Recommended News Category: Podcast

HOSTS: Laura Pavin and Jess Love

Guests: Kevin Outterson, executive director, CARB-X and professor of law, Boston University. Ted Schroeder, CEO, Nabriva Therapeutics. Amanda Starc and Craig Garthwaite, healthcare economists, Kellogg School of Management at Northwestern University.

HOST: Madeleine Finlay

Guest: Dr. Jennifer Rohn, Head of the Centre for Urological Biology at University College Londo

Madeleine Finlay (1:14)

It can start with a suspicious twinge. An urgent need to pee. Tummy pain. Then comes the burn.

Anyone who’s had a urinary tract infection knows how agonizing they can be. Some infections go away on their own. Many need antibiotics.

Simple. Except beneath the surface of this very common infection, there’s a lot of mystery, unanswered questions, and unnecessary suffering. And it gets to the heart of the challenge of tackling antimicrobial resistance.

Carolyn (1:58)

Once you get a recurrent UTI, I’m afraid that the chances of getting another one are quite high. It’s almost as if you don’t clobber it the first time, it’s more likely to get entrenched and come back again and again.

Madeleine Finlay (2:12)

About 20 to 30% of all UTIs recur within about six months. But for some, they never go away.

Carolyn (2:21)

I literally kept a record of how often I was having to go to the loo, and it was eight times in an hour, every hour, every day. And of course, when that happens to you, you withdraw into your own world of pain.

Madeleine Finlay (2:37)

Chronic UTIs also present another problem. Often the infections don’t show up on tests.

Carolyn (2:45)

It was like being slapped in the face, first of all. And at the time, I was naive enough to think, well, the doctor’s know best. And if they’re telling me there’s no infection, then, okay, it must be something else.

Madeleine Finlay (3:00)

But as researchers learn more about the problem bacteria, they’re understanding why our current tests and treatments just aren’t up to scratch.

Jenny Rohn (3:10)

You know, I know it’s a terrifying and awful thing, but it’s also really fascinating, and I have a lot of respect for the bacteria because they are tiny, tiny little things. They’re two microns. They’re tiny little things, and they can bring people to their knees.

And they have so many ways to outmaneuver us.

Madeleine Finlay (3:29)

So today, we’re asking, what’s the latest understanding of UTIs? What’s happening when someone gets a chronic infection? And is there anything on the horizon that could help flush an infection without contributing to our overuse of antibiotics?

From The Guardian, I’m Madeleine Finlay, and this is Science Weekly.

Dr. Jenny Rohn, you’re head of the Center for Urological Biology at University College London. First of all, can you explain what a UTI is and who’s most at risk of one?

Jenny Rohn (4:10)

A UTI is simply an infection of the urinary tract, which is basically your waterworks. That can be your kidney, your bladder, your urethra, which is the little tube that connects the bladder to the outside world. But usually when you hear the term UTI, you’re talking about a bladder infection.

And these are caused by bacteria. There are a lot of bacteria living in your back passage, as we all know. Most of them are friendly, but some of them are not friendly.

And they can, in certain situations, can migrate into the urethra and then up into the bladder and cause problems. And although anyone can get a UTI, it is most common in women, probably because of the anatomy. So our back passage is much closer to the urethra than a man’s back passage.

It can also be very common in children and also in the elderly, things start to equalize a bit and men start getting UTI as much as women. But by and large, this is a disease of women and about one in two women will get one in their lifetime.

Madeleine Finlay (5:04)

Right, so bacteria that migrate from the back passage to the urethra can cause a UTI. But how exactly does that happen? And how does an infection then take hold?

Jenny Rohn (5:16)

So they get up there, they climb up through the urethra and end up in the bladder. So there’s lots and lots of urine and the urine is flowing the wrong direction. It’s trying to wash out all the bacteria.

But these uropathogens or bacteria that cause UTI have all sorts of tricks in order to cling in in this inhospitable environment. So they have sticky appendages that help them to latch on to the bladder wall despite the urination. And they also have ways of hiding from the immune system and from antibiotics.

Two of these ways are, one, they can actually burrow into the bladder wall, which is kind of horrific to think about. So they actually dive into your cells and take up residence inside them. Well, it’s nice and cozy.

There’s plenty of nutrients in there. There’s no antibiotics. There’s no immune system.

Another thing that bacteria can do is they can form these slimy communities known as biofilms on the inside of the bladder wall. And these were also very resistant to antibiotics in the immune system. Those are two that I’ve mentioned, but there are dozens and dozens of strategies they have to get around our defenses and our drugs.

Madeleine Finlay (6:22)

It’s so impressive. And I wonder, once you’ve got this UTI, how do they tend to be diagnosed and how accurate is a diagnosis? How easy is it to pick up that somebody has got a UTI?

Jenny Rohn (6:35)

Diagnosis is definitely a problem. If you have a really raging UTI, you don’t really need diagnosis. You’ll be well aware if you’ve had one that it’s obvious, right?

Your urine is full of cloudy pus, often blood. You’ve got terrible pain when you urinate. Nevertheless, the GP still wants to see some evidence that you’ve got a UTI.

And so what normally happens is you get a dipstick, a little piece of paper is dipped into your urine and it changes color if you’ve got a UTI in theory. And then if it looks like you’ve got a UTI based on the dipstick, they’ll send your urine off for a midstream culture. They try to grow bacteria from your urine.

Now both of these techniques are a little bit flawed and they’re very old fashioned. I want to point out that the midstream urine culture was pretty much invented by Alexander Fleming in the 1920s and things like the dipstick, they don’t work very well. They’re very insensitive.

So imagine you’ve got an infection and a lot of the bugs are actually hiding in biofilms or hiding in your bladder wall. Then the bugs won’t be in your urine or they’ll be in your urine at a very low level. So these tests often fail to pick up a bone a feed a UTI.

It’s kind of like tossing a coin, whether you’re going to test positive for UTI, if you have maybe a lower grade infection that wouldn’t show up in these very old fashioned tests.

Madeleine Finlay (7:51)

A 2017 study found that UTI diagnostic tests gave the wrong result in at least a fifth of cases. For people with chronic UTIs, infections that don’t go away after a typical course of antibiotics, this can be a real problem and make diagnosis very hard. As Carolyn found, she was on a trip up to Scotland in 2015 when she was hit with an initial infection.

Carolyn (8:19)

We got as far as Berwick-on-Tweed, and I suddenly thought, God, I’ve got UTI, how weird, come out of nowhere. And it got worse and worse, and by the time we got up to Edinburgh, I was rushing to the loo, I was in pain, saw a GP there, and I got a call two or three days later to say the test had showed negative, there was no infection, which was really strange.

Madeleine Finlay (8:42)

When her first course of antibiotics didn’t clear the infection, she went back to her GP at home for more tests.

Carolyn (8:48)

My own GP could not identify a UTI. The test kept coming back saying nothing abnormal discovered or contaminated, simply nothing. I was starting to think I was going mad, inventing it all in my head.

Madeleine Finlay (9:05)

So while the tests weren’t picking up Carolyn’s infection, she had to suffer through months and months of living with an unabated UTI.

Carolyn (9:15)

Obviously at that point, you’re thinking, well, how am I going to live like this? You know, I love to go to the theater, I love to do all sorts of things. I couldn’t go anywhere.

Your sex life is an impossibility, like if you’re in that much pain. My life had become so tiny. When you don’t know if you’re going to get any better, it is just horrific.

And depression kicks in. My greatest salvation was finding a group that I could work with and talk to of other women who had similar things. And we’d have lunch in a local pub and everybody would talk about it and help each other.

Madeleine Finlay (9:53)

Then Carolyn found Professor James Malone Lee, who was pioneering research and treatment for chronic UTIs, including the long-term use of antibiotics.

Carolyn (10:04)

I was on antibiotics for three and a half years and gradually, gradually, my symptoms started to get better and I started to have the odd good day.

Madeleine Finlay (10:16)

Today, Carolyn is UTI-free. But despite her success, the long-term use of antibiotics is a fine balance. It doesn’t come without side effects and the risk of antimicrobial resistance.

Currently, the guidelines state that men should be prescribed five to seven days of antibiotics, whereas women are typically given a three-day course. Campaigners like Carolyn argue that this often isn’t enough to clobber that initial infection and prevent UTIs coming back. But if we don’t tackle antimicrobial resistance, we won’t have anything to treat UTIs with.

Back to Jenny.

Jenny Rohn (10:57)

Antimicrobial resistance has been on the rise for the past century. The number one resistant bug at the moment, according to the WHO and a few other studies, is E coli. So E coli is the most common UTI bug.

It’s also the one that’s the most resistant. It’s really a problem. So the more antibiotics humans take and animals, the more drugs are out there in the environment, in the water supply, in the soil.

And then every time a bacteria encounters an antibiotic, those that can resist will survive and those that will die will die. So that just selects, kind of evolutionarily, for a bacteria that are resistant. And then they love spreading these resistance genes around.

They spread on little things called plasmids, little bits of DNA and they’re like business cards. The bacteria can pass them from one to the next, say, hey, I’ve got this really useful bit that allows me to resist penicillin. Would you like it?

If you don’t do something about it, pretty soon we’ll be back to an era where you can’t have an operation, even a routine operation because it will be too risky.

Madeleine Finlay (11:53)

That’s obviously terrifying. So is there anything else that can help treat UTIs or other non-antibiotic treatment options that are on the horizon?

Jenny Rohn (12:04)

There are some pretty good studies with D-mannose. D-mannose is a sugar you can buy over the counter. It prevents certain bacteria from binding to the bladder wall.

It’s got some pretty good data. There’s a little bit of controversy. And equally, cranberry extract.

Again, people go back and forth about whether this is useful, but by and large, the study suggests that it can help a little bit. But these are very sort of modest weapons against UTI. I would consider using them, but they’re not gonna be as good as antibiotics when antibiotics work.

As far as the future, there are a few things on the horizon, disappointingly few, I would say. This whole area has been neglected for decades. There isn’t a lot of research.

There isn’t a lot of drug development, most likely because it’s a women’s disease. People aren’t interested in it, and it’s not necessarily gonna be a blockbuster drug. And maybe there’s no profit margin in it.

But there’s a few things on the line. There’s an interesting new vaccine called Urimune, which has been reporting some excellent findings. I should also mention probiotics.

People are looking at using our good bacteria to fight the bad bacteria. And I think that’s a very promising strategy.

Madeleine Finlay (13:06)

Jenny, this infection is so common. It affects 400 million people every year worldwide. And yet we’re nowhere near the kinds of tests and treatments that we need.

What needs to happen, do you think?

Jenny Rohn (13:21)

This would all start with awareness that it is a serious problem. We need better education at the medical school curriculum. So I teach medical students as my job as a professor and most of them have absolutely no idea that UTI is a complex disease.

In the textbooks, you know, all is well. It’s just a, it’s a trivial disease. You know, you diagnose it this way and you treat it this way.

The students have no idea.

Madeleine Finlay (13:46)

This lack of knowledge around UTIs and chronic infections, not just amongst medical students, but doctors and even sufferers, was something Carolyn and her support group were keen to tackle themselves.

Carolyn (13:59)

We set up a not-for-profit company called Chronic Urinary Tract Infection Campaign, CUTIC. What we’d really like is to see the women’s health strategy expanded to include chronic UTI. And if we get a change of government, we would like the new health minister, whoever that’s going to be, to actually take notice of chronic UTI and be prepared to talk to us and the specialist doctors to have a look at how we can get to the bottom of this disease.

In five years from 2018 to 2023, there have been over 1.8 million admissions for UTI. And these are NHS England’s own statistics. And the NHS mortality rate for UTI is 4%.

So four people in every hundred will die of UTI. And chronic UTI is still not taken seriously.

Madeleine Finlay (14:59)

Finally, Jenny, what advice would you give to maybe somebody listening today who might want to protect themselves from a UTI or perhaps thinks that they have a UTI but isn’t getting the treatment that they feel they need?

Jenny Rohn (15:14)

Well, protection from UTI, there’s no simple answer, but it is widely understood that you do need to have good hygiene. Of course, if you produce feces, you should wipe from front to back. People say it’s useful to urinate before and after sex, and you can understand why, because you can sort of flush out the waterworks.

Drinking lots of water is important. The more you urinate, the more you’ll be facilitating that natural flushing process. Don’t hold your urine in, because it’s known that retaining urine will then set up a situation where you’re sort of fermenting the urine in there.

It should be being flushed out constantly. So don’t hold your urine. As far as if you think you have a UTI, and you’re not sure, and you go to your GP and they fob you off, say, listen, I’ve got these symptoms.

I know that the diagnostic tests are a little bit insensitive. I would like to insist on a second opinion, or I would like you to take the test again. And if the tests come back negative, I’d like to have a course of antibiotics.

And if then it clears up, I know that I had one. I don’t know how successful you’ll be because of antimicrobial resistance. Most GPs are under orders not to give unnecessary antibiotics.

So you might have a fight on your hands. But I know a lot of patients are successful just by advocating for themselves and being quite verbal. So maybe don’t take no for an answer.

Madeleine Finlay (16:36)

A big thanks to Dr Jenny Rohn and to Carolyn. You can find out more about Carolyn’s campaign, CUTIC, at cutic.co.uk. And we’ve put a link to that in the show description.

And if you’ve been following our General Election coverage on the Politics Weekly podcast, you might have noticed that you haven’t heard from our political editor Pippa Crearer and correspondent Kieran Stacey yet this week. Well, they’ve been busy on the campaign trail and they’re going to be back on Thursday with all their insight and a late night analysis of the twists and turns of the last TV debate before the election. So just search for Politics Weekly UK wherever you listen to your podcasts.

And that’s it for today. This episode was produced by me, Madeleine Finlay and Holly Fisher. It was sound designed by Joel Cox and the executive producer is Ellie Beurie.

We’ll be back on Thursday. See you then!

HOST: Maggie Fox

Guest: Kevin Outterson, Executive Director, CARB-X and Professor of Law, Boston University

Maggie Fox (0:01)
Hello and welcome to One World One Health, a place to talk about the planet and our problems. Climate, human health, and animal health are all connected, and the One Health approach recognizes how much all of us on this planet rely on one another. This podcast is brought to you by the One Health Trust, with bite-sized insights into ways to help.

