Human and Animal Health. This is about an hour 40 minutes. [inaudible conversations] good morning. The Senate Health education and labor subcommission 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, your staff shared commitment to preparing for preparing. This is a type of partnership that drives results ultimately in congress. More than 100 years ago the discovery of antibiotics revolutionized modern medicine. Some experts consider penicillin to be the single most important drug ever created. Antibiotics alone have extended our average lifespan by 23 years. But the rise in Antimicrobial Resistance threatens to undo 100 years of medical progress. Minor infections could become incurable bleeding 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 on our 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. They know we must use antibiotics responsibly. They know that keeping people healthy and out of the hospital is critical to reducing 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 worldclass Health System that reaches every person in every community from kansas to massachusetts, and invest in our workforce empowering a legion of medical professionals to prevent infections from turning into pandemics. And we can keep our people healthy by keeping our planet healthy. Last week we saw the four hottest days on planet earth ever recorded. While the planet will turn our coastlines and waterways into petri dishes, diseases will spread faster and new strains will spread farther. Our Climate Crisis feeds the Antimicrobial Resistance crisis, and the only answer is to act now. We need a whole of government approach to prevent the next Public Health emergency. And as we saw with covid19 pandemic, when crisis strikes, it doesnt strike in a vacuum. And Antimicrobial Resistance crisis will disproportionately threatened the people who interact the most with the medical system. It will threaten our health care workers, our friends and family who have disabilities, who are pregnant or who are elderly. It will worsen and sulfuric all. Epidemic and strike in every Community Whether or not have the resources to respond. It will bankrupt our working class and strained a system plagued by inequality. What with the wisdom of hindsight we can improve our pandemic preparedness. We can build a resilient Healthcare System design with people at the very center, decide to take care of all americans. We can deliver the ingenuity of American Innovation but it will only save us from crisis if the treatment is accessible for everyone. Just as a patient without funding is an hallucination, innovation without access is a fantasy. We can and must create a different future, one that does not repeat the sins of the past. The witnesses here today, doctors on the frontlines, haitians living with the risk of Antimicrobial Resistance, Companies Developing new medications and research connecting the health of our people and our environment where light our path forward. They are fighting for a better future, and Congress Must listen and respond. It is time we guarantee a prepared and equitable whole of government plan to prevent a crisis. With that i will now turn to our Ranking Member, senator marshall, for his opening statement. Well, thank you, mr. Chairman for queen told a cheering on Antimicrobial Resistance. I got to chile 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 the best. And ill tell you why this is near injured to my heart. Certainly since the secondyear medical student, try to understand bacteria and yeast infections and fungus, but the story that i remember issuing up for my ob gyn residency program. We were delivering 15 15 to 0 babies at a working 36 hour shifts. But the story that haunted everybody was a young lady that had a csection and had died maybe three months before i got there, and she died from a resistant bacteria from sepsis, a complication from a csection. Very few days or weeks went by what we didnt talk or they didnt talk about that case. Was there a month or two and were having a very high infection rates, higher than i was comfortable with with postoperative patients. So i started culturing patients and that something you typically dont do when you have a multibacteria, grampositive gramnegative causing this type of infection but i cultured several people and headache methicillinresistant staph aureus. I had never even seen the patient with it. I had read about it, is that i started to go why all these patients having a methicillin resistance . I looked in the further end of using wimax and called guerrilla selling as a prophylactic and were treating common urinary Tract Infections. They were treating everything with it. And obviously this do i suppose was a third of fourth generation was inducing Drug Resistance. So here we are today, and why is this important . 