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Hello, and welcome to CDC's AMR Exchange webinar. 

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We're very excited that you have joined us today to learn more about CDC's Antimicrobial Resistance Solutions Initiative 

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and the work CDC has done over the past 10 years to protect Americans from antimicrobial resistance.

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My name is Stefanie McBride, and I'll be your moderator for today's webinar.

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At CDC, I serve as the Associate Director for Policy and Partnerships in CDC's Antimicrobial Resistance Coordination and Strategy Unit.

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Today, we are joined by four of my CDC colleagues who will share information about the impact of Antimicrobial Resistance Solutions Initiative in preventing, 

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detecting and responding to outbreaks of antimicrobial-resistant, 

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also called drug-resistant, bacterial and fungal infections in both healthcare and in communities.

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First, I will speak with Dr. Gwen Biggerstaff, 

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who is the Deputy Director and current Acting Director of CDC's Division of Foodborne, Waterborne, and Environmental Diseases, about CDC's efforts to combat drug-resistant enteric and fungal infections.

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Then, I will talk with Dr. Mike Bell, Director of CDC's Division of Healthcare Quality Promotion, about CDC's work to protect patients and healthcare workers across different healthcare settings from antimicrobial resistance.

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Next, we'll hear from Commander Paige Armstrong, Director of CDC's Global Health Center, about how CDC's investments in combating antimicrobial resistance globally protect Americans at home and abroad.

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And finally, I'll speak with Dr. Cliff McDonald, who is the Senior Advisor for Microbiome Health in the Division of Healthcare Quality Promotion,

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about the impacts of CDC-supported applied research programs to address our most pressing antimicrobial resistance challenges.

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Thank you so much to our panelists for joining us today, and we can't wait to hear from each of you.

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Before we begin our panelist conversations, I'd like to provide a very brief overview of CDC's Antimicrobial Resistance Solutions Initiative

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and highlight important work happening across the agency that we may not get to today in our discussion.

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Antimicrobial resistance, or drug resistance, is an urgent public health threat in the United States

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causing millions of infections and thousands of deaths every year.

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Thirteen years ago, CDC published the first Antimicrobial Resistance Threats Report,

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starting a chain reaction of events

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that revolutionized our ability to combat antimicrobial resistance. This included publication of the U.S. National Strategy to Combat Antibiotic-Resistant Bacteria in 2014,

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release of the U.S. National Action Plan to Combat Antibiotic-Resistant Bacteria in 2015,

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and the first Congressional appropriation of funding to CDC

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to support implementation and support of the National Action Plan for fiscal year 2016.

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This funding established CDC's Antimicrobial Resistance Solutions Initiative,

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which you will hear about during today's webinar.

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Over the past 10 years, the AR Solutions Initiative funding to health departments and partners has built a national infrastructure for detection and response,

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enhanced healthcare quality and safety,

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improved the appropriate use of antibiotics and antifungals,

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strengthened awareness of actions everyone can take to protect themselves from getting infections,

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and developed innovative solutions to antimicrobial resistance challenges.

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Combating antimicrobial resistance is complicated, and given this complexity, CDC's Antimicrobial Resistance Solutions Initiative is a whole-of-agency effort.

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Experts across at least eight CDC divisions and offices work every day to protect Americans from the threat of antimicrobial resistance.

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These divisions and offices implement programs and strengthen partnerships to combat antimicrobial resistance caused by nearly two dozen drug-resistant pathogens,

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including those that cause healthcare-associated infections, enteric bacteria, fungal diseases, drug-resistant sexually transmitted infections (or STIs),

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drug-resistant bacterial and respiratory pathogens, and drug-resistant tuberculosis.

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These pathogens can spread in many different ways, including through transmission in health care, transmission in our communities,

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through food and water, through animals, and through the environment.

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Our panelists will share examples of AR Solutions Initiative impacts across healthcare-associated infections,

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enteric pathogens, fungal pathogens, and our impacts

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combating antimicrobial resistance around the world.

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Before we turn to our panelists, I'd like to highlight a few other agency efforts combating antimicrobial resistance.

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First, let's talk a little bit about invasive bacterial and respiratory infections.

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CDC's Division

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of Bacterial Diseases in the National Center for Immunization and Respiratory Diseases leads effort to protect Americans from these threats.

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CDC has improved the data available for action against these resistant pathogens.

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The agency has moved from a partial view of what we know about drug-resistant streptococcal infections in the United States

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to a more complete view of that threat to Americans. CDC's long-standing population-based surveillance maintains information on invasive disease.

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But this new effort

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has expanded our knowledge of the burden of these drug-resistant infections to non-invasive disease as well.

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Globally, CDC works with the ministry of health and non-governmental partners to strengthen laboratory diagnostic and

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surveillance capacity for Bordetella pertussis, which causes whooping cough,

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and this led to the detection of the first drug-resistant cases of Bordetella pertussis in Brazil, Mexico, and Peru.

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CDC's 2019 Antimicrobial Resistance Threats Report lists drug-resistant Neisseria gonorrhoeae as an urgent antimicrobial resistance threat.

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To protect Americans from this sexually transmitted infection, CDC's Division of STD Prevention supports health departments to address antimicrobial-resistant STIs

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by improving surveillance for emerging resistance trends, informing response efforts, and supporting public health actions that help sustain the effectiveness of the last available treatment for drug-resistant gonorrhea.

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CDC has also invested in drug-resistant gonorrhea surveillance and laboratory testing through the Antimicrobial Resistance Laboratory Network, improving our ability to detect changes in susceptibility patterns across different populations, and detect resistant infections sooner for improved public health response.

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Additionally, CDC has expanded drug-resistant gonorrhea surveillance beyond traditional STI clinics into emergency departments where more people are seeking STI care.

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CDC is at the forefront of innovation to end tuberculosis, or TB, in the U.S. and around the world as a public health threat.

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In the United States, CDC supports the National TB Molecular Surveillance Center and several large public health laboratories to perform whole genome sequencing to monitor TB trends, including outbreaks, at a national level.

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Collectively, these laboratories complete at least 9,000

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genetic sequences on isolates per year.

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This work supports implementation of new treatment regimens by evaluating any pre-existing resistance to available TB and new TB drugs.

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When a person has tuberculosis, it's critical that they fully complete their prescribed treatment.

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Previously, the standard of care in the United States was for in-person, directly observed therapy.

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With AR Solutions Initiative funding, CDC's Division of TB Elimination supported a trial and found that electronic or video directly observed therapy was as effective as in-person directly observed therapy for TB treatment.

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This helps health departments maintain the highest standard of care while using their resources efficiently.

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To address drug-resistant TB globally, CDC works with partners, including other U.S. government agencies and ministries of health, to improve tuberculosis diagnosis, treatment, and prevention.

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The AR Solutions Initiative funding supplements other CDC appropriations to support CDC’s Division of Global HIV & TB to combat drug-resistant tuberculosis in several countries, including Vietnam, India, Zambia, Lesotho, Malawi, Eswatini, and Uganda.

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AR Solutions Initiative funding supported the Preventing Tuberculosis Overseas Pilot Sites, or PTOPS, project in Vietnam and Tanzania,

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implementing short-course preventative treatment for latent TB infection, and informing policies for latent TB infection testing prior to arrival in the United States.

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An antimicrobial-resistant threat

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somewhere is an antimicrobial-resistant threat everywhere.

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CDC's Division of Global Migration Health works tirelessly, in collaboration with other CDC centers and offices and external partners, to prevent the spread of infectious disease threats from entering the United States.

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In Mexico, CDC partnered with the Mexico Ministry of Health to establish a national surveillance network for antimicrobial resistance in primary healthcare facilities;

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laboratories in all 32 Mexican states are now trained in antimicrobial resistance laboratory testing protocols; and more than 200,000 health professionals in Mexico have completed new online training for primary healthcare providers.

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A study conducted in collaboration with the Global TravEpiNet, or GTEN, partner, a network of travel clinics across the United States, showed that travelers can serve as sentinels for emerging antimicrobial resistance threat[s], and reinforced the need for targeted pre-travel messaging around diarrhea prevention

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and prudent antibiotic use,

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as well as collection of travel history in ill-returning patients in order to guide appropriate treatment.

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If you'd like to learn more about the work of CDC's Antimicrobial Resistance Solutions Initiative after today's webinar, please check out our Antimicrobial Resistance Investment Map, which can be found at ARinvestments.cdc.gov.