If something’s alive, it’s evolving, and nothing evolves faster than microbes, such as bacteria, viruses, and fungi. They can all quickly change to resist the effects of antibiotics and other drugs used to fight them, something called antimicrobial resistance. These superbugs directly kill more than a million people a year. You might think drug companies are racing one another to bring new antimicrobials to market, but they aren’t.

In this episode, we’re chatting with Kevin Outterson, a professor of Law at Boston University, and the founding Executive Director and Principal Investigator of Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator, or CARB-X, a global nonprofit partnership working to speed the development of new life-saving antimicrobials.

Kevin, thanks so much for joining us.

Kevin Outterson (1:16)
I’m glad to be here. Thanks for inviting me.

Maggie Fox (1:18)
So tell us just where we stand. Are drug companies pumping out all sorts of new antibiotics and antimicrobials?

Kevin Outterson (1:25)
The earlier you go in the research and development process, the more optimistic the story will be. If you look at the basic research labs, the universities and the early work being done by lots of the small companies in this space, amazing science, really interesting things. So the problem in my view isn’t predominantly…the bottleneck isn’t scientific, it’s really economic. Then the closer you get to the market, because of these economic difficulties, the more bankruptcies you see, the more companies that are struggling and getting out, the more dire the situation looks. So great science, especially early in the areas that we work at CARB-X, and the economics grind them into the ground when they get closer to reaching patients.

Maggie Fox (2:08)
Now, when you talk about economics, what do you mean? It just doesn’t pay to make these antibiotics?

Kevin Outterson (2:13)
You know, these are extremely valuable drugs to society. But what did you pay for your last antibiotic? I mean, typically, the copay at a Walmart is $4 for an antibiotic. They’re wonderful drugs that are largely very inexpensive. If a company spends 10 or 15 years bringing a brand new antibiotic to market, the first thing that the company wants to do is to sell it, to try to reimburse their investors. But for excellent reasons, all the doctors and the health systems want to keep that antibiotic on the shelf and save it for when we absolutely need it at some point in the future.

We have this situation in which the new antibiotics reach the market, they’re given a label from the World Health Organization as Reserve, hold them in Reserve. It’s wonderful for health and long-term global health, but it’s a disaster for the company. When they get FDA approval, it’s time for them to make money; instead, they watch their antibiotics not sell very much. And so we need to think about a different way to pay for antibiotics because they’re extraordinarily valuable to society. But that’s not been reflected in the way the R&D is being reimbursed.

Maggie Fox (3:20)
Okay, you’ve introduced a lot of ideas here and the idea of keeping a drug in reserve. Let’s go back a little bit and talk about why we need these new drugs and why some of them might be extra special and extra valuable.

Kevin Outterson (3:33)

Well, when you think about every drug class in human history, you know, anti-cancer drugs, or heart disease drugs, or pain drugs, or anything. Probably, the most impactful, the biggest bang on helping human health has been the antimicrobials, led by antibacterials, antibiotics: the most important thing in human history in terms of a drug class.

But unlike most drugs, like cancer drugs, aspirin, or heart disease drugs; these drugs, because of the biological factor of resistance, the fact that evolution causes the bacteria to develop traits that make the antibiotics less effective against them, these are the only drugs in which we need a sustainable, renewable strategy because the moment they’re invented, that’s the peak of their effectiveness, they begin to lose it immediately.

Aspirin was invented more than 100 years ago, it still works great on me, and hopefully on you too. But antibiotics, the best antibiotic we’ve seen, maybe in history, you need to recreate that in every generation, so the R&D challenges are uniquely different in this space.

Maggie Fox (4:35)
And that’s because these microbes quickly develop resistance the minute a drug hits a market. Sometimes some of the microbes are already resistant, right? They are already resistant microbes out there, the drug hits the market, and those are the microbes that then succeed.

Kevin Outterson (4:49)
Yeah, but it’s not instantaneous with bacteria. It’s a slower moving process. The bacterial genome is larger than a virus. So while we saw billions of cases of COVID and a relatively quick emergence of global varieties that may or may not be covered by the vaccines quite as perfectly as we hope, and every year, we get a different flu vaccine because the flu changes remarkably, your bacteria move more slowly.

But you’re right, it is without a doubt that the more you use it, the more resistance develops. And we want these drugs, these antibiotics, to last for 50 or 100 years, not five or 10 or 20 years. And so that means let’s take good care of them. We call that stewardship. Let’s use them only where necessary, let’s not waste them on agricultural uses for which they don’t help or in uses for people for which we don’t need them, [like] taking antibiotics when you have a virus. It doesn’t do you any good, it actually harms your microbiome, and it also accelerates resistance for the rest of us. So we need to protect them because eventually, they will go away. But my goal is, on the stewardship side, we put plans into place so that the next new antibiotic could last for 100 years. That’s a worthy goal.

Maggie Fox (6:01)
And so why can’t a company just develop one that will last longer? Why can’t they come up with the science to make them more flexible?

Kevin Outterson (6:08)
You’re asking a lot from a company that may only have 14 years left on its patent to create a drug that’s going to last 100 years. But there are almost no sales during those first 14 in which the company has the patent. How are they supposed to reimburse the investors for the several 100 million dollars’ worth of R&D that was put into it?

So we have to think about a different way to pay for these drugs. We call those delinked pull incentives. Things like subscription models that are coming out of the United Kingdom and some other G7 countries.

Maggie Fox (6:37)
Why can’t governments just either pay upfront or develop these drugs themselves so the companies don’t have to worry about losing money?

Kevin Outterson (6:44)
The subscription models are paid for by governments, and so the idea of push incentives like CARB-X, that I lead, or pull incentives, like a subscription model. These ultimately are paid for by governments, and especially the governments of the wealthier countries will contribute more.

But maybe your question was, why can’t the government just take over the entire function for antibiotic R&D? And to that, I’d say, I can’t name, at least in the US where I’m most familiar or in Europe, any research-intensive product that is entirely produced by the government without cooperation and partnership with private industry. And maybe you can, but even things that the government provides, like a bridge, they hire private companies to do the engineering and installation. Or the military, which is a very government [centric] function, the government doesn’t build the tank or missile themselves. They recognize the fact that they set the parameters and what’s needed, and then they put it out to bid to private companies who are able to actually execute more efficiently.

So I would like to hear about a research-intensive product that actually is produced entirely by a government and that we’re happy with the way that’s working. I think what’s more likely is public-private partnerships, with government and private industry and academia, public health stakeholders working together to get the sort of antibiotics we really need. Make sure that companies don’t get bankrupt, and make sure we have an adequate supply of these so that the 1.27 million people that The Lancet article tells us are dying each year from resistant bacterial infections, that these people actually have something that works for them, not just in the high-income countries, but everywhere in the world.

Maggie Fox (8:24)
And of course, that’s what you’re trying to do with CARB-X. Can you tell us a little bit about CARB-X?

Kevin Outterson (8:31)

CARB-X is nonprofit. We make grants. We also give the small companies that dominate the space a lot of technical, scientific, and business help, because usually, they’re quite small. They do what they do extraordinarily well if they have 10 or 15 people, but they need additional help. And they’re not getting it today from the rest of the ecosystem. So CARB-X has been awarded over 800 million US dollars since our founding in 2016. We spend that money to support the preclinical from hit to lead all the way to the end of Phase One, a pipeline for therapeutics prevention, including vaccines and diagnostics globally.

We’re funded by three governments, the US, the UK, and Germany, and two foundations, the Wellcome Trust and the Gates Foundation. And collectively, our vision is to ensure that highly innovative antibacterials, these products that are therapeutics, prevention or diagnostics, don’t die in that valley of death, that they actually get the money they need so that it can progress to the end of the Phase One trials.

Maggie Fox (9:32)
So you’re supporting this research and development early in the process. Tell us what the valley of death is.

Kevin Outterson (9:38)
We start at hit to lead, which is that the company has an idea, has some chemistry, a series of drugs that might work, a series of molecules really, and they’re testing it and beginning the early test in the petri dish to find out which one of the many in their lab actually work. It’s very early research. It’s frequently just out of universities. In a healthier market, like cancer, there’s lots of private investment in this preclinical and early clinical space when it begins testing in humans.

Maggie Fox (10:08)
And that’s because cancer drugs make a lot of money. Right?

Kevin Outterson (10:12)
Right, they make a lot of money. That drives not only lots of private investment in the preclinical space, there’s over 1000 cancer products in clinical trials in humans right now. So money does drive the R&D agenda.

Maggie Fox (10:26)
But for antibiotics? Not so much.

Kevin Outterson (10:28)
For antibiotics, there’s a real shortage of truly innovative products in the clinical pipeline, things that are being tested in people today. And WHO has looked at this and declared that it’s grim. And then in the earlier stages, we see lots of amazing science coming out of the universities, things that have been funded by national institutes like the NIH in the US, or their equivalents in many other countries. But these little companies that are spun out need some money to take it from the idea stage until it’s ready to actually be tested in a person. And that is the valley of death for antibacterials right now. There’s no private money to help those companies get over that hurdle. CARB-X is the largest funder in that space.

Where we start at the hit-to-lead stage, we’re about 12 or 13 years away from any sort of approval by the FDA. So we’re developing today supporting at CARB-X, things that are not for tomorrow but are for the next decade and decade after. If you want good drugs in the 2030s and 2040s, you’ll see these projects at CARB-X today. It just takes time.

Maggie Fox (11:36)
You’re a professor of law. Are there legal barriers that people might not think about in the effort to develop better antimicrobials?

Kevin Outterson (11:43)
The way I got into this field was, I was studying the way that intellectual property law, patents, etc, how they function well, and sometimes not so well in drug innovation more generally, and then became fascinated with how they are uniquely challenging when it comes to antibiotics. I don’t think there’s a problem with our patent system with antibiotics. But there’s clearly a problem in the way that we pay for antibiotics, how we reimburse for them. It’s not so much a straight-up legal barrier, but it’s changing the way we think about this.

One analogy is fire protection equipment. I’m sitting at Boston University right now and in the ceiling, there’s fire protection equipment. The people who built that were paid for that equipment decades ago, and the workers who installed it were paid on the day that they installed it. We’re not waiting until there’s a fire that breaks out to pay for the fire protection equipment in my office. We pay for it in advance so that we’re prepared.

For antibiotics, for the first decades and years of antibiotics, we paid for them only after the fire starts, when a patient is sick. And the amazing change that people are embracing is that we need to pay for antibiotics in a different way, thinking about them more as preparedness than response. That is the subscription model that the United Kingdom is pioneering. That is the bill in the United States, the Pasteur Act, and similar efforts in other G7 countries to change the way that we pay for antibiotics. I think that’s the most fundamental legal shift that has to happen.

We’re at a tipping point. Every week that goes by, I hear of another company that calls it quits. And some of these are public companies, and many of them are private, just little, affairs. I wonder how many highly trained antibacterial R&D people are left in the world. A lot of these people, like microbiologists, have skills that can transfer to other areas. There’s only so much of that getting paid that you can take before you need to pay the mortgage. And it’s understandable that this is not a lucrative field that doesn’t attract new talent.

This is a drug class that needs a sustainable plan. We can’t just do one and done for antibacterials. We have to think about how we’re going to do this for generations, and continue research efforts that sustain across our children and grandchildren, and great-grandchildren. Right? So we definitely need to think about this more like a piece of infrastructure. It’s the water pipes in Boston, or it’s a bridge across an important roadway or something because those assets we protect and plan and maintain. But antibiotics — nobody’s really protecting and maintaining it as an infrastructure asset and we should.

Maggie Fox (14:13)
So what can governments globally do? Can the global community help on this?

Kevin Outterson (14:19)
There are two big things that are happening. The first is that the G7, the seven wealthiest countries on Earth, have been working on this issue for some time. Germany headed the G7, they were the presidents last year. They specifically called out CARB-X and GARDP and Secure, a project at WHO, things that need to be supported in order to turn the tide against drug-resistant bacteria. That will continue this year with Japan being the leader and in May, there are several interesting things that Japan may be able to announce as they make progress on this issue.

The second is that the United Nations rarely holds high-level meetings on infectious diseases. And they’re going to have one on September 24 on antimicrobial resistance, which is a follow-through from an earlier meeting a couple of years ago. But it enables the governments of the world to each say, what are we doing ourselves? And what are we doing together to address this problem? So I’m very hopeful for concrete suggestions that follow with funding that have the support not just of the health ministries, but also the financial ministries, the people with money so that collectively we can do something useful against this problem.

Maggie Fox (15:28)
Kevin, thanks so much for joining us.

Kevin Outterson (15:31)
Thank you for having me.

Maggie Fox (15:35)
Listeners can share this podcast which is brought to you by the One Health Trust by email, LinkedIn, or your favorite social media platform.

And let us know what else you’d like to hear about at owoh@onehealthtrust.org. Thanks for listening.

Host: Ethan Rhee

Guest: Su Chiang, PhD, Senior Alliance Manager, CARB-X

00:11 Ethan Rhee
Welcome to the first episode of season two of the Antibiotic Resistance Awareness podcast. I’m your Ethan Rhee. In season two, I hope to bring you more interviews from those who are directly involved with antibiotic resistance. Today’s episode, we will be interviewing Dr. Su Chiang, who is a senior alliance manager at a global nonprofit partnership that accelerates antibacterial products to address drug resistant bacteria. The organization is called CARB-X and it stands for combating antibiotic-resistant bacteria biopharmaceutical accelerator. I would like to welcome Dr. Chiang to the podcast. Hello, Dr. Chiang, thank you for taking time out of your busy schedule to join me on my podcast. Could you give us a brief introduction on your background and career?

00:54 Su Chiang
Yeah, absolutely. Hi, Ethan. Thank you very much for inviting me to your podcast. And thank you for spreading the word about antimicrobial resistance or AMR for short. It’s a very important problem, and I think it’s really important for everyone to know that each of us has a role to play. So thank you so much for doing this. So about me, I started my career with a bachelor’s degree in biochemistry followed by a PhD in molecular microbiology studying Vibrio cholerae. That’s the bacterium that causes cholera. I then did postdoctoral work on mycobacterium tuberculosis, which is the bacterium that causes tuberculosis, before moving into research roles that were away from the lab bench. Initially, I worked on a program funded by NIAID. That’s the National Institute of Allergy and Infectious Disease, that provided research and development resources to researchers across the United States. And then I worked in a university tech transfer office, helping academic researchers move their discoveries into product development and towards commercialization. And then in 2018, just over four years ago, I joined CARB-X at Boston University.

