Antibiotics are too cheap

It's a common trope to bemoan the lack of resources that pharma companies put into antibiotic development. But why should they, when so much more money can be made in other fields? The newest example can be found in the excitement over Xofigo, which increases median survival in metastatic prostate cancer from 11 to 15 months. A positive step, but calling it a "big deal", as the Cleveland Clinic's Robert Dreicer did, speaks more to how awful most cancer treatments are.

The cost? $69,000, fully reimburseable by insurance. And the side effects? 47% serious adverse events vs 60% for the standard treatments. This may be the best thing out there, but it is still a terrible drug by any objective standard.

Compare this to the performance of anti-MRSA drugs. Without antibiotics (or inappropriate ones) the 30-day mortality for bacteremia is > 80%; with appropriate antibiotic treatment it is about 25%. Serious adverse event rates are typically a few percent. Drug costs are some $120 for vancomycin, and 10 times that for daptomycin, which is considered to be scandalously expensive.

It would be nice if pharma companies were willing to spend hundreds of millions of dollars to develop a drug that they can sell one time for a hundred dollars; but we don't live in that world. The fault is ours: we fear cancer and are willing to spend almost anything to hang on, sick and miserable, for a few additional months. We don't fear bacterial infections nearly enough, it seems.

Antibiotics are too cheap. As Laurie Piddock put it: "The price of antibiotics needs to relate to their value to society and should not relate to the price of previous products." Until we begin to value a life lost to infection as highly as a life lost to cancer we can expect to see little investment in new ant-infectives.

 

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Why there aren't more antibiotics

Well, there are more reasons than can be covered in a single post, so I'll start with just one: economics. More specifically, return on investment. And the economics here, as in so much of medicine and health care, are driven by fear rather than by a rational cost-benefit analysis.

Antibiotics have been so good for so long, that few people fear losing a life they cherish to a bacterial infection. Antibiotics are one of the few medicines that reliably cure people rather than just alleviate symptoms or slow disease progression. And they do it with so few side effects that doctors feel comfortable prescribing them just in case they might actually be helpful, or to make a patient feel like they are being treated. In other words they are used as both prophylactics and placebos, as well as effective treatments for specific diseases. I can't think of any other class of medication that answers to this description.

And they are cheap. A daily dose of vancomycin costs about $10, and it will reduce the mortality rate of systemic MRSA infections from about 80% to 30%. Think about that - for a couple hundred dollars, patients go from near-certain death to a decent chance of a full recovery. Daptomycin, at around $120/day, is considered a very expensive antibiotic, prescribed reluctantly for MRSA by some physicians, even though it will give better outcomes for some infections.

For perspective, compare these costs to those of the newer targeted cancer chemotherapies: $50K (and higher) for treatments that make patients miserable and extend life by weeks or months at best.

Any rational analysis of life-days saved by the most expensive antibiotics would conclude that they are more valuable than targeted cancer chemotherapies by at least a factor of ten. A rational market would price them accordingly, attracting more investment into new antibiotic R&D.

But that's not likely to happen, and the chief reason is fear. Because antibiotics have been such good drugs (and cancer drugs have been such bad ones) we don't fear death from bacterial infections nearly as much as we fear cancer. The result is that cancer has been romanticized. Think about how many book, movie and mini-series plots are driven by a battle with cancer; how cancer patients are encouraged to view their illness and treatment as a hero's journey; and how we as a society have declared war (the most romantic pursuit of all) on cancer.

There's no mystery here about the economics of antibiotic development - they stink. Drug companies are much better off putting their resources into drugs they can charge stratospheric prices for (ie cancer treatments) or ones they can keep patients on for life (like statins). Drugs that are cheap and actually cure people in a couple of weeks are just not going to be on their radar.

 

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