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We are so proud of what the Antimicrobial Resistance Solutions Initiative has accomplished over its first 10 years.

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Before we move on, I just want to emphasize that we do this work every day to protect people.

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We celebrate with those who have survived drug-resistant infections, but we grieve with the families and loved ones who have lost people to drug-resistant infections and infections that have led to sepsis.

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We also, today, want to take an opportunity to recognize our CDC colleagues, as well as colleagues across the U.S. government and in other countries who are responding to several public health emergencies

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and thank them for their effort, and please know that we are here to support you in whatever you need.

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While today is about looking back, we are also excited to look ahead. This includes publication of the next Antimicrobial Resistance Threats Report, as well as expanding our portfolio of innovation work, including to explore the connection between the human microbiome and antimicrobial resistance.

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Speaking of looking ahead and looking back, we are so excited to have all of our panelists join us for this discussion today, and now, I think I have talked enough, so let's get started. Thank you so much, everyone, and Gwen, especially we'll start with you today. Thank you so much for being here.

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So, as a reminder, Gwen is,

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the Acting Director of our Division of Foodborne, Waterborne, and Environmental Diseases. And so, Gwen, to start out,

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can you provide a short overview of CDC's work over the past decade on drug-resistant enteric and fungal pathogens? 

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Yeah, and thanks for having me. I'm excited to be here to talk through some of our work, like you said, looking back and looking forward. Over the past decade, our work has really been about building and integrating systems. It strengthens our ability to detect and track and respond to drug-resistant enteric and fungal pathogens.

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We've made major investments, to improve our ability to detect resistance early and understand transmission.

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And a lot of that, you'll hear this a couple times as I give some examples, is around key advances like the use of whole genome sequencing.

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By integrating epi and lab data and leveraging our health partnerships, advanced methodologies and system integration really supports rapid, effective, and informed public health actions.

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And I'll start by highlighting just a few programs. I'll go through them relatively quickly, and there's more information about all of them online. But we have a few, kind of critical groundbreaking programs, for enteric pathogens, so pathogens that are spread through food, water, the environment, and animals.

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And I know you asked about the last decade, but I'd be remiss if I didn't note that all three of these programs, PulseNet, NARMS, and FoodNet, are turning 30 this year, which is very exciting.

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So, PulseNet is our program that connects data from public health laboratories across the country, allowing us to rapidly detect outbreaks by comparing DNA fingerprints of the pathogens in PulseNet.

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And it's evolved to stay at the cutting edge. In the last decade, that includes transitioning to whole genome sequencing, or WGS, which has really improved the speed and the precision of our outbreak detection.

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NARMS is the National Antimicrobial Resistance Monitoring System.

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And it's a long-standing collaboration with CDC, FDA, and USDA.

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And it's really a fantastic example of a One Health approach. NARMS provides critical information for treatment recommendations, regulatory decisions, and prevention strategies.

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And I wanted to note that NARMS has also advanced from phenotypic-based testing methods to real-time, genomic-driven antimicrobial resistance surveillance.

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And what that means is that we can detect resistance patterns years before traditional methods. So that gives us increased sensitivity and higher resolution, and we can act more quickly.

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The last program I mentioned was FoodNet. This is the active population-based surveillance program that provides us gold standard data to estimate the burden of foodborne illness and monitor trends over time.

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PulseNet, NARMS, and FoodNet, together with the Antimicrobial Resistance Lab Network, form a connected national ecosystem, that supports advanced testing, data integration, and situational awareness across the whole country.

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The programs are complementary, and through investments from food safety and antimicrobial resistance funding, we've really modernized our lab methods. We've strengthened partnerships with public health labs nationwide.

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I'm going to switch gears a little bit, I want to make sure I have time to touch on fungal as well. And in the last decade, we've also significantly expanded our efforts to, to address the growing threat of drug-resistant fungal infections.

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Through the AR Lab Network, CDC and our state partners have built the capacity to detect and respond to pathogens like Candida auris and other resistant Candida.

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And, and other pathogens like azole-resistant Aspergillus fumigatus.

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These organisms are particularly challenging because they can be difficult to identify, and they're often resistant to multiple drugs. And in some cases, like C. auris, they can spread rapidly in healthcare settings.

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So, similar to the advances that I mentioned in PulseNet, our Mycotic Diseases Branch has also expanded the use of WGS in order to better understand how these fungal pathogens emerge and spread.

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And through the AR Lab Network, we can now support specialized testing, outbreak response, and surveillance for established and emerging fungal threats.

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So, these advances, these investments have and continue to strengthen our national preparedness, which means we have a more coordinated approach, and we are more prepared to address antimicrobial resistance in both fungal and enteric pathogens.

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Thank you for that, and I think I want to spend a little bit more time on the enteric pathogens, if we can. And I'm glad you mentioned NARMS, especially the technological advances that have really enabled our ability to detect these drug-resistant threats so much faster than we could have in the past.

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Could you talk a little bit more about the role NARMS has played, including our partnerships with other U.S. governments, departments, and agencies in protecting Americans from antimicrobial resistance?

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Yeah, absolutely. I love talking about our work because it has such clear, actionable, outcomes. So, NARMS data provides information that helps clinicians choose effective treatments.

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It supports regulatory and stewardship decisions, and it informs prevention activities across the entire food system.

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I mentioned the One Health approach with NARMS, and this really is critical because it's a partnership with CDC, USDA, and FDA, and all of our state partners, which means the data in NARMS include information from ill people, retail meats, and food animals. And so that really lets us track how resistance is emerging and spreading across all of those sectors.

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And that view of resistance among humans, among food, and among animals is just one of the clearest examples to me of the One Health approach in action, and kind of what that means for public health and protecting people.

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A couple of examples where NARMS has really contributed directly to public health and clinical practice. In 2021, so a few years ago, CDC collaborated with the University of Virginia and California Department of Public Health to establish clinical breakpoints for azithromycin-resistant Shigella.

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And this really helped enable clinical labs test for resistance more effectively, and that directly improves patient care and treatment decisions.

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NARMS data also help guide, you mentioned, infections associated with travelers and travel.

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And NARMS data are really important to guide recommendations that clinicians and travelers can use to help keep themselves safe, and to choose effective treatments when people do come home if they have acquired an infection during their international travel. This is particularly true for a couple of pathogens that I'll highlight, with extensively drug-resistant Salmonella typhoid, and Salmonella Newport.

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So, as I mentioned, NARMS is turning 30, and as it continues, it continues to evolve. And because of things like whole genome sequencing, we can identify resistant strains earlier, before they become a widespread public health threat.

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And I'll highlight two recent investigations that kind of show that evolution and the connection between NARMS and PulseNet. So, one is around the changing epidemiology of drug-resistant Shigella infections.

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The data that we have from NARMS has helped us identify and describe that change in epidemiology to really let us continue to progress and try to limit the impacts of that public health threat.

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The other is identifying novel transmission vehicles, like the Salmonella outbreak that we recently saw linked to moringa powder. That was the first known outbreak of a Salmonella infection that carried an NDM-1 gene, and we wouldn't have known that without the connection between these systems. It highlights how complementary NARMS and PulseNet can be,

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and how critical they are in detecting outbreaks, but also in detecting different vehicles and how they can spread an antimicrobial-resistant infection and cause illness. 

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Okay, let's talk a little bit more about PulseNet. That was a great transition, thank you. And I want to especially talk about how that surveillance platform has evolved over the last decade. It's a really incredible example of what's possible just within a few years.

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So, how has the transition in PulseNet from the use of pulsed-field gel electrophoresis, or PFGE, to whole genome sequencing changed the capabilities and workflows

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of our partners at state and local health departments and public health labs, and are there specific ways the agency's Antimicrobial Resistance Solutions Initiative has helped address challenges and help meet the resource needs of those partners? 

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Absolutely. Couldn't have done it without those investments and that shared priority setting. PulseNet transitioning from PFGE was just absolutely transformational, moving from PFGE to WGS. When PulseNet started 30 years ago, the use of PFGE was similarly revolutionary. It really changed the specificity and the precision of our cluster and outbreak detection.

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And now with WGS, we've taken another huge leap forward. We can characterize pathogens with better precision, and we've improved how timely we are in detecting and responding to outbreaks. So what that means is we can find outbreaks earlier, and we can stop them when they're smaller.