02:11 Ethan Rhee
When I was researching topics for my next podcast episodes, I came across various articles talking about how antibiotic companies were going bankrupt, and that there has been a steady decline in antibiotic discovery, as when I connected with CARB-X I wanted to learn more about why these antibiotic companies are facing these challenges. Could you explain how CARB-X fits into this scenario?

02:31 Su Chiang
Sure, I’d love to. First, there are a couple of points that I’d like to start with to help explain why it has been so difficult to make new antibiotics. Personally, I think most of us, I certainly did for you know, an embarrassingly substantial portion of my career, I think most of us take antibiotics for granted. They were the first wonder drugs, you took them and your bacterial infections were cured. Not that you got a little bit better, not that you lived a few months longer, but people were cured by antibiotics, and they would otherwise have died. Today, antibiotics enable modern medicine, risky procedures like chemotherapy, dialysis, and organ transplants are all much safer procedures because antibiotics are available. And we got used to this situation in the mid 20th century. And we’ve largely forgotten how bad it is when there are no effective antibiotics. So how do antibiotics stop working? Right? And to a first approximation, as soon as patients start taking new antibiotics, bacteria find ways to evolve and escape the activity of those drugs. That’s a natural process that the bacteria undergo to survive. Unfortunately, it means that our existing antibiotics are becoming less effective against bacteria, and we are not developing enough new antibiotics to replace those.

03:59 Ethan Rhee
So if new antibiotics must continually be made to address antibiotic resistance, why has there been a decline in antibiotic discovery?

04:06 Su Chiang
Well, first, funding is a huge problem. You may have heard the number quoted that on average it takes a billion US dollars and more than a decade for a company to develop a new antibiotic. Unfortunately, we as a society, globally, have been under investing for decades in antibacterial research. And as a result of that there’s much less money going into antibiotic R&D compared to for example, cancer. Second, once new antibiotics are approved by regulatory agencies, like the FDA, for example, doctors will reserve them, they’ll save these new antibiotics for situations in which older antibiotics don’t work. This is called stewardship and it’s essential for public health, because it helps to slow the spread of antibiotic resistance. The problem is, while it’s essential for public health, it’s financially disastrous for companies. With low sales volumes and payment policies that don’t reward the true value of antibiotics, it’s difficult for companies to recover the R&D costs that went into creating those new antibiotics. So companies in this area, they can and they do go out of business, even if they succeed in getting a new antibiotic approved. Now, there are efforts ongoing around the world to fix these broken economics of antibiotics. But until that gets done, we need to keep innovation and development going so that the pipeline isn’t empty. And that’s what CARB-X helps to do. So, as you mentioned, CARB-X is a nonprofit. It’s a global nonprofit. It’s based at Boston University. It was founded in 2016. And we have been funded by the US, the United Kingdom and the German governments, the Wellcome Trust, and the Bill and Melinda Gates Foundation. We believe we’re the world’s most scientifically diverse early development pipeline of antibacterial products. And our purpose is to get life-saving products for patients into the pipeline. We support product developers from anywhere in the world who are creating new drugs, new vaccines, rapid diagnostics, and other types of products that address antibiotic resistance. And we take a comprehensive approach, because while antibiotics cure bacterial infections, vaccines help prevent them, and the best infections are the ones that we never have. And as you may have discussed elsewhere in the podcast, as we learned during COVID rapid diagnostics are critical to help slow the spread of disease and rapid diagnostics would help doctors to test at a single medical appointment whether a patient has a bacterial infection, and if so, which antibiotics would be effective.

07:01 Ethan Rhee
I really find stewardship and access to be important and preserving new antibiotic discoveries. In my previous research and interviews, I found that antibiotic stewardship is an effort to gauge and improve how antibiotics are prescribed by clinicians and used by patients. The CDC website says that this is a critical way to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. Can we talk about that?

07:27 Su Chiang
Yeah, absolutely. This is very important. As mentioned earlier, stewardship means saving antibiotics for situations in which doctors are confident that they will work. And this is in order to slow the development of resistance. This means not using new antibiotics if older ones can cure the infection effectively. And it means using existing antibiotics only when appropriate. I think you’ve mentioned this before, that antibiotics don’t work against viral infections, so they should never be prescribed or used for viral infections. On the other hand, patients who need antibiotics should get them and that’s access. Unfortunately, all over the world, there are patients who are not getting the antibiotics that they need, particularly in low- and middle-income countries. And the goal that we have to achieve is to balance stewardship and access so that vital products are available to patients who need them anywhere in the world, while also slowing the spread of antibiotic resistance to preserve these drugs for future generations.

08:38 Ethan Rhee
So how does CARB-X support this? I see that you developed a Stewardship and Access Guide.

08:44 Su Chiang
Yes, CARB-X and our international partners developed a guide to help our product developers create their own stewardship and access plans so that when they get their antibacterial products to market they can achieve what we call access not excess, for these essential medicines. So an ideal stewardship and access plan must be developed. Or I should say, ideally, the stewardship and access plan should be developed when their product enters pivotal clinical development, meaning that it’s getting pretty close to regulatory approval. And the plan should outline how the company will ensure responsible stewardship and appropriate access in low- and middle-income countries.

09:27 Ethan Rhee
Okay, so as I understand it, companies funded by CARB-X have contractual stewardship and access obligations. So what happens if they can’t meet those obligations?

09:39 Su Chiang
Right. Well, we are all in this together. So responsibility for stewardship and access is shared by companies, governments, funders, industry, health professionals, patients, everybody. And if an individual company can’t meet its stewardship and access obligations, then the Wellcome Trust, which is one of our funders, has access rights that are modeled after the US by dual rights. And very roughly speaking, this means that the Wellcome Trust can step in to help ensure access in low- and middle-income countries, if a CARB-X funded company isn’t able to meet its stewardship and access obligations on its own.

10:25 Ethan Rhee
I see. I saw on your website that there’s quite a list of CARB-X graduates, how are they doing after graduating from the program?

10:33 Su Chiang
We’re very excited that many of our graduated programs continue to progress towards commercial launch. And in fact, two diagnostic products that we supported are now on the market in Europe and seeking FDA approval for the US market. And these are from T2 Biosystems, and from Specific Diagnostics. Specific Diagnostics, which was a private US company, was actually acquired in 2022 bybioMérieux, which is a global leader in in vitro diagnostics. And that was super exciting for us. On the therapeutic side, I’ll just briefly mention two products that are currently in advanced clinical development, post CARB-X. The first is a product called VE303, from Vedanta Bioscience. This is a live biotherapeutic. It’s a mixture of eight bacterial strains that is intended to restore the gut microbiome and prevent recurrent Clostridium difficile infections. This is in phase two clinical trials. And the other product I wanted to mention is called GSK 3882347. This is from GlaxoSmithKline. It’s an orally available small molecule drug that prevents E. Coli from binding to the wall of the bladder. And this is in phase one clinical trials for preventing recurrent urinary tract infections caused by E. coli.

12:00 Ethan Rhee
And those are some interesting names. Well, I think that the work that CARB-X is doing is so unique, and so important, and making sure we have the necessary tools to continue fighting antibiotic resistance. I read that CARB-X has received over 1160 expressions of interest from companies or institutions located in 40 countries in just the first five years. Where do you see CARB-X 10 to 20 years from now?

12:30 Su Chiang
That’s a long time to be looking into the future. So you know, it would be fantastic if economic and societal incentives align, and the antibiotic ecosystem becomes fully self-sustaining on a global basis. Bacteria evolved to escape our medicines, and that’s never going to end. So we have to evolve our efforts. And we’ll never be able to stop either. What CARB-X’s specific role will be over the next decade or two is not something that I’m able to predict. But I can say that we’re always looking to understand what are the most urgent clinical needs, what has gone well, and what could be done better in our own processes. And after the first five years, we’ve implemented targeted funding calls to focus our investments on the most critical gaps in clinical care. We are building portfolio-wide efforts so that we can have benefit across multiple projects. And we’re working with partners to shorten the path between good ideas and real world solutions for AMR. So while I can’t, I really can’t answer your question in any detail, I can say that we will be here doing this as long as we’re needed. And as long as we’re able to.

13:54 Ethan Rhee
Thank you so much Dr. Chiang for joining us here and sharing your knowledge and expertise. We’ve learned so much and I hope to continue as part of the younger generation to keep antibiotic resistance on their minds as they’re navigating through the healthcare system. We hope CARB-X can continue to grow and accelerate important companies discovering AMR products.

14:16 Su Chiang
Thank you so much, Ethan. It’s been a pleasure.

14:18 Ethan Rhee
Thank you. 

14:25 Ethan Rhee
I want to thank Dr. Su Chiang for joining us and a special thank you to Robin Berghaus for helping me get connected with Dr. Chiang for this interview. That is the end of this episode. And don’t forget to click the follow button on Spotify and follow me on Instagram at ARA.podcast. Thanks for listening. This is Ethan Rhee for Antibiotic Resistance Awareness podcast. And that’s a wrap.

Hosts:
Lance Price, PhD, Professor, George Washington University
Matthew Wellington, Public Health Campaigns Director, PIRG

Guest:
Erin Duffy, PhD, Chief of Research and Development, CARB-X

00:14  Matt Wellington
Hey everybody. Welcome to another episode of Superbugs Unplugged. My name is Matt Wellington, I’m the public health campaigns director for PIRG, one of your hosts. And I am joined here by Dr. Lance Price of the Antibiotic Resistance Action Center. My other host for the podcast. Hey, Lance, how’s it going?

00:31  Lance Price
I’m sick.

00:33  Matt Wellington
Yeah, everybody’s sick. My daughter has a pretty nasty case of the croup right now. I don’t know what caused it. I understand that is a side effect of other things like RSV. So who knows what’s going on there. But yeah, things kind of suck right now in terms of illness. They really do. It’s.

00:51  Lance Price
They do. Do you take her outside, too? That fresh air is supposed to help with croup.

01:01  Matt Wellington
Yes. We took her outside this morning a little bit, and she was in her brand-new snowsuit. She’s 14 months old, so she’s running around and walking and we have a snowsuit that’s too big for her. So we have to roll up the sleeves and the legs. And so she looks like an absolute balloon. It’s hilarious. But she was like running around the backyard with her little sunglasses on. It was great. Yeah, but she sounds terrible. It’s kind of scary.

01:28  Lance Price
I’m sorry. It’s very stressful.

01:29  Matt Wellington
Yeah. Did they get you sick or did you get sick on your own?

01:33  Lance Price
Oh, my daughter likes to cough right into my face. It’s pretty awesome. So if you’re yawning, she’ll cough into your mouth. It’s awesome.

01:44  Matt Wellington
Ruby takes her little finger and just kind of puts it in my mouth and twirls it around a little bit. That’s one of her favorite things to do.

01:53  Lance Price
Yeah, kids are gross.

01:55  Matt Wellington
They really don’t understand. Yeah, it’s tough for all daycare classes now. Right now, pretty much.

02:05  Lance Price
I’m excited. I mean, despite being sick, I’m really excited about Erin Duffy, our guest. But you’ve got some news first, don’t you?

02:14  Matt Wellington
Yeah, I’ve got some, some news to share on the antibiotic resistance front. So as we record this episode today, the FDA just came out with their latest report on antibiotics sales to agriculture. It’s the ADUFA report and it’s pretty underwhelming, to be honest. There’s that one less than 1% decrease in the sales of medically important antibiotics to meat producers from 2020 through 2021. So not much of a change at all in either direction. And, you know, that’s been the case pretty much since 2015 when the FDA took the steps. They took on growth promotion and increasing veterinary oversight. After they did that, there was a slight, you know, good decline in sales until 2017. And since then, it’s actually slightly increased, you know, from 2017 through 2021. So it just highlights that the FDA’s approach is not exactly effective right now for reducing antibiotic use for the long term on farms. There’s no, as far as I can tell, no targeted, you know, approach for reducing the use of these drugs. So of course, we’re urging the FDA to take the lead there and to, you know, take some lessons from the European Union. That’s they’ve been able to basically have sales of antibiotics to veterinary medicine in the last ten years. And they did it through setting targets and measuring against their progress. So we are definitely urging the FDA to take a similar step. But yeah, not much, not much else in the report other than not much has changed.

03:56  Lance Price
Are you ever, every time I hear it, I always want to say ADUFA. I don’t know. It’s just got a funny name.

04:02  Matt Wellington
Animal Drug User Fee Act. Yeah, I do feel it’s a very ridiculous outcome.

04:09  Lance Price
Did we ever talk about how from 2016 to 2017 there was this huge jump in therapeutic use? So you see this, you see this, you know, apparent. Well, you see a definite drop in total amount, but then it looks like there’s this big just a shift in what they were calling a bunch of drugs. Right. So they were saying, oh, yeah, these weren’t after all, these weren’t for growth promotion, these were for disease prevention.

04:40  Matt Wellington
Well that’s a good distinction too, you said therapeutic use and the FDA considers disease prevention a therapeutic use, but we do not. To us, therapeutic use means treating disease and disease. You know, preventing disease brought on by industrial farming conditions to me is not a therapeutic use. But we agree to disagree with the FDA on that one. But you’re right, you know, it’s just we see it as, you know, a shift in the labeling. And I think they did tackle the low hanging fruit on antibiotic misuse in their previous actions, but have not really done much of anything since then. So that’s antibiotic resistance in the news, not to be a bummer. But we do have an upbeat episode. We go it was quite a roller coaster. We talk about antibiotic development, we talk about how antibiotic resistance affects lower and middle income countries differently than high income countries. But ultimately we end on a positive note. So even though I have been a little bit of a bummer in my introduction here, I encourage folks to listen to the full episode because you’ll definitely have some hope at the end of it. And we have a special guest joining us, Dr. Erin Duffy. She is the chief of research and development at CARB-X, a global biopharmaceutical accelerator for the discovery and early development of products to prevent, diagnose and treat bacterial infections. So folks might remember we had the executive director of CARB-X, Kevin Outterson, on our previous episode. So Dr. Duffy is his colleague and she is going to take us through some of the more scientific pieces of what CARB-X does. So stick around to hear that episode. But we’re going to take a break right now. We’ll see you when we get back.

