tv Dr. Matt Mc Carthy Superbugs CSPAN August 22, 2019 9:00pm-9:56pm EDT
doctor matt mccarthy thank you for joining us tonight. [applause] thank you all for coming out. excited to be here. when i was working on the book i spent five years researching and writing and there was a point when my wife was sitting across from me at the dining room table and i had a stack of journals next to me she's kind of squinted her eyes and i could tell she was deep in thought. she said all the guys how to die in depth with the infection die and that is when i spent a lot of my time focusing on is yeast infections that are difficult to treat and that is one of the types of bugs you might not always hear about i found people
have a lot of questions about these topics and it's a fascinating topic but also complicated and what i'm going to try to do is clarify a little bit and also do a short reading so you get the sense of what it's like to be a superbug hunter because that is what i do. it is a drug-resistant microbes that can be a bacterium, parasite and even a virus. some people would say hiv is a superbug. other people would say definitely not, we should restrict to just drug-resistant bacteria. when i went on a radio show to promote the book i got an e-mail
after from a professor who said i don't like the term superbug. you should be using the term difficult to treat infection and i said that isn't much of a book title and moreover that doesn't actually what i'm talking about many of the superbug as i treat are not hard to treat. they may be resistant to many antibiotics but as long as they are susceptible to one antibiotic then we don't have a problem. it will be e. coli which is a very common cause of urinary tract infections and what comes along with that report is a long list of all the antibiotics that won't work and that will freak out the doctor. as long as there is one it means it won't work as long as there
is an f-16 susceptible and you can treat that so i spend a lot of time figuring out what do you do if it is resistant and that is the starting point for my book. so i'm going to do a little bit of reading what it's like to be in the room with somebody that has an infection for which there are almost no treatments. and then we are going to talk a little bit about what's happened to him and where this whole field is going because this is what i spend my time thinking about and i love to share the stories of the patients but also the scientists try to come up with a cure. it was after dawn when i felt the bug on my hip on both sides put down my coffee and glanced at my pager i was needed in the emergency room. 2014 and unseasonably warm october day and it had a flurry of anxiety and excitement.
after 11 years i accepted a position as a staff physician at the presbyterian hospital. they center on the upper east side of manhattan and a patients just arrived within infection, one that stumped the team in the er. a moment later i was before a group of residents and my new patient. the young man arriving within african-american mechanic from queens named jackson with dark green eyes and a cross on his neck he had been shot in a large area surrounding the woodstove launched in his leg that looks infected. as i peered into the edges of the entry wound just above his knee a student handed me a piece of paper. the printout revealed that the results of the tests that caused my eyes to bowl which. my patient i discovered was infected with a nimble and aggressive new bacterium that was resistant to every antibiotic except for one.
i only used it a few times in my career and never with good results because it was so outrageously toxic. it might kill bacteria but it destroys kidneyadisgrace kidneyr internal organs in the process leaving many patients with just two options, dialysis or death. antibiotics that have proven so effective a short time ago where now useless and if i wanted to save him it was my only option. i shook my head and handed the paper back to my students. not good at more than 20,000 people die every year in the united states from antibiotic resistant infections into the pipeline to treat them as always ois alwayson the verge of dryin. i carefully considered my words. you have an infection i said. he looked at the men and women standing in a horseshoe behind me. how severe. he took a small breath of air waiting for me to say something.
it felt like an hourglass had been flipped. suddenly the room was hot area i took off my coat and rolled up mroll up mysleeve, quite severe. his eyebrows raised and i extended my hand got caught myself. i wasn't supposed to touch this patient without protection. i pivoted back to 19. everybody out, now. i pointed towards the door. i will be right back. it's very hard to treat. jackson was now breathing very quickly on the verge of hyperventilating. she gasped where the bullet entered beneath his finger tips they were multiplying devouring muscle and bone m.i. going to lose it in truth i wasn't sure.