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And so, we are now able to identify much smaller outbreaks and continue to identify those geographically dispersed outbreaks quickly.

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It's helped integrate our lab and epi data, as I mentioned before, across human, food, animal, and environmental sources. But it's also dramatically shifted our AR surveillance capacity. So, I mentioned, with the connection between NARMS and PulseNet.

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But WGS allows us to identify antimicrobial resistance markers directly within the genome.

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And so, effectively what that means, as an example, in 2025, NARMS performed genomic analysis for antimicrobial resistance on more than 96,000 isolates.

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That's compared to just fewer than 19,000 isolates only five years ago. So having the access to those data really has just exploded our view and the data that we have to make decisions from.

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This transition from PFGE to WGS, these advances, did require and still require substantial investments. Lab infrastructure, workforce training, sequencing equipment, bioinformatics capacity at the state and local level, and across all public health labs.

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It entailed overhauling the workflows and processes across the entire PulseNet network. Not just how the data are produced, but how they're processed and how they're shared.

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It was monumental, and we couldn't have done it without the AR Solutions Initiative. The initiative played a critical role in meeting those resource needs. Because of the AR Solutions Initiative, CDC could work with all of the laboratories across PulseNet;

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we could provide tools and training and operational support in order to successfully transition to WGS. So, because of these investments, genomic data are now more available. They're also increasingly integrated into and readily available through systems like BEAM, which is a public-facing dashboard where you can look at some of these data.

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PulseNet and NARMS are better connected to support a more coordinated, One Health, fast public health response. So overall, it's been a huge advancement, like I said, really transformational, and those investments across the board have really been the cornerstone of making that happen.

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Thank you.

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Okay, so I want to switch gears a little bit now and talk about drug-resistant fungal infections. And so, resistance to antifungal drugs is a growing concern in the United States and around the world, and your division has led CDC's public health efforts

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related to drug-resistant Candida, Candida auris, Aspergillus fumigatus, and emerging threats, like drug-resistant dermatophytes.

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From your perspective, what laboratory detection and reporting improvements have been most effective to support outbreak response to these emerging threats?

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And what further investments would be most effective in strengthening national capacities for detection, prevention, and response?

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Yeah, as you said, these drug-resistant fungal infections are an increasing public health threat, and really over the last decade, we've focused on strengthening national capacity for that detection, the surveillance, and then responding to those infections.

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And fungal infections are frequently underdiagnosed and underreported, making laboratory testing and access to that testing particularly important.

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Unlike the bacterial pathogens that we've been talking about, many clinical laboratories have limited ability to identify fungi or perform antifungal susceptibility testing. So, building that surveillance and those lab capacities through the AR Lab Network has been absolutely critical.

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One of the most significant advances has been the ability to detect and characterize pathogens like C. auris. And through the AR Lab Network, public health labs can now perform that specialized testing that many clinical labs can't perform independently. This includes things like species identification,

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that susceptibility testing that I mentioned, and colonization screening for C. auris and other Candida species.

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These capabilities are critical for detecting outbreaks early and supporting response efforts, particularly in healthcare settings,

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because detection of C. auris, whether through clinical isolates or screening swabs, can prompt the use of a whole set of special infection control preventions. Measures like the use of specific isolation precautions and PPE, and specialized environmental disinfection practices to help limit transmission.

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And CDC often recommends Point Prevalence Surveys to identify the extent of transmission within a healthcare facility and guide containment strategies. And without that critical testing, you're behind in starting all of those activities.

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You also asked about other emerging threats, like the azole-resistant Aspergillus fumigatus, and drug-resistant dermatophyte infections.

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And these fungal pathogens have really unique diagnostic challenges. There's even more limited capacity for testing for these pathogens, but the AR Lab Network has expanded to be able to provide testing for these emerging threats as well. And it really has changed how we're able to inform clinical care.

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The investments in fungal surveillance, that lab capacity, they've significantly improved our ability to detect and respond to these emerging threats. However, significant challenges do remain. We have gaps in awareness,

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limited diagnostic options, and limited antifungal treatments that are available. So, we really have to continue these investments to stay ahead of these emerging threats.

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Thank you so much. You, just in that short amount of time, brought up so many themes that have been critical to the success of the Antimicrobial Resistance

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Solutions Initiative over the past 10  years. Things like

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embracing advances in technology in order to respond faster,

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control outbreaks and protect patients; the use of the One Health approach, which is recognizing the connection between human health, animal health, and our environment;

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and importantly, the connection between public health and healthcare, and how that collaboration is really critical to the success of all of our efforts, especially when it comes to things like infection prevention and control, appropriate treatment,

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and protecting patients and healthcare workers. And with that, I would like to transition to Dr. Mike Bell, who, again, is the Director of CDC's Division of Healthcare Quality Promotion. Mike, thank you so much for being here today.

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And why don't we start a little bit to think about

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specifically, the relationship between antimicrobial resistance threats and healthcare.

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So, your division and your partners work every day to protect patients and healthcare workers, improve healthcare quality and safety, and make sure that healthcare provision in the United States is as safe and effective as possible.

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Can you share a little bit about how antimicrobial resistance threats have impacted our ability to provide safe, quality health care for Americans?

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Yeah, I'd be delighted to. Thanks, Stefanie. You know, just backing up a layer for context, we think about the health system in the United States as where a patient goes to see a clinician to solve a problem, right?

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But if you take a very high-level look,

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our health system is the safety net

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for essentially everything that happens in this country. Doesn't matter if it's a pandemic, a hurricane, wildfires, you name it, at the end of the day, we expect healthcare facilities and the entire health system, not just acute care hospitals, we're talking rehab facilities, dialysis, nursing homes,

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et cetera, to be there to support our people, right? To take care of whatever problem arises.

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That safety net is invisible most of the time.

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But we need to work constantly to make sure that it's good enough to help our country through the next thing, right?

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Parallel to that is antibiotics.

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Again, we tend to think about the antibiotic as something I prescribe to my patient, or I take, because I have an infection to deal with.

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But antibiotics are a profound and crucial safety net for almost every aspect of medical care. If you think about the advances that we've enjoyed in the past generation or two—surgical treatments,

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transplant medicine, cancer care, burn care—all of those things are almost magical compared to what we could do 100 years ago.

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But at the same time, they all hinge on the availability of effective antibiotics. So, think about it: if I'm crossing the street, I get plowed over by a truck, right?

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EMS staff can scoop me up, carry me to the emergency department where Paige works. She will take care of me, get me to the trauma surgeon. All of that happens beautifully.

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But I've also got road dirt in my belly.

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That's going to cause an infection. And if you can't treat that infection, all of the skilled care that leads up to that moment is wasted.

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So, antibiotics are more than just a specific treatment for one thing.

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They are a foundational safety net for all of the care that we look forward to every single day.

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So, that having been said, if you think about

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how this has changed our approach to medical care, it has driven very significantly

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the practice of tracking problems in healthcare. This is often referred to as surveillance. It sounds a little bit spy-like, but in fact, it's just the basic activity of keeping your eyes open and tracking where things are happening, so that you can focus your attention on the problem, and then do something about it.

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If you think back, 35-40 years ago, one of the earliest antibiotic-resistant threats was methicillin-resistant Staph[ylococcus] aureus.

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MRSA, to those of you who lived through the 90s and 2000s. We don't talk as much about it now.

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A lot of progress has happened, but in the day, there was this issue of penicillin-based antibiotics that you would normally use for an infection versus MRSA infections that require something different. And that, I think, trained the entire health system to think about this

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from soup to nuts, basically. From detection to diagnosis to understanding resistance patterns, and then driving effective treatment.

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Because without that, somebody that you thought you were treating with the right antibiotic would keep getting sicker, devolve into sepsis, and possibly die.

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So, I see that as the origin story, if you will. And then if you look at how the AR Solutions Initiative and AMR [antimicrobial resistance] writ large has impacted how we work, 

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the waterfront is huge. Almost every single aspect of healthcare has been affected by these investments.

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Thank you for that perspective. And I think that

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I want to dive deeper into three of the things that you have mentioned here that I think are going to be relevant. We'll talk a little bit about infection control, and then we'll talk about

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laboratory detection and diagnosis, and the role that that plays in treatment, and then

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hopefully we'll have time to get to some questions about appropriate antibiotic use. But first, let's talk about infection prevention and control. And your division has some of the world's foremost experts

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in actions that healthcare providers can take,

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and everyone in a healthcare facility can take to protect patients

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and protect the people that are working in that facility.