06:21  Laura Rogers
Hi, this is Laura Rogers, deputy director of the Antibiotic Resistance Action Center. If you like what you’re hearing, could you do us a favor and rate review and subscribe to the podcast? We really appreciate it. Now, let’s get back to the episode.

06:34  Matt Wellington
Hey, everybody. Welcome back from the break to another episode of Superbugs Unplugged. I’m here with Dr. Lance Price, and Dr. Duffy is our special guest for today. Hey, Dr. Duffy, thanks for joining us.

06:45  Erin Duffy
Hi. Thank you for having me. Happy to be here.

06:48  Matt Wellington
Of course. And so we were lucky enough to chat with one of your colleagues, Kevin Outterson from CARB-X pretty recently. So hopefully our viewers have a little bit of a primer on what CARB-X is. So I wanted to start with just your background. Can you tell us a little bit about yourself?

07:05  Erin Duffy
Sure. So again, Erin Duffy, I am the head of research and development here at CARB-X. I am a chemist by background, trained formally at Yale and spent a little bit of time at Pfizer doing drug discovery right out of a postdoc. But then the meat of my career was actually with a small company founded as Rib-X Pharmaceuticals that became Melinta Therapeutics, a pure play antibiotics company, where our goals were to discover, develop new antibiotics. We did that over about 17 and a half years. And then unfortunately, and I suspect this is going to be part of our conversation once we launched our first antibiotic and commercialized it, we ran into some challenges, market headwinds, which required us to close the research and development shop to focus on market products. And so I left there in 2019 and joined CARB-X.

08:10  Matt Wellington
Awesome. You’ll have to be patient with me with the chemistry it is the only class that I did not do super well on in college, so.

08:18  Lance Price
I didn’t even know chemists could speak. So this is really awesome to microbiologists. You know, we had a lot of competition with us.

08:27  Matt Wellington
Yeah.

08:27  Lance Price
What’s pure play?

08:29  Erin Duffy
Oh, sorry. Pure play. Meaning that we were, which is pretty true of most biotechs, we were solely focused on the development of new antibiotics, not, you know, and oncology agents or whatever, whatever. But we had a foundational technology out of Yale that actually was the subject of a Nobel Prize mid-stream in our company in 2010. Not that I won it, but the founders did. And that was to describe at the atomic level what one of the most prolific targets for antibiotics looked like. And that then allowed us to use that and design new antibiotics against it.

09:09  Lance Price
And I thought you said parallel play. You know, I can see my daughter’s nursery from here and they do a lot of parallel play and I just didn’t know that. I was just imagining chemists all trying to like, you know, almost like shared workspace. Okay.

09:25  Erin Duffy
I’m sorry to disappoint you, but yeah.

09:29  Matt Wellington
Well, I definitely am curious to hear about the challenges, the market challenges. You mentioned before I asked that, as I said, hopefully our listeners are already primed with what CARB-X is, but can you just give us a little bit of what CARB-X is and what we’re all about.

09:43  Erin Duffy
Sure. Absolutely. So I’m sure Kevin told you this, but I’ll remind you what the acronym means, which is combating antimicrobial-resistant bacteria biopharmaceutical accelerator. Those last words are what make the X. And long story short, we are a project at Boston University School of Law that is funded by three international governments. So the U.S., the UK and the German government, as well as two foundations including the Wellcome Trust and the Bill and Melinda Gates Foundation. We’ve been given to date just about $800 million to deploy for the support of companies that are designing and developing new antibiotic attacks, new vaccines and other preventatives against bacterial infections and new diagnostics.

10:36  Matt Wellington
So one thing that and lots of the things Kevin said stuck with me from his interview is that we titled that episode “King of Analogies” because he was just throwing them about left and right. One thing that I came away with was it sounded like CARB-X is doing what I would consider like letting all the flowers grow, right? So it seems like you’re kind of open to every and all approaches to addressing antibiotic resistance, but you all have the strategic goal, like, are you thinking ten years from now we want to have three antibiotics developed, four diagnostic tools in place X, Y and Z? Or is it just throwing spaghetti at the wall, seeing what sticks, which if it is, that’s totally fine. I’m just curious if there is that strategic. Here’s what we want the next ten years.

11:24  Erin Duffy
Yeah. So I’m not the queen of analogies except maybe bad ones, so I’m not going to go there. But I would say that it has evolved. So when Kevin was first awarded this grant in 2016, I would say it was more of the spaghetti on the wall, which is I don’t think Kevin had any idea if ten people would apply, 100 people would apply, 1000 people would apply. And so they had very broad calls of, you know, we do fund only through active funding calls. We can talk about that. If you want to have a very broad, just bring us stuff that might be relevant for antimicrobial resistance. And then as we’ve matured, we’ve built some portfolio analysis tools so that we can look at, you know, the landscape of pathogens and infections that they cause and where we’re heavily invested and where we’re not well invested. And you know what? What sorts of things are in that box, how mature they etc. And then that has allowed us to refine for what we look at. And I think probably the best expression of that is this year in October we launched the first what we’re calling omnibus solicitation or funding call since 2019, and we publish three funding themes and there are very specific funding themes. The first is we’re looking for new oral therapeutics for a variety of infections. The reason for that is all those antibiotics that you know and probably have used with your children. I know you’ve both mentioned young children, things like Zithromax, Augmentin, you know, these are products that are being eroded because of resistance in the community. And so we’re looking to replace those with new antibiotics. So that was one call. The second call was for vaccines, maternal vaccines for neonatal sepsis. Not a huge problem in high income countries, but a massive problem in low middle income countries. These vaccines are very hard to develop. And then the final set of themes was for gonorrhea. And this was a broad based. If you have something for gonorrhea, whether it’s a treatment, a preventative or a diagnostic, we want to hear from you. And this was after a careful analysis of what where the holes are in our current portfolio and where the needs are in the world.

13:55  Matt Wellington
Yeah. Lance, you’re going to jump in.

13:57  Lance Price
Yeah. I mean, no, that’s really exciting. So for the neonatal sepsis, is that primarily E. coli? I know we have a lot of that. And I mean there are E. coli strains that cause neonatal sepsis. You see that in the U.S. But I don’t know about low- and middle-income countries or is it other organisms?

14:16  Erin Duffy
Yeah. So actually, there’s a pretty neat study that was done called BARNARDS. This was work out of Oxford University, Tim Walsh’s lab, supported by the Gates Foundation. And what they found pretty contemporary study was a predominance actually of Klebsiella pneumonia. So if you were to rank pathogens from sort of most likely to cause and do cause neonatal sepsis down, it would sort of go like Klebsiella pneumonia, and maybe said that five more times. And then in fact, E. coli, Acinetobacter baumannii and Staph aureus actually as well. So those are the four main pathogens.

15:01  Lance Price
Tim is amazing, Tim Walsh I mean, this guy.

15:05  Erin Duffy
You could have.

15:06  Lance Price
Him on the show at some point.

15:07  Erin Duffy
I know you do. You do. You do. He’s terrific. Yeah.

15:12  Lance Price
So discover MCR1and then also New Delhi metallic protease. Yeah. Wow. Okay so the end.

15:22  Matt Wellington
Man of the year, Lance gushed about his favorite scientists.

15:25  Lance Price
Oh well he’s an amazing guy. So the oral antibiotics make sense and vaccines. Awesome. And then yeah, the gonorrhea. Let’s talk about gonorrhea a little bit. It’s one of my favorite topics. So super resistant strains now and nearly pan resistant, right?

15:45  Erin Duffy
Yeah, absolutely. You know, there’s you know, we always talk about resistance to classes, but in fact, in the case of gonorrhea, we’re not just down to one class that is effective. We’re down to one antibiotic in one class, and that is the cephalosporin, very old. And it’s an IM injection. It’ll make you think about it if you have to get the injection. But even there, particularly in low- and middle-income countries, the resistance rates are certainly concerning.

16:18  Matt Wellington
So you’ve mentioned lower and middle income countries a few times now. And I know when I was looking at some of the background on your work, CARB-X talks about antibiotic resistance and the burden primarily falling on LMICs. So how does that come into play? You know, obviously we use antibiotics in the U.S. We’ve talked about antibiotic resistance in the US context, but how is it different in LMICs? What are the different challenges? What does it look like?

16:46  Erin Duffy
Oh, well, you know, so I mean, it’s frightening, frankly, is how it looks. But so this year in actually January, I think late January of this year, a really amazing paper was published in The Lancet that sort of commonly known as the GRAM paper. And there for the first time described what the burden looks like worldwide. And also then mortality and morbidity, morbidity associated with bacterial infections. And, you know, the numbers are staggering in and of themselves and I’m sure you talked about that with Kevin, but if you were to plot where those infections happen, they’re not here. Okay? So they are all in low middle income countries. It’s really alarming. And even more alarming than that is the disproportionate burden on children of babies, particularly neonates. It’s shocking.

17:42  Matt Wellington
And what because we did have one of the researchers of that study on the podcast several months ago, and I’m trying to remember what he told me in the interview was partly it’s that it’s just a lack of access to antibiotics in those countries. Is that your take as well, or are there other things coming into play with resistance factors, or is it the case that these people with infections could be easily treated if they happen to live in the United States with these infections? Or is there something else happening?

18:13  Erin Duffy
Well, certainly it is true that access is a major, major, major driver. And that’s because, you again, the health care system is very different. I mean, if you’re a woman who is pregnant and delivering a child, you might drive for two days to go to a place that certainly doesn’t look like any hospital that you or I would ever come into contact with. And so it’s just the levels of the health care system are different. The access to these antibiotics, as you said, is very low, but then also the misuse of antibiotics that we can get drives resistance. And so it’s sort of all of that combined. You know, actually earlier I think Lance mentioned, you know, New Delhi metallo-beta-lactamase, why you think it’s called that because the first patient who showed up with it was from New Delhi. That’s how these things are named. And so anyway, it’s all three of those factors, I think.

19:12  Lance Price
I think, you know, the other thing I was so happy to see your focus on the LMICs, too, is that, you know, we talk about antibiotic resistance undermining modern medicine all the time, right? So that’s, you know, one of the messages that seems to resonate with people. But in low- and middle-income countries, I mean, the antibiotic is modern medicine. And if that fails, you die, right? So that $5 antibiotic doesn’t work. You don’t, you don’t hook people to hundreds of thousands of dollars’ worth of equipment. Right. I mean, so that’s the thing that really strikes me is that these are modern medicine and they’re failing. And so, yeah, well, tell us, how do you when you think about diagnostics, when you think about drugs, how do you know? What is it you’re looking for to support that specifically helps in that context?

20:07  Erin Duffy
Yeah, it’s a great question. You know, and I think it’s so much easier for better or for worse, to have this conversation now. Three years almost. Exactly. And to, you know, COVID, because if you if you roll the clock back to, you know, I believe in May of 2020, if you had a respiratory infection and suspected you might have COVID, you couldn’t get a test, you couldn’t figure out if you had it, there weren’t therapies and there weren’t vaccines. You know, so this is terrifying and it’s sort of the same here. So but in the low and middle income country setting, you need all of these things, but you definitely need a diagnostic. But that diagnostic needs to be, you know, cheap available at the lowest levels of the health care system. So it’s going to be, you know, a blunt instrument. But at least to say, you know, bacterial and maybe, you know, idea what it is and some resistance markers so that you can properly treat, you know, is critical. But then having the right antibiotics or at least enough options for antibiotics once you understand what that is, is key. Now, of course, the third part of this and again, you know, we have code to thank for this is prevention, because you know, the best infection is the one you actually never get. And so if we had good bacterial vaccines available, that I think would be a game changer in low and middle income countries.

21:39  Matt Wellington
I want to ask you about the diagnostics. So what you described that tool where, you know, it says here’s the here’s what the infection is or roughly what the infection might be resistant or not resistant, does that even exist in higher income countries? Like does that is that something physicians have access to here in the U.S.?

21:57  Erin Duffy
At the highest levels of the healthcare system, you know, for different syndromes? And when I say syndromes, I mean infections. Right? And for you have to think about sample types as well. But yes, there are these big systems and then you have these cartridges that you swap in and out. And so it depends. But certainly there are infections for blood sorry, diagnostics for bloodstream infections. After you take the blood and you culture it and say growing the bacteria, then identifying it and saying to what it is susceptible can be done. But that’s at your highest levels of the health care system and it’s not available with all of the infections types and sample types and, you know, whatever that you want. So for instance, in gonorrhea, you know, we have this call. Turns out that it’s really difficult to measure bacteria and things like vaginal swabs and urine. Partially that’s a collection problem. But anyway, so there’s a lot of work to be done and bacterial vaccine and bacterial diagnostics. Now, the good news is for respiratory diseases, we had so many groups, small companies, big companies who dove in to the COVID world in 2020 kind of stopped what they were doing to develop tests for all levels of the healthcare system. Well, those people, you know, they’ve made some really interesting products and now we have the ability to pool them in and hopefully get them excited about what else they can build and build it for, you know, bacterial infections.

23:39  Matt Wellington
Yeah. I mean, the COVID tests amazed me. I just took one this morning. Ready took a little swab, little piece of cardboard and in 15 minutes I knew to a degree whether or not I had COVID. Yeah. So that’s the idea, right? It’s something super simple, cheap that physicians can use. I guess one follow up question I have is how we’re talking about like COVID in particular, you know, versus virus who knows how many potential bacterial infections. So how would you narrow it down in a test like that? Would you develop it for the top three bacterial infections? You might find it in a region. How would that work?