3 million americans this you will get some type of an antimicrobial resistant superbug this year. 100 americans will die today. When hundred will die tomorrow. And every day this year from some type of a resistant bug. And i see the need for this rising as diabetes and obesity overwhelm our society, those are set up for more resistant organisms. And again in my field of obstetrics, our csection rates are going up for the same reasons and were going to have more infections and more resistant bugs. And then of course sexually transmitted diseases. For years without penicillin resistant gonorrhea but now its resistant to others so its certainly something us everyday in my practice. Those industries are using today compared to 2017 when we pass legislation i bet dr. Apley will talk about that as well. So im proud what weve done in agriculture will need to look in the mirror. We many physicians, Nurse Practitioners and p. A. S you to look at the mirror. Half of the antibiotics we prescribed are probably not indicated. I wish i could tell you which hath it is but certainly my profession needs to look in the mirror. We start need to do more cultures and pay more attention to this as well. Heres the challenge before us. I talked about this one there are people dying every day from some type of resistant organism. Thats probably caused by 20 or 30 different bacteria. Its not that youre going to develop one antibiotic thats going to take care of all of these. You develop an antibiotic and maybe its specific to an infection from a kidney infection and another antibiotic could be specific for a pneumonia and another antibiotic for pelvic infection. So thats what its so costly. Thats what is so costly to develop these. Realizing we need 20 or 30 new antibiotics to take on these key infections. As opposed to, say, a diabetic drug is going to be able to give that to tens of millions of patients or even alzheimers drug, its developed, it will probably be given to 1 million patients. When we develop these types of antibiotics we are hopefully only to use them each a handful of times and just makes the economics of it next to impossible. We have many professional friends and colleagues have asked me to have this patient centered hearing so im so proud of the Allstar Group of witnesses we have. I know its going to be a great hearing. And again i want to emphasize, thank you to your staff as well, chairman, at the Committee Staff working together to bring this to light. This is an issue that this committee can literally make a difference today. People asking why i left Practice Medicine to cover and i would tell them look him in medicine i could impact 30, 40, 50 people a day. Here you and i can impact the lives of thousands of people. Certainly one of people to death at a may and i from antimicrobial resistant bacteria. So proud to be on the 40 hearing from her witnesses. Thank you. And i would ask senator marshall for you to introduce our first witness if you would. You bet. [inaudible] the last six years in congress. Dr. Apley of course is a veterinarian with a phd in pharmacology at the college of veterinary medicine at the kansas state university, home of the fighting wildcats. He teaches multiple courses with iterative food animal medicine, clinical pharmacology come Antimicrobial Resistance. His Research Interests include Infectious Disease, antibiotic efficacy, resistance, antibiotics stewardship which is an issue here today, drug residues that will be interesting in applications of drugs in food animals. Dr. Apley is a nationally recognized for his work and is among the most influential veterinarians in cattle industry. He recognizes the value of his work dr. Apley was appointed a voting them of the president ial Advisory Council in combating antibiotic resistant bacteria. He completed to terms on the council serving as vice chair. He currently serves as a diplomat at the American College of veterinary clinical pharmacology and is in the American Veterinary Medical Association. Dr. Apley thank you so much for agreeing to be here and to testify. We look forward to your information. Should a introduce the next one . Dr. Apley, go ahead. Whenever you feel comfortable please begin. Thank you. Chairman markey, Ranking Member marshall, members of the subcommittee and my esteemed colleagues, good morning. My name is mike aptly, a veterinarian and also serve as an alternate member on the American Veterinary Medical Association committee on antimicrobials. Clinical use of antibiotics and research into the optimal use has been my focus since 1987. Today we are addressing the issue of antibiotic resistance. More specifically, the issue of acquired antibiotic resistance were antibiotics that were previous effective against the bacterial pathogen have lost the ability to have an impact on the outcome of disease caused by the pathogen in humans or animals. We can think of worse resistance as the worstcase scenario of there being no possible treatment for a bacterial disease. Or resistance can mean that our initial animatic choice doesnt work and it is later in the disease process went and effective antibiotic is used. This delayed effective intervention can result in a more prolonged disease course, an increased chance of debilitation, or an eventual failure of antibiotic therapy. Resistance to our initial antibiotic choice can also mean the remaining options have undesirable side effects which complicate recovery. Acquired animatic resistance may occur due to a mutation in bacterial dna which is passed down through the subsequent generation, but the other more alarming route for acquiring resistance occurs through the