Human and Animal Health. This is about an hour 40 minutes. [inaudible conversations] good m good morning. The Senate Health education labor and pensions subcommittee on primary health and Retirement Security will come to order. Thank you for joining us today for the primary health and retirement subcommittee hearing superbugs. The impact of Antimicrobial Resistance on modern medicine. Thank you, especially to Ranking Member marshall to you and your staff shared commitment to preparing for presenting the Antimicrobial Resistance crisis in the United States. This is the type of partnership that drives results ultimately in congress. More than 100 years ago the discovery of antibiotics revolutionize modern medicine. Some experts considered penicillin the single most important drug ever created. Antibiotics alone have extended our average life can by 23 years. But the rise in Antimicrobial Resistance threatens to undo 100 years of medical progress. Minor infections could become incurable leaving patients with chronic illnesses like Cystic Fibrosis most at risk. Routine surgeries could turn into deadly procedures. A paper cut could become lethal. But with the benefit of a century of scientific advancement are side this does not have to be our fate. Our scientists and medical leaders already know what needs to be done. They know that the only medicine better than an antibiotic is prevention. We know we must use antibiotics responsibly. We know that keeping people healthy and out of the hospital is critical to reduce Antimicrobial Resistance yet more than 100 million americans lack access to primary care. But we here in congress can do something about that. We can invest in our Community Health centers and Public Health infrastructure. We can build a worldclass health cyst comes that reaches every system and community from kansas to massachusetts and invest in our workforce and powering a legion of medical professionals to prevent infections from turning into pandemics. We can keep our people healthy like keeping our planet healthy. Last week he saw the four hottest days ever recorded while the planet will turn our coastline into waterways and petri dishes diseases will spread faster and new strains will spread further. Our Climate Crisis feeds the Antimicrobial Resistance crisis and the only answer is to act now. We need a hall of government approach to prevent the next Public Health emergency. As we saw with covid19 when crisis strikes it doesnt strike Antimicrobial Resistance crisis will threaten the people who interact the most with the medical system. Itll threaten our healthcare workers, our friends and family who have disabilities, who are pregnant or who are elderly. In a worse and an opioid academic whether or not they have the resources to his bond. With the wisdom of hindsight we can improve our pandemic designed the people at the very center designed to take care of all americans. We can deliver the ingenuity of American Innovation but it only save us from crisis if treatment is accessible for everyone. Just as a vision, our funding is an hallucination and is a fantasy. We can create a different future one that does not repeat the sins of the past. The Witnesses Today doctors on the front line, doctors living with the risk of Antimicrobial Resistance, Companies Developing new medications and researchers connecting the health of our people and environment will light our paths forward and are fighting for a Better Future and Congress Must listen and respond. It is time that we prepare an equitable government plan to address the crisis and with that i will now turn to Ranking Member senator marshall for his opening statement. Thank you mr. Chairman for holding this on Antimicrobial Resistance. I could barely sleep last night i was so excited to get here. This is why we came to congress was to fix problems like this. And i will tell you why this is near and dear to my heart. Since i was a second year medical student, trying to understand bacteria and yeast infections and fungus the story that i remember, we were building delivering 15 to 20 babies a of the star that haunted everybody was a young lady that had a csection and had died maybe about three months before i got there and died from a resistant bacteria. From sepsis. A complication from the c section and there were days and weeks were they didnt talk about that case. A month or two we were having a very high infection rate. Higher than i was comfortable with the postoperative patients. I started culturing patients something you typically dont do when you have a multibacterial calling this types of infections. I cultured several people and they had a mrsa infection. I looked into it further and they were using a prophylactic and were treating common urinary Tract Infections. Obviously this new was a third or fourth generalization cephalosporin was inducing drug resists. So here we are today and why is this important . The million americans this year will get some kind of Antimicrobial Resistance superbugs this year 100 americans will die today and 100 will die tomorrow. And every day this year from some type of resistant bug. And i see the need for this pricing as diabetes and obesity overwhelm our society those are setups for more resistant organisms and in my experience you will have more infections and antiresistant bugs. For years weve had in his stead penicillin resistant it is interesting i did research on this cds he and the World Health Organization both agree that human overviews is the main cause and im sure they