24:19  Erin Duffy
Yeah, it’s a good question. So, I mean, typically these things are more syndrome focused and by that I mean, okay, this is for respiratory tract infections. Okay. And then, you know, you’ll hopefully be able to have enough on the test to be able to determine what the key pathogens. So you’re looking for the key pathogens that cause that syndrome. You know, so, you know, we talked in the case of neonatal sepsis about, you know, the big four, if you’re talking about a lower respiratory infection, you know, a deep pneumonia infection, you know, you’re talking about, you know, things like Klebsiella pneumoniae. We mention that Pseudomonas, staph aureus, you know, it’s a similar grouping. So you’re going to look for that. And then, you know, depending on the sophistication of the tool and again, at what level it sends, that’s where you get into the nitty gritty of. Okay. And it also is carrying X marker where X is something about resistance.

25:20  Lance Price
So I’m curious about the economics of, say, a diagnostic for low- and middle-income countries, because it’s my understanding is that one of the big barriers to bringing new point of care diagnostics into places like the United States is this unpredictable reimbursement. Right. So, you know, if there’s not clear reimbursement, then a doctor’s not going to order it. And if the doctors aren’t going to order, then nobody’s going to produce it. Right. So it seems like the technologies are out there. There needs to be the effort, the investment. And so my understanding of CARB-X is that you do the push piece, so you have this non-dilutive funding at the beginning. But then and you know, we talked a lot with Kevin about, you know, pull incentives, but how would that work in low- and middle-income countries? How would you pull?

26:17  Erin Duffy
Yeah. No, I think these are excellent questions. I’m definitely not the expert to answer these questions, but I will say that that certainly if you’re talking specifically about diagnostics groups who think a lot about this are a group that we work with quite closely called Find. And I don’t know if you’re aware of them, but you know, Geneva based, you know, very big focus on diagnostics for low-income countries across the board, including antimicrobial resistance. But then also the lead at CARB-X of our diagnostics portfolio is a woman called Betsy Wonderly Trainor, super energetic. You know, a really bright gal. And recently she was part of a convening group at the National Academies of Science to start grappling with these questions of reimbursement for diagnostics. So it’s conversation, but it’s certainly something I would say in a less well developed than, for instance, the PASTEUR Act that I’m sure Kevin spent some time talking with you about for treatments.

27:26  Lance Price
Well, I think if anybody can solve this, it’s somebody named Betsy Wonderly Trainor.

27:30  Erin Duffy
I think. Really. I mean, honestly, no, she’s terrific. You know, she’s had a quite a long history of both development and deployment of diagnostics for emerging diseases, including in low- and middle-income countries. So she’s very passionate about it, super connected and really trying to make a difference.

27:55  Matt Wellington
I feel like this is a good, good time. So if you don’t mind, let’s go back to your personal experience with Melinta, right? So we’re talking about the push and pull incentives, the market challenges. Can you give us the details of what happened with the antibiotic at Melinta? Because I think it’s always helpful to have the stories to go along with the principles at play here. So walk us through what happened.

28:19  Erin Duffy
Sure. So I’ll tell you the long version and then we can cut it to the short version.  We have to roll the clock back a little bit. So around 2005 or 2006 at the latest, we actually brought this antibiotic. So our technology, it was all focused on the ribosome, which is, as I mentioned earlier, prolific target for many antibiotics. And we had put our first products that were new ribosomes targeting antibiotics into first in human clinical trials and they were moving along. But we’re a small private company and the investor said you should bring in a more advanced product so that you can get on the market faster. And of course that will allow us to continue to reinvest in R&D. Seems smart. So we brought in this fluoroquinolone that we named delafloxacin, and it’s in the same class as Cipro. Everybody’s heard of Cipro, but it had a better resistance profile and arguably put clinically a better safety profile. And it had been in the hands of Abbott Laboratories, you know, big organization who were developing it. But what happened was around that time there was a company, big company called Aventis, now Sanofi, and they had an antibiotic that was meant to replace Zithromax. It was called Ketek and it was put on the market. And then some idiosyncratic liver toxicity started showing up. And mind you Zithromax is used in kids, your kids, you know, and earaches and bronchitis and sinusitis. And so, these things need to be really safe. So that was a problem. And it really served to shut down the regulatory path for people developing community-based antibiotics. So Abbott got out, gave it back, gave delafloxacin a send back to the people who had created it, which was a Japanese pharmaceutical company. And then we licensed it from them and then we pivoted it towards hospital infections so that we could move it on a regulatory path. But this took some time. Okay? And then we were just about to start. We just finished our Phase two program, which is the first time you demonstrate efficacy in people for the infection you’re trying to cure in 2010. And at that point, the FDA released new guidelines for certain paths towards approval, and that was one of them. And so that caused us to stop. And, you know, because we’re ready to jump into phase three with a plan. So we had to back that up a little bit and took some time. Okay, I’m telling you all this because time is important with the drug, because all those years that you have delays, just eat the patent clock off of your marketing product. Okay. So fast forward 2012. We were trying to raise money in an initial public offering to do those Phase three pivotal trials with delafloxacin. And there was something that was being discussed in Congress called the GAIN Act, which was generate antibiotic incentives now, and the whole story behind that was they recognized that all these companies had a big pause because of Ketek and what happened in the regulatory environment and realized that many of these products would launch after their patent clock had expired. Okay. Not really a great economic story if you think about it. Okay. But GAIN passed and we went and we did our clinical trials. And in 2017, we gained approval. So great. Great approval of our antibiotic. At the same time, we did a reverse merger with an antibiotic company that had run into some challenges with their product that the FDA, this company was called Sempra. They were public and had money but problems and we were not public and needed money to build a marketing team. So was a married match in heaven. So approval of the antibiotic reverse merger. Now we’re a public company, so it’s not bad about that and it’s great. But then we made this decision, which seemed like a really smart decision, which was, well, delafloxacin is meant for the hospital. So you’re going to build a sales force. Why not send those people in with more than one antibiotic in their back? And so we bought three other antibiotics from a company, the medicines company, who decided to divest themselves of antibiotics. I think because of the market conditions. And so now here we are, we have four antibiotics that are on market, two that are launching both important antibiotics and two that have been on the market for a while. It was great and we took on a little debt in addition to the money that we got from the reverse merger to do that. But we were off. We thought this was great. But then the reality of the market conditions that came in and over the next three quarters, the amount of revenue that we received over the four antibiotics was not enough to sustain them on the market. Incredibly. And so that’s when we made the decision in the, I guess, the fourth quarter of 18 to close the research and development shop and find a home for those assets, which we did the preclinical assets, and then to really focus on what we could do to move these antibiotics forward again in oncology company with four branded products for a minute, having this, probably can’t imagine it can you. And so anyway, so then. R&D was closed and then that following year, 2019, in the fourth quarter, actually Melinta filed for Chapter 11 bankruptcy protection. Now, there’s a good news story to that. I have to say, let me just cap this by saying that was sort of the nadir, but now Melinta was brought out of bankruptcy by the group from whom they took the debt, Deerfield and Melinta as a going concern. They’re a focus company with multiple products, including the ones that I mentioned. And so they’re back in business and looking to build, which I think is a good sign.

35:00  Matt Wellington
That was quite a journey. So I think.

35:03  Erin Duffy
Sorry about that.

35:06  Matt Wellington
Reminded me of like it almost was like I felt like there should be like a Hulu documentary special made about this quite, quite a story as you were telling the story, a couple of things stood out for me. You said market conditions several times. You talked about the sales force and it just paints the perfect picture about how the current drug development structure just it does not work for antibiotics. If we want to keep antibiotics effective, it just does not work. You know, sales based on volume, which a company needs, it literally just will not work for antibiotics if we want to keep those drugs effective for the future. So that stood out to me quite a bit.

35:46  Lance Price
Yeah. So I wonder, Erin, how does that of somebody who came out of this, you know, for profit drug world now you’re working with CARB-X. I mean is that shaken your sort of vision of how markets work. I mean what is that Yeah. How does that experience sort of shape your thinking?

36:11  Erin Duffy
Yeah, I mean, it’s a good question. I you know, I guess I’m here because I, you know, I, I believe like, I think we all do that the world needs these products. And, you know, there’s this is a challenge. It’s a different challenge than the scientific challenges that I’m used to tackling. But, you know, somebody has to do this stuff. And thankfully, we have people who are behind us. So we’re curating that pipeline for when. And you know, there are others, including, you know, Kevin, who are working on the how. And I think both need to come together. It’s a puzzle, you know, would have been easy. I’ll tell you to just go to a different therapeutic area. Sadly, when we closed the R&D shop, I had 25 colleagues with whom I worked in New Haven, Connecticut, and I’m proud to say that all of them were gainfully employed shortly after we closed the R&D site. Not a single one of them in antibiotics, not a single one. Okay. So it’s easy to retreat. But I think, you know, we all know we need these things. And I do believe fundamentally smart people and passionate people will help us figure out the other side of the equation.

37:30  Matt Wellington
But it is so clear to me, especially after hearing the story in detail, like it’s a policy problem, obviously there’s a science problem that you’re dealing with, but at the end of the day, it’s a policy problem. We have to figure out the policies that will make this system work. So thank you for sharing the story with us. So I guess pausing for a second, is there anything you wanted to discuss, Dr. Duffy, that we haven’t touched on yet? Because I actually I feel pretty good about where we’re at right now. Lance I don’t know. Is there anything else you wanted to discuss?

38:03  Lance Price
Oh, I could talk for hours. We could do like we could do one of those long podcast recordings. But no.

38:12  Matt Wellington
Yeah. So on your end, Dr. Duffy, anything you feel like you were really burning to talk about that we didn’t ask you?

38:19  Erin Duffy
You know, I think sensing that, that I think we’re still trying to figure out, frankly, because you’re right, it is a policy problem, okay? The science of science. And, you know, I mean, we can tackle hard problems, but the question is, how do you get the non scientists in the world to go yeah, I get it. I mean, it’s good. And I say that because, you know, I think we’ve tried various things. You know, we talk about antibiotics underpin all modern medicine. That’s true. But you know, it’s not at the level that people worry about, know people worried when they felt there were no therapies for COVID. People worried in the eighties and nineties about getting HIV. Okay. So they were activated and motivated and I guess I’m curious to know, you know through all of this if you think there are ways to reach people. I mean we’re talking this obvious podcast hopefully it’ll be out there but how do you make how do you make you know like the gal who’s sitting right now at the dry bar having her hair done, listening to this podcast, because that’s what you do, listening to the dry bar, I think, you know, But like we need to do something about that, you know.

39:44  Matt Wellington
I mean, my, my take and it is a core part of our audience, the salons and barbershops. So we get a lot of play with Superbugs Unplugged there. But my take on the public facing piece of it is if I just sit here and really think about it, I can come up with three immediate family members who have had drug resistant infections. All of them are a little bit different, you know, difference in severity. But one of them was fatal. One of them was nearly fatal. And I think most people, when they really think about it, antibiotic resistance has touched them directly or their loved ones directly, and they don’t even really know that. And I think partly it’s because it’s always couched or, often couched in a larger medical problem. Right. So, you know, a cancer patient surviving cancer and then unfortunately dying from a drug resistant infection is just part of a larger story. And so I think it’s up to folks like me, I’m a non-scientist full disclosure. I’m a non-scientist. So it’s up to people like me, I think, and other advocates to work with physicians in those patients to help tease those stories out and have those physicians tell their stories. But the actual patients tell their stories, too, you know, and we do that every day. I have a great farmer that I work with because we work a lot in agriculture here and trying to reduce antibiotic use there. And he talks about how he had MRSA infection. And I guess his doctor, he was upset with his doctor for not starting antibiotic treatment sooner. And his doctor had a great conversation with him about why he didn’t make that decision, because he doesn’t want to spur antibiotic resistance unnecessarily. And it totally changed this guy’s life. He changed how he produces animals based on it. He switched from a conventional model to now raising his animals without antibiotics. So I think it’s up to I think it’s really about helping physicians to talk about this in a way that is public facing and is understandable to the public, not as just this kind of ambiguous medical problem. And then people me to, you know, put a megaphone in front of them and get it in the media and understand how people understand that if they really think about it, this has already affected them. You know, I think the amoxicillin shortage, I know that’s not necessarily about antibiotic resistance, but it’s giving us a glimpse of what the world will look like without antibiotics. And that has been on headlines all over the country. Right? Amoxicillin shortage. People are freaking out for good reason. What I think we need to do is connect the dots that, yes, and if we don’t act on this soon, you’re going have a lot more to freak out about.

42:19  Lance Price
I think, too, it’s you know, as we see E. coli getting more and more resistant, this is going to become a salon conversation because you’re going to see urinary tract infections that are very, very difficult to treat. And so unfortunately, I mean, I think it’s a crisis. It’s going to lead people to start to feel that. Yeah, unfortunately.

42:45  Erin Duffy
Yeah that’s really good point in the urinary tract infection you know touches so many sort of different levels of people. Right. But you’re you know, to your point about, you know, a lot of young women have, you know, what are, you know, non-complicated urinary tract infections. But we also have not again, because, you know, these markets have not been attractive. We haven’t had a lot of innovation for new oral antibiotics for urinary tract infection. You have a college girl let’s say, gets urinary tract infection. Pretty sure she doesn’t think she’s signing up for 14 days of intravenous antibiotics because all the ones that are oral unfortunately don’t work anymore. So these are all these funny things that seem like, you know, just I’ll just go get an antibiotic. But you can’t.

43:36  Matt Wellington
I mean, gonorrhea, right? Talking about college kids, that’s something to worry about. Not. Yeah, yeah, yeah. So I think I think we just have a lot more work to do to penetrate the public’s consciousness, which is a really hard thing to do. And to Lance’s point, I think unfortunately it often takes a crisis to do it right.

43:55  Lance Price
I think we’ve also, you know, we’ve had 70 years of, you know, faith in technology that’s been reaffirmed whenever there was a new antibiotic. Right. So, you know, we as a society, we’ve been taught to disregard this issue. And what I don’t think that most of society sees is that pattern is coming to a quick change, you know, and.

