Considerable attention has been given to this week’s news about hospital (healthcare) acquired infections (HAI) at NIH with a “superbug.” *
There has been probably misplaced criticism of NIH for not making its finding of transmission of a bacteria between patients public, as well as wonder at the high-tech tools that enabled NIH to track down this killer organism.
These articles all overlook the more basic underlying problems, which I am aware of because of my practice as an Infectious Disease physician.
These relatively new, highly resistant strains of bacteria—carbapenem resistant Gram negative bacteria as Klebsiella and Acinetobacter—are not just at NIH. This is a widespread problem throughout much of the country.
I am called to treat highly resistant bacteria like this regularly. These isolates are relatively common in nursing homes and LTACs (long-term acute care centers, often used for patients with prolonged need for ventilator care), and are transferred to hospitals when these more chronically ill patients are transferred to a hospital for an acute problem. In some of these long-term care settings, the resistant bacteria becomes endemic, and the centers become breeding grounds and reservoirs for resistant organisms.
There have been marked attitudinal changes in this country that I have witnessed over the past 30+ years I have cared for patients, fueling the emergence of resistant organisms.
First is the unrealistic expectation in the U.S. that people will live forever, if only enough technology and resources are spent on them.
A corollary is that we almost never letting anyone die in peace. Even if a patient has a living will and has made their explicit wishes known, too often a family member (and sometimes, physicians as well) will challenge the decision to allow a natural death. And ethics committees and state regulations tend to err on the side of treatment rather than acknowledging that care is futile and against the patient’s wishes. So we throw more antibiotics at the patient, because of this “obligation” to continue treatment…and the bacteria become more resistant and the healthcare workers more burned out.
Combine the burnout and emotional toll on healthcare workers of providing futile care day after day with short staffing in the name of cost savings, and you have a recipe for further transmission of infections between patients.
The NIH story is but the tip of the iceberg. Until the issue of futile care is addressed and there is consensus regarding the “community” good vs. an individual’s “right” to care, no matter how futile nor what risk that poses to others, we will not win this battle against increasingly resistant bacteria.
(Note: I will expand and add references when time permits; I'm traveling.)
Gina Kolata: Genome Detectives Solve a Hospital’s Deadly Outbreak
Deborah Blum Hunting a Superbug
Updated links: I had missed seeing:
Eli Perencevich Not a failure, a lesson. The NIH Clinical Center KPC Outbreak
There has been much needed and interesting discussion since I posted yesterday. As a practicing Infectious Disease physician regularly confronted by caring for patients ill with multi-resistant organisms, two articles particularly resonated--that of Dr. Perencevich, above, and Maryn McKenna's The 'NIH Superbug': This is Happening Every Day. Her title captures the key point and of much of what had been troubling me; that this is all too common an occurrence. As she notes:
"If I had to distill what bothers me most about what I read this week, it is that much of the coverage was either a villain story (hospital permits deadly infection!) or a hero story (genomic detectives save the day!) But in fact, the story of CRKP is neither. It is a story of systems breaking down. As a topic, systems are deeply undramatic. But unless we start paying more attention to systems — for research funding, for disease surveillance, for drug development; for addressing, in an organized way, the accelerating loss of the antibiotic miracle — the result will be deeply dramatic: more outbreaks, and more deaths."
Hopefully, because the focus of these concerns is on the prominent NIH, there will be ongoing discussion of the conditions that lead to the development of these resistant "superbugs" now, and perhaps progress on all these fronts.
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Klebsiella pneumonia isolate image: CDC via Wikipedia