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Can you share a little bit about how CDC's Antimicrobial Resistance Solutions Initiative has helped

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work with public health and healthcare partners to prevent infections from happening in the first place in both inpatient settings and outpatient settings, and who are some of the key partners that CDC's been able to work with to implement those programs?

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Partnership is at the heart of everything we do.

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This is a massive undertaking. If you look at the scale of the U.S. health system, it's vast. I'll go into some numbers in a moment, but this is not something that an individual, a single agency, or a single facility can manage alone.

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If you think about how a hospital works in an urban environment, for example, that hospital can do everything perfectly, but if they're receiving patients from a facility that's not,

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those patients are bringing in infectious material. It can be a colonizing organism, it can be an actual infection. There are no barriers. People and infections move

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happily across political boundaries, geographic boundaries, certainly through doors and windows. So, the scale of this is huge. We need all the help we can get, which ranges from

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our public health colleagues, we have, thanks to the AR Solutions Initiative, been able to

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build a workforce across the United States. In the United States, the HAI/AR programs, Healthcare-Associated Infections and Antimicrobial Resistance programs, started out as a desperate move

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15 to 20 years ago

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when we would call a health department because there's an outbreak at a hospital, and be told, “Oh, we don't do health care. They have doctors and nurses.”

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How wrong we were to think that public health wasn't needed there.

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Our initial investments through the years started with just having one person who can pick up the phone and say, “Yes, I'm the healthcare desk.” You may be a junior person who doesn't know what to do next, but at least we have a connection with the health department. Why is that important?

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Our health departments are the people who have feet on the ground, who go to the local community locations. During COVID,

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these places, the HAI/AR programs that we've invested in through the years, and now many of them are 20 or 30 people strong, they have incredibly robust expertise, they're able to do a lot of what we had to do here at headquarters 30 years ago. They were the ones during COVID who had relationships with the nursing homes.

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And they could go in, and they were a recognized familiar face, and people would say, “Oh, yes, it's Stefanie, come on in.” “Hey, we need help with this.” As opposed to if it was some stranger from a government agency calling,

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the reaction is totally different. So, the beauty of the health department is that they're part of the community, that they are actually on the ground doing the stuff. And by building out the ability to help healthcare facilities do better and track progress,

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that has been a game changer. It is something that we're working very hard to make sure we don't lose. Obviously, all of these things are built on people that are supported by dollars, and so making sure that we're able to maintain that into the future is a crucial part of what we're doing.

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When we think about infection control writ large,

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there's a lot baked into that phrase, right? I've already mentioned you have to know where to look, you have to be looking all the time, you have to be tracking how you're doing. But at the end of the day, what you're really after is keeping the bad thing from spreading, right? You mentioned preventing it in the first place, that's great, and I'll say more about that in a moment.

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But the reason people call us, is there's a bad thing, we need you to keep it from spreading. And it can spread from a dirty environment, it can be person to person, like COVID. Whatever the challenge, that's what infection control is. It is 

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the label for the practices and tools that you use to keep stuff from spreading, keep it in one place, so you can then clean it up and make it go away.

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If you think about the investments, not just in the health department, but across the health system writ large that have been possible

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thanks to the AR Solutions Initiative, those range from

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better implementation practices, better tracking practices. You'll hear me say things about some of the platforms that we have in a moment, but we use those investments to create a system that gives us essentially real-time information on many important aspects of care.

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The types of things that we think about

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really range from the data streams that we get

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that help us target where problems are happening.

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The National Healthcare Safety Network is

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America's way of tracking healthcare quality and patient safety.

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It got built almost 40 years ago with a paper-based system that has gradually evolved along with our technology stream.

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Today we've got 39,000 facilities that are actively connected. That ranges from hospitals to nursing homes to rehab facilities, dialysis centers, ambulatory surgery, I could go on. But it is a vast catchment of all of the care locations.

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It was designed to pinpoint where the problem is. This was a system that was designed for the people who do infection control, and they need to know which patients in which unit are having a problem, so they can go there and implement, like you heard Gwen say, the special PPE, the special cleaning, et cetera, et cetera.

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The other thing that I would flag in terms of infection control and partnership is that it's not just public health.

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There are professional societies that represent hospital epidemiologists, infection control professionals, the infectious disease world writ large.

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There are professional societies and the actual health systems themselves that represent the health system, the very complex systems that we use to deliver care, to keep the doors open, to keep the staffing going, to keep the products flowing.

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Those partnerships are absolutely essential, as are our relationship

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with patients and their advocates. We hear regularly from people who have lost family members to infections, to sepsis, who come to us and say, “We need help on this thing.” And they are incredibly powerful partners to raise awareness, to drive progress on these important issues that otherwise,

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without a face and a human being tied to them, can seem like just another thing on a laundry list, but those patient partnerships are incredibly important, as are some of the nonprofits that have helped us through the years, like The Pew Charitable Trusts.

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They have been huge drivers of success in what we've done. So, getting back to my original point, not something we can do alone. 39,000 is a lot of facilities, and if you think about what we're really asking.

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We want every interaction between every clinician, every patient, every visitor, every surface

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to be perfect every time, for every patient.

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It's a big ask. It is. We need help.

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I feel like there are a lot of people listening today that are ready to be those partners.

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And so, just a couple of

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more questions for you before we transition. So, first, can you talk a little bit about the impact of improvements in our ability to detect and respond to antimicrobial-resistant bacteria and fungi, some of the things that Gwen had described, and how those efforts have actually impacted patient outcomes and healthcare safety?

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So, absolutely. I think the fact that we're no longer driving blind,

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right? The systems that we use to detect outcomes, also detect practices, right? So we're only, we're not only looking at how many of these infections were there, but we're also looking at how well did this facility

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maintain the practices that we want to see, right? Because it's both.

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And the ability to do that makes it possible for us to not only detect the problem, but understand where to help the solution.

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The other piece of this is on the laboratory side.

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You mentioned the AR Laboratory Network, which has been built on the dollars of the AR Solutions Initiative, thank you very much. That is a way that we were able to take CDC-specialized laboratory capability and push it out

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closer to the front lines of the country, where clinicians have easier access, through their health departments or through regional laboratories to testing that usually isn't maintained in a hospital or in a small locality.

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The other piece of this that I think is really fascinating is working in a hospital, if you think you have an outbreak, and you want to start testing people to see who the carriers might be, 

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it's really hard to do because our payment system for healthcare requires a patient and the patient's treatment in order to justify the test.

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If you're screening people, there is no such justification, even though it's really important.

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And so, by investing in the AR Lab Network and making screening testing possible, we're able to bring that to bear without a charge to the facility.

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And for those of you who are looking at the details, facilities are given a very specific budget for their laboratory directors to do a certain amount of tests outside of the billable ones. And once you run through those, they just don't have the resources. So, we're able to do the screening test

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to say, well, we have one infection of this type that is resistant to all treatment.

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Does anyone else carry that? Let's check all the roommates. Let's see if any of the visitors, let's see if the household has any evidence of this, because our containment ring might have to be bigger in order to make sure that it's not spreading. That surveillance testing has been pure gold.

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The ability to do that quickly, and for free, essentially, it's not free, we pay for it, but it is an amazing tool that's made such a huge difference.

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Okay, and to wrap up, I'd like to just spend a couple of minutes, if we can, on antibiotics. As you mentioned in your response to my first question, 

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antibiotics are critical for so many components of healthcare today, and we all have a responsibility to make sure that the drugs we have today remain effective for as long as possible.

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Can you talk just a little bit about some of the measurable improvements that we've seen in the appropriate use of antibiotics, and are there antibiotic stewardship interventions that have really been effective in improving how we use antibiotics in the U.S. over the past 10 years?

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So, this past decade represents really wonderful success in antimicrobial use and stewardship.

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One quick word, stewardship doesn't mean ‘don't let people use antibiotics.’

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We want people to use the right antibiotic at the right time, in the right amount, for the right duration. So do everything perfectly, like I asked for before, but we don't want to withhold antibiotics when somebody needs them desperately.

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Like in the emergency department, where somebody might be descending into sepsis, they need it right away. We don't want people to dilly-dally. But that having been said, we don't want silly use of antibiotics. They are precious, we want to use them right.

