Thank you, Mr. Chair and honourable committee members. I'm honoured to have the privilege and opportunity to present to you on antimicrobial resistance, or AMR.
I come to you as director of the Sinai Health System-University Health Network antimicrobial stewardship program. Sinai Health System and University Health Network are two academic health care organizations in Toronto that are widely recognized as local, provincial, national, and international leaders in health care.
As a note, without getting into semantics, I'm going to be using “antibiotics” and “antimicrobials” interchangeably for this presentation.
I became an infectious diseases physician so that I could cure people. Antibiotics are used to cure, miraculously. Antibiotics to infectious diseases physicians are like scalpels to surgeons. The only difference is that infectious diseases physicians don't really get the glory, the antibiotics do.
The heuristic of reliably curing people with any old antibiotic is gone. Frequently now, doctors guess at the infection they're treating, and often guess wrong. Increasingly, even when they know what infection they're treating, doctors find themselves at a loss to choose a curative antibiotic.
As potential patients, you should be scared. As lawmakers, you should be rightly driven to action by this most important global public health crisis of our generation.
I'll be describing four things for you. What are antibiotics? What is AMR? Why should the House of Commons Standing Committee on Health and the Canadian public care about AMR? What can you and Canada learn about tackling AMR from the Sinai Health System-University Health Network antimicrobial stewardship program?
What are antibiotics? Organisms in the environment, especially bacteria and fungi, fight each other for survival. By and large, antibiotics are the weapons used by fungi to ward off bacteria. Alexander Fleming taught us to exploit these weapons to kill bacteria, so that now, not only environmental bacteria, but also animal, fish, bird, and human bacteria, known as the microbiomes, are also exposed to antibiotics intentionally.
What is AMR? Antimicrobial resistance, or AMR, is basic Darwinian selection. Most bacteria exposed to antibiotics die off, but bacteria that have randomly developed a mutation rendering them resistant to the antibiotic end up thriving. These new emerged strains of bacteria are therefore antibiotic resistant. There really are only two things required for AMR to develop: bacteria and antimicrobials. AMR occurs naturally in the environment, but when the drug-resistant genes in bacteria take hold in a community, a farm, or a household, the ability to reverse the growth of drug resistance is uncertain.
Human bacteria shouldn't really have natural antimicrobial resistance. We don't usually interact closely with fungi and their antibiotics, so neither should our bacteria, unless we are exposed to antibiotics. The more we use and abuse antibiotics, the more we risk our microbiome developing resistance. We are where we are today because of rampant global antimicrobial use of little or no value.
Why should you and the Canadian public care about AMR? Canadians pride themselves on their health care. Canadians have come to expect safe pregnancy and delivery in neonatal care, management of common infections such as pneumonia or urinary tract infections, routine surgeries, and even organ and stem cell transplantation. These are threatened by antimicrobial resistance. For some of these conditions, this is a present-day threat rather than a future one.
Up to half of pathogens causing infections in cancer and surgery are already resistant to first line antibiotics in the U.S. I'd love to quote Canadian data, but we really don't have it, although it's likely comparable. Whereas untreatable infections were unheard of when I first started practising medicine, physicians like me are already routinely seeing patients for whom we use novel therapy to treat routine infections. Many antibiotics are rendered so obsolete by drug resistance that manufacturers have stopped producing them and clinicians have stopped learning about them.
When I started practising medicine, the only common AMR acronym in our medical lexicon was MRSA, or methicillin-resistant staphylococcus aureus. Today, that list includes KPC, ESBL, NMDA1, VRE, CDI, and the list goes on.
The fact that we have antibiotics supply insecurity—and I can't recall the last time we didn't have a shortage of one antimicrobial or another—exacerbates the problem. These drug-resistant organisms cost the health care system billions of dollars. This is juxtaposed with the over $1 billion we spend on prescription antibiotics in Canada, of which about half of the use is unnecessary.
Estimates by the World Bank are that the future AMR risk is greater than the global financial crisis of a decade prior. More importantly, it's a threat to national security and public safety and threatens Canadians in a manner greater than violence and accidents. However, AMR doesn't have headlines. There are no walks, runs, bike rides, golf tournaments, or galas for antimicrobial resistance. There's no ribbon, and the pharmaceutical industry has largely distanced itself from antimicrobial development.
