics can come after you see you can charge a higher rate for your drug that will drive up the cost of healthcare it will also guarantee we have more people taking aar risk. So those are the things you will hear about so i want people to hear a proposal to have the informed opinion whether or not that is a good or bad proposal because that will become something that politicians will be asked about on the campaignre trail in 2020. The antibiotic market is broken what is your plan to ,fix it you will have slack jaw is at first but we will hear about ways to move forward so in england they say the pharmaceutical industry doesnt want to do this . Good riddance we should nationalize the process it should be seen like a public good like water or electricity and to pull the resources and not worry about what is profitable. And maybe thats how we move forward to have the government get more involved in healthcare. So we will be hearing conversations about what we do because any expert will tello you the antibiotic market is broken. That is important because i am forwarded articles all the time about new discoveries like new treatment for mrsa or ways to treat superbugs it is a molecular gene editing technique to manipulate a certain sequence of nucleic acid a 15 yearold british girl who had micro bacterium sepsis killing her the used radical new treatment and saved her. This will not be available to any of you or to me. The reason is under the current economic model to develop a treatment for a rare infection is so extraordinarily risky we dont haved anyone willing to do it. Will cost billions of dollars and decades of research somebody has to foot the bill. That thist was like global warming. Here is the mistake to go down this avenue so i do see superbugs as a story or as a conversation s starter. And diagnostics how we detect them so does anybody have questions or comments . Talk about the problem of superbugs. Is it bigger or in a yeast infection or spread over 100 different areas and ten people die and each space so tell me. 20000 doesnt sound like that huge of a number compared to cancer or Heart Disease spent the case was recently made by the who that said by the year 205,010,000,000 people will die worldwide every single year and by 2050 this will be a bigger issue than Heart Disease or cancer. This is the bigger story. So talking about this topic is striking the right tone so i worry i am fear mongering. If i talk about best Case Scenarios so many people have a loved one from a superbug or profoundly debilitated. So to talk about this shouldnt keep you up at night is not true either. Somewhere in the middle. And then to play around with the headlines but it was superbugs are everywhere. Dont panic so what that was about that they are everywhere. They could be on your arm that if you swab inside of a doctor or nurses knows 5 percent of us have mrsa inside of our nostrils. We are colonized we are not infected and that is a big distinction. But just a superbug living on you harmlessly means you are colonized. Know if you have a fever that is thean infection so a lot of research is what it is the trigger going from an innocent and harmless pathogen to a lifethreatening infection. Part of that is the immune system. The most important thing you can do listening to this right nowg to talk with the doctor and find out do you have a normally functioning immune system cracks is hard to understand without knowing medical conditions. To understand they are on a medication to weaken the immune system or medical condition that weakens the immune system. And then to understand and then we knew he was high risk with came on chemotherapy we did everything we could go i did not shake his hand i would shoulder bump and i write about him in the book despite her best efforts he still got a staff infection and he had had those his entire life. We knew there was a subtle alteration with his immune system to predispose him to a staff infection and when he got chemo i it exploded. So it is tricky for the onesizefitsall commentary because people differ i dont have infections my whole life i consider myself at the normally functioning immune system every morning i go into the emergency roomg i go to the patient with a superbug infection and how i will treat them brick i am not scared when i go in. Im confident how to treat them. Now starting on a course of steroids for another condition weakening my immune system it could be in the back of my head i need to make sure i follow strictke precautions because i am at risk. And with that basic level so am i functioning is a good first step. Depending on how big the issue is with the more sophisticated diagnostic technique to pick up a superbug we never could before that doesnt mean it will harm you in any way. So the first step is understanding the risk. Locust on the planet as a judgment are superbugs a judgment on our generation quick. I have been asked a lot of question about superbugs i have never gotten anything like that so thank you for making me think about this in a new way. So would say we brought the problem upon ourselves by inappropriately prescribing antibiotics and using them in ways they were never intended. The New York Times article two weeks ago how we use tuberculosis and syphilis drugs in the orange grove those that swab the me in the grocery store, 50 percent has superbugs because we pump chickens and pigs full of antibiotics. I dont know if it is a judgment but there are two schools of thought how we got into this. Using them inappropriately in the other school of thought that i write about also is the idea that these superbugs have always been around us for millennia. The diversity of life the way the genes have been mutated but any antibiotic you could dream of there is a bacterium that could destroy that to be resistant. The comparison is the monkey theory that you give them a typewriter to strike keys at random eventually they would type out the words of shakespeare. If they mutate enough they will mutate into ways of antibiotics and then we selected out for the specific superbugs. I like the idea the diversity of life means we always have inherent resistance. That partially absolves us as we bring about the most prominent superbug. But i havent made the locust comparison. That is interesting. What about toe fungus . Is it a colonization or infection curable topically . So toe fungus. I am glad you say monday and it is the most tricky to treat and one of the classic things we are taught in medical school is when you see fungus get a biopsy of the toenail because it might not be that and people so often mistaken for something else. One of the antifungal drugs is so harsh you would not want to give it to a patient without being absolutely certain that is what it is. I see a lot of patience to pull off their sock and say i have a toe fungus for years and doesnt respond to anything it turns out