The MRSA Map

Dr. Joan Casey

Green acres may not be the place to be.

When Joan Casey was a PhD student she started reading up on the idea that antibiotic use in our farm animals might be making us sick. Research over in Europe told her that MRSA was traveling from pig farms to people, and she wanted to know if the same thing was happening here. Five years later, and now on staff at the UCSF School of Medicine, she believes it is.

Her research (on FRONTLINE) led to Pennsylvania farm country. Using data from about 160 million electronic records on about 450,000 patients in the region, her team found that (1) total MRSA from 2001 to 2009 went up every year, and by as much as 34% (2) people living closer to these farms and to the crop fields that are located nearby were about 38 percent more likely to have a MRSA infection than people living farther away, and (3) the people getting MRSA are not like the ones who used to get it. They’re not old and sick; they’re young and they’re healthy.

Casey’s team put together a map of their findings. Each red dot is the home address of a person that had a MRSA infection. The blue bits are the pig farms.

Now for the tricky part. Industrial farms are an easy target. We know they ply our food animals with antibiotics, not to cure disease, but because antibiotics accelerate growth. So you have a ready to slaughter animal in much quicker time thus saving owners money on feed and care, which in turn keeps the price of our (expensive protein) food down – just the way we like it.

But at what cost? Joan Casey says innocent children in rural Pennsylvania are getting hurt (google “MRSA infection” images) so you can eat cheap meat.

Sacrificing others so we can live comfortably is nothing new. The link between child labor, sweatshops, and affordable goods and clothing, for example, is well documented.

As population numbers rise and land and fresh water become scarce, the demand for cheap food will increase, implicitly egging on whatever our industrial farms can do to provide us with affordable meat. As if that isn’t enough, our new global inconvenient fact, climate change, portending even less arable land due to drought and flooding leading to food shortages, will put further pressure on this industry to cut corners.

Dr. Joan Casey has shown us where that leads. The question for us is whether we will follow.

The Global Village of Infectious Disease: The Beat Goes On

Ever since it became known that Ebola virus disease was in Dallas, Texas, it has been front page news. That remains the case even though health authorities agree it won’t spread to any significant degree, for example, outside of the patient’s immediate family.

But authorities agree on something else too, something vastly more important, because, unlike Ebola, it’s likely to affect you and me: the fact that infectious diseases of all kinds are growing – and moving – worldwide. That is the real takeaway from the Ebola outbreak; from the SARS outbreak before that, and from HIV/AIDS before that – we in North America are not only not immune from the trend, we’re in the crosshairs.

Scientists figured this out at least 6 years ago, and just 3 graphics help us understand the story. The first is a map of the regions of the world where there is a high risk for future or emerging infectious disease events to occur. Notice the prominent role of the US and Europe:

The next point is that not only are infectious diseases on the move, they’re becoming increasingly resistant to standard antibiotic treatment; for example:

And what’s one of the biggest reasons for all this? Global air travel:

Where we and our air cargo go, the bugs go, as we witnessed with the man who brought Ebola from Africa to Texas. We saw the same thing happen with the spread of SARS in 2003 and the pandemic influenza of 2009, where the rapid global spread of disease occurred through major travel hubs.

Today, our world population is just over 7 billion people; by 2050 it’s estimated to be 9 billion, suggesting these disease trends will continue. But there’s one more thing that we haven’t even touched on that may have the greatest impact of all: climate change. Our best scientists agree it will affect the spread of infectious disease – but exactly in what ways, is the (epic?) story yet to be told.

Ebola Lands in Dallas, Texas: Welcome to The Global Village

Okay, the Ebola virus is here, and yes, that really matters – but probably not for the reason you’re thinking.

It landed in Dallas, Texas, on a flight from Africa on Friday, September 20th. The person in whose body Ebola hitched a ride began showing symptoms on September 24; on September 28 he was hospitalized and is reported to be in critical condition.

The crucial medical fact about Ebola is this: it can only be transmitted when the patient is sick and showing symptoms and even then only though direct contact with that person’s body fluids, notably blood, vomit, or excrement. Healthcare workers, therefore, need to be very careful, as the African experience shows. But the rest of us will be okay: “I have no doubt that we’ll stop this in its tracks in the U.S.,” says Tom Frieden, Director of the Centers for Disease Control and Prevention. So a local, internal spread of the virus isn’t really the issue.