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One thing that I'm very happy to report is that the overall bulk of use has decreased by almost a quarter across kids and adults, over the past decade or so. And more importantly, 

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the number of unnecessary or incorrectly prescribed antibiotics has essentially been cut in half.

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Now, that means there's work to do, because there's still half of whatever was left over, that is wrong and unnecessary. But a 50% reduction in 10 years makes me really happy. And, you know, notwithstanding that there's more to be done, I think it reflects a couple of things.

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One is the Core Elements that we published years ago.

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The Core Elements of Antimicrobial Stewardship in inpatient settings, which is now being mirrored in outpatient settings with a new release coming out, but that basically gives facilities

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the list of things they should have in place in order to make sure that they can do a good job of managing their antibiotic use. And that kind of format

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changes the conversation from a very hazy, you know, just do better, to, no, no, no, do these 10 things, and implement them this way, and you will have success. And sure enough, we're seeing that impact.

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It does have a dotted line to human factors and human factors engineering writ large

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where, as we see better progress and improvements in electronic health records and online computer prescribing systems, we will see better and better ability to implement best practices across prescribing.

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Not to take away the thoughtful choices of the clinician, but to help add information that can make the choices better.

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And those same human factors type technologies

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track back to the infection prevention and control that we talked about, to make things goof-proof, to make things easier, to make success a guarantee.

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Thank you for that. I think

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what you have shown is that this is not just work that's happening here in Atlanta at CDC headquarters, but this is work that is happening in every community

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across the United States. I'd be willing to bet that every person who's listening to this right now has received care at, or had a family member that has received care at, one of those 39,000 healthcare facilities enrolled in the National Healthcare Safety Network. So, this is work that is affecting

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every person, every day. So, thank you for the leadership that your division has shown

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in that.

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We want to transition now to talk about not what's happening in our individual communities here at home,

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but to talk about what's happening around the world. So, Paige, thank you so much. As a reminder, Commander Paige Armstrong, is the Director of CDC's Global Health Center, who

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I'm sure has nothing happening right now, and has very graciously taken time to be with her today, but thank you so much, Paige, and we really appreciate your willingness to talk with us today.

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CDC's global antimicrobial resistance work spans multiple networks, multiple platforms, multiple initiatives that engage a pretty broad set of partners across a very broad set of geographic settings.

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Can you talk a little bit about how the agency's global antimicrobial resistance work fits into CDC's broader global health portfolio and the agency's global health priorities? 

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Sure. Yeah, absolutely. Thank you so much for having me, because you're absolutely right. This is not just a problem in the United States, but rather a problem across the world. We talk a lot about the continuum between domestic and global. What does that mean? That really means that

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a threat anywhere can be a threat here. And so, while we do all of these fantastic things with the networks, with healthcare, with surveillance in the United States, if there are threats that are emerging in other places around the globe, they have the ability to

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move between countries, and ultimately back to the United States. And so, our work really focuses on controlling things at their source. This is a common theme across a lot of things, including what you rightly noted, which is the Ebola outbreak that we're dealing with right now.

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And again, I just want to thank all of our colleagues, be it overseas with the ministries of health, our colleagues here at CDC and across the government for their incredible efforts controlling that infection right now.

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But to that point, antimicrobial resistance is also another infection that we need to control at its source. There are so many different resistant bugs that can be appearing in any place with any type of resistance mechanism, and we need to know it as soon as possible so that we can

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try to contain it, as we heard. And then also ultimately prevent it from compromising some of the tools, the bacteria, the antibiotics that we have.

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So, how do we do that? Well, we work very closely, as Dr. Bell said as well, with our partners, with our ministries of health, to build infrastructure, surveillance systems, laboratory networks, and workforce that can work in all of those same healthcare facilities around the globe.

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It's really important that we have strong infrastructure, strong surveillance systems to detect things early, laboratories that can actually identify them correctly, and then help guide those same individuals that are working and trying to care for patients overseas.

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I think this is also not just within the human community, but rather within the One Health community overseas as well, and that be the animal community, the environmental community, and so that's another place that we really want to work across the sectors to make sure that everyone has systems to detect things early and control them at their source before they spread further.

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Thank you.

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So, you talked about the importance of this global infrastructure and these platforms and programs that help us know what's happening,

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share that data, and then act on it to protect people everywhere.

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How does CDC work to ensure that data from these platforms and programs

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is translated as effectively as possible to on-the-ground public health action? This could be actions we may take here in the United States based on that work, or things that we do with our partners around the world.

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Are there mechanisms that CDC uses to align these programs with other global health efforts, either here at the agency or elsewhere, in order to maximize their impact?

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Yeah, absolutely. We have a fantastic network of presence overseas. We have actually country offices and regional offices in over 60 countries, and then when you apply the fact that some of those work regionally, we're working in many countries in which these are equal threats.

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With those country offices, we have experts in the field every day working to improve the surveillance systems, and then ultimately, like you said, the data systems to make sure that when something emerges in one place, it gets communicated to another place, and ultimately that all of that information

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comes together in a way that we can track new and emerging threats.

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One case may not trigger an alert or a system, or someone might not think anything of it, but when it's three, four, or five across multiple provinces, all of a sudden, that might be something that we can alert the ministry of health on and act on.

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Again, we're working hand-in-hand with the ministries of health, with our national public health institutes, national public health labs, and many other partners that are also working in this space.

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But I also want to call attention to some of the networks that my colleagues here have noted, whether it's the Global Antimicrobial Resistance Laboratory & Response Network, I hope I got that whole name right, or PulseNet.

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In addition to their success in the United States, they've also been able to expand in the global reach. I think, again, with that recognition that there's interconnectedness

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between the global pieces and the domestic pieces. And so through those networks, there's capacity built, surveillance systems, data systems, and all of that information is able to come together in a way that we can start really painting the picture and understanding things better, and then ultimately

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acting on it to control these threats. 

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Thank you. Yeah, you mentioned two important networks there, and I think the

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ability to take what we've learned here in the United States and expand that to have global reach is really a highlight of the success of our work together. And so for my last question for you in this part of our discussion is,

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what are the most critical remaining gaps or challenges that CDC and our partners must continue to address

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so that we can sustain the capacities that we've already built globally to combat antimicrobial resistance, but also to grow them? This is a threat that continues to evolve and change, so if you could talk about some of those gaps and challenges, we'd really appreciate it. 

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Sure. So I think, you know, we talk also about the complex nature of outbreaks and global health these days. I think we are always going to be faced with some challenges that we can't necessarily predict.

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It makes me think of some of the situation that's going on in Ukraine right now with the conflict, and how we've also seen, unfortunately, some multidrug-resistant pathogens emerge there.

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Again, these are places where, once we see these complex issues, we can really try to lean in, work again closely with the ministries of health partners, try to identify some risk factors, and determine how we can put systems in place to detect these threats early before they spread.

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But I would also just say that, you know, the remaining gaps also have to do with some of the infrastructure. While we've made incredible strides and progress built on many decades of programs like the PEPFAR program for global HIV and TB that's really built a lot of surveillance system networks, the workforce, the laboratory, and so forth,

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that there still are, you know, things that need to be bridged. So, whether that's enhanced laboratory capacity or even just more decentralized access, whether it's some new diagnostic tools to make sure that we're keeping up

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with some of these evolving threats. Or, like you said, or we talked about before, the data systems. I think data systems still need to be pulled together.

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We've had some success across a few countries, too, including in Vietnam, where we've recently, converted the system from a paper-based system to a more data-based system that can actually, again,

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kind of collate this information so we can track it and see what threats are emerging. We're also using innovative tools to get ahead of things, like,

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whether it be a wastewater surveillance, or a novel surveillance system, or working with the animal populations, too, to make sure that we're detecting them on the front end, and why there might still be a sentinel case. So, yeah, lots has been done. It's fantastic, the progress we've made.

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But we also need to continue to put the pressure on to maintain those gains, not have any backsliding, and then hopefully even

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grow further.

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Yeah, thank you for that. I think your remarks really do highlight the

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interconnectedness between our work here and our work around the world, and some of the things that you mentioned are very similar to what we heard about from Gwen and Mike: the importance of partnerships, the importance of infrastructure, the importance of using data for action, the importance of the One Health approach. And so

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it's, I think, a lesson for all of us to think about just the impacts of the work

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around the world, in protecting us here at home, and vice versa for all of our partners.