its not a toe fungus thats why its not responding. What you need to do is get a biopsy and look under a microscope at what is reported to be fungi now it is something else. So radiologistis looking at a test xray they will say you dont know that is a fungus ball until you put in a needle and pull fungi out. T so one of the problems is a misdiagnosis and putting people on the wrong drugs. L patients where it doesnt. My father actually passed away from an infection and couldnt figure it out so i appreciate all of your efforts to tell the story. Story. I am also interested in the genetics in terms of you talk about susceptibility. Are they looking at okay this group is sensible or this group isnt susceptible, is that a way to also look at this . Absolutely. Great question. When you hear about the Term Position medicine or personalized medicine, it is a next generation we are all going to have our genomes completely sequenced to know everything about what makes us tick and eventually have a database where we can say you have the mutation that leads you to the susceptible to stand for fungus or something else. We are not there yet. We are largely just building a database so its not at the point you could walk into a clinic and get a full readout that will say you should stay away from basements but that is where we are headed. One of the things i want to mention is we are in the midst of a very controversial and complicated algebraic i dont know if anyone has heard of this one. It is a fungus ive been studying and reading and writing about for years and no one cared and that was put on the front page of the New York Times in april and a story was written by a pair of excellent journalists and i was quoted in the article and its about this fungus that has become resistant to all of our antifungal drugs and it was spread from one patient to another. The article was about the fact that these two journalists couldnt get anyone to talk about it. No hospital wanted to acknowledge that they had this but they have patients that had this type of infection. I was invited to talk on some tv shows about it, and that made people very uncomfortable where i work because they didnt want to get labeled as this is a hospital that is infected with something great and in fact, mount zion i had to mention that they ripped out some of their interior infrastructure and some other places to make sure the facility was clean and put everyone on average and we got into the position where experts were not allowed to talk about or educate people on what the dangers were and after that, Chuck Schumer declared that this should be an emergency by senator saying we need federal resource dollars to become an outbreatheoutbreak of a deadly. We were kind of scratching our heads and said this isnt even one of the top 50 pathogens i worry about. Do we know there is an outbreak in new york and that we have babies that cant be vaccinated until they are 12yearsold and we have people walking into our emergency room with measles and its been gone for so long doctors may not even recognize it and you could be infecting hundreds, so putting the stuff in perspective i think is a really important thing to do and what you see is that many of the experts associated with Academic Medical Centers are hamstrung in their ability to talk about this. And cannot even just go out and say we solve the case and treated the person or we didnt treat the person after person died. Here is how we treat them and here is why we need more resources to generate the drugs that will save people. A young man whos about to be treated with a dangerous antibiotic, what happened . Gimmick to drug i needed to use is something we used to using the 60use inthe 60s and 70s andl out of favor because it was so toxic its like putting puttinge church and into somebody. It can kill the bacteria that also mess up your organs. Ive gone on social media, twitter. I thought it was important to address that the but they were n failing us. What i had to do with him as multiple courses but only kept the infection at bay. It wa was a non antibiotic solution for him and that is something i had to do for him and that is a scary prospect that antibiotics are considered the greatest political achievemenmedical achievementofs have to revert to a pre antibiotic era. The history of this is something that fascinates me and something i write about which is Alexander Fleming discovered the first antibiotic penicillin that became commercially available in the 1940s. In the 90s if they technique we realized weve got to do something and weve been playing catchup ever since. We dont want that to happen again. I think ive mentioned before trying to strike the right tone it is a very important issue that is an epidemic that we had the chance to change course and investing new drugs so this isnt a pandemic or the most important medical issue of the 21st century but actually it will be just one of many medical issues but that is going to require a dedicated resource. Did you have a question . This is a question i remember of my medical School Classmates there are two different types of steroids, corticosteroids and prednisone is a corticosteroid that can sort of geek in your immune system but its good for autoimmune conditions because sometimes your immune system is attacking itself so we often give credit to zone to tap that down. Completely different than one which a bodybuilder would use they get five days of prednisone to help with their lungs that isnt something that is going to predispose you to infection. What im talking aboubut im tae that take 20 milligrams per six months that can predispose you to infection. Your generalization of the need to invest in new drugs and approaches to, what does that mean, cant do Big Pharma Companies do a better job than the evil government investing . I quote a pharmaceutical ceo who raised the price of a very common antibiotic by 5000 and said he has an ethical mandate to charge as much as he can for his antibiotics because hes accountable to shareholders and not to parents. In the book i dont paint them as evil and i dont think the government is evil but people are looking out for their own business interests and these companies are saying we lose money on this and there is no such thing as corporate altruism. To use the example of one of the companies that makes him i drugs and recognize the patent was about to expire so they came up with a clever idea which is the approach to the native american tribe and they said do you know theres something called tribal sovereign immunity which is if we transferred our content to you to your tribe you can in both tribal immunity and no one can challenge it. These are the types of corporate shenanigans that are going on where people are trying to make profits off these drugs that could save our lives. That transferring to the reservation was ultimately thrown out in