Editorial

Walk into a shop or restaurant ... and cough. Everybody will notice — and many will rapidly move away from you. Cough in a hospital waiting room and you will find a cotton swab in your nose as health workers rush you into isolation.

The Coronavirus Under Research Exclusion, or CURE, HIV-COVID registry — www.hivcovid.org — is an institutional review board-approved registry that has been developed by experienced HIV providers from Arizona Liver Health in Chandler, Arizona, and the University of Maryland, Baltimore, to capture real-time information from providers all over the United States about patients with HIV who have contracted COVID-19. Our goal is to help elucidate the natural history of COVID-19 in patients with HIV, determine the effects of treatments and analyze the impacts of factors like age, CD4 count and comorbidities on COVID-19 outcomes. Updates are published biweekly and shared with providers around the world to expedite the understanding of COVID-19 in this patient population.

Nontuberculous mycobacterial (NTM) lung disease is a chronic and debilitating condition, and although considered rare, some studies have estimated that prevalence is increasing about 8% each year in the United States. In 2019, it was estimated that 98,000 to 113,000 patients were diagnosed with the condition, according to unpublished data.

The Infectious Diseases Society of America has advocated for the implementation of antimicrobial stewardship programs (ASPs) in every hospital. This year, CMS, under rule 3346-F, agreed, and now requires, that even previously exempt critical access hospitals implement an ASP. CMS is vague on what an ASP is or means and states: “For the implementation of antibiotic stewardship programs, guidance is available from several organizations, including IDSA, [Society for Healthcare Epidemiology of America (SHEA)], American Society for Health System Pharmacists (ASHP) and CDC.” The documents issued by ASHP and CDC are not true guidelines. Essentially, CMS leans heavily on the joint IDSA/SHEA guidelines, first published in 2007 and updated in 2016.

Much of published antimicrobial stewardship literature has focused on reducing the use of broad-spectrum antibiotic therapy. However, in addition to the use of broad-spectrum antibiotics, prolonged antimicrobial use is also associated with the development of antimicrobial resistance. Durations of therapy often are determined upon discharge, and this transition period has not been a focus of many antimicrobial stewardship interventions.

Antimicrobial resistance, or AMR, is a major public health issue. Bacterial diseases we used to successfully treat with antibiotics are re-emerging as serious threats, killing an estimated 700,000 people each year, a number that is predicted to reach 10 million by 2050. If the AMR challenge is not solved by then, the cost associated with it will run into an estimated $100 trillion dollar expenditure.

Dr. Tedros Adhanom Ghebreyesus reconvened the emergency committee on the Ebola outbreak in the Democratic Republic of the Congo, or DRC, for the fourth time, barely a month after the last committee meeting. The precipitating event was a case found in Goma, a major urban center in DRC. There has also been international spread to Uganda.

Dr. Tedros Adhanom Ghebreyesus was wise to reconvene the emergency committee for the third time to review the Ebola outbreak in the Democratic Republic of the Congo, or DRC. Again, the committee did not vote to declare a Public Health Emergency of International Concern, or PHEIC.

The discovery of antibiotics, one of the greatest advancements in the history of medicine, was nonetheless a victim of the law of unexpected consequences: this miraculous life-saving tool gave rise to the unanticipated grave new danger of antibiotic resistance.

Antibiotic overuse contributes to the growing problem of antibiotic resistance and the development of multidrug-resistant organisms, or MDROs. It is predicted that by 2050, 10 million people a year may die from MDRO infections. Currently, at least half of all hospitalized patients and up to 70% of long-term care facility residents receive antibiotic therapy, of which 30% to 50% is considered inappropriate. To highlight the need for urgent action in combating antimicrobial resistance, the CDC published a comprehensive analysis outlining the threats posed by MDROs. In 2014, WHO published a global report on antimicrobial resistance to further describe the threat, as well as outline efforts underway to combat antimicrobial resistance. Antimicrobial stewardship has been consistently identified as an important tool to combat antimicrobial resistance. In response to the national and international call to action, health care accreditation standards from CMS and the Joint Commission were updated to require acute-care hospitals and long-term care facilities to have active antimicrobial stewardship programs (ASPs) with dedicated medical staff expertise and leadership.