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.
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.
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
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