i squeezed his hand and tried to imagine how to summarize the nuances of the case for his wife and children. they would need to take special precautions to be in the same room. his eyes began to water. i left the room, removed my gown and gloves and addressed my team. one of the residents groundouts she scurried to put in the order and we washed our hands and moved on to the next patient. i will pause right there and say this is what it's like to have these kinds of conversations and i started the book this way because i felt like so much of the conversation around the drug-resistant bacteria takes place at 30,000 feet talking about the policy proposal were over prescription of antibiotics
or global issues that caused this epidemic but haven't addressed what it's like for the patients. the book is full of stories from patients who are not only dealing with this but are suddenly asked to be part of the clinical trial and that is what my book is about. when i was just starting off as a young faculty member, i was invited to be the principal investigator on a clinical trial studying a new antibiotic one that could treat superbugs. the book is about me approaching patients that are infected and scared and nervous and asking if they are willing to try a new and unproven drugs, one that had never been used before at my hospital. i work at new york presbyterian which is the top hospital in new york, 16 years in a row. they pride themselves on their reputation and what i found is
our hospital didn't carry many of the antibiotics that had been approved. every once in a while we find success in approving new drugs. it doesn't mean it goes to the shelves of your hospital or your doctor knows how to prescribe it or that it will ever reach you. so how does this happen and what is the reason for that? more importantly, what does this mean for the future drug development, and i think one of the things people don't recognize is that every hospital has something called a formulary committee where they decide what drugs to add and what drugs they are not going to use.
they were able to buy in bulk based on making specific deals with companies. so, for example at my hospital, you can make these kinds of arrangements and get a good deal on the drugs, however many of the new antibiotics coming out are so extraordinarily expensive that the pharmacies i pharmacy e hospital can't afford to use them. and i thought this was a fascinating conundrum and in fact my book is about one of these new antibiotics. it didn't go anywhere, or go to the hospitals in my community. the reason is the company wanted to charge thousands and thousands for a single dose. and the hospitals that we can't afford that.
it will break our budget. now, whether they are having that same conversation about the cardiovascular drugs for cancer drugs i'm not privy to that. they seem to have the best for the other patients but when it came to infections, we seem to be not dropping the ball, but at least willing to not stop the latest antibiotics. and look up the ones approved by the fda last year. they almost certainly are not in your local hospital, and part of that is because it costs so much money. then the question is why does it cost so much money? it isn't simply that they are greedy, but to get a drug approved by the fda, typically take us ten years and a billion dollars to go through phase one, two and three clinical trials. if you are developing a drug for blood pressure, high blood
pressure or four high cholesterol, it's going to be worth it because that is a drug that they will prescribe to patients and they take this every day for the rest of your life or some variation of that. think about an antibiotic they are prescribing and short courses, doctors are very stingy about prescribing them. there is a lot of talk now about how you fix it and that is what my book is about, addressing not only from the patient's perspective, but what about everyone else. you may not have a superbug infection that one day you were somebody in your family might come and where the pipeline of new drugs going to be, what are we going to have available? a great example of the risk of getting into the antibiotic development world is a drug
called plays on my sin. a company spend years and tens of millions of dollars to get the truck finally approved by the fda in june of last year and they filed for bankruptcy last month. and the reason for that is when an antibiotic is approved it isn't a blanket approval of you can now use this for any condition. it gets approved for very specific conditions. and it got approved for urinary tract infections and the company was banking on it being approved for blood stream infections and that subtle decision of what the approval is going to be four can make all the difference in whether or not a company survives or not. if you are a small start up, you cannot absorb that kind of position. so, we are now looking at the larger pharmaceutical companies as the ones who will hopefully save us. that is a scary prospect especially if we see there is a
trial going on right now in oklahoma with johnson and johnson that intentionally misled people to use of the assemblies that are on a harmful. harmful. for the last 75 years they are partnered in making antibiotics datamodel is that the federal government fund scientists to discover new molecules, new antibiotics an: newantibioticss look promising, a pharmaceutical company will sweep in and say we've got the resources to do the trials to get the drug approved. and increasingly, the companies are saying we don't want to do this anymore because we are losing money. the school of economics study said when a company invests in a new antibiotic that they typically lose $50 million. for, there are a number of
