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March 6, 2013
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Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.
Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.
Klebsiella
Great posts have been written about the “end of antibiotics” and superbugs in a variety of flavors.
Yesterday, the CDC issued an alarming warning about Carbapenem-Resistant Enterobacteriaceae, aka CRE. The enzyme that produces the antibiotic resistance, was first identified in 2001 from an isolate of Klebsiella. According to the new CDC report, in a 2012 survey of US hospitals, “181 (4.6%) reported one or more infections with CRE (145 [3.9%] in short-stay hospitals; 36 [17.8%] in long-term acute-care hospitals” LTACs).”
The background for the resistant bacteria’s emergence and spread across the country is well described by Maryn McKenna and Liz Szabo/USA Today (with a great infographic), and won’t be repeated here.
I want to share my perspective as an infectious disease practitioner who cares for patients with these infections regularly. As I have mentioned more privately, there are cultural issues driving the emergence of resistance, especially in the U.S., first with MRSA, then VRE, and now with CRE. Warning: my observations may not be politically correct—but they reflect 30+ years of patient care. These include:
— The belief many have that people will live forever. There used to be more of an acceptance of death. But with television/movies portraying advances in medicine unrealistically, the public now often has an expectation that their loved ones will not die. Some seem to feel that any death must be a result of medical error, and there are a number of malpractice attorneys vying for their attention with aggressive advertising reinforcing that belief.
— Pharmaceutical companies and their sales reps push doctors to use the latest wonder drugs. If a physician uses older agents, s/he is likely to be portrayed as not keeping up to date with medical advances.
— Individual “rights” above all. Physicians and families focus on the possible benefit for one patient, with little or no concern as to public health implications of treatment. This sounds harsh, but should we reconsider treatment of nonviable patients for the good of the community. This warrants thoughtful discussion.
In the hospitals where I work, patients with superbugs tend to be admitted from LTACs or nursing homes. Many of these patients are comatose and have been unresponsive for years. Some are more recently poorly responsive, often from head injuries or strokes. Common denominators are presence of urinary catheters, feeding tubes, tracheostomies (breathing tubes), and often multiple bedsores. And commonly, the families want “everything” done, no matter the cost to the patient in terms of pain and suffering, or to society. (They may never even come to visit their “loved one” but are insistent with their demands for aggressive care). Living wills may not be honored—and certainly won’t be if any family member objects. And then there is the whole “sanctity of life” argument…that results in flogging patients with no likelihood of recovery…torturing them, it often seems.
I’ve cared for patients with these superbugs. First, it was MRSA, then VRE, and now these multi-resistant gram negative bacteria, CREs. Here is an example of a report from one patient.
Antibiogram: Notice that the only antibiotic that the Acinetobacter is susceptible to (S) is colistin. The bacteria is resistant to everything else. The Proteus also is resistant to many antibiotics.
And here’s what the Acinetobacter resistance looks like nationally.
In the past couple of years, I’ve started to have to use an old antibiotic, polymixin (or colistin). There are no other options. It causes renal failure and results in the need for dialysis. While I only work part-time now, I have yet to see a patient get better and leave the health system after receiving polymixin.
The hospitals I am familiar with—one in particular—are extraordinarily careful. They are proactive in screening high risk new patients for CRE, MRSA, and VRE, and are very careful with isolation…yet breaches of isolation occasionally happen, due to medical emergencies or human error, especially as staffing is spread more thinly. There are tangible costs to the screening and isolation, but there are more intangible ones as well—it is a burden to health care practitioners to don gowns, masks, gloves, and booties when entering a room, and for the nurses, to be so attired for extended periods of time. Patients tend to get attended to less often, and to feel more isolated.
Overseas, many important antibiotics are sold over-the-counter. Here, they are squandered as growth-promoters, or marketed aggressively and unrestrainedly. At the same time as antibiotics are being misused, which leads to increasing resistance emerging, there is little incentive to develop new antibiotics, as they are only used for brief periods of time. Pharma is far more interested in the next “me, too” drug for “Low-T” or hypertension—drugs that will be taken for years—rather than one prescribed for only a week or two.
So we breed more and more resistant organisms, and squander the few good antibiotics we have left—in the name of being “pro-life” and pro-individuality. We should have restrictions on “antibiotic last rites” with specific indications for use of some antibiotics. Until there are restrictions on antibiotic use—saving them as a national security treasure—and requirements to use them judiciously, we will never control antibiotic resistance.
Suggested reading:
Maryn McKenna: ‘We Have a Limited Window of Opportunity’: CDC Warns of Resistance ‘Nightmare’
Liz Szabo and Peter Eisler: CDC sounds alarm on deadly, untreatable superbugs
The CDC’s report: “Vital Signs: Carbapenem-Resistant Enterobacteriaceae,” MMWR, March 5, 2013. 62 (Early Release);1-6
Eli Perencevich: KPC, CRE, MDR-GNR: Call ‘em what you will, but call for a national response!
The Center for Disease Dynamics, Economics, and Policy
Credits:
“Molecules to Medicine” banner © Michelle Banks
Klebsiella-wikipedia
About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.
