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Fungal infections should be included in antibiotic overuse policies
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Despite recent initiatives from WHO and the CDC advocating for reduced antibiotic prescription rates in an effort to curb antibiotic resistance, these plans focus on bacterial infections while ignoring considerations for fungal infections. Not yet recognized as a public health threat, the emergence of multidrug-resistant fungal infections has the potential to become a grave national issue, particularly for elderly patients, immunosuppressed patients and neonates.
Read a comment from an expert contacted by Infectious Diseases in Children on whether fungal infections should be a part of the national discussion on antimicrobial resistance, and additionally, what obstacles are currently keeping them out of the discussion spotlight.
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Compared with the wide range of antibiotics available to treat bacterial infections, there are only a handful of effective antifungals that are actually used. With a limited number of antifungal drugs, antifungal resistance can arise very quickly, which is a huge problem. The reason there are very few antifungals is that, evolutionarily, fungi are much more closely related to humans than bacteria, sharing many of the same basic biological processes as human cells. Therefore, most antifungals would most likely also inhibit a process in the host, which can result in cytotoxicity or other negative side effects.
I don’t know if anyone has clearly demonstrated this in the clinic yet, but in laboratory settings, bacteria that have been co-incubated with certain fungi have demonstrated enhanced resistance to antibacterial therapies. The prime example is MRSA, which is resistant to most drugs with the exception of vancomycin. That leaves vancomycin as the “last line of defense” against MRSA. However, if you co-incubate Staphylococcus aureus with Candida albicans — at least in laboratory settings — the S. aureus will become resistant to vancomycin. I don’t know if anyone has examined whether a fungus could be contributing to antimicrobial resistance when a clinician finds MRSA they can’t treat. This is not something you would look at presently, but rather as a new development.
A sparse number of effective antifungals, an utter lack of effective vaccines against fungi, and laboratory findings indicating that fungi can increase resistance in bacterial infections are just a handful of reasons that fungi should be included in the national discussion. The obstacle that currently prevents fungal infections from being addressed, however, is their prevalence.
We simply don’t hear about fungal infections as often, but when patients do acquire them, the mortality rate is significantly higher. Further complicating the matter is that most fungal infections are not reportable to public health authorities. When a hospital identifies a patient who has an infection like MRSA or [severe acute respiratory syndrome], they are required to report it to the authorities; however, this is not the case with fungi. I believe there are more fungal infections in hospitals than the authorities know about, but these infections are severely underreported.
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Vincent M. Bruno, PhD, is the assistant professor in the Department of Microbiology and Immunology at the Institute for Genome Sciences, University of Maryland School of Medicine.
Disclosure: Bruno reports no relevant financial disclosures.