proposals on the table to fix this and this is one of the things that i think is going to become one of the most important political issues of the one is just talking about which is how do we negotiate with the pharmaceutical industry to get them to make new antibiotics. and there are -- i'm going to pause for questions but i'm going to start with this information to spur some information. the two types of incentives on the table that you are going to be hearing about in 2020 and beyond are things called push incentives and pull incentives. i will use the pharmaceutical company as an example because they make the antibiotic that i write about. they make $3 billion last year selling botox. you can go to that company or one like it and say the corporate tax rate is 15%. we will cut it by 3% if you promise to invest, and a legally
binding contract, to invest excess profits into the new antibiotics. that is a push incentives that will push the company to do something they otherwise might want. then there are things called polling incentives which is to say to the company if you take that risk of getting a new drug approved you spend a billion dollars and actually does get approved. right now you get five to seven years of market exclusivity. we will make it 25 so that no one can challenge you and your husband. it means you can charge a higher rate for your drugs. that will drive up the cost of healthcare and it will also guarantee we have more people taking the risk. these are the kind of things you are going to be hearing about and one of the reasons i wrote the book is i want people when they hear a proposal for a year from now to have an informed opinion about whether or not it is a good proposal or a bad proposal because it is going to become something that politicians on the campaign trail are going to be asked
about in 2020 or before. see the antibiotic market is broken, what is your plan to fix it i think that you will have a lot of them at first but eventually we will start hearing about ways we should move forward and in fact in england, they are saying the pharmaceutical industry doesn't want to do this, good riddance. we should nationalize this entire process. the antibiotic should be seem like a public good, seem like water or electricity and we should pool their resources, and testing the drugs and not worrying about what is profitable. this is right and that may be how we move forward in this country i think there is an inherent resistance to having the government getting more involved in healthcare. on the other hand if you are somebody that thinks that is a good idea you may be more supportive and we will be hearing conversations about what we do because any expert will tell you that the antibiotic market is broken and that's
important because i get forwarded articles all the time about new discoveries that a new treatment or you may have seen the reported last week to treat superbugs and what it was about is a molecular gene editing technique using an enzyme to cut and manipulate certain acids and a 15-year-old british girl who had something called micro bacterium in her lungs killing her they used this new treatment and saved her. that treatment is never going to be available to any of you and it won't be available to me. it is under the current economic model developing a treatment for the rare infection. it's so extraordinarily risky that we don't have anyone that would biwould be willing to do . to go from saving the
15-year-old go to the fda approval is going to cost billions of dollars into decades of research into someone has to foot the bill and the question is who is going to do it. and i hope that through the book you will have some ideas and that you may say this is a lot like global warming or this is a lot like this other problem and here is how we tackle about it or didn't tackle that one. here's a mistake to go down this avenue thinking so and so it's going to picisgoing to pick up s this problem we should actually be doing something else. so i see it as a story as a conversation starter and something that will get you up to speed on what is the latest in treatment and diagnostics and with the next phase is going to be. i will pause there. i know that's a lot and i will just say does anyone have any questions or comment?
>> told me a littltell me a lite about the actual problem, is it getting bigger, is it in a specific infection, is spread over 100 different areas and ten people were dying and each one of these can't tell me a little bit about this. 20,000 doesn't sound like that huge of a number versus your other examples of cancer and heart disease. excited by the year 2050, 10 million people will die worldwide every single year and by 2050 this will be a bigger issue than heart disease or cancer. this will be the biggest story that we have to worry about. those are worst-case scenarios. i found the hardest thing about talking about the topic is sparking debate restricting the
right tone. if i talk about the best case scenarios i know people who died from a superbugs or have been profoundly debilitated from it and so to talk about how this isn't something that should keep you up at night isn't true either it is somewhere in the middle. i had an op-ed in "the new york times" two weeks ago. they played around with the headline but i believe the final headline was superbugs are everywhere, don't panic. what that was about it is they are now everywhere. by the definition of a drug-resistant bacterium they may be on your arm.