44:20  Erin Duffy
Know it’s true. You know, I was reading, I don’t know. could have been yesterday, could have been two weeks ago. But there was an article, I think it was in the Wall Street Journal about infrastructure aging where, you know, water treatment and distribution is concerned around the country. Right. Because we haven’t invested in this stuff. Nobody buys a house or rents an apartment thinking I’m not going to have safe water to drink. Right. Nobody in. Okay. People in low- and middle-income countries do, but not in the U.S. Right. But antibiotics are like that water. You don’t think about it. You don’t think when you go to have a, you know, a filling or, you know, to have a hip or a knee replaced or any anything else that, you know, what if what if I get an infection and there’s an antibiotic that works against it? Nobody even thinks about it. Your doctors don’t talk to you about it. You know, you just expect it’s there.

45:13  Lance Price
Yeah, but I mean, I think Matt and I are. We’re going to crack this, you know this. And I don’t really know. I mean, I, I, you know, I listen, there’s a, there’s a podcast that I listen to The Drive and it’s, you know, about longevity. And you know, personal health and how do you, you know, what are the things that you can do to hedge your bet and try to live a little longer? And I think about this all the time. We should be on that podcast because this is what’s going to pull the rug out from under people, right? Because as we get older, you know, no matter how well we’ve taken care of ourselves, we get more and more susceptible to infections. And, you know, I think that this could I don’t want to end on such a negative thing.

45:57  Erin Duffy

No, it’s not. Negativity, actually, which is that, you know, coming back to CARB-X and I mean this as sincerely as I can say it, it is remarkable to me how many high-quality researchers doing really innovative stuff are out there and remain active in this field. Okay. And that’s why we’re here, is to pull that energy and pull what they’re doing. The situation will be fixed. I think, you know, there will be a policy fix. There has to be. And thanks to these people today, 92 different companies and hopefully counting more soon, they’re making it so that the stuff will be there when the policy is fixed. And I think that’s an important message. It’s not like, you know, everybody packed up shop and went somewhere else.

46:46  Lance Price
And people like you, thank you for staying in the fight.

46:50  Matt Wellington
Yeah.

46:50  Erin Duffy
Yeah, I’m honored to do it. It’s good fun.

46:54  Matt Wellington
Well, I think that’s a good place to end. High note. Thank you, Dr. Duffy, for. For joining Lance and I. This has been great. Both said the interview with Kevin and you, I think this is a really great one-two punch to tackle, you know, drug development and antibiotic development and what it’s going to take.

47:12  Erin Duffy
I really appreciate it, and I hope you feel better Lance. Thank you. I look forward to listening. And thanks again.

47:21  Matt Wellington
All right. See you.

47:22  Erin Duffy
Take care.

47:23  Matt Wellington
Bye.

Host: Cary Adams

Guest:Kevin Outterson, Executive Director, CARB-X and Professor of Law, Boston University

Cary Adams: [00:00:02]
Welcome to Let’s Talk Cancer. I’m Cary Adams, the CEO of UICC. Antimicrobial resistance or drug resistance is a serious health threat to humanity. Today, around 1.27 million people die every year as a direct result of drug resistant infections. By 2050, this number could reach 10 million and cost a cumulative $100 trillion of economic output without collective action. Drug resistance occurs when germs are not killed by the medicines designed to destroy them. Why? Because the overuse or misuse of today’s antibiotics and other antimicrobials makes them ineffective over time. They simply don’t work. Drug resistant infections are especially dangerous for cancer patients because the treatment they receive exposes them to a greater likelihood of infection. Few people know that today the infection has become the second leading cause of death in patients with cancer. To mark World Antimicrobial Awareness Week, we speak to Kevin Outterson, executive director of CarbX, an international public-private partnership to accelerate global antibacterial innovation. Kevin, welcome and thank you very much for giving us your time today.

Kevin Outterson: [00:01:23]
Always happy to do anything to help the fight against cancer.

Cary Adams: [00:01:27]
The WHO has added antimicrobial resistance to its list of ten biggest threats to health worldwide. So perhaps to begin with, could you explain why antimicrobial resistance occurs and why it’s becoming such a major health risk?

Kevin Outterson: [00:01:43]
When you think about different types of medicine, antibiotics are probably one of the most important classes of drug in human history. They’ve really done amazing things to extend human lifespan. But most drugs, aspirin, for example, is going to work just as well on you today as it will on our grandchildren in 50 or 100 years. Aspirin will always work. Heart disease drugs will always work. If there’s amazing prevention or cures from cancer, it should always work. The difference is that for anything with a microbial target – antiviral, antibacterial – you have to worry about evolution. You have to worry about the target, the microorganism changing over time and therefore becoming resistant. So for antibiotics, penicillin was an amazing discovery. But as soon as we started using it, we needed to start discovering another penicillin just to avoid falling behind. So it’s different from anything else that we’ve looked at. And we’ve become so used to having these drugs, these amazing miracle, the original miracle drug, that we don’t understand, that we have to work hard just to avoid slipping behind.

Cary Adams: [00:03:08]
We have at UICC, been looking at this for the last year and a half because it was raised with us by certain cancer societies that they were seeing that one in five cancer patients were actually being affected by an infection and many of those led to them being in intensive care as a result of that infection. So what is it about cancer patients specifically that that leaves them open to antibiotic resistance?

Kevin Outterson: [00:03:36]
I published, together with some infectious disease physicians, a review that looked at this issue and the Clinical Journal of the American Cancer Society last year. And but anyone here who’s a survivor of cancer has a friend or family member who’s gone through cancer, you understand how invasive some of the treatments are, the visits to hospital, the openings into the skin that are required for treatments, the fact that some of these treatments suppress or modify your immune system in ways that might be killing the cancer but make you more vulnerable. And so you have to be more careful about the other things in life. You total all these things up and the data shows that while antimicrobial resistance superbugs are a problem for everyone, for people with cancer, the risks are really three times higher that they’ll get a fatal infection from these superbugs because of all the things that cancer treatment does to make you higher risk. Wonderful treatment but like you said before, we want to be careful that the advances in cancer aren’t undermined by the old foe of infection.

Cary Adams: [00:04:48]
UICC is working hard to sensitize the cancer community about this issue because many of the people I talked to are unaware of the challenges that AMR poses to cancer treatment in the future. And we want the cancer community to be ambassadors for the AMR story that they are there talking to governments and and hopefully get them to think differently about how antibiotics are used in their country and around the world. Now, one of the things in your report that you mentioned, you talked about the need for AMR surveillance systems for cancer patients. Perhaps you could give us a little bit more about that because we do struggle as a cancer community anyway with just basic information through cancer registries. Perhaps you could expand on why you think AMR surveillance systems for cancer patients are so important.

Kevin Outterson: [00:05:34]
We were surprised when we did the review just how little detailed data there was that tracked in a careful way using medical records, as well as just top line statistics on the experience of cancer patients with infection and particularly with drug resistant infection. And so when a cancer patient dies, even if the actual cause of death was a drug resistant infection, that’s almost never shown on the death certificate. Something else is almost always there. Maybe the cancer itself, the underlying cause of death. But the proximate cause was the infection that interrupted the course of treatment that may have been working. So we think that there’s a need for a lot more data to understand what is the actual experience of these patients with infection, What sort of drugs are they receiving? Most of those antiinfective drugs, the antibiotics and whatnot are really amazingly inexpensive. There’s been lots of complaints about the cost of cancer therapy, but the antibiotics are like the bargain in this process. But what we don’t know is how many patients with cancer are failing from specific drugs become resistant. And then what are we going to do to make sure that in five or ten years we have a replacement for those things that are failing today?

Cary Adams: [00:07:11]
And your organisation which you’re the founder of I believe CarbX stands for Combating antibiotic-resistant cacteria by a pharmaceutical accelerator, which is a mouthful in itself.

Kevin Outterson: [00:07:24]
You can see why we call ourselves CarbX.

Cary Adams: [00:07:27]
I prefer CarbX, it’s a lot easier for me. It’s a lot easier for me. But I mean, the other side of the coin of this is, okay, we want to see antibiotics used more sensibly around the world, not misused or abused in any way. But also we want to develop new ways in which we can address the issue. So what challenges are there in progressing research and development for new treatments? What are the barriers? Why aren’t we seeing more antibiotics coming onto the market? I mean, we see so much investment and so many companies investing in cancer treatment and care. A lot of new medicines planned to come out in the next five, ten years. What’s stopping us getting new antibiotics?

Kevin Outterson: [00:08:18]
The antibacterial research community often looks over longingly at the pipeline and the money going into cancer. Look how many antibiotics we’ve had in the last decade. Look how many are in the clinical pipeline. It’s So few compared to the amazing work that’s being done over in oncology. And if I had to say one word is the difference: it’s money. There’s great reimbursement. Companies can make money selling cancer drugs or having trouble making money selling antibiotics. The science, amazingly, is remarkable. All of the basic research money that’s been going into the NIH and similar agencies around the world, remarkable new things coming out in the antibacterial world. Science, I don’t think, is the right limiting step. It’s money. We aren’t paying for antibiotics as if they’re valuable to society. We’re doing that for cancer drugs and we’re getting a lot of them as a result. We haven’t done anything similar for antibiotics.

Cary Adams: [00:09:23]
It’s a real challenge, isn’t it? Particularly when you’ve got a medicine, which actually the more it’s used, the less value it is. So that’s an unusual market condition, isn’t it, for a drug or a medicine to come into use in health systems around the world.

Kevin Outterson: [00:09:40]
From the language of economics, we’d call it a negative externality. It would be like a factory that makes something but pollutes all of its neighbours. And antibiotics are a drug class that helps the patient in front of you, but may very well be delivering a less valuable drug. Or, on the flip side, more resistant bacteria to everyone else. And so that calls for being really cautious on how we use these drugs. We don’t want to give them inappropriately to any patient because it could damage their microbiome and it certainly can damage the usefulness of the drug for everybody else, including our children. So we want to be careful with them. And that really is the root of the problem: that a new antibiotic comes to market for excellent reasons, we put them behind glass and we say break glass only in case of emergency. We try to use it as little as possible for the first five or ten or 15 years. But for a company that spent 15 years bringing a product to market, they get FDA approval and then they’re told, let’s use your brand new drug almost with no one for as long as we can. That’s a great answer for public health. It’s a terrible answer for the company. It’s why the majority of them are going bankrupt and leaving the sector. That’s why we have so few new drugs. The reality has penetrated to the boardrooms of the drug companies.

Cary Adams: [00:11:11]
We’re going to have to find another way of rewarding that investment because the standard ROI process doesn’t work.

Kevin Outterson: [00:11:17]
The United Kingdom is doing exactly that. They have pioneered a new way to pay for antibiotics. They’ve selected two antibiotics there. Those contracts are live now. It’s a remarkable first of the world system really paying us a subscription. Let’s pay for the value of having these antibiotics in England without any regard to the volume of sales in the country. So paying for the protection value. There’s a proposed legislation in the US, There’s processes in other G7 countries also looking to do the same. But really the United Kingdom has been the pioneer in the rest of the of the leading countries. Their wealth, the countries of the world need to follow suit.

Cary Adams: [00:11:58]
There are other things as well. What about diagnostics? How is that going? Can you see developments and improvements in the way we can diagnose infections?

Kevin Outterson: [00:12:07]
Diagnostics is a key issue. We learned so much about the importance of diagnostics in COVID. We had both positive and negative experiences. We broke the barrier of getting rapid diagnostics into the hands of people in their homes. There are arguments five years ago that all of us couldn’t be trusted to do these sort of tests at home, that it had to be done in doctor’s office. Well, you know, a couple of billion test results later, I think people are pretty comfortable now with lateral flow SATs, rapid tests and do it all the time now. And so the question is, can we get a diagnostic into the hands of patients and into the hands of treating physicians, not just in the shiny hospitals and capital cities, but everywhere that patients need this information? Because if you could reliably tell a patient you don’t need an antibiotic, you have a viral infection, we save a lot of unnecessary use of antibiotics. And also, if you can tell a doctor this patient, the superbug they have is resistant to everything you would normally give them, and you must get drug X or drug Y, the new things or else die. All of that is amazingly important clinical information, so we’re working hard to get that done. There are economic challenges that are different from what I described with antibiotics, but that are daunting in this space. And I’ll just say the simplest of them is that if an antibiotic is really inexpensive, $5 or $4 a script that you pick up at WalMart, a diagnostic that is designed to encourage you not to take that drug if it’s going to be cost effective just at that patient silo, the diagnostic has to be almost free. You can’t have a $10 diagnostic to save a $5 prescription. So there needs to be some thinking on ways to make the diagnostic free or nearly free, which is what we do with the PCR test. We get billions of those for free from the government because otherwise you’ve put people in an impossible situation. You have to spend more money in order to to save money by not taking the antibiotic when the antibiotic is so cheap.

Cary Adams: [00:14:34]
Let’s move on to the World Antimicrobial Awareness Week 2022. The title of that is Preventing Antimicrobial Resistance Together. So let’s just pick that apart slightly. So it implies obviously, prevention. So what can be done at global and national level to improve infection prevention and to control it? What what is the best practice that you’ve seen around the world?

Kevin Outterson: [00:15:01]
I think the best infection is the one that never happens. To create a brand new drug is really an amazing scientific and technological feat that takes 15 years and lots of money. A similar amount of money spent to improve the quality of the water supply and the sanitation systems in major cities or medium sized cities and poor countries around the world could have an amazing impact. We have vaccines that are effective against some bacteria and some viruses. And getting those vaccines into the arms of people that would benefit from them – which is really almost everybody – is an amazing, cost effective strategy. So while I focus on trying to get new technologies to the market, it’s important that these prevention technologies, whether they be vaccines or clean water, clean food, sanitation, that these are also advanced. It doesn’t matter what the infectious disease threat is, if we have a good primary care system, we can deal with it in the first few months while we try to devise something more specific. And similarly, a lot of the reduction of mortality in the wealthier countries in the 20th century, the early part of the latter part of the 19th was due to things as simple as clean water, as profound and powerful as that. So it doesn’t help if a cancer patient gets 21st or 22nd century technology cancer treatment, but then goes home to a situation in which clean water, clean food and sanitation is not assured. So I believe in prevention. Everyone does. It’s a powerful thing and we need to continue to make the case for it.