There is, however, a deeper concern: Is the fact that Ebola made its way here a one-off, or does it portend a future where all bugs, especially those resistant to to antibiotics, although once geographically limited, now have a global reach?

The evidence overwhelmingly supports the latter view. Disease, like us, and because of us, is on the move everywhere; thus: “A disease outbreak anywhere is a disease risk everywhere,” says Dr. Frieden. That is because international travel has grown dramatically and it’s estimated that one billion people are travelling every year, most of them by air. In fact, worldwide tourist travel alone is expected to almost double over the next 15 years:

Since flights take people half way around the world in less than a day, that is well within the incubation period of many infectious diseases. That is why long-distance travel of persons and materials has long been recognized as a factor that drives the emergence of infectious disease; and now, increasingly so, as population levels rise.

The other thing is that germs don’t just attach themselves to people. Like you and me they hitch rides on airplanes too. For example, MRSA, the flu virus, E Coli, and diarrheal bugs are found throughout a plan, as this CNN report tells us. Moreover, the bugs will hang out in the plane for days: MRSA, which kills more than 11,000 Americans every year, was found to last 7 days on the seat pocket, 6 days on the armrest and seat, 5 days on the window shade and tray table, and 4 days on the toilet handle of planes.

The upshot of all this is well put by Dr. Cesar Arias, professor of medicine at the University of Texas: “Bugs don’t have passports. They don’t respect borders. They can travel very easily. And, in fact, this has been shown for MRSA.”

Notice that it’s not just MRSA that’s a frequent flyer. All the bugs on the graphic below – and many more – are joining the club every day.  Welcome to the Global Village of infectious disease.

Seeing the World in New Ways

It seems we humans don’t quite understand our place in the world.

“Everything that you can actually see with your eye is just the smallest sliver of life on this Earth,” says Bonnie Bassler, professor of microbiology at Princeton University, in the New York Times video, “Seeing the Invisible,” posted below. “Most of life is invisible,” she says. “We still have this idea that we’re the most central feature of Earth, [yet] it’s the humans that are the bystanders. But now we get [that] most of life is microbial. If you look at the Tree of Life, only this tiny little part is every single thing you’ve seen.”

In all of life, only Animals, Plants, and some Molds and Fungi can be seen by us (top right). This causes us to overvalue our role in the world and grossly undervalue the role unseen organisms play in our daily lives.

Dr. Bassler continues: “Every higher organism is covered inside and out with bacteria. And humans would not be alive if [if it weren’t for] these little 24/7 partners. And they have all kinds of fabulous behaviors.” For example, they talk (do they gossip?). “We discovered that bacteria can communicate using a molecular language. We used to think that social behaviors were the purview of higher organisms. What we now understand is that bacteria were probably the first organisms on this Earth to ever communicate with one another.”

But why are we “covered inside and out with bacteria”? Should we try and get rid of them? To the contrary; the new understanding is that we need them to be healthy: they aid digestion, build nutrients, and help us fight disease – and more.

Remember, Dr. Bassler described bacteria as our “partners.” And just like when we mistreat our human partners, when we mistreat our bacterial partners, we will pay a price, and a heavy one at that.

A virus that eats bacteria. If we could see these things, would we take infectious disease more seriously?

A case in point is our misuse of antibiotics – poisons – which attack all our bacteria, not just the bad guy, much like cancer radiation therapy attacks all cells not just cancerous ones. So instead of being left, say, bald, weak, thin, and nauseous, we are left more prone to infection, obesity, childhood diabetes, food allergies, celiac disease, and even cancer.

A leading exponent of this new science is Martin Blaser, MD, professor of medicine at New York University. It’s all laid out very nicely in his well-received 2014 book “Missing Microbes: How the Overuse of Antibiotics is Fueling our Modern Plagues.” The “plagues” being the above-mentioned diseases.

