Prevention, after some prodding by the US
Congress [12], have developed rational
public health plans to combat antimicrobial resistance. We should follow their advice. We need to be aware, however, that
the emphasis on surveillance of antibiotic
resistance can be a double-edged sword.
On the one hand, it is essential to help
guide therapy. On the other hand, it can
be used as a powerful marketing tool to
influence inappropriate use of new drugs
that need to be reserved for the treatment
of severe infections.
The “old” literature is rarely if ever referenced by the “new generation” of experts. George Santayana’s famous statement that “Those who cannot remember
the past are condemned to repeat it” is as
true as ever [13, p. 284]. Thank goodness
that the message has finally gotten
through. The torch has been passed to a
new generation. We can only hope that it
is not too late.
7.
8.
9.
10.
11.
12.
13.
Acknowledgments
I thank my numerous colleagues in adult, pediatric, and surgical infectious diseases, clinical microbiology, and hospital epidemiology who have
fostered the appropriate use of antibiotics.
Potential conflicts of interest. C.M.K. was a
member of an advisory board of Health Learning
Systems, a client of Ortho-McNeil.
Calvin M. Kunin
Department of Internal Medicine,
The Ohio State University College of Medicine
and Public Health, Columbus
References
1. Spellberg B, Guidos R, Gilbert D, et al. The
epidemic of antibiotic-resistant infections: a
call to action for the medical community from
the Infectious Diseases Society of America.
Clin Infect Dis 2008; 46:155–64.
2. Darwin C. On the origin of species by means
of natural selection. London: John Murray,
1859.
3. Jawetz E. Antimicrobial chemotherapy. Annu
Rev Microbiol 1956; 10:85.
4. Finland M, Jones WF, Barnes MW. Occurrence of serious bacterial infections since the
introduction of antibacterial agents. JAMA
1959; 170:2188–97.
5. Kunin CM, Tupasi T, Craig WA. Use of antibiotics: a brief exposition of the problem and
some tentative solutions. Ann Intern Med
1973; 79:555–60.
6. Kunin CM, Efron HY. Audits of antimicrobial
usage. Veterans Administration ad hoc interdisciplinary advisory committee on antimicrobial drug usage guidelines for peer review.
JAMA 1977; 237:1001–2.
Kunin CM, Edelman R, eds. The impact of
infections on medical care in the United
States: problems and priorities for future research. Ann Intern Med 1978; 89(Suppl):
743–866.
Burke JP, Levy SB. Summary report of worldwide antibiotic resistance: international task
forces on antibiotic use. Rev Infect Dis 1985;7:
560–4.
Kunin CM. The responsibility of the infectious
disease community for the optimal use of antimicrobial agents. J Infect Dis 1985; 151:
388–98.
Marr JJ, Moffett HL, Kunin CM. Guidelines
for improving the use of antimicrobial agents
in hospitals: a statement by the Infectious Diseases Society of America. J Infect Dis 1988;
157:869–76.
World Health Organization global strategy for
containment of antibiotic resistance. Geneva,
Switzerland: World Health Organization,
2001.
US Congress, Office of Technology Assessment. Impacts of antibiotic-resistant bacteria,
OTA-H-629. Washington, DC: US Government Printing Office, 1995.
Santayana G. The life of reason. Vol. 1. New
York, NY: C. Scribner’s Sons, 1905.
Reprints or correspondence: Dr. Calvin M. Kunin, 2447 Coventry Rd., Columbus, OH 43221 ([email protected]).
Clinical Infectious Diseases 2008; 46:1791–2
2008 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2008/4611-0027$15.00
DOI: 10.1086/588057
Reply to Kunin: Rationale
for Antibiotic Development
Incentives
To the Editor—We appreciate the
thoughtful comments of Dr. Kunin and
all of his efforts through the years to promote the proper use of antibiotics [1]. We
would like to respond with several points.