Cary Adams: [00:16:49]
Which is great, and in fact, prevention a really common theme with the cancer community as well, because, you know, vaccinations, for example, for HPV, avoiding cervical cancer in the future, reductions in tobacco use, obesity control, all these things. We know 40 to 50% of cancers are caused by modifiable risk factors. So there’s a lot of alignment in the space with our own approach, which is why we need to work on 1. Prevention and 2. early detection. And things are a lot easier then. But let’s move on to this issue. I mean, I’m actually sitting here wearing my light blue jumper. I noticed that you’ve got a light blue shirt on. It’s the colour of AMR awareness represents a multisectoral approach, collaboration against a shared health threat. Why do you think it’s important that, for example, the cancer community and others get together with the AMR community to actually raise this issue and to take it forward?

Kevin Outterson: [00:17:46]
Communities like cancer can help. I live in Boston. There’s a march for a lot of diseases here and causes and they raise great money and you name it. There’s a group for it, many of them cancer, but not just cancer groups. Very effective patient mobilisation. There’s not that many patients who identify as “I’m a survivor from a drug resistant infection”. You know, there are some groups. There’s the Sepsis Alliance, there’s survivors of a Clostridium associated, a bacterial disease that results from use of antibiotics, that destroys the gut microbiome and then creates a terrible form of diarrhea. The cystic fibrosis community in the US this year has made it their top priority to to educate US government on the fact that people suffering from CF are now doing better because the new drugs are much better. But they’re still on their last antibiotic. So to the extent that other patient groups rely on antibiotics, this is a good moment for those groups to also stand up and say, yes, we need to keep this thing going because we don’t want to wake up one day and find out that all the antibiotics don’t work.

Cary Adams: [00:19:06]
I mean, the cancer community is starting to get involved. UICC is lead in that, working with many, many organisations around the world. We have a new publication that we’re sharing to educate the cancer community, But I agree with you. Why should it stop at the cancer community? I mean, any individual who has an illness has to be treated in hospital is probably exactly the same level of risk of getting an infection and then possibly dying of it. So moving away from communities, what about individuals? What can we do individually? Kevin, what should I be doing in the way that I operate? I mean, if I’m offered an antibiotic by my doctor, should I be asking the question “why you are giving this to me?” Should I be challenging that? I mean, what is it that I should be doing?

Kevin Outterson: [00:19:48]
Well, I’d always encourage you to have a reasonable conversation with your doctor about what they’re saying. But if you talk to doctors, they frequently say that they’ll give an antibiotic because the patient is asking for it or that the physician is feeling pressure to do something. There’s a lot of research work that identifies this and articulates how this happens. And in the US, a lot of physicians are rated by the health insurance plan. The patients give them a rating like a Yelp rating or an Airbnb rating. And if a doctor tries to be really strict in not giving antibiotics, all it takes is a couple of patients giving them a 1 for there to be trouble with their reimbursement from health insurance. So we can be informed patients that ask reasonable questions and don’t demand an antibiotic when you have a viral infection. We also have a lot of power as consumers. For years, the Food and Drug Administration tried to regulate the use of antibiotics in the animal agricultural sector in the US, and there was a lot of politics and it didn’t go anywhere fast for decades. The biggest change in the past few years in terms of agricultural use of antibiotics, the United States has been major corporations like McDonald’s and Chick-Fillet and other chain food restaurants and big retailers beginning to announce and then implement transitioning to antibiotic free types of meat and not just having it as an alternative, but making it the default choice, especially for chicken. So our power as consumers is immense. And this change happened at these major corporations because they were listening to their customers and their customers are saying, we would prefer this and and boom – amazing change, something that was politically impossible for decades. And companies are voluntarily doing it to follow their customers. There’s ways to get involved politically to make sure that adequate resources are given to this fight in every country. Drug resistant bacterial infections are killing more people around the world than either HIV or malaria. You’re pretty close to the total of HIV and malaria combined. Just think of the global mobilisation that’s been done against those diseases. That’s part of the reason why drug resistant bacteria kills more, because we’ve been successful in moving those numbers down. But tremendous global effort, lots of political salience stories in the press and everything else. People understand this, these problems that we need to respond to them. We don’t have nearly that level of political, social, emotional mobilisation yet against drug resistant bacteria.

Cary Adams: [00:22:43]
Well, hopefully the cancer community, both for individual level and at community level, can make a difference. Kevin, it’s been great talking to you and thank you very much for giving such great answers to the questions and bringing to light the key challenges we have in this area. UICC will continue to push this around the world to our community. I’m glad that we’re working in partnership. I think this is something that we can really shine a light on and hopefully we can get national governments and global leaders engaged in something that you say is a big threat longer term. So thank you very much for your time, Kevin. Really appreciate it.

Kevin Outterson: [00:23:17]
I appreciate the work the UICC is doing to make sure the safety net of antibiotics is there not just for the cancer patients, but for everybody.

Cary Adams: [00:23:28]
I hope you enjoyed this new episode and if you did, please leave us a review on Apple Podcasts and Spotify. We need to spread the word about antimicrobial resistance and this looming threat to global health, so please do share this episode with others. UICC has a dedicated page to antimicrobial resistance on our website, uicc.org. There you can learn more about AMR and also find a social media toolkit with texts and images for you to download and share with your network.

Host:
Candace DeMatteis, Vice President, Policy & Advocacy, Partnership to Fight Infectious Disease

Guest:
Erin Duffy, PhD, Chief of Research and Development, CARB-X

00:04  Candace DeMatteis
Welcome, everyone. I’m Candace DeMatteis, vice president of policy and advocacy for the Partnership to Fight Infectious Disease. And I’m happy to welcome you to our podcast, Infectious Conversations. Through Infectious Conversations, we’re having discussions with health care professionals, policy and other experts to get a grip on how to squash superbugs. Our goal is to better understand the threat of antibiotic and other antimicrobial resistance, or AMR, the threats that they pose and the need to address them now. We also want to better understand how we can build on lessons that we’ve learned throughout the COVID 19 pandemic and other health care experiences to change the course toward improving health outcomes for everyone. Today, our segment features a discussion with Dr. Erin Duffy, the chief of research and development at CARB-X. Erin is an expert in drug discovery and problem solving in the antibiotic arena. Most of her professional growth was with Melinta Therapeutics. Founded as Rib-X Pharmaceuticals, where over 17 years she became executive vice president, chief scientific officer, and R&D site head. Her entry into the pharmaceutical sector began with Pfizer Central Research. Erin’s formal training was at Yale University, where she completed a Ph.D. in physical, organic chemistry and an HHMI postdoctoral fellowship in computational structural biology. Ooh, nightmares from organic chemistry are coming back. So I’m so good, so excited that we have smart people like you who can not only manage the entry level, but go on to a PhD. We’re so thrilled at PFID to have CARB-X as an active supporter and task force partner. CARB-X is a global nonprofit partnership that supports companies developing antibiotics, vaccines, diagnostics and nontraditional products to address resistant bacterial infections and sepsis. Today, we’re so thrilled to talk to Erin about the CARB-X research portfolio and why it is critical to invest in diverse products and diagnostics that really take a comprehensive approach to help prevent, diagnose and treat sepsis. Erin, thank you so much for joining us today.

02:29  Erin Duffy
Thank you for inviting me. Happy to be here.

02:32  Candace DeMatteis
Well, as I mentioned, we’re thrilled to have you and your expertise will be so invaluable. So let’s talk a little bit more about CARB-X and can you tell us a little bit more about what you do at CARB-X specifically?

02:45  Erin Duffy
Sure. So as you said, we are basically the implementing partner of three international governments and two foundations to not only give financial support, but probably even more importantly, scientific and business support to the groups who are advancing these new potential treatments, prevention and diagnostics for bacterial infections. Now, my role as the head of R&D at CARB-X, we don’t do any research internally, sometimes much to our chagrin. But I have a team of experienced colleagues in all three pillars, and our goal is to shepherd these programs. We build support teams around them that bring expertise that they may lack. I should have said most of our companies are actually really small companies that we support, often maybe 5 to 10 FTEs at most. And typically they are experts at the foundational technologies which are really interesting and varied, but not always, or they are experts at how to take those ideas and translate them into something that will be products. And so what we do is we identify those gaps. We bring in subject matter experts who then sit with these teams on a monthly and a quarterly basis and really help them think through problems and advance through the development stages.

04:14  Candace DeMatteis
So if a company, do they come to you and say, hey, we need help with finding funding or we’re encountering this hurdle in the research process? I’m just curious, did they come to you, too, with the problem identified or is it kind of a two-way street where you also will look and say, how are you dealing with this? And maybe they were like, oh, we didn’t know. If you do that, what would you suggest? How does that work?

04:41  Erin Duffy
Yeah, so I should have said our funding is all through open funding calls, so it’s not a rolling basis. But we’ve let’s see over the course of time here, CARB-X was begun in 2016 and actually commenced the first funding call in September of that year. And so through the years now, we have had eight distinct and unique funding calls through which 92 companies out of over 1000 expressions of interest, but 92 companies or institutes in some cases have come into the portfolio funded by us. And so for those programs and portfolio, we do assemble these companies, support teams right off the bat. And that’s a conversation. It’s, you know, look, we think that these are gaps in your program. What do you think? You know, what do you need? And we try to come to some middle ground so that we’re not overbearing. It is their projects, but we’re giving the support where needed. So that’s sort of one aspect. The other aspect that is both for portfolio but then also for the greater ecosystem. You know, researchers who may not be in portfolio is that my team has begun identifying what we call common challenges that not one company or product developers are facing, but many. And so then we will design a unit of work and work with external researchers to get it done so that then we can hopefully in the ideal sense, you know, unblock a path for many companies that they’ve been struggling with and will publish these results, etc.. So that’s another way that we help is by again identifying problems more on a portfolio level and then trying to do something rapidly that many of them can benefit from.

06:36  Candace DeMatteis
So talk a little bit, if you don’t mind, about why is something like CARB-X needed? Obviously you bring a lot of value, but I’m curious about what was the gap that led to CARB-X being founded? And you talked about different government and private foundation funding as well. So I’m really curious about what was that gap?

06:55  Erin Duffy
Yeah. So, you know, when you introduced me, you know, I spent the most of my career in a little company, you know, begun, as Rib-X Pharmaceuticals and then becoming Melinta Therapeutics. And we were a pure play antibiotic discovery company from day one with a pretty neat technology that had come out of Yale. And the company was begun in 2001. And that was the year that, you know, a new antibiotic called Zyvox trade name Zyvox (linezolid) was launched. And it was the first new antibiotic in many, many years. And there was a lot of excitement around it. And it had both I.V. and oral forms and things looked really great. And in fact, its sales were, you know, in the billion-dollar range or so after a few years of launch. So it looked like a great time to get into antibiotics. We had this neat technology that was going to unlock new ways of bringing antibiotics, etc., but a lot of the big companies started getting out of antibiotics, and it was a mathematics issue really in terms of how much money you’re putting in to research, not that it’s a different in antibiotics to any other therapeutic area. There’s still, you know, the time to do the discovery and then the clinical trials and the launch. So that part isn’t different. It’s what happens on the back end. And if you think about it for a minute, if you take an antibiotic, you’re typically taking it for 5 to 14 days at the most. Not everybody has an infection at the same time. So you don’t have chronic disease and not everybody’s taking it. And so, you know, it’s really a volume problem in terms of the amount of money that you can make. So companies, big companies did the analysis and said, you know, this isn’t an area where we should be trying to create value for our shareholders. So then it was left to all the little companies to do this work. And, you know, there were some other environmental issues that happened. There was a failure of a drug in the mid 2000 and antibiotic that really depressed the regulatory environment. It made it challenging for about four years to really progress new antibiotics through clinical trials and onto the market and so that was tough for your little company. It’s tough to raise money anyway. Now you’ve got a time delay to really advancing your product. And so as many of these companies finally did achieve that goal, including ours, we received FDA approval in 2017 for our first antibiotic, and it launched in January of 18. Exactly three quarters later, we made the decision to shut the antibiotic research and development and I think not many months after that, the company filed for bankruptcy. And we weren’t the only company.

09:51  Candace DeMatteis
But still ultimate financially not successful.

09:56  Erin Duffy
Exactly. And we weren’t the only ones. You know, there was another high-profile bankruptcy, a company called Achaogen and similar story after their first launch. And then a few other companies didn’t go bankrupt, but they were sold or broken up for assets for, frankly, not very much money. So anyway, so you’ve got this problem, but the US government really was a leader here through the ASPR and BARDA. We now know BARDA because of COVID and all that they’ve done there, you know. But BARDA really has two remits, one is to protect Americans and really provide for their health. And the other, of course, is, you know, protecting against bio threats. And many of your big bio threats are bacterial pathogens. And so they had an interest in supporting companies who had a commercial indication. So, you know, urinary tract infections, lung infections, whatever, if they could show activity against potential biowarfare pathogens. So then once that drug was launched, they could bring it into the national stockpile. And so what they were seeing was this decline in innovation, largely because a lot of companies were out and small companies were struggling. And so they said, well, we really need to do something about this. It’s a matter of national security that we have a good stockpile. And so they created this request for proposals and we applied for it and Boston University applied for it. And then, you know, through the PI of CARB-X, Kevin Outterson partnering with BARDA, they encouraged the Wellcome Trust to come in. So those were the first two funders and then subsequently the Bill Melinda Gates Foundation, the UK government and the German government all joined for the same reason, you know, recognizing that, you know, it’s really a matter of national security, if you think about it.

12:03  Candace DeMatteis
Well, we certainly learned what infectious pathogens can do, and it certainly doesn’t discriminate with COVID 19. Absolutely. I want to turn and talk a little bit about one serious problem that we have, and that’s sepsis. As you know, September is Sepsis Awareness Month. And there’s a big gap in what exactly is sepsis. And that said, the awareness month is so important, what causes it, how it can be avoided, and the fallout if it’s not. I mean, it can be quite fatal, as you know. So I understand that at CARB-X, sepsis is an important focus of your research. So can you talk a little bit about why that’s such an important focus in what CARB-X is doing around sepsis?