The overuse of antibiotics is also driving the rising tide of antibiotic resistance, the idea that we’re going back to a pre-penicillin era because bacteria have  figured out how to outsmart our antibiotics. That matters because, for example, more than 200,000 patients get infections every year while receiving healthcare in Canada and more than 8,000 of these patients die as a result. In the US, where they track individual pathogens, methicillin-resistant Staphylococcus aureus (MRSA) alone (one of many “Gram positives,” on the Tree of Life) causes more than 80,000 severe infections and more than 11,000 deaths every year. So without antibiotics, where will we be?

The solution to this global crisis, says infectious disease specialist Brad Spellberg, MD, will only come if we change the way we think about our microbes: “This whole thing about winning the war against microbes … nah! We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!”

In other words, when it comes to understanding our place in the world we are not who we think we are – and neither are they.

The invisible world made visible:

Overcoming the Disadvantages of Topical Antibiotics is Necessary to Achieve Universal Decolonization

Disinfecting the skin prior to surgery has long been a standard of care. Whether with iodine, chlorhexidine washes or other antiseptic surfactants, reducing the bacterial load on the skin surface has been established as an important mechanism to control the rate of post-surgical infection. The nose, which is a warm, moist environment ideal for bacterial growth, however had been difficult to decolonize.

Up to 30% of patients are carriers of Staph aureus. Colonization rates of the serious antibiotic resistant version of Staph aureus, known as MRSAid (one of the 3 major superbugs), range from 2% in Canada to 80% in Shanghai. Ordinarily, these pathogens do not impact patients until they are weakened by illness or surgery. Post-surgical infection is a risk for patients colonized with this pathogens and therefore has led to the need for removing or reducing the bacterial load carried around by these patients just prior to surgery.

In several studies, the nose has been identified as the key reservoir of Staph aureus and MRSA, representing 40% of the bacteria load in one small area. Because the nose is not washed on a regular basis, unlike other body parts, Staph aureus can easily flourish in the nose and become a source of contamination for other body parts. Because of delicate mucosal tissue and the presence of cilia in the nose, the antiseptic washes used for hardier skin surfaces are not appropriate for use in the nose. Instead, nasal decolonization has been done by topical antibiotics such as mupirocin.

Topical antibiotics have 3 significant disadvantages that have resulted in many infection control experts rejecting pre-surgical nasal decolonization protocols. With sub-optimal patient compliance, infection control experts fear the resulting antibiotic resistance formation brought about by sub-optimal doses of antibiotics that occur when patients stop mid-way through their antibiotic treatments. Poor patient compliance, despite advisories about the severity of MRSA and Staph aureus infections, is the leading disadvantage of antibiotics.

The problem is the inconvenience and unpleasantness of antibiotic creams in the nose. Patients are known to dislike the Vaseline™-type viscosity of mupirocin and often do not comply with the 3 times a day for 5 days treatment protocol. Incomplete doses of antibiotics leads then to antibiotic resistance which in turn adds to, not subtracts from, the risks already present with patients colonized with Staph. This is the primary reason why many hospitals have not opted for nasal decolonization protocols despite the 30-40% reductions in surgical site infection rates demonstrated in clinical trials.

The second disadvantage of antibiotics is the time required to decolonize. On average, decolonization using topical antibiotics requires about 5 days which implies that patients need to be screened and identified early enough for the efficacy of antibiotics to kick in.

The third disadvantage of antibiotics, however, is the inconvenience to patients and the costs to the health care system to culture for and identify Staph aureus and MRSA carriers.  Because of antibiotic resistance concerns, only carriers of Staph and MRSA are given nasal decolonization therapy. New rapid diagnosis technologies have emerged, but prior to Photodisinfection, there was little acceptance of these rapid diagnostics because antibiotics, the decolonization remedy, still required 5 days treatment for effect. The saving of 2-3 days prior to a 5 day treatment protocol did not justify, to many, the additional cost of same-day rapid diagnosis.

Technologies that overcome the disadvantages of topical antibiotics and allow for universal nasal decolonization are going to play an important role in health care associated infection control. These technologies must not generate resistance, must be safe for all surgical patients, even if they are not carriers of Staph aureus or MRSA. Finally, these technologies need to be easy to use, easy for patients to tolerate and fit well into the pre-operative work flow.