we are colonized with this bacterium, we are not infected with it and that is a big distinction to make that if you have a bacteria or superbugs that is just living on you harmlessly we will say you are colonized with it. if it turns into a bump and you have a fever that could be an infection so the researchers figuring out what is the trigger that sends something from an innocent harmless pathogen to potentially life-threatening infection. part of that is your immune system. the most important thing you can do if you are listening to this right now saying should i be worried or not, to talk with your doctor and find out are you somebody with a normally functioning immune system, it is kind of hard to understand without talking to someone who knows your medical condition. so many of my patients don't recognize that they are on a medication that may weaken your
immune system. i have a father-in-law who recently got chemotherapy. we knew he was high risk and we kept him out of the basement. we did everything we could. i didn't shake his hand. i shoulder bumped him and write about in the book despite best efforts, he still got a staph infection and he had staph infections have been part of your life so we knew there was a subtle alteration that presupposed into these infections and when he got chemo, the whole thing exploded. so, that's where it is tricky to talk about this as a one-size-fits-all of how much of a problem it is because people differ, and i'm somebody that tt hasn't happened by chance my whole life. i consider myself to have a
normally functioning immune system. every morning i go into the emergency room and i go to the patient that has a superbug infection and find out how i'm going to treat them. i'm not scared when i go in. i go in confident we are going to find how to treat them. if i just started on a course of steroids for some other condition that weakens my system, it might be in the back of my head i need to make sure that i follow strict precautions because i'm at risk. so just understanding that on a basic level. we are able to swap into 2% of the bacterium are superbugs.
if you have an open wound on your hand and grab it. are they a judgment on our culture or our generation x. >> i've been asked a lot of questions about superbugs but i've never got enough on or anything like it. thank you for making me think about this in another way. >> they used it in ways that were never intended. it's about ho how these tuberculosis and syphilis drugs in our orange groves and there
are stories of people who swap the meat in your grocery store, 50% of that has superbugs because we pump our chickens and pigs will antibiotics and we have seen the overprescribed these. i don't know that it's a judgment, but many of those two schools of thought for how we got into this. one is we use an antibiotic in appropriately aninappropriatelyt this on ourselves. the comparison is the infinite monkey theorem that if you get
monkeys a typewriter and let them strike keys at random they will eventually type out the word that shakespeare if you gave them enough time. it's the same thing if you let dna mutate enough it will resist antibiotics and when we started using these we selected out for these specific superbugs. it partially absolve us from this and we are sort of bringing about the most prominent superbug but i haven't made the comparison before. i think that is an interesting one. if we ask about toe fungus. is it a colonization, infection,
curable topic, can it explode into something greater and kind of as an example -- >> is one of the tricky things to treat and one of the classic things we are taught in medical school is when you see toe fungus you should get a biopsy of the toenail because it might not be bad and they might mistake it for something else. one of the antifungal drugs be e use is actually so harsh you wouldn't want to get back to a patient without being certain that that is what it is. i end up seeing a lo seeing a lf patience bupatients but all thid say i have this for years, doesn't respond to any of the stuff they give me, and it turns out it isn't toe fungus. that's why it isn't responding. what you need to do is get a biopsy and look under a microscope. i spent one morning every week
looking under a microscope at what is reported to be fungi and turns out to be something else. we also resist a chest x-ray and they will say you don't know that is until you stick a needle in their. so, a lot of times the problem here is a misdiagnosis and putting people on the wrong drugs. it's like let's just give him some cream and it should go away because i end up seeing the patients where it doesn't. my father actually passed away from an infection and couldn't figure it out so i appreciate
all of your efforts to tell the story. story. i am also interested in the genetics in terms of you talk about susceptibility. are they looking at okay this group is sensible or this group isn't susceptible, is that a way to also look at this? >> absolutely. great question. when you hear about the term position medicine or personalized medicine, it is a next generation we are all going to have our genomes completely sequenced to know everything about what makes us tick and eventually have a database where we can say you have the mutation that leads you to the susceptible to stand for fungus or something else. we are not there yet. we are largely just building a
database so it's not at the point you could walk into a clinic and get a full readout that will say you should stay away from basements but that is where we are headed. one of the things i want to mention is we are in the midst of a very controversial and complicated algebraic i don't know if anyone has heard of this one. it is a fungus i've been studying and reading and writing about for years and no one cared and that was put on the front page of "the new york times" in april and a story was written by a pair of excellent journalists and i was quoted in the article and it's about this fungus that has become resistant to all of our antifungal drugs and it was spread from one patient to another. the article was about the fact
that these two journalists couldn't get anyone to talk about it. no hospital wanted to acknowledge that they had this but they have patients that had this type of infection. i was invited to talk on some tv shows about it, and that made people very uncomfortable where i work because they didn't want to get labeled as this is a hospital that is infected with something great and in fact, mount zion i had to mention that they ripped out some of their interior infrastructure and some other places to make sure the facility was clean and put everyone on average and we got into the position where experts were not allowed to talk about or educate people on what the dangers were and after that, chuck schumer declared that this should be an emergency by senator saying we need federal resource dollars to become an outbreatheoutbreak of a deadly .