12:55  Erin Duffy
Sure. So, you know, from just a unmet medical need perspective and I’m sure you saw in the it was late January of this year in The Lancet, there was a really a landmark paper that’s sort of commonly known as the Gram paper, which revealed results from a 2019 study of infections worldwide and what the mortality and morbidity was, and the association with antimicrobial resistance, which is, you know, the challenge here. I mean, you know, bacteria have evolved for the history of time. And as they do, they often render products that had been effective, ineffective, which is why we always need new antibiotic products. People know that now, I think because we talk about COVID variants, it’s kind of the same thing anyway. So in that GRAM paper, one of the things among the many things they highlighted were the syndromes or the indications, things that people present with, disease states, that have the highest mortality. That’s either directly attributable to antimicrobial resistance or associated therewith. And the first category with the highest mortality was lower respiratory tract infections. So hospital associated, bacterial pneumonia, ventilator associated bacterial pneumonia, that sort of thing. But the second was bloodstream infections, which is really what we’re talking about here with sepsis. So you have bloodstream infections. This is when a bacteria gets into the bloodstream, whether it comes from a leaky gut and bacteria then gets into the bloodstream or whether there’s a primary infection site like lung. And again, it gets into the blood. And then once that happens, things progress pretty rapidly to a syndrome that ends up being much more, you know, host directed, meaning the body has cytokine storm strikes trying to fight this infection and things go downhill pretty quickly.

15:11  Candace DeMatteis
Can you talk a little bit, that study that you’re talking about was so important and what a, you know, really, again, highlighted the impact that antimicrobial resistance is having now. And you talked about bloodstream infections or sepsis. But as I understand it in a CARB-X portfolio is not just on the treatment side, but also on the diagnostic side. And that sepsis can be a challenge to diagnose because there are multiple symptoms presenting different people differently. So how is that, what are some innovations around sepsis on the diagnostic side, maybe that CARB-X is following or helping to progress through the pipeline?

15:54  Erin Duffy
Sure. So I should have said and you know, we aim in all of the syndromes where possible to have treatments, preventatives, of course, you know, the best infection is one you never have. So prevention, of course, is very important. And then diagnosis. And again, I think, you know, if we would have had this conversation and even late 2019, you know, most people might have not been able to resonate with this. But with COVID, far before we had the vaccines, you know, we had things that were being explored for treatments. And of course, how important was diagnosis to have it, to not have it? Can I go out and can I not go out, so, you know, all very important anyway so in the area of sepsis or bloodstream infections, you know, we do have programs in all three pillars and I’ll mention all of them. But starting with diagnostics, you know, they’re really, you know, how you how you diagnose an infection in the blood as obviously take a blood sample and then you have to not only look for is it bacterial, okay. So that’s one thing. Is the infection bacterial versus viral, for instance, and then what is the bacterial species? And we call that bacterial identification. So is a staph aureus or MRSA, is that, you know, E. coli or, you know, any of the other big pathogens? So you want to know that. And then the third part is you want to understand what treatments it will be susceptible to. And so that’s called the antibiotic susceptibility testing. And so all of this is important, but a key thing is the time to result, right? Because as I said, you know, sepsis progresses really quickly. And so you need to be able to understand this and then provide a suggestion for treatment in a timeframe that’s meaningful. And so the innovations are sort of three fold, I would say that we’re supporting. The first is, you know, there are two ways to do the analysis of blood. One is what they call host culture. So, you know, you get the blood and you figure out what the bacteria are and then off you go, the others direct from whole blood. And so you can imagine direct from whole blood. It’s like direct mail or whatever that’s faster, that’s challenging. And there’s a lot of technical hurdles with how to process the samples well and then how to be able to have good sensitivity and specificity. Many of our programs in bloodstream infections do in fact emphasize direct from whole blood. And two of the products that were early in our portfolio, one from T-2 biosystems and one from specific diagnostics are both direct from whole blood, and they’re actually marketed in Europe and they’re preparing for their FDA approval. So there’s that. The second thing that those products do is that in addition to the bacterial identification, they also highlight if prominent resistance genes. So you think about this like the variance for a minute, whether it BA4 or BA5 or whatever we’re up to now numbers. And similarly with resistant genes, it can be things like carbapenems. There’s extended beta lactam cases, fluoroquinolone resistant markers. And so they look for those. That’s not the same as automated susceptibility testing. It’ll say there are these resistance genes, so maybe don’t use products from that class, but what it doesn’t say of all of the antibiotics and types of antibiotics that are available, you know, in theory, who can cover the bacteria associated with sepsis? Which ones is this bacteria actually susceptible to? So that’s the other innovation that we’re supporting. And then the third one is all about that turnaround time, how to get it. You know, in the ideal case, definitely less than 8 hours and even less than that. Recognizing that, you’re never going to impact the first antibiotic they give because they’re just going to give you something broad spectrum just to try to get under control. But then how do we manage treatment in a, you know, in the most responsible way? And the sooner you can know this result, the more you can impact that decision.

20:30  Candace DeMatteis
That makes a lot of sense. But it sounds like a lot of complexity and things working together to get that window narrowed and get the right treatment for the patient at the end within that golden time frame, if you will.

20:46  Erin Duffy
Yeah, absolutely. You know, and I have to say, I’m not a diagnostics expert by any means. And if my diagnostics colleagues are listening, they’re cringing at everything I’m saying here. But, you know, the interesting thing about diagnostics, you know, all these areas have their complexities. But with diagnostics, you have the chemistry, right, which is how do I determine what bacteria are there and how am I doing that? But then the other is what is either the box or the cartridge or whatever it is that you put that assay on to do the work? And, you know, these require fundamentally different types of people. You know, you have your biology and chemistry types over here and you have the engineers over here. But both of these pieces have to come together in order to make a product that’s usable at appropriate levels of the health care system. Now, think about it for COVID the very beginning of COVID. Actually, some of our product developers got involved in this and had assays that they could switch to, you know, maybe detecting COVID. This stuff was done on a benchtop, right, with beakers and plungers and whatever, whatever they could do to get it done in hospitals. But then that’s very different from, you know, boxes that can be at your local hospital or your doctor’s office, which is very different from those things we got in the mail. You know, the orange boxes with the little thing on a cartridge. I mean, amazing that you could do that.

22:14  Candace DeMatteis
It really is. And phenomenal in the short time frame. And we’ve seen it develop too. I think sometimes we forget that. But it was truly remarkable. It saved a lot of lives as a result. I’m curious, are you seeing any new trends that you’re in the research and development space of new treatments for infection, anything that’s really kind of more cutting edge or we’ve heard other speakers have talked about phage therapy, for example. That really is kind of a throwback. I learned with our last podcast. But I’m curious, are there other trends that you’re seeing?

22:55  Erin Duffy
Yeah, so I would say three main areas. And again, just staying with the theme of sepsis, recognizing that we fund research for many other syndromes to stay there, you know, meaning in diagnostics for a minute. The next level of I think really cool stuff is to use, you know, everybody’s talking about AI, you know, back when I was a computational scientist, we just used kind of computational science, but now it sounds cooler anyway. That’s really using big data to make predictions about whatever and one of it’s actually two of our diagnostics companies both focused on direct from blood predictions of bloodstream infections are looking at predicting what, again, not only the species, but the resistance is again based on big data and that’s the big data or the genome sequences that they will collate over time and make these predictions. So it’s really cool. I have to say, you know, they’re both early, but they’re certainly their bacterial ID is outstanding. And then, you know, they’re really making great backgrounds and prediction of resistance markers. So that’s a neat space I think, to watch. I think it will fundamentally change, you know, how diagnostics are used and then how treatment is affected in hospitals and centers. So I think that’s a big thing. And the other areas treatment’s been tough. You know, for once you’ve got sepsis just because again, you know, it becomes often more about the host and the inflammatory response than it does the infection at some point. But there’s a really neat company in California called Cellics, and I was literally just talking to them this morning, so they’re fresh on my mind anyway. They have this really cool nano sponge. Okay, so it is therapeutic, but it’s not like a small molecule inhibitor of something and it actually has three different ways it works. But the sum total of it is it basically it’s called a sponge because it attracts bacterial toxins, you know, and then also both pathogen and host inflammatory factors. And so it’s basically sits there and tries to sort of sop up all the bad stuff and do that quickly and effectively. So again, they’re early, but that is really neat. And if that works, I think it would be a terrific addition to the armamentarium. Then you go to prevention. And so there’s a more, I would say, traditional prevention, which is still terrific. You know, the Glaxo Ventures for Global Health has an invasive non type, nontyphoidal salmonellosis (iNTS). It’s a lot of words, vaccine that among the things that invasive non typhoidal salmonellosis (iNTS) causes is sepsis. And this is particularly a challenge in sub-Saharan Africa. And this group is poised to commence clinical trials with this investigational vaccine. So we’re pretty excited about that. And then to your point, we have other products that are focused on decolonization of the gut, of bad bacteria that, you know, in patients, for instance, that have certain hematological cancers or awaiting transplantation or other diseases where they might have a leaky gut, you know, are very much at risk for, you know, bloodstream infections and sepsis. And so there are two approaches. They’re both in our portfolio. One does use bacteriophage, and these are CRISPR-engineered. So CRISPR portion, the subject of the Nobel Prize in chemistry a couple of years ago. And so what these bacteria phage do is they go in and they basically like haul out the bad guys, just cut them out of the gut. So if you think about it in the analogy of a neighborhood, it’s like you get rid of the bad actors in the neighborhood. You have the question, who moves in? But, you know, it’s an interesting idea to remove the bad bacteria. And hopefully what you establish is a healthier gut and then you forestall breakthrough bacteremias. On the other side of the coin are live biotherapeutic products. And there are companies like Vedanta, Boston based company Seres, also a Boston based company, which put both of them who, rather than looking to cut out the bad bacteria, are trying to sort of, you know, knock them out by putting consortia of good bacteria in. So they’re basically replacing bad stuff with good stuff. And again, hoping to restore gut health so that you don’t have these breakthroughs. So a lot of neat innovation and innovation that’s maturing. Seres isn’t a person human study with their product, and we hope Vedanta will be here. You know, in the short term, too. There’s a company, a Danish company in our portfolio using this CRISPR engineered bacteriophage approach for removing E. coli. And this is important for patients with certain cancers. And they’re also in a first in human study looking at safety principally. So a lot of stuff moving closer to patients. Oh, really neat.

28:37  Candace DeMatteis
And also encouraging and exciting. And their approaches are so, so different. That’s very encouraging. One thing I wanted to talk about, too, is like a policy. We understand that Congress has is considering legislation that addressed some of those issues that you were talking about. You’re successful on the R&D side, but then the market just isn’t there to help these companies maintain stability and be financially viable. And we understand that the PASTEUR Act, which is under consideration in Congress, includes incentives for developing some of those new treatments and diagnostics that you were talking about to fight resistant infections. Do you have an opinion based on your experiences of the importance of policies like that?

29:25  Erin Duffy
Oh, yeah, I think they’re huge. You know, we so people talk about, you know, the different strategies to make this a viable therapeutic area and market again in two terms. So there’s the push incentives and that’s funding. So that’s grant funding like what we do. And then advanced development partners like BARDA, I mentioned like the AMR Action Fund that was created by some foundations and most of the Big Pharma, it’s more of a venture fund, but we’ll fund downstream from us and others, GARDP, etc. So these are people giving money to advance these products, to approval and to patients. But then there’s what they call the pull incentives and honestly, it’s like a seesaw. If you don’t have both, you know, it’s actually, you know, so we can pile all the money we want into these innovative products. But if there’s no market at the end, you know, it’s just going to be a disaster. So, you know, we need them. And certainly they’re two different pieces of legislation. The PASTEUR is one that we’re very excited about. It follows, I would say really leadership at the in the UK who built a small version of this and launched it. I think it was last year. And you know, this is kind of like a Netflix model, I guess. So the idea is that if you come with a new product, a therapeutic or preventative or, you know, diagnostic that that meets, you know, really does meet a high unmet need that then the product will basically be bought. So the company then doesn’t build the sales force and do all of that. They’ll be given a certain amount of money upon approval. Well, it won’t all come at once. You will be tiered over time, but it’ll be enough of an incentive that the company can sort of recoup what they invested and hopefully also be encouraged to continue to do this. We think we need these innovations. It also will continue to encourage product developers to focus on the areas where the highest need is. So we think that’s great. You know there is another piece of legislation that was called DISARM and I forget what it’s evolved to now but this is a little different where it’s looking specifically at hospital based products and taking them out of the DRG. The DRG is basically I forget what the letter stand for but basically it’s the whole treatment plan. If you come to the hospital and you present with X, it’s the bed, the nurse, the I.V. bags, the antibiotic, if you need it, and whatever, whatever else. And that all comes with a price tag. So obviously, if your antibiotic is part of that, there’s only so much you can charge for it. Right. And so what this legislation would do would be to take the antibiotic out of the DRG and allow it to be priced for what its value is.

32:40  Candace DeMatteis
I did want to ask, and we typically do this in the podcast as we would close it out, is want to give you a chance. If there are one or two things that people listening to the podcast would walk away with that you hope sticks with them and encourages them to take action either for themselves or, you know, for all of us more broadly on these issues, what would you suggest that they walk away with?

33:07  Erin Duffy
I think number one is we really need this to get done and we just can’t wait and wait and wait. So your voice is very helpful there. But then the other thing to think about, you know, I just don’t think we think about I think I think of antibiotics like running water in a house in a first world country. Right. So when you buy a house or you rent an apartment, do you ever ask, is there running water? Is it something I even think about? The answer is no. And so when you go for, you know, to have a child or, you know, everybody of a certain age and I’m certainly there at this point now is going to be thinking about a knee replacement or a hip replacement or a shoulder replacement or maybe you’re on dialysis or, you know, any of these any time you go into the hospital, you’re having cardiac arterial bypass surgery. None of this. None of this. So all of these medical innovations and oh, by the way, for all those fancy immuno-oncology drugs that we hope are going to be great for cancer patients, somedays none of these is effective if you don’t have a stable store of effective antibiotics and other products. Think about that the next time when you’re going to have your teeth cleaned and they ask you to take an antibiotic the day before, think about why they do that. You know, this is all about, you know, livelihoods that we’ve come to take for granted without these products.

34:38  Candace DeMatteis
You know, great parting thoughts. And Dr. Erin Duffy, thank you so much for all the work you’re doing and for joining us today on Infectious Conversations.

34:48  Erin Duffy
Thank you. It’s been really a pleasure.