The Black Death Has Shut Down a City in China, and Struck 4 People in Colorado – and That’s Just This Month.

Yes, that Black Death, also known as The Bubonic Plague, or simply “the plague,” has hit Yumen, a city of about 30,000, in NW China this month. On 16 July it killed a 38 year old man and as a result health authorities had to quarantine 150 other people. They also sealed off Yumen by setting up police roadblocks around its perimeter, stopping people from going in or out. China Central Television announced that the city has enough rice, flour and oil to supply all its residents for up to one month.

This is the same plague that was responsible for one of the most devastating pandemics in human history, causing the deaths of an estimated 75 to 200 million people, peaking in Europe in the years 1346–53, killing 30–60% of its population and reducing the world population from an estimated 450 million down to 350–375 million. All of which explains China’s swift response.

Unfortunately, the plague has not been relegated to the history bin nor is it confined to northern China. In Eastern Colorado, for example, at the beginning of the month, 4 adults were infected by the plague. They are believed to have contracted it from a single source, a dog, who died from it.

Since 1957, 60 human cases of the plague have been identified in Colorado alone, and 9 were fatal. Although human cases occur infrequently, the plague is severe and potentially life-threatening if not quickly treated with antibiotics.

The following graphics show us the extent of the problem at home and abroad:

So both the good news and the bad news is the same: antibiotics are needed to treat bacterial-based diseases such as the plague. The reason this is bad news is that our world leaders in health — e.g., the World Health Organization, the US Centers for Disease Control and Prevention, the New England Journal of Medicine — have sounded the alarm on the growing global crisis of antibiotics resistance. The Lancet puts it this way: “[W]e are at the dawn of a post antibiotic era,” with “almost all disease-causing bacteria resistant to the antibiotics commonly used to treat them. In other words, antibiotic-resistant bacteria, like the proverbial time bomb, are poised to wreak infectious havoc on a worldwide scale.

The global nature of the pathogen problem can be seen in the graphic below. Notice, though, it under-represents the problem because, for example, it doesn’t include current or recent epidemics such as C. difficile and MRSA in the US, Ebola in West Africa, not to mention the recent appearance of the plague.

Now imagine life without antibiotics – what then? Scientists warn us that even the 14th century plague bacterium could develop drug-resistance and become a major health threat. In 1995, for example – before the global development of antibiotic resistance – a new multi-drug-resistant form of the plague was found in a 16-year-old boy in Madagascar. The strain developed resistance to 8 antibiotics including streptomycin and tetracycline.

We don’t know which one (or more) of the multitude of microbes that live among us will develop resistance and become a runaway pathogen: who, for example, would have ever guessed the plague pathogen?

What the authorities are telling us, however, is that our 70 year old antibiotic shield has been permanently pierced. Leading organizations such as the Harvard School of Public Health also agree on the one thing above all else that we, the people, need to do: it is this.

Get Ready for the Sea Change in how we Think About Our Microbes and Therefore How We Treat Infectious Disease

Every so often someone comes around that changes the rules of the game, changes the very way in which we think about a subject. In medicine, in the world of bacteria, antibiotics, and the global crisis of antibiotic resistance, that person is the impeccably-qualified clinician-researcher Brad Spellberg, MD, Chief Medical Officer, Los Angeles County and University of Southern California. This is a man who possesses a unique blend of experience, youth and energy, and professional heft. In other words, he is not a dreamer, he’s a visionary, and he and the colleagues he runs with are on the leading edge of thought that I hope will transform infectious disease medicine, and more.

Excerpted below is what he said earlier this year during a panel discussion at an Institute of Medicine seminar, “Antimicrobial Resistance: A Problem Without Borders.” As you read what he has to say keep in mind that biological principles generalize, not just across organisms but also across species, up to and including the “highest” ones. What he says about the needed paradigm shift from one of war to one of peaceful coexistence is profound. And it took him all of 2 minutes to say it:

Brad SpellbergI like to go back to first principles before I tackle complex problems. This whole thing about winning the war against microbes … nah!

We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!

So what we need to do is flip it around. We’re not at war with them. What we need to do is, in the immortal words of Dave Gilbert, achieve peaceful coexistence. The question is, what strategy do we deploy to achieve peaceful coexistence?