court. What i find so interesting are the reactions of the people that hear about it. Patients usually shake their heads. Patent lawyers say thats cool and most of us are just like i cant believe this is where we are at with these things. Pharmaceutical companies have to make tough decisions. Ive been on the Advisory Board where they try to come up with plans of what they should invest in those were the conversationss that we are having. There was an article last weekend in the Washington Post about somebody that got acute compartment holds and drumming their arm and its thing that happened just like that. Is that what we can expect with this colonization . Im not familiar with that article that i have treated patients and its terrifying. Its basically where the limb swells up and there there is ne for the blood and all of the inflammatory molecules to go and you often have to go to the operating room and cut it open and let it come out. I do not usually see that as a result of superbugs. I see them cause all kinds of infections that compartment syndrome is usually something i see from other types of injuries but it brings up the point i hit on earlier that increasingly we are using non antibiotic techniques to treat these kind of things and in the book i write about a number of patients who could only be saved their infections by the scalpel and that is what Alexander Fleming was dealing with. We are seeing the shift back to that. If you walk into the hospital here you are going to get excellent medical care. We have got a solid array of antibiotics to treat the infections that are in the community but we have to be looking ahead. I want is to be something where we have people engaged in the subject and knowledgeable about it and then listening to policy proposals and making informed decisions. The semantics of whether or not you would put a virus in the umbrella of a superbug. As i mentioned at the beginning some people would only say that the drug resistant. Drugresistant. Its a superbug and its a virus. I would call that one. Where they are coming from and what drugs will and wont work. All of this has to do with how they will be used. We are coming up with new vaccines and we have to be testing and getting informed consent its a tricky thing and i write a lot about this. I didnt always know if it was informed consent and there are patients who are often from marginalized groups who may say yes to what i ask them because they are worried they wont get good medical care if they dont and that frightens me that somebody may not fully understand what they are getting themselves into that they feel like they have to say yes and so it is a complicated thing to explain to somebody what it means to enroll in a Clinical Trial and a lot of what i write about is what those conversations were like. And you may find you are asked to participate in a Clinical Trial and i think the most interesting thing that somebody asked me an if it stopped me ded in my tracks as they said i just have one question. Would you give this drug to your mother and i thought i hadnt even asked myself that, but that was such a clarifying question. The answer was yes. That is a useful technique. When a doctor said al says all s stuff that doesnt make sense what you do this for your family member, would you try prednisone for three weeks if this were your family member, and that stuck with me. Its one of those patient interactions that stuck with me through the years rather than the policy proposals of the dollars and cents into the pharmaceutical ceos saying something that makes my blood boil it being in the room with a patient. What are your thoughts on the future of the prevention side of the equation in terms of medical professionals and patients and family members so that everyone is aware of the issue and the latest. This is important to hit upon. Ive been an antibiotics steward. Its a thankless and painful job. What happens if a doctor wants to use the precious antibiotic or expensive antibiotic or anything that isnt the routine group of five antibiotics used you have to get approval and that is done by the antibiotic. They will look at the case and say you should use penicillin into the doctor will say please i told the patient we were going to use this. They are so excited. Can you please do it and then they would say actually theres another option that is cheaper and safer and better. And those conversations always happen. No one is aware that the conversations are happening and i talk about in the book how it is a vital aspect. Its a growing more and more into the next time you are in a hospital that is something thats interesting to me because it also gives a second set of eyes looking at the case. I used to be a steward on the nights and weekends and saying no to a doctor that wants to use a drug isnt a fun job. They say i know i need an antibiotic i only feel better when i get the z. Pack. You want to make your patients happy. Saying no might be the right thing to do. I know somebody that is a team doctor for the yankees and said that if derek cheaters once an antibiotic you are giving him the antibiotic and if you dont give it to him he will have to find a new team doctor because there is an aspect of the relationship where the patient had a lot more control than they might have realized. It is a hard thing to do. They work nights and weekends, there at 11 p. M. , he earned the trust of their patients and they can say no and they know they have one of the best doctors in town. But they are increasingly fragmented and the medical society. Its hard to say no when you havent established any kind of report or trust with the patient and you are just a called in the wheel of the machine as a doctor saying i looked at the case and we are not going to give antibiotics. Its so impersonal they are left feeling cold. The ones who didnt know me would be like who is this guy. Educated people their parents took them to the doctor every time they had a sniffle, and we have no immune systems left. We get these horrible diseases. I was talking last night in boston or two nights ago with my old classmates and we were talking about how important it is to let our kids play in the dirty sandbox and for every potential danger the first thing we can do so i completely agree with you that we should make sure that we are exposing people to the diversity of the world to the life around us because trying to live in a bubble is only going to cause problems later. How we do that i think is up for debate. You should let their kids pick their nose and eat it, i dont know that we need to go that far but there are people more to come on that front. [laughter] anyway, i think our time is up and i just want to say thank you all for coming out and for such fascinating questions. This is really great. I will stick around outside. Thank you
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