Dr. Kunin reminds us that the Infectious
Diseases Society of America (IDSA) has
been addressing the problem of antimicrobial resistance for over 40 years. In
combination with the National Institutes
of Health, the Centers for Disease Control
and Prevention, the US Department of
Veterans Affairs, and the World Health
Organization, extensive efforts have been
made to avert the problem of microbial
resistance as much as possible. These efforts have been primarily through sur-
1792 • CID 2008:46 (1 June) • CORRESPONDENCE
veillance, attempts by the IDSA to promote “antibiotic stewardship,” direct
interaction with legislators, scholarly
publications regarding concerns about antibiotic resistance, and consultations with
regulatory agencies on clinical research design. The recent IDSA Public Policy Commentary [2] stresses how these efforts have
had limited success to date, considering
that the level of antimicrobial resistance is
now greater than it has been in the history
of anti-infective agents and that we are
witnessing a dramatic egress of the major
pharmaceutical companies from the development of newer anti-infectives. The
promotion of “antibiotic stewardship” is
a critical role for the IDSA, and considerable efforts are ongoing. This guidance
[3] is just one example of multiple current
efforts. However, the IDSA is an organization of ∼9000 professionals and currently has no regulatory authority for “antibiotic stewardship” for the 11,000,000
licensed physicians and health care workers who are entitled to use antibiotics in
any way that they feel is appropriate. The
complex problem that these unregulated
physicians and health care workers face is
that of being asked to place a subset of
their patients at risk for mortality due to
curable infectious diseases by either withholding antibiotics or shortening the
course of therapy. In addition, unlike in
many other countries, they are asked to
take this potentially high-risk, conservative medical approach in a nation in which
medical law suits are frequent and risk
avoidance strategies are highly valued by
the general population. Against this background of biologically inevitable antimicrobial resistance, the failure of previous
strategies to minimize microbial resistance
development, the lack of significant antiinfective development through federal
government agencies, and the egress of the
major pharmaceutical companies from
anti-infective development, the IDSA, after considerable research involving the top
executives in the pharmaceutical industry,
has suggested the financial incentives as
described in its commentary [2] as an ad-
ditional approach. In addition, it emphasizes the importance of educating the general population to influence our policy
makers to take action against this developing crisis.
Regarding Dr. Kunin’s comments that
the IDSA leadership has “conflicts of interest,” it is our belief that the most appropriate solution to possible perceived
conflicts of interest is disclosure. The readers can then decide for themselves whether
the personal benefits that result from the
IDSA leadership’s interaction through
shared research, professional education,
and consultation with the pharmaceutical
industry are their motivation or whether
trying to stem a public health crisis and
save the lives of thousands of children and
adults dying from infections due to resistant organisms is their primary goal.
Acknowledgments
Potential conflicts of interest. B.S. has received consulting fees from Pfizer; has received
research support from Astellas, Gilead, Elan, Enzon, Novartis, Merck, and Pfizer; and is on the
Speakers’ Bureaus for Merck, Pfizer, and Astellas.
D.G. serves on the Speakers’ Bureau of Abbott
Laboratories, Bayer, GlaxoSmithKline, Lilly,
Merck, Pfizer, Roche, Schering-Plough, and Wyeth. J.B.’s employer has received research grants
from AstraZeneca, Cubist, Elan, GlaxoSmithKline,
Johnson & Johnson, National Institutes of Health/
University of Alabama, Wyeth, and Novartis and
reimbursement for J.B.’s role in consulting for
AstraZeneca, Cubist, Johnson & Johnson, Pfizer,
Schering-Plough, Trius Therapeutics, Cerexa/Forest, and Wyeth. H.W.B. serves as an advisor and
consultant to Cubist, Johnson & Johnson, Pfizer,
Schering-Plough, and Targanta; serves as a speaker
for Cubist, Pfizer, and Schering-Plough; and owns
or has owned shares of Pfizer and Cubist. W.M.S.
serves on advisory boards for Pfizer, Cubist, and
GlaxoSmithKline; serves on Speakers’ Bureaus of
Pfizer, Cubist, GlaxoSmithKline, Schering-Plough,
and Bristol-Myers Squibb. J.G.B. serves on HIV
advisory boards for Bristol-Myers Squibb, Abbott
Laboratories, and GlaxoSmithKline. J.E.E. serves
on the scientific advisory boards of Pfizer, Merck,
and Gilead; has participated in educational programs regarding fungal infections funded by Pfizer,
Merck, and Astellas; has received research laboratory support from Pfizer, Merck, and Gilead; has
received consulting fees from Cerexa/Forest; has
received research grants from Enzon; and has participated in the Bristol-Myers Squibb Freedom to
Discovery research program.