I think we need to start thinking of infections, by and large, in most cases, as accidents. There is no advantage for bacteria in most cases to infect us. They are much better off being non-infectious commensals in our gut.

In some cases we do have to have treatment to remove them from where they’re not needed. That may be antibiotics, it may be phages [viruses that target pathogenic bacteria], it may be single pathogen therapies, it may be immune enhancers; it’s all of the above: there isn’t going to be a single strategy. We need to relieve the pressure on any one strategy so that they can’t immediately adapt to that strategy. And I really do think that in the future we will be increasingly treating infections by a combination of targeted therapies; targeted to the bug, and therapies targeted to the host. It is the host inflammatory response that does cause the majority of signs and symptoms of infections that patients experience.

Moderator, Harvey Fineberg, MD, PhD, President, Institute of Medicine:  That’s a very interesting turnabout in thinking about the microbial world in which we coexist as the natural arrangement; and, our job in a sense is to figure out how we coexist, peacefully, as you put it.

It does invert the usual way we think about, if you will, the war metaphors of invasion, defense, and, if you will, destroying the enemy.

Brad Spellberg: Absolutely.

Harvey Fineberg: So it does reverse things.

Further exposition of Brad Spellberg’s thinking can be found here, at the New England Journal of Medicine; and a useful backgrounder about the new understanding of our bacteria and us – yes, we’re a team – is this popular essay, recently published in the New York Times.

Here is the panel discussion:

Is MRSA a Security Threat?

The conventional security threat.

If you’re a writer or a filmmaker in search of a fresh storyline then look no further than the 172 page thought-packed report just released by Britain’s Ministry of Defence, “Global Strategic Trends – Out to 2045,” which warns us of emerging security threats over the next 30 years.

It features our usual suspects: climate change driving millions from coastlines creating havoc, and the increasing threat of cyber-attack as information and communication goes digital. Trending upwards, for example, are the rise of robots, drones and corporate armies, e.g., Blackwater, that will change how we do war, and; as a predicted 3.9 billion people are likely to suffer water shortages, it will replace, or complement, oil, as a primary cause of global conflict.

Then we’re introduced to the new kid on the block: for the first time in its 5 year reporting history the MoD lists antibiotic-resistant pathogens as a “security threat.” The reason is two-fold. First, as antibiotics are rendered useless, infections caused by battlefield wounds will result in more lost lives and limbs than is the case now.

Second, and more compelling, is the effect of the anticipated combination of 4 events: (1) an increase in world population from the current 7.2 billion to 10 billion, (2) the fact that the fastest growing segment of the population will be the elderly – the number of people over 60 will be 2 billion in 30 years, representing a quarter of the globe’s population, (3) urbanization – by 2045, the proportion of people living in cities will increase from the current 50% to around 70% of the world’s population, and (4) poverty – 1 billion people throughout the world already live in slums, lacking basic amenities, and there could be almost 3 billion people living in these conditions by 2045.

The best economic evidence we have says inequality is rising to unprecedented levels, especially in the United States. The MoD report says if we don’t handle the coming economic and demographic shift properly the result will be the overcrowding of a vast and vulnerable (elderly & poor) population. That, in turn, will drive an increase in communicable disease where “social unrest or even violence could ensue.”

The emerging security threat: The enemy within - a million of these guys fit on the head of a pin but they kill & wound us more than our recent wars have.

But if framing infectious disease as a security threat is where we’re headed, take a look at where we are right now using just 1 disease-causing microbe, MRSA, as a case study. In the US alone it kills at least 11,000 people a year and blinds, amputates, and disfigures, etc. more than 80,000. Compare those numbers to a known and conventional security threat, the Vietnam War. Over its 20 year history ending in 1975 it killed roughly 3,000 US military members a year and blinded, amputated, and disfigured, etc. just over 7,500 more.

And that’s just a comparison to MRSA. All known antibiotic-resistant pathogens in the US result in about 23,000 killed and 2 million wounded every year. Over a 20 year period, that’s 460,000 dead and 40 million injured. The Vietnam totals are 58,300 dead and just over 150,000 wounded.