horizontal transfer of resistance genes between different bacteria by means of transferable genetic elements which encode for resistance mechanism, a method of transfer and the means to be incorporated into the dna of the bacteria receiving the genetic elements. These transferable genetic elements may contain the genetic codes of more than one resistance mechanism. With many of these mechanisms encoding resistance to multiple antibiotics. This is to multiple Drug Resistance, or mdr. The conditions leading to a acquired antibiotic resistance reached a point where this resistance has an impact on the use of an antibiotic include frequently applied antibiotic selection pressure, a highly mutable population of bacteria with a short generation time here this selection pressure may result in a higher proportion of the pathogen population being resistance as will as of the expansion of an already resistant bacterial population i reducing the numbers of other bacteria competing for the same resources. The latter situation highlights the importance of the Health Impact of our normal bacteria. To be clear this is a generalized account of the nature of acquired antibiotic resistance. Discussions should be held in relation to specific combinations of antibiotic exposure, the bacteria of interest, and invited to which of the antibiotic bacterial interaction occurs. We have pathogens which of acquired resistance to most and in some cases all of our antibiotic options and we have pathogens which maintain susceptibility to our most basic firstline antibiotic choices. The severity of the antibiotic resistant challenge to our health is illustrated is a characterization of the major resistance threats to human health by the centers for Disease Control and prevention, or the cdc. More specifically their 2019 209 antibiotic resistant threats report identifies 18 bacteria and fungi as might be involved in more than 2. 8 million antibiotic resistant infections each year, resulting in 35,000 deaths. When severe and potentially fatal diarrhea caused by with her to antibiotic use is considered, this raises estimates to 3 million infections and 48,000 deaths. The complex relationship of animatic resistance to our Healthcare System is reflected in a 2022 special report by the cdc on the impact of covid19 on antibiotic resistance. The American Veterinary Medical Association has also published a document identifying antibiotic resistance challenges encountered in veterinary species. Consideration of a challenge of antibiotic resistance has led to the National Action plan for combating antibiotic resistant bacteria, carb. An important component of carbon is the one Health Approach which recognizes relationships between the help with humans, animals, plants in the environment. Consistent with this one Health Approach the fda center for veterinary medicine is in the last year of the current five year action plan for supporting antimicrobial stewardship in veterinary studies. With the recent progress report. I would also like to highlight a resource on antibiotic resistance within the u. S. Department of health and human services. The president ial Advisory Council on combating antibiotic resistant bacteria, or at carb. Pat carb produce a first of 11 reports in 2016 with the most recent report of 2023. I suggest this resource is the only way to her from experts but also as a bridge to meet Additional Resources in the field. Thank you very much for the opportunity to be at this morning and forward to our discussion. Thank you, doctor come so much. And now im going to introduce doctor helen boucher. Dr. Boucher is the dean as well as professor of medicine at Tufts University school of medicine and the chief academic officer of tufts medicine Health System in boston, massachusetts. She is a practicing Infectious Disease physician, and not a wildcat but a jumbo. She also served as director of stuart a levy center for integrated management of Antimicrobial Resistance. In 2015 dr. Boucher was appointed to the president ial Advisory Council on combating antibiotic resistance bacteria. Dr. Boucher, you may proceed. Thank you, chairman markey, it Ranking Member marshall and distinguished member of the subcommittee. Thank you for holding a hearing on at the microbial resistance and for inviting me to test my behalf of Diseases Society of america and in my capacity as a dean at the Tufts University school of medicine. As an id physician i see firsthand how amr in the birth of new antimicrobials is harming patients. Amr is everyones crisis and everyones responsibility. I will briefly outline key drivers of amr, what amr is one of the Significant Health crises of our time and urgently needed solutions. As doctor albert pointed out the beautifully amr pathogens ability to evolve to resist antibiotics, making those drugs ineffective. One resistance occurs in nature, antimicrobial overuse in humans, animals and the environment speech resistance. Antimicrobials are unique in that used in one individual can impact efficacy and the rest of the population. Despite some progress, antibiotics continue to be misused. In 2016 about half of hospitalized patients were present at antibiotics and 3o 50 were inappropriate. Environmental factors are accele