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let me get this straight. instead of fixing the lack of research which i dont completly agree there is just google new antibiotic research and theres quite alot. you want to almost ban antibiotics that already have created resistent bugs? soooo after the fact. and im sure many stains come from old homes but alot of it is coming from misuse in cattle which no one in the medical feild is considering and blaming it the public instead. when taken right it shouldnt produce new strains. the over use in cattle, it being in the water supply, not finishing it, perscrbing the wrong antibiotic, all should be looked into. find away to increase research and find a antibiotic that works differently then the tradtional ones while ur at it.
Link to thisThe irony is not lost on us, that Scientific American publishes a post on drug resistance, when both America is the largest user and also science demanded and enthusiastically embraced drugs use in animals, when other countries said it would be bad idea…but had to follow suit.
I bet if you look back at prior issues of SA youll find studies in it extolling the use of drugs in farm animals to gain weight and reduce infections, increasing yields.
Link to thisIn addendum:
All the studies that were produced on drugs use benefits in animals, i wonder how many had the negative of drug resistance listed. I bet a theme would emerge about who sponsored the papers and the results omitted from the paper.
Perhaps its time to stop publishing papers in ALL reputable journals, where results and implications are omitted.
Link to thisThanks. Animal use of antibiotics has been widely written about, particularly by Maryn McKenna, and was not intended to be the focus of my piece or observations.
Link to thisI did note that “Here, they are squandered as growth-promoters…,” which seems to have been overlooked by some readers, as the prior one. Agree it is a major problem–just not what I was focusing on.
Dr.Stone, this is music to my ears. Nurses seem to understand these dilemmas quickly because we are the ones caring for (=torturing) the poor patients who should be allowed to die a natural death. We sure do have issues with denying the inevitable fact of death in this culture. I wish more doctors would catch on — but then dead people don’t sue — family members do.
Link to thisOn a societal level, I don’t think we can fix MRSA without re-examining prisons. Not sure about other resistant bugs, but the way a single MRSA strain goes endemic in a prison? Ugly.
As far as hospitals, I am personally rather annoyed we couldn’t scrounge up funding for me to study the specific strains of MRSA floating around out med center. There’s 3 million dollars in hospital insurance rate for screening patients for MRSA… and no money for subtyping those strains to see if they are all the same. You can be as “careful” as you want about screening incoming patients… but if you’ve got an endemic strain that’s being passed around from patient to patient (much like in a prison), hospitals don’t seem to actually want to know. Maybe they’re lawsuit-phobic, maybe they don’t have the staff to fix the problem… but there just seems to be this enormous culture of an ostrich approach of ignoring it and hoping it will go away.
Link to thisThank you. I don’t know how nurses can do what they do…I know many feel guilty over “torturing” patients, especially when the family does not bother to visit. Many doctors agree, but are extraordinarily, and justifiably, concerned both about liability and about being second-guessed. There is extreme pressure, for example, to place PEG feeding tubes, rather than letting someone die in peace, because “Quality” reviewers are likely to question that. (Similarly, I am still angry with the ICU doc who refused to give my mother more morphine as she was dying–and told me this–because he was afraid as to how it might look on a chart audit.) So much of what we do is to patients, rather than for them, because of fear. Thank you for understanding and advocating for patients.
Link to thisTotally agree about prisons. Sorry you didn’t get funding. Undoubtedly one of the things fueling TB in prisons as well is the poor ventilation and crowding. I was told by one prison warden that the ventilation/oppressive heat was not improved so as not to be seen as “coddling” the prisoners, infection control and community health be damned.
Link to thisI do think that one of the problems is fragmentation among many planners–at the risk of being politically incorrect yet again, many “opinion leaders” are academics who are far removed from the trenches and unaware of problems that practitioners see regularly. Yet practitioners, such as myself, have no voice because we are not “academic” enough to have opinions worthy of consideration. So multi-faceted problem, with some of the players being oblivious to each others’ concerns.
The United States national debt is 16.7 trillion dollars. We cannot keep spending money to keep old people alive for a few more months. We are burying our children in debt.
Link to this‘Fraid I disagree with you on this one. For me, the issue is not–nor should it be–just age. It is mental status and the quality of life vs. suffering. It is maintaining people with no likelihood of recovery with extraordinary care, such as chronic ventilators and dialysis, when they appear to be vegetative with no likelihood of recovery. We have the resources. We squander them on many other unnecessary things.
Link to thisAs far as hospitals screening patients for MRSA,ORSA, and VRE, we do it on admission (you might be surprised how many patients come in as carriers) and at least every week, unless we have reason to swab sooner. We do our level best to contain it but it is EVERYWHERE and caring for patients is a contact sport….not to mention docs that don’t wash hands, laundry collectors, housekeeping, and all the other ancillary services that are in and out of rooms. Unless you set up a separate unit (as we once did for Acinetobactor, you are pretty much doomed to share your germs with everyone. (And I’d be willing to bet the number of MDs and RNs that are carriers is also pretty high.)
Link to thisthanks for your perspective. It’s appalling to me to think that someone’s end of life directives can be over-ridden, but the point that families are the ones suing is fair. Sigh. It seems so much bad medical care stems from a (completely understandable) CYA philosophy. I wish it were different.
Link to this