Ella Balasa: Antibiotic resistance, chronic disease, and covid-19—a triple threat

Antibiotic resistance is singlehandedly the greatest threat to vulnerable populations such as people like me with cystic fibrosis. And currently, this threat is compounded by the emergence of the covid-19 pandemic, in which the reality of becoming ill with this severe respiratory virus could lead to a pan resistant Pseudomonas aeruginosa infection in my lungs. A drug resistant infection that ravages my lungs is something that I have unfortunately experienced before, unrelated to covid-19, but I am unlikely to survive a second time.

Cystic fibrosis is a genetic disease characterized by a build-up of thick sticky mucus in the lungs which traps bacteria and leads to a life-long risk of infections overtime causing lung damage from the cycle of inflammation and infection. This eventually leads to respiratory failure from the lungs sustaining a severe amount of damage. Despite some recent medical advances in treating the underlying cause of cystic fibrosis, many are still plagued by the relentless bacteria in our lungs and require multiple week courses of antibiotics each year, mostly intravenously.

Throughout my life I have spent weeks in the hospital each year getting treated for these infections that have over time become more and more difficult to treat—using the same few antibiotics cycled many times.

I am running out of options. There is a severe unmet need for new types of antibiotics in populations where their use is chronic. For me, oral and inhaled antibiotic effectiveness is waning, having used them nearly constantly the past few years to subdue the persistent infections. In my most recent past, even intravenous antibiotics have lost their potency.

Last year, I became very ill with the RSV virus compounded with an exacerbation of pseudomonas in my lungs. I was using some of the strongest antibiotics in our arsenal—colistin and meropenem, intravenously. I was using supplemental oxygen through a nasal cannula 24/7. I was doing inhaled breathing treatments every two hours to reduce severe inflammation. I was coughing incessantly and spitting globs of green mucus which would have been teeming with thousands of colony forming units (CFUs) if I would have grown them in a petri dish. My lung function was 18%. It took all of my energy to put my hands above my head to wash my hair in the shower. My muscles weren’t getting enough oxygen delivered to them from my failing lungs. After weeks on these antibiotics, I experienced no improvement in my symptoms and I was fearful of my condition leading to respiratory failure. 

I resorted to an experimental treatment called phage therapy which was luckily successful. I was desperate to find something that had any amount of potential to treat the infections that would have surely taken my life if they wouldn’t have been stopped. I am not the only patient seeking novel and non-FDA approved treatment options because of the possibility of dying from an antibiotic resistant infection, but I’m only one of a few who have had the opportunity to try.

My harrowing story isn’t just limited to a rare case of antibiotic resistant infection in the cystic fibrosis population. In the future, in the general population, simple procedures like caesarean sections and chemotherapy will be too dangerous because of the prevalence of antibiotic resistant infections that we don’t have new treatments for. Even now, there is a growing population of individuals dealing with resistant infections—some of these being covid-19 patients.

The convergence of the threat of covid-19 and antimicrobial resistance is a cocktail for devastating effects for the cystic fibrosis population, the immuno-compromised, older people, and many other chronic illness communities. This pandemic has presented a critical situation where the steadily growing problem of antimicrobial resistance has become a tidal wave with the compounded risk of covid-19. There is a substantial risk of bacterial infections concurrent with covid-19 positive patients for those with chronic conditions. 

Although the allotment of resources being invested into the development of covid-19 therapies and vaccines are vital to eradication, the treatment of those secondary infections from bacteria that can result in the clinical setting where covid-19 patients are treated, require just as much attention and resource investment. Developing novel antimicrobials is as paramount as the need for covid-19 therapies, because the threat of antimicrobial resistance will remain and further escalate until the emergence of a next pandemic.

Once the risk of covid-19 is past us, the risk for vulnerable populations will remain because of the many bacterial infections that circulate in the clinical care setting. Those that spend a lot of time in and out of hospitals will remain at elevated risk of catching a nosocomial infection that can’t be treated with the few antibiotics we have. What can we do for them? There are very few antibiotics to treat multidrug resistant organisms. This isn’t an acceptable response to covid-19 as it has risen to the top of pharmaceutical companies’ research goals, so why should a different type of infection or even a secondary infection like bacterial pneumonia in covid-19 patients be any more admissible to not have treatment for? 

Minimizing the rate of resistance would involve innovative approaches for new anti-infective products outside of traditional antibiotics. We need to start looking at alternate ways of attacking these organisms through harnessing the immune system, inhibiting bacterial cell interactions, and breaking down biofilms as bacteria have an uncanny ability to develop resistance mechanisms rapidly. We need to elevate antimicrobial resistance as an equally significant threat as the other pandemics we have experienced, yet as of now, this one passes under the radar of the majority. If another viral or even worse, bacterial pandemic emerges, the inability of our current antibiotic arsenal to treat the infections would be quickly and devastatingly apparent. 

This will require action on the part of many players and stakeholders working together and it begins with sharing our voices as patients and physicians, reaching policy makers, researchers, and investors. I hope for a future where antimicrobial resistance won’t be the greatest threat to my life and to many others.

Ella Balasa was diagnosed with cystic fibrosis at the age of one. She is an advocate for the development of novel therapies for the treatment of antibiotic-resistant infections and speaks publicly about the value of patient voice in research. She serves as a member of research committees for the CF Foundation, is a director for the US Adult CF Association.

Competing interests: none declared