we were kind of scratching our heads and said this isn't even one of the top 50 pathogens i worry about. do we know there is an outbreak in new york and that we have babies that can't be vaccinated until they are 12-years-old and we have people walking into our emergency room with measles and it's been gone for so long doctors may not even recognize it and you could be infecting hundreds, so putting the stuff in perspective i think is a really important thing to do and what you see is that many of the experts associated with academic medical centers are hamstrung in their ability to talk about this. and cannot even just go out and say we solve the case and treated the person or we didn't treat the person after person died.
here is how we treat them and here is why we need more resources to generate the drugs that will save people. a young man who's about to be treated with a dangerous antibiotic, what happened? gimmick to drug i needed to use is something we used to using the 60use inthe 60s and 70s andl out of favor because it was so toxic it's like putting puttinge church and into somebody. it can kill the bacteria that also mess up your organs. i've gone on social media, twitter.
i thought it was important to address that the but they were n failing us. what i had to do with him as multiple courses but only kept the infection at bay. it wa was a non- antibiotic solution for him and that is something i had to do for him and that is a scary prospect that antibiotics are considered the greatest political achievemenmedical achievementofs have to revert to a pre- antibiotic era. the history of this is something that fascinates me and something i write about which is alexander fleming discovered the first antibiotic penicillin that became commercially available in
the chance to change course and investing new drugs so this isn't a pandemic or the most important medical issue of the 21st century but actually it will be just one of many medical issues but that is going to require a dedicated resource. >> did you have a question? >> this is a question i remember of my medical school classmates there are two different types of steroids, corticosteroids and prednisone is a corticosteroid that can sort of geek in your immune system but it's good for autoimmune conditions because sometimes your immune system is attacking itself so we often give credit to zone to tap that down. completely different than one which a bodybuilder would use
they get five days of prednisone to help with their lungs that isn't something that is going to predispose you to infection. what i'm talking aboubut i'm tae that take 20 milligrams per six months that can predispose you to infection. your generalization of the need to invest in new drugs and approaches to, what does that mean, can't do big pharma companies do a better job than the evil government investing? >> i quote a pharmaceutical ceo who raised the price of a very
common antibiotic by 5000% and said he has an ethical mandate to charge as much as he can for his antibiotics because he's accountable to shareholders and not to parents. in the book i don't paint them as evil and i don't think the government is evil but people are looking out for their own business interests and these companies are saying we lose money on this and there is no such thing as corporate altruism. to use the example of one of the companies that makes him i drugs and recognize the patent was about to expire so they came up with a clever idea which is the approach to the native american tribe and they said do you know there's something called tribal sovereign immunity which is if we transferred our content to you to your tribe you can in
both tribal immunity and no one can challenge it. these are the types of corporate shenanigans that are going on where people are trying to make profits off these drugs that could save our lives. that transferring to the reservation was ultimately thrown out in court. what i find so interesting are the reactions of the people that hear about it. patients usually shake their heads. patent lawyers say that's cool and most of us are just like i can't believe this is where we are at with these things. pharmaceutical companies have to make tough decisions. i've been on the advisory board where they try to come up with plans of what they should invest in those were the conversationss
that we are having. >> there was an article last weekend in the "washington post" about somebody that got acute compartment holds and drumming their arm and its thing that happened just like that. is that what we can expect with this colonization? >> i'm not familiar with that article that i have treated patients and it's terrifying. it's basically where the limb swells up and there' there is ne for the blood and all of the inflammatory molecules to go and you often have to go to the operating room and cut it open and let it come out. i do not usually see that as a result of superbugs. i see them cause all kinds of infections that compartment syndrome is usually something i see from other types of injuries
but it brings up the point i hit on earlier that increasingly we are using non- antibiotic techniques to treat these kind of things and in the book i write about a number of patients who could only be saved their infections by the scalpel and that is what alexander fleming was dealing with. we are seeing the shift back to that. if you walk into the hospital here you are going to get excellent medical care. we have got a solid array of antibiotics to treat the infections that are in the community but we have to be looking ahead.