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in all of the countries where we're working. And I do want to just take another second to thank all of our CDC country office partners and regional office partners for the support they provided to the AR Solutions Initiative's successful implementation over the last 10 years. There have been some 

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really impactful programs that have been implemented in collaboration. So, we're going to turn now

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to Cliff McDonald, who's been waiting very patiently. Cliff, thank you.

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Last, but certainly not least. Paige just mentioned the importance of innovation, thinking about how we're modernizing data systems, how we're using wastewater surveillance to detect emerging threats globally, and so, Cliff, I want to ask you a few questions about

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CDC's investments in antimicrobial resistance innovation and implied research. And so,

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CDC's AR Solutions Initiative has supported many programs, platforms, and networks, many, too many to name, and most of which I don't know what the acronyms stand for, so it would be a futile effort anyway. And over the past decade, we've seen some really innovative approaches to some of our most pressing challenges related to antimicrobial resistance.

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Could you take a few minutes and highlight what some of those innovations are, and how they've been critical for preventing the emergence of antimicrobial resistance, controlling resistance in both healthcare and in communities, and protecting people?

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Sure, well, thank you. Let me begin with talking a little bit about, a network of nearly a dozen

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academic medical centers, who are leaders in the fields of infection control

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and healthcare epidemiology. They're known as our Prevention Epicenters. One of the most notable accomplishments that they have had over the last 10 years,

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and even from before that,

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is work in an area, that now falls under a concept we call pathogen reduction.

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And, this involves reducing the bioburden of multidrug-resistant pathogens that colonize the human body.

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Colonization is when a microorganism, usually a bacterium, and often an antibiotic-resistant pathogen, takes up residence in or on the human body.

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And although it's not causing infection at the time, it increases that patient's risk for going on and developing an antibiotic-resistant infection.

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The practice of regularly bathing

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patients using chlorhexidine antiseptic

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and applying an antibiotic, mupirocin,

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to the nose, has now become a prevention practice

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practiced in over half of all U.S. hospitals. And this is a form of pathogen reduction.

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In addition, these Prevention Epicenters have worked tirelessly to help develop several of our electronic digital quality measures, which will, either soon or eventually be deployed

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in our National Healthcare Safety Network, we heard from Dr. Bell about. Of course, these measures and the infections that Dr. Bell was talking about are often antibiotic resistant, because they are

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healthcare-associated, occurring in people after they've been in the hospital.

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The measures that they've been working on include, and these will basically,

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reduce the burden of reporting. It'll make it completely electronic.

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Just a press of a button, or not even a press of a button, automatic all the time. These measures include the hospital-onset bacteremia measure, an acute sepsis events measure.

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And, both of those will soon be deployed, in the National Healthcare Safety Network. And another measure that is a little bit earlier in development, the non-ventilator-associated pneumonia measure, as we now realize that

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it's one of the most common infections, is people just on the ward

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developing pneumonia

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for various reasons, not even with a ventilator. Through CDC's AR Solutions Initiative funding, the Prevention Epicenters have also studied the impact of enhanced environmental cleaning

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on infection rates, and also innovated in a novel antibiotic stewardship intervention using personalized clinical decision support. This is part of integrating with the electronic health record

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and helping the clinician

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determine when antibiotics are needed and what antibiotics. Working alongside the Prevention Epicenters program has been the Modeling Infectious Diseases in Healthcare Network, or we also call it MInD, M-I-N-D, it's an

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apt acronym. In one of their early projects, they estimated the effects of a coordinated approach for action to reduce antibiotic-resistant infections, and they demonstrated how such a coordinated approach, if fully implemented,

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could prevent over half a million infections over five years.

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Some of these same Prevention Epicenter leaders participate in a standing contract system. We have another acronym for that, we call it SHEPheRD, the idea of shepherding, these projects through.

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Notable studies from that program have included an intensive environmental and healthcare personnel sampling project that detected unobserved

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transmission of a pathogen that I'm very familiar with, Clostridioides difficile, in ICU patients.

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Another more recently reported study, from the SHEPheRD network, has been using, this is like that clinical decision support, but using a

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clinical decision support tool embedded in the electronic health record that gives a probability estimate of a patient having community-acquired pneumonia. And through a randomized trial that they did evaluating that, they showed that the novel intervention

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could decrease inpatient antibiotic use by an average of

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over four in-hospital days of therapy. The AR Solutions Initiative also provided funding for other shorter contracts, including early funding to an academic partner for wastewater surveillance. You mentioned that. This initial investment has grown into the CDC's National

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Wastewater Surveillance System.

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It was so integral during COVID

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for standing that up.

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And then finally, applied research led by global partners. Bring it back to global.

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Global partners on the levels of colonization with drug-resistant bacteria in several countries. This led to the

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consortium known as the Antibiotic Resistance in Communities and Hospitals [ARCH] research consortium. This consortium has shown that colonization with these resistant bacteria is at least seven to twenty times

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higher at these ARCH sites than colonization rates in the United States. And again, alluding to that fact that

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all these problems

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don't observe national borders.

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Thank you for that, Cliff. I think that's an incredibly impressive range of work that affects many different settings, many different populations,

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and involved many different partners. And so I want to focus a little bit more about this cross-sectoral collaboration. You mentioned

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academia, healthcare facilities, and other partners, even in just a few examples that you gave.

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Can you give us some examples of partnership between CDC and external organizations that has been successful at taking what those applied research and innovation projects have learned and turning those into practical, scalable interventions that are, like you mentioned about the pathogen reduction,

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used in many healthcare facilities in the U.S. today? 

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Sure. Let me begin with one that we're really proud of, because it's really brought resources to bear to a larger ecosystem to understand antibiotic resistance, and that is partnership with the Food and Drug Administration, FDA, to establish the CDC and FDA Antimicrobial Resistance Isolate Bank.

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Which is one of the world's largest collections of antibiotic-resistant

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isolates, mostly bacteria, but fungi also, gathered from national reference laboratories and tracking activities. And they're taken from specimens in healthcare, food, and community settings. By safely providing isolates to approved institutions, 

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they do vet these institutions where these are sent, the CDC and FDA AR Isolate Bank

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improves patient care and supports solutions against drug-resistant threats. After 10 years of service, the Isolate Bank has shipped more than 500,000 isolates from over 13,000 isolate panels.

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The Isolate Bank helps strengthen diagnostics by supporting laboratories and validating tests,

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informs research to develop drugs like antibiotics and antifungals, develop diagnostic tests, and support regulatory requests or applications to FDA. It also supports testing to ensure drug effectiveness and

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promote study of the genetic mechanisms

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of resistance. NIH has been another important partner that we've worked with in several AR-related areas. Most notably, we co-edited a special issue of The Journal of Infectious Diseases titled The State of Microbiome Science at the Intersection of Infectious Diseases and Antimicrobial Resistance. And we'll

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speak more about the microbiome in a moment. Another partnership is related to the Prevention Epicenter's work I mentioned previously, involving use of chlorhexidine antiseptic and mupirocin antibiotic to reduce infections, proving the effectiveness of this

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practice was done in collaboration with a large hospital network, namely the Hospital Corporation of America. Following those initial studies, a collaboration was undertaken in Orange County, California

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demonstrated that the use of chlorhexidine and mupirocin in hospitals, nursing homes, and long-term care facilities across a region significantly lowered infections, hospitalizations, costs, and deaths.

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Recognizing the early cost effectiveness of this approach, Cal Medicaid [Medi-Cal]

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chose to continue funding this intervention beyond the planned study period. But this is just one local example of collaboration with the Centers for Medicare

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and Medicaid Services [CMS]. Understand that that is probably the most major payer of healthcare services in the United States. Of course, it's the U.S. government. Medicare, as we know it.

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It's really been an important partner along the way in so many ways, and it can't really be overstated. For example, through its conditions of participation

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rules, rules-making process, CMS has incentivized the establishment of antimicrobial stewardship programs in all U.S. hospitals, and you heard that from Dr. Bell

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about the importance of stewardship. It occurred first in nursing homes and then actually followed in hospitals. And then CMS has also incentivized reporting of both antimicrobial use data and resistance data to our National Healthcare Safety Network.

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So it's been an important, important, partner. 

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Yeah, thanks. I think the examples you gave highlight the interconnectedness of our work across the U.S. government, so what we're talking about today at CDC isn't work

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we could do alone. You mentioned FDA, NIH, CMS, there are many others that I am not going to try and name, because I don't want to be accused of leaving anyone out. But that work has been critical to achieving the goals of our U.S. national strategy for combating antimicrobial-resistant bacteria and fungal species.