will talk about this. But one of the first things i did i was so impressed there was a veterinarian not on staff literally consulting on a weekly basis focused on nutrition and cutting back the antibodies and i am so impressed with how if you are antibodies those industries are using today. To 2017 i bet the doctor will talk a little bit about that as well. Im proud of what we have done in our culture but we need to look in the mirror. Half of the on products resist to are probably not indicated. Certainly my profession needs to look in the mere need to do more cultures and pay more attention to this as well. Here is a challenge before us. I talked about those 100 people dying every day from some type of resistant organisms that is probably caused by 20 or 30 different bacteria. It is up to you will develop one antibody itll take care of all these. You develop an antibody and maybe it is specific to an infection from a kidney infection and another antibody is for pneumonia and another for pelvic infection. That is why it is so costly to develop these. Realizing that we need 20 or 30 new antibiotics to take on these key infections. As opposed to see a diabetic drug thatll give to tens of millions of patients are even in alzheimers drug it should be given to 1 million patient. When we develop these types of anabiotics we are hopefully only going to use them each a handful of times and it just makes the economics of it next to impossible. We have many professional friends and colleagues who have asked me to have this patient centered care so im proud of the Allstar Group of witnesses we have. I know it will be a great hearing and again i want to emphasize thank you to your staff as well german the Committee Staff working together to bring this to light. This is an issue that this committee can literally make a difference today. People ask me why left the practice of medicine to come here and i would tell them in medicine i can impact 30, 40, 50 people a day in here you and i can impact the lives of thousands of people. Certainly 100 a i mentioned dying proud to be here and look forward to hearing from eyewitnesses. I would asked senator marshall for you to introduce our first witness if you would please. [inaudible] the last six years in stick years in congress. A veterinarian with phd in pharmacology at the college of veterinary medicine at the Kansas State University home of the fighting wildcats. He teaches multiple courses related to animal medicine, clinical pharmacology Antimicrobial Resistance in his Research Interests include Infectious Disease anabiotic efficacy resistance drug residues thatll be interesting and applications of he is a nationally recognized doctor and is among the most influential veterinarians he recognizes the value of his work. Dr. Appellee is a devoted member of the president ial Advisory Council will and recently completed two terms on the council serving as vice chair and is currently serving as a diplomat of America College of veterinary clinical pharmacology and is a member of the american veterinary american association. Thank you for being here and i look forward to hearing your information. Go ahead. Thank you. Members of the subcommittee and my esteemed colleagues. Good morning my name is mike aptly and i served as a member on antimicrobials. Clinical use of antibiotics and research has been my focus since 1987. Today we are addressing the needs of anabiotic resistance more specifically the issue of acquired anabiotic resistance for anabiotic several previous the effective against bacterial pathogen have lost the ability to have an impact on the impact of the disease caused by that pathogen in humans or animals. We can think of worse resistance as the worstcase scenario of there being a possible treatment for a resistant disease or it could mean that our initial choices dont work and it is later in the disease process when an effective anabiotic is used. This delayed effective intervention can result in a more prolonged disease course and increased chance of debilitation on eventual failure of antibiotic therapy for resistance are anabiotic choices can have side effects which can complicate recovery. Acquired anabiotic resistance requires to a mutation of bacterial dna which is passed down through the steps and generations but the other more alarming route for resistance occurs to the horizontal transfer resistance chain between different back area by means of transferable genetic elements. A method of transfer and the means to be incorporated into the dna of the bacteria we are being genetic elements. These transferable genetic elements may contain the genetic code of more than one resistance mechanism which many of these mechanisms have resistant to multiple antibiotics. Multiple will Drug Resistance or mdr. The conditions leading to acquired anabiotic resistance reaching a for this resistance has an impact on the use of anabiotic include frequently applied anabiotic, a highly mutable population of bacteria with a short generation time in this may result in a higher proportion being resisted and the expansion of an already resistant bacterial population by reducing the numbers the latter situation highlights the importance of the Health Impact of our normal bacterial flora. To be clear this is a generalized account of the nature of acquired anabiotic resistance. Discussion should be held in relation to the specific combination of anabiotic exposure the bacteria is interest and how it occurs. We have pathogens which require assistance to most and in some cases all of our anabiotic options and we have pathogens which maintain susceptibility to our most basic anabiotic choices. The severity of the anabolic resistance is illustrated in the characterization of the major resistance threat to human health by the centers for Disease Control and prevention or the cdc. What specifically between 19 anabiotic resistance starts identifies 18 bacteria and fungi estimated to be involved in more than 2. 