Brad Spellberg,1 David Gilbert,4 John Bradley,3
Helen W. Boucher,5 William M. Scheld,6
John G. Bartlett,7 and John E. Edwards, Jr.2
Division of Infectious Diseases and 2Research and
Education Institute, Harbor–University of California
at Los Angeles Medical Center, Torrance, and
3
Division of Pediatric Infectious Disease, Children’s
Hospital and Health Center, San Diego, California;
4
Providence Portland Medical Center, Portland,
Oregon; 5Division of Geographic Medicine and
Infectious Diseases, Tufts-New England Medical
Center, Boston, Massachusetts; 6Division of
Infectious Diseases, University of Virginia Health
Sciences Center, Charlottesville; and 7Division of
Infectious Diseases, Johns Hopkins University
School of Medicine, Baltimore, Maryland
1
References
1. Kunin CM. Why did it take the Infectious Disesases Society of America so long to address
the problem of antibiotic resistance? Clin Infect
Dis 2008; 46:1791–2 (in this issue).
2. Spellberg B, Guidos R, Gilbert D, et al. The
epidemic of antibiotic-resistant infections: a call
to action for the medical community from the
Infectious Diseases Society of America. Clin Infect Dis 2008; 46:155–64.
3. Dellit TH, Owens RC, McGowan JE Jr, et al.
Infectious Diseases Society of America and the
Society for Healthcare Epidemiology of Amertica guidelines for developing an institutional
program to enhance antimicrobial stewardship.
Clin Infect Dis 2007; 44:159–77.
Reprints or correspondence: Dr. John E. Edwards, HarborUCLA Medical Center, Research and Education Institute, 1124
W. Carson St., RB2, 2nd flr., Torrance, CA 90502
([email protected]).
Clinical Infectious Diseases 2008; 46:1792–3
2008 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2008/4611-0028$15.00
DOI: 10.1086/588058
Reply to Kunin: Infectious
Diseases Society of
America’s Efforts to Contain
Antibiotic Resistance
To the Editor—The leaders of the Infectious Diseases Society of America
(IDSA) appreciate Dr. Kunin’s [1] historical perspective on how the infectious diseases community has struggled to deal
with antimicrobial resistance, and we
share his desire to learn from that perspective as we move forward. However, we
must take issue with the notion that the
IDSA is late in addressing resistance and
off-base in our recent efforts to stimulate
anti-infective discovery as part of the solution to this problem. The IDSA has a
long history of highlighting concerns
about resistance and the importance of
antimicrobial stewardship, including those
activities, which Dr. Kunin proudly cites
in his letter [1], that occurred during his
tenure as IDSA President in the mid1980s. The IDSA’s recent growth in membership and our resultant enhanced ability
to speak more forcefully and effectively
about important public health policy matters during the past few years has allowed
us to play a larger, more visible, and we
believe more effective role than in the past.
We are not late; we are just more capable.
We strongly agree with Dr. Kunin on
the need for more-effective efforts to promote better use of existing drugs. The
IDSA joined with the Society For Healthcare Epidemiology of America to develop
new antibiotic stewardship guidelines, and
together, we are actively encouraging their
implementation. Infectious diseases specialists should play a role in fostering appropriate use of antibiotics; however, we
are only a few thousand among several
hundreds of thousands of physicians and
other health care providers who prescribe
anti-infective agents. We are well armed
with the knowledge to educate, but we are
hampered by a health care delivery system
in which patients expect more rather than
less treatment and in which physicians are
ever mindful of possible medical liability
dangers. In addition, neither the IDSA nor
individual infectious diseases specialists
have any real authority to control the use
of antibiotics; education and advocacy are
our only real tools. Moreover, it must be
acknowledged that tens of millions of dollars have been expended over the past several decades in trying to educate physicians and the public about the judicious
use of antibiotics with only limited success, as evidenced by the increasing problem of drug resistance.
Even with improved use of antibiotics,
we are still going to need new agents in
the future. Clearly, combating antimicrobial resistance requires a multifaceted set
of solutions. That is why we are also calling
for a more robust research agenda involv-
CORRESPONDENCE • CID 2008:46 (1 June) • 1793