August 14, 2013 | 3
Remember the story of the elephant and the blind men? I feel I am revisiting it whenever I go back and work another stretch in the hospital as an infectious diseases physician. There are great articles giving a broad overview of the rise in antibiotic resistant organisms, especially Carbapenem resistant enterobacter, written by Maryn McKenna, Helen Branswell, and Laurie Garrett…but as an infectious disease physician, I wish I could better convey what it is like, being in the trenches caring for such patients, and why we are losing this battle.
Resistant organisms have the upper hand, in part, because there are too many competing, often disparate interests. These include the conflicting interests of patients, families, hospitals, nursing homes and lawyers. There is also an enormous lack of communication between these groups. Further complicating matters are the hodgepodge of conflicting regulations.
For example, Maryn notes that in Israel, considerable success was achieved by a country wide system of tracking patients with multi-drug resistant organisms, so that they could be identified and appropriately isolated on admission. Similar attempts in hospitals I am familiar with in Pennsylvania and Maryland have met with varying/little success. Some hospitals were reluctant to screen high-risk patients, knowing that nearby nursing homes were likely to refuse admission due to the added costs and burden of caring for isolation patients. Similarly, it sometimes felt like the nursing homes were playing “Hearts” and passing on the Queen of Spades, neglecting to mention that a transferring patient harbored an multi-drug resistant organism (MDR).
My nursing home visits to do consults have also shocked me. While we were careful to isolate patients within the hospital, I learned that a different set of rules applied to nursing homes. There, a patient’s room is considered their home, and they cannot legally be transferred to another room without their permission. This makes it very difficult to cohort, or place patients with a specific type of infection, in limited areas of the facility and with dedicated equipment and staff. While in-hospital isolation patients are generally confined to their rooms, in rehab units (even within a hospital) or nursing homes, the patients comingle, sharing equipment, which might then transmit the bacteria to others. Except in extraordinary circumstances, nursing home patients cannot be confined to their rooms, as it is considered an infringement of their rights.
Even within hospitals, busy emergency rooms often ignore isolation precautions, with contact precautions instituted only after the patient is admitted to the hospital floor.
There are philosophical differences, too, in approaches to patient care that I’ve mentioned before. There are those physicians who seem to regard it as a personal failure if a patient dies, and who refuse to honor advance directives, essentially by saying that there is always hope for improvement. There are families, often who have been estranged and neglected their “loved one” for years, who suddenly appear and insist that “everything be done” for—or, more realistically, to—the patient.
It seems that each time I work now I see patients with infections that are more and more difficult. Now they are not just hospital-acquired infections. Some occur in anyone receiving healthcare, or caring for an ill family member. Increasingly, we have to commit patients to having long-term intravenous antibiotics, because no oral drugs are effective. Such patients either have to have extensive support at home or are institutionalized in a nursing home for the duration of their therapy, putting them at risk of new nosocomial infections and complications from the in-dwelling IV catheters themselves.
We often have to use colistin now, an extremely toxic antibiotic, for the CRE organisms. I haven’t used it often, but have yet to see anyone recover who has received it. Colistin causes renal failure, leading to the need for dialysis and subsequent complications.
Because of pharma’s profit incentives and the financial motivations, which almost exclude any other considerations, there are almost no antibiotics in development. Further, the limited supply of effective antibiotics are being squandered on agriculture, unnecessary treatments for colonization or superficial infections (likely to not require any treatment) and on futile care.
I would love to see the IDSA (Infectious Diseases Society of America), the American College of Physicians, and other medical groups engage in a serious discussion of antibiotic stewardship and limiting use of some classes of antibiotics. For example, should we continue to aggressively treat patients who have no likelihood of recovery, knowing that they are a breeding ground for multi-resistant organisms that threaten the community? When millions lack access to basic healthcare, is it appropriate for the government to invest so heavily (Medicare and Medicaid) in futile, aggressive, and extraordinarily expensive end-of-life care?
Sometimes I think development and appropriate use of antibiotics should be treated as a national security issue rather than an open market free-for-all. Then I come back to the realities of decision-making and politics here in the US…in the meantime, I will continue to try and remind myself that my role in the ICU or long-term care has become that of a technician, rather than a holistic physician. And I will continue to practice, buoyed by wonderful and often inspiring patients, and by my fascination with the ever changing world of infectious diseases.
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