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You also really highlighted the importance of private sector collaborations and supporting development of new drugs and diagnostics through the isolate bank, and then, again, we're back to that public health and healthcare connection, and I think everything we've touched on today

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has emphasized the importance of that relationship. And I want to use that as a jumping-off point for our final question for you today, which is about the microbiome. So, after many years of serving as the Associate Director for Science in the Division of Healthcare Quality Promotion,

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you recently took on this new role as the Senior Advisor for Microbiome Health, and just personally, very excited to get to work with you on this.

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Could you tell us a little bit more about the role of the microbiome in protecting people from infectious diseases and combating antimicrobial resistance, and what are some of the things that CDC is looking to do in this area? 

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Sure. Well, I've been talking about pathogen reduction, and that's very integrated also to the microbiome, and we'll come back to that, but let me just begin by saying a few words about the microbiome and its importance.

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First, of course, microorganisms are found everywhere in the environment, and on our bodies, in our bodies, and where they exist in communities when they're in

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people or animals, and they're in the body, but not causing infection. They're in communities that work together, that live together, and they're called microbiomes. The human microbiome, such as on the skin and the gut, especially,

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our intestines is one of our biggest microbiomes, helps maintain health and does protect against infection.

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A healthy microbiome is a critical component of many of our body's core functions, whether it be the immune system, the metabolic system, nervous system, or endocrine systems.

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Diets, of course, diets rich in a wide variety of whole foods, fiber and fermented foods, they support a healthy microbiome.

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But medications, such as antibiotics, as well as other dietary and environmental exposures, food additives, environmental toxins, these can disrupt the microbiome, allowing pathogens

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to colonize. I mentioned colonization. There's an important role of the microbiome that sort of pushes out pathogens. It's there all the time. It's through competition, it's through other things. And once those pathogens come in

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and take up residence, colonize, they can then go on and multiply and cause infection. Over the past 10 years, CDC's AR Solutions Initiative has supported nearly 40 short-term

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contracts to study the microbiome, including projects that

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just for some examples, describe the typical effects of antibiotics on the microbiome, building towards a future we're hoping for, I remember sitting in Dr. Bell's office talking about this early on, a future state where we'll have standardized microbiome disruption indices that could predict the risk

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for developing an infection in a patient. They've also discovered biomarkers to distinguish

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Clostridioides difficile colonization from infection. This is a troublesome area in diagnosis. They characterize resistant pathogen reduction

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methods. In fact, one method that seems to work is fecal microbiota transplantation. I know that sounds strange to some if it's your first time, but it actually does work

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to control C. difficile infections. And then also, there was a study of a novel beta-lactamase enzyme that you'd ingest

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with your antibiotic and break down the antibiotic and protect the microbiome while still allowing the absorption and treatment. Other aspects include measuring the effects of antibiotics early in life on carriage of antibiotic-resistant pathogens, and weight gain during childhood. And that was

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these studies found to be associated. The Prevention Epicenters have also been working in this area. Two recent studies I'll highlight. One is a study of, again, FMT, or fecal microbiota transplantation,

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in 11 renal transplant patients after their transplant who were colonized with multidrug-resistant pathogens. At the end of the study, eight of nine of those patients who completed all the treatments were cleared of their colonization, and the FMT-treated

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participants had a longer time to recurrent infection versus eligible control patients who were not treated. So, there is promise in what we're talking about here. Another study was a single-center, open-label, non-randomized clinical trial, again, of FMT, used as a discovery tool

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in long-term acute care hospital patients – these are very sick,

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long, chronically sick patients, often on ventilators – who were colonized with multidrug-resistant pathogens. Compared with controls in the six months after the prevalence survey that found these patients, those who received the FMT

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had numerically fewer positive blood cultures, less intense intestinal dominance with these pathogens – you know, as I mentioned, 

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it's often that people get overgrown with these in the hospital –

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and fewer days of antibiotic therapy. So again, showing that promise. CDC's new initiative – so to speak to that, what we're working on together and excited about – is called the Advancing Microbiome Solutions for Better Health. It aims to protect Americans from infectious disease threats, building infrastructure,

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enhancing scientific rigor and empowering states and communities. Through this new initiative, across the Department of Health, it's not just with us, we hope to protect Americans from infectious disease associated with microbiome disruption through threat detection, outbreak response, some of the things we've been hearing about, and reducing inappropriate antibiotic use that Dr. Bell was talking about.

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We'll be working to identify and implement interventions that maintain and restore a healthy microbiome across the lifespan – we already know diet does, 

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whole foods do, avoiding food additives – and develop and execute a healthy microbiome applied research agenda and product development pipeline. We really do need

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products developed that reduce this problem with overgrown AR pathogens. And we'll be engaging internal and external partners to accelerate progress towards these goals, of course, and working together towards this, and it is exciting.

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Thank you, Cliff, and thanks for your scientific leadership that you've provided to the Division of Healthcare Quality Promotion, and

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like we said, excited to continue this new area of work related to the microbiome. And so,

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again, just want to reiterate, these areas of innovation, they are intentional investments. We have identified a gap, identified a challenge, and have been able to use Antimicrobial Resistance Solutions Initiative resources to bring together the best and the brightest to try and solve these problems. And so, what we've been able to achieve over the last decade has been incredible, and is

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literally changing public health practice and healthcare. So, it's really exciting that we've had the opportunity for those collaborations.

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We have just about 10 minutes left, and so I'm going to do a

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last two sets of questions that I'm going to ask everybody, and you each get one minute to respond.

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Gwen, I'm going to start with you, and then we'll just go down the line, Gwen, Paige, Mike, and Cliff, and then we'll come back the opposite direction on the second question. 

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We're going to look back first, and then look ahead. Over the past decade,

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when we think about the work that's been supported under the AR Solutions Initiative,

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what are the measurable improvements that you're most proud of, and what would the landscape have looked like

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if those resources and those networks and partners had not been able to be brought to bear?

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I mean, I think you kind of encompass it in the question, right? I mean, I think that there's a lot to be proud of, but a lot of it is the advances that we've accomplished, so the new

460
01:17:08.060 --> 01:17:23.580
technologies that we've brought to bear, how that's changed our systems and our networks, but how we've moved that forward as a network with our partners. I think we all mentioned, kind of, those relationships across the board, and how important it is that

461
01:17:23.580 --> 01:17:41.720
the data that we have, we wouldn't have without our partners and state and local health departments. We wouldn't have those without all the public health labs. We wouldn't have that standardization and the ability to bring those data together without these advances in data modernization and the other tools that we've been brought to bear. We wouldn't have been able to take advantage of things like whole genome sequencing.

462
01:17:41.720 --> 01:17:44.649
We would have slower outbreak detection. We would have

463
01:17:44.650 --> 01:17:52.330
more delayed identification of resistance. We'd have, you know, less ability to treat things effectively the first time around.

464
01:17:52.330 --> 01:18:05.169
And we would be driving blind – to your point, right? – a lot of the time around, kind of, the best ways to prevent illnesses and protect people. So, I'm really proud of how far we've come, but it is that we have done it in partnership

465
01:18:05.170 --> 01:18:10.000
with all of those different groups, and that we've moved together to make those changes. 

466
01:18:10.001 --> 01:18:11.500
Thanks. All right, Paige, over to you.

467
01:18:11.680 --> 01:18:34.280
Sure. So, in the global space, I would say that in the last 10 years, the amount of progress we've made in recognizing the importance of, and then subsequently implementing infection prevention and control programs in the healthcare space, as well as, I think, some of the strides that have been made in workforce training, but particularly in the laboratory networks and the laboratory space.

468
01:18:34.320 --> 01:18:44.090
Going from, I think, a lot of places where there just wasn't even a full appreciation of the importance of infection prevention and control to contain these threats.

469
01:18:44.090 --> 01:318:58.020
But then also being able to identify them and identify resistance patterns. I've just seen such strides, and that's really what ultimately allows you to kind of pinpoint and use the narrowest tool necessary to achieve the job so that we retain those other tools in our toolbox for most effective care and treatment of patients around the world.

470
01:18:58.020 --> 01:19:05.379
Thank you. Now, Mike, over to you. Beat that.