8 million anabiotic resistance infections each year resulting in 35,000 the when severe and potentially fatal diarrhea caused by related to antibiotic use is can a this raises it to 3 million infections and 40,000 deaths. The complex relationship of anabiotics to our Healthcare System is reflected in a 2022 special report by the cities on the impact of covid19 on antibiotic resistance. The American Veterinarian Association has also published documents identifying anabolic resistance challenges encountered in veterinary species. Consideration of the challenges has led to the action plan an important component is the one held approach and recognizes a relationship between the health of humans animals plans and the environment. Consistent with this one held approach the fda center for veterinary medicine is in the last year of the current five year action plan for supporting antimicrobial stewardship with a recent progress report. I would also like to highlight a resource on anabolic resistance within the u. S. Department of health and Human Services or the president ial advisory counts on combating anabolic greatest bacterial. It produced the first of 11 reports in 2016 with the most recent report in 2023. I suggest this resource is not only a way to hear from matt but also as a bridge to resources in the field. Thank you very much for the opportunity to be here this morning and i look over to our discussion thank you dr. So much and now im going to introduce dr. Helen boucher. The dean as well as professor of medicine at Tufts University school of medicine and the chief academic officer of tufts medicine in boston, massachusetts. She is a practicing Infectious Disease physician and not a wildcat but a jumbo. She also serves as director of the center for integrative management of Antimicrobial Resistance in a 2015 dr. Boucher was appointed to the president ial advisory counts will of combating antibacterial resistance. Dr. Boucher may proceed. Thank you. Thank you for holding a hearing on Antimicrobial Resistance and for inviting me to testify on behalf of the Infectious Disease society of america and in my capacity as a dean of medicine. As a physician i see firsthand how it is harming patients. Amr is everyones crisis and everyones responsibility for i will briefly outline key drivers and why amr is a Significant Health crises and urgently we need a solution. As dr. Apley pointed out we are happy to evolve to resist antibiotics making those drugs ineffective resistance occurs in nature and antimicrobial overuse in humans, animals and the environment. Antimicrobial products are unique in their use and individuals can impact efficacy and the rest of the population. Despite some progress antibiotics continue to be misused. In 2016 about half the cost lies nations were prescribed antibiotics from 30 to 50 of those were inappropriate. Environmental factors are also expiring the amr. Climate change, pollution, and denser population settings can all facilitate the spread of amr through waterborne pathogens infected burns and it increases respiratory infections in 2019 and estimated 1. 27 Million Deaths worldwide were directly caused by amr and amr played a part in mayberry 5 Million Deaths. Pulling more than 4. 6 billion annually with 1. 9 billion costs for medicare. Antimicrobials enable modern medicine. Other complex carriers carry a risk of infection are only possible with anabiotics of work. Amr puts all these therapies to which americans are entitled at risk due to our lack of novel i specialize in caring for patients undergoing Organ Transplantation in these patients must be on medicine to prevent rejection. In the beverly inability and an infection is a leading cause of death in this population. Ive had the sad duty of caring for a person for which we had no effective antibiotics. He was unable to proceed to the transplant and had to go home on hospice. Ultimately leaving his two young sons fatherless. Amr is also impacting healthy individuals in our community i have cared for otherwise healthy women with resistant urinary Tract Infections that are no longer treatable with antibiotics. This has required two weeks of intravenous therapy obviously started in the hospital. The opioid academic is also feeling amr. Individuals who inject drugs are two times more likely to experience an invasive amr infection. It disproportionately affects and military service siegler at heightened risk for infected wounds. We appreciate the Health Committees ability and think Ranking Member marshall for spearheading an annual letter to have congress provide funding the most important thing the subcommittee can do is have a policy to spur the discovery and development of novel antimicrobials. A subscription model would pay for these based on their value instead of volume to drive private investment and antimicrobial r d over 200 organizations support this approach. R d incentives must repair with resources for stewardship. Stewardship programs optimize antimicrobial use improve Patient Outcomes and lower healthcare costs. Unfortunately many healthcare but it is l