i want is to be something where we have people engaged in the subject and knowledgeable about it and then listening to policy proposals and making informed decisions. >> the semantics of whether or not you would put a virus in the umbrella of a superbug. as i mentioned at the beginning some people would only say that the drug resistant. drug-resistant. it's a superbug and it's a virus. i would call that one.
where they are coming from and what drugs will and won't work. all of this has to do with how they will be used. we are coming up with new vaccines and we have to be testing and getting informed consent it's a tricky thing and i write a lot about this. i didn't always know if it was informed consent and there are patients who are often from marginalized groups who may say
yes to what i ask them because they are worried they won't get good medical care if they don't and that frightens me that somebody may not fully understand what they are getting themselves into that they feel like they have to say yes and so it is a complicated thing to explain to somebody what it means to enroll in a clinical trial and a lot of what i write about is what those conversations were like. and you may find you are asked to participate in a clinical trial and i think the most interesting thing that somebody asked me an if it stopped me ded in my tracks as they said i just have one question. would you give this drug to your mother and i thought i hadn't even asked myself that, but that was such a clarifying question. the answer was yes. that is a useful technique.
when a doctor said al says all s stuff that doesn't make sense what you do this for your family member, would you try prednisone for three weeks if this were your family member, and that stuck with me. it's one of those patient interactions that stuck with me through the years rather than the policy proposals of the dollars and cents into the pharmaceutical ceos saying something that makes my blood boil it being in the room with a patient. >> what are your thoughts on the future of the prevention side of the equation in terms of medical professionals and patients and family members so that everyone is aware of the issue and the latest. >> this is important to hit
upon. i've been an antibiotics steward. it's a thankless and painful job. what happens if a doctor wants to use the precious antibiotic or expensive antibiotic or anything that isn't the routine group of five antibiotics used you have to get approval and that is done by the antibiotic. they will look at the case and say you should use penicillin into the doctor will say please i told the patient we were going to use this. they are so excited. can you please do it and then they would say actually there's
another option that is cheaper and safer and better. and those conversations always happen. no one is aware that the conversations are happening and i talk about in the book how it is a vital aspect. it's a growing more and more into the next time you are in a hospital that is something that's interesting to me because it also gives a second set of eyes looking at the case. i used to be a steward on the nights and weekends and saying no to a doctor that wants to use a drug isn't a fun job. they say i know i need an
antibiotic i only feel better when i get the z. pack. you want to make your patients happy. saying no might be the right thing to do. i know somebody that is a team doctor for the yankees and said that if derek cheaters once an antibiotic you are giving him the antibiotic and if you don't give it to him he will have to find a new team doctor because there is an aspect of the relationship where the patient had a lot more control than they might have realized. it is a hard thing to do. they work nights and weekends,
there at 11 p.m., he earned the trust of their patients and they can say no and they know they have one of the best doctors in town. but they are increasingly fragmented and the medical society. it's hard to say no when you haven't established any kind of report or trust with the patient and you are just a called in the wheel of the machine as a doctor saying i looked at the case and we are not going to give antibiotics. it's so impersonal they are left feeling cold. the ones who didn't know me would be like who is this guy.
>> educated people their parents took them to the doctor every time they had a sniffle, and we have no immune system's left. we get these horrible diseases. >> i was talking last night in boston or two nights ago with my old classmates and we were talking about how important it is to let our kids play in the dirty sandbox and for every potential danger the first thing we can do so i completely agree with you that we should make sure that we are exposing people to the diversity of the world to
the life around us because trying to live in a bubble is only going to cause problems later. how we do that i think is up for debate. you should let their kids pick their nose and eat it, i don't know that we need to go that far but there are people -- more to come on that front. [laughter] anyway, i think our time is up and i just want to say thank you all for coming out and for such fascinating questions. this is really great. >> i will stick around outside. thank you.