Governments have been seduced into investing in industrial approaches to AMR, which are necessary, by the way, but it's at the expense of investment in the proven domains of public, animal, agricultural, and environmental health, which explore social determinants. I'd be remiss if I didn't point out the acuity of this need in our indigenous populations.
What can you and Canada learn about tackling AMR from my antimicrobial stewardship program at Sinai Health System and University Health Network? It's the first and largest of its kind in Canada. It reflects all that is right in tackling AMR in Canada, but it also shines a light on all that prevents further advances in AMR. In 2009, leaders with purse strings at my hospitals recognized the need to spend money to improve patient care and safety. They mandated a program with accountability and allowed the experts, people such as me, to run the show. Eventually the two organizations realized that collaborating and having a joint program with shared oversight would improve the efficiency of the two programs. Agreements were needed and policies implemented, but it got done.
The backbone of our program is a substantial and continued investment and obsessive focus on high-quality surveillance and epidemiologic studies of antimicrobial resistance and use in our hospitals. Over time we gradually built an interprofessional team that includes nurses, pharmacists, physicians, data and computer professionals, and management and project implementation experts.
Starting locally, we demonstrated improvement in antibiotic use coupled with financial savings. Bolstered by these successes, the Council of Academic Hospitals of Ontario, and subsequently, Health Quality Ontario, funded exporting our program and approach out of the province. The ecosystem we developed has spilled over to Public Health Ontario and national and international research projects and has helped train AMR leaders in other provinces.
Our pharmacists have taken leads in educating other pharmacists nationally, as well as running an innovative and groundbreaking course dedicated to the topic of antimicrobial stewardship. Our nurse steward, the first position of its kind in Canada, is poised to make knowledge of infections and antibiotics the core competency for nurses.
We have also enlightened health care leaders that these programs need project and program management professionals. Our manager is a major reason for our ongoing growth and success.
We have subsequently established best practices and made it easy for providers to access them. We have transparent reporting of our successes and failures, and yes, we have failed repeatedly. They can be seen on antimicrobialstewardship.ca. We also have a substantial and growing research enterprise refining how we can improve antibiotic use.
Although I'm proud of our program, what you really need to know are the things Canada needs. Mirrored on that, we need leadership with purse strings, expert leadership with a built-in accountability structure, and a substantial dedicated commitment to standardized, reliable surveillance of antimicrobial resistance and use across Canada, accompanied by epidemiologic inquiry.
We need to look at AMR interprofessionally, and ideally, with a one health view. That means involving the environment, animals, and humans.
We need to evaluate and scale up excellence across the country. We need to invest in tomorrow's AMR leaders. We need to definitively identify and make accessible what is accepted antibiotic practice. In Canada, we have no national standards of appropriate antibiotic use.
We need scientific investment. In Canada, antimicrobial stewardship and resistance research funding is less than $10 million per annum. Embarrassingly, my institutions' investments add up to upwards of 10% of this overall national investment.
The Canadian antimicrobial resistance surveillance system, the term “system” being a euphemism, doesn't have dedicated funding. It piggybacks on a benevolently unrelated envelope of infectious disease funding, and it is a patchwork of information that frustrates the many users it aims to satisfy.
That funding pales in comparison with the Canadian Institutes of Health Research's funding of $273 million for cancer or oncology, with another $95 million from the Ontario Institute for Cancer Research, $91 million from the Fonds de recherche Santé Québec, and numerous other research sources, including charitable foundations and industry.
Honourable committee members and Mr. Chair, on behalf of Sinai Health System and University Health Network, I am here to tell you that Canada needs federal leadership, with accompanying funding to move past the pan-Canadian framework on AMR to pan-Canadian action on AMR.
Expert health and scientific leadership needs to be put in place with an accountability structure involving provinces, territories, and the federal government, bringing together various disciplines in a one health approach that would be implemented with surveillance systems to gather, collate, and study antibiotic resistance and use.
Canada has the capacity to lead the world on this effort. We need to develop the next generation of experts, lure them into this mission critical field with an exponential increase in dedicated funding, independent of the important and, I fear, disregarded Naylor report, which I support. These new experts will research, innovate, and disseminate the necessary solutions to tackle AMR.
Thank you for your attention.