471
01:19:05.590 --> 01:19:25.010
I won't reiterate what Gwen said about systems of detection and monitoring, or about the awareness and focus. I am so grateful that awareness has been raised of this crucial issue. We are in a different world now, where people actually recognize the concept

472
01:19:25.130 --> 01:19:31.849
of antibiotic resistance, right? We can say an easier phrase, drug-resistant, and people actually know what's in the background of that.

473
01:19:31.900 --> 01:19:44.780
So, from a global awareness perspective, people are thinking about this in a way that they weren't even close to a decade and a half ago. I'll also say that we have more people speaking to it.

474
01:19:44.810 --> 01:19:58.220
The fact that we've been able to elevate the voices of our patient advocates, of families and patients themselves, that to me is a wonderful sea change in how we approach this vast problem as a nation.

475
01:19:59.040 --> 01:20:00.000
Thank you. All right, Cliff, over to you. 

476
01:20:00.001 --> 01:20:20.810
I'll just piggyback on this. I've been here 25 years at CDC, and I'm proud to hear of all these accomplishments, and just the way that they really do complement one another. I mean, as Dr. Bell just said, the greater awareness, we just see it now. We see something that wasn't being seen before.

477
01:20:20.900 --> 01:20:25.180
And along with that, I guess, just getting back to that innovation side.

478
01:20:25.280 --> 01:20:28.249
At least within healthcare, seeing

479
01:20:28.410 --> 01:20:32.200
this development of a concept that,

480
01:20:32.720 --> 01:20:52.530
we've known about colonization for a long time, but understanding that the amount of colonization and the way the antibiotics affect the microbiome, and even just the understanding of the microbiome. So, I think it's this timing, just maybe serendipity, that as we're starting to recognize the size,

481
01:20:52.540 --> 01:20:53.880
and really, the

482
01:20:54.430 --> 01:21:06.029
bigness of this problem – it's really a big problem, we mentioned, especially globally – that as we recognize that, we're also starting to see new ways

483
01:21:06.140 --> 01:21:12.199
of dealing with it that we never had before. And that maybe chlorhexidine and mupirocin today.

484
01:21:12.370 --> 01:21:16.000
But I'll just segue into what I think you're going to ask next. 

485
01:21:16.001 --> 01:21:32.000
Yeah, well, that's a great train of thought. Just so everybody has a chance to be prepared. We looked back, now let's look ahead. We look ahead to the next 10 years. What do you think will have the biggest impact on our ability to combat antimicrobial resistance?

486
01:21:32.001 --> 01:21:42.080
And for me, I'll just say, I think it's the combination of all these things, the awareness, even greater awareness, with new diagnostic tools to be able to detect

487
01:21:42.290 --> 01:21:50.980
the colonization with the AR pathogen, to even see it's there, also, even see it coming.

488
01:21:51.190 --> 01:21:56.070
Seeing it in the microbiome as it's been affected by antibiotics. And then I'm,

489
01:21:56.410 --> 01:22:00.700
again, hopeful for the future, where we'll have ways of

490
01:22:01.310 --> 01:22:08.920
changing that. Maybe in the future, getting back to what our conversations were so many years ago, of

491
01:22:09.100 --> 01:22:17.509
even personalized microbiome indices and ways to reshape that microbiome in a more favorable direction.

492
01:22:18.040 --> 01:22:20.860
Alright, thank you. Mike, same question, over to you.

493
01:22:21.290 --> 01:22:39.989
So, the future could be near or far. I'll let y'all decide how far into the future I'm talking about. But, you know, in addition to sort of the personal care component that Dr. McDonald just described, I think that we will need to, sooner or later, hopefully sooner,

494
01:22:40.400 --> 01:22:50.730
evolve from the health system and its actions and approaches that are really based on standards set 150, 200 years ago

495
01:22:50.900 --> 01:22:55.190
to implementing new technologies, new approaches, new pathways

496
01:22:55.300 --> 01:23:06.419
that do a better job of meeting the needs of today and the future. I think there is a tremendous need to evolve our health system into what it ought to be.

497
01:23:06.550 --> 01:23:15.000
I still see so many examples of healthcare looking essentially like a shinier version of, you know, 1890.

498
01:23:15.190 --> 01:23:18.650
And that can't continue if we want to succeed.

499
01:23:18.940 --> 01:23:20.000
Thank you. All right, Paige, over to you. 

500
01:23:20.001 --> 01:23:37.650
Sure, at risk of potentially repeating Dr. Bell here, I think the threats of the future are not the threats of the past, and so they do require a different model and a different look. I think from the global health space, the same holds true, and so what I want to just kind of emphasize, which I don't know if I've come across with as

501
01:23:37.650 --> 01:23:54.609
of yet is just that this is another threat that is truly part of the global health security piece and the national security piece that we talk about with many other emerging threats. It might not be the thing that spreads in two days or creates an outbreak of 100 in a matter of a week.

502
01:23:54.760 --> 01:24:17.689
But it's that slow, smoldering threat that if we don't pay attention and we don't treat it as a threat, we can see it surpassing all of these other things. And so, I think we just need to continue to put the pressure on, make sure that we have these systems and platforms that really, truly benefit global health security, inclusive of, the antimicrobial-resistant threat.

503
01:24:17.690 --> 01:24:28.380
And that we continue to evolve, as Dr. Bell said, to make sure that our teams in the field are working with the ministries and doing all of the things on the cutting edge to make sure this doesn't become a bigger threat.

504
01:24:28.510 --> 01:24:30.000
Thank you. And Gwen, last word, over to you. 

505
01:24:30.001 --> 01:24:42.559
Really common threads, right? Adapt and evolve. The pathogens that we're talking about are continuing to adapt and evolve, and we have to do the same. We're seeing new and different pathogens, and we're seeing new and different ways that people are exposed to them.

506
01:24:42.560 --> 01:24:57.730
On the food and fungal side, particularly for the food side, I mean, the huge shift in rapid diagnostic tests and culture-independent diagnostic tests are things that we have to be really ready to face. They're here now. And our current systems, like you said, we can't keep doing the same things that we've been doing.

507
01:24:57.730 --> 01:25:17.110
And on the fungal side, looking at some of the options that we're going to have, I think we're on the cusp of a lot of changes with serologic and metagenomic approaches. And, as you were talking about, being able to use the microbiome for prevention efforts. So, I think we have a lot of exciting things coming in, but we have to maintain that flexibility, that adaptability.

508
01:25:17.110 --> 01:25:27.219
And a lot of that takes continued resources and dedication. So, between having the right resources and having the right people at the table, I think it's going to be a lot of work, but really exciting work.

509
01:25:27.480 --> 01:25:42.159
Thank you for that. And thank you to all of you for both being here today, and for the work your centers and divisions have led, not just over the past 10 years, but for many decades here at CDC. We are all safer and healthier because of that work.

510
01:25:42.830 --> 01:26:01.170
Before we close out today, I just want to take a minute and thank every person that has joined us live here today or may be watching this recording in the future. And I also want to thank our partners. We've had a chance today to highlight just a few of the critical partnerships that have been established and strengthened over the past decade.

511
01:26:01.170 --> 01:26:04.980
And none of this would have been possible without you.

512
01:26:05.550 --> 01:26:24.110
And last, but absolutely not least, I want to thank every person at CDC that's working to combat antimicrobial resistance. So, we could have taken a whole day and talked to every division and office working on this project, but unfortunately, I feel like we would have lost a lot of our audience during that point.

513
01:26:24.110 --> 01:26:41.960
Thank you to all of the subject matter experts and scientists, laboratorians, epidemiologists that lead these programmatic efforts. Thank you to the policy, communications, and partnership staff across the agency who work on raising that awareness about antimicrobial resistance.

514
01:26:42.060 --> 01:27:00.609
And thank you, absolutely, to all of the management and operations staff at the agency. Without their efforts, implementation of this work would be impossible, and so we just want to say a huge thank you to everybody that helps us use the resources we have most effectively and reach the populations that we're trying to reach.

515
01:27:01.890 --> 01:27:20.689
Last thing I want to say is that you will receive a survey for joining today's webinar. We appreciate it if you take just a minute to fill that out. We want to make sure that these AMR Exchange webinars are bringing you the information that you're finding most helpful in the ways that are most easily accessible to all of our partners.

516
01:27:21.100 --> 01:27:30.200
Looking forward to continuing the work that we've all started to sustain this domestic and global infrastructure to combat these threats. And thank you all.