So here’s the question. If you are wounded or dying does it matter whether the cause is bullets or bacteria? We can even take it one step further. If a security threat infiltrated the US killing and wounding 23,000 and 2 million people respectively, every year, we would call that domestic terrorism and we would be living under a state of emergency. So looking at the current infectious disease carnage in this way, and given that the British Ministry of Defence is framing the rising global crisis of antibiotic resistance as a coming “security threat,” why aren’t we calling it that right now?

Do the Right Thing

Margaret Riley, Ph.D.: When we use an antibiotic it is like using an H-bomb because we are decimating the majority of our body's microbial cells. Antibiotics are not "smart bombs," they're indiscriminate killers.

We expect a lot from our doctors. So when something comes along telling us they’re not doing what they should, it’s both surprising and disappointing.

Such was the case 2 weeks ago with the release of a survey that found that doctors prescribe antibiotics even when they shouldn’t, and do so for reasons that are highly questionable. For example, 28% of doctors will give an antibiotic simply because the patient asks for one, and 15% will prescribe them out of malpractice concerns – yikes!

But it’s another finding that’s even more worrisome: 11% of clinicians say their reason for prescribing an antibiotic when it’s not indicated is that, well, it won’t cause any harm and, besides, maybe it will do some good, perhaps in the way that a placebo will.

Oops. The problem with this “it will do no harm” school of thought is that it’s not only flat-out wrong, it’s also dangerous.

So says Margaret Riley, Ph.D., professor of biology at the University of Massachusetts, Amherst. She analogizes the taking of antibiotics to the ingestion of a hydrogen bomb on the basis that it kills everything, all of your body’s bacteria, the good and the bad. Antibiotics, she says, are not like a laser-guided missile that kill only the bad bacterial cells. Sound familiar? Think cancer.

Because in this sense, the effect on your body of a course of antibiotics is similar to the effect of a course of radiation to treat cancer: in both cases you’re using a shotgun to kill a fly and so you end up with “collateral damage,” examples of which are well-known in the case of radiation therapy – hair loss, fatigue, decreased appetite, radiation sickness, and so on.

The collateral damage caused by inappropriately prescribed antibiotics puts patients at risk for allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile, according to the US Centers for Disease Control and Prevention.

But remember, at least with radiation treatment there are cancer cells to be destroyed. But what this survey is saying is there are no disease-causing bacterial cells around to kill – but nevertheless 11% of clinicians write these collateral-damage-inducing scripts for antibiotics on the basis that, in their misguided view, it does no harm.

One more thing: it’s this over-prescription of antibiotics that drives the growing global crisis of antibiotic resistance. A problem so severe that even the Prime Minister of Great Britain, David Cameron, got on board this month publicly warning us that “We are in danger of going back to the dark ages of medicine to see infections that were treatable not be treatable and we would see many thousands of people potentially die from these infections.”

So back to our survey. The explanation for the physician-poor result, according to Russell Steele, MD, head of pediatric infectious diseases at the Ochsner Health Center for Children in New Orleans, Louisiana, is that “Education wears off in 5 years.” Residents and interns, he says, get it right when it comes to prescribing antibiotics, “but once they’re out in practice, they start sliding, and use antibiotics indiscriminately.”

Okay, that’s a start. And while we may appreciate this honest admission of indiscriminate use of antibiotics by physicians, on this critical issue at least, we expect more from our doctors – we expect them to do the right thing.

Here is Dr. Margaret Riley’s interesting (she has puppets!) lecture:

Why We Need Technology

Dr. Spellberg: Antibiotic resistance and the collapse of the antibiotic research-and-development pipeline continue to worsen. If we're to develop countermeasures that have lasting effects, new technologies that complement traditional approaches will be needed, he says.

Our last post featured Brad Spellberg, MD, a leader in the field of infectious disease, and his claim that the root cause of antibiotic over-prescription is fear among physicians. Namely, when they’re not sure whether to prescribe an antibiotic or not they will too often go ahead and do so, typically caving in to the demands of their patients. This drives antibiotic resistance, the phenomenon that is rendering our antibiotics increasingly useless.

But what, exactly, are these physicians afraid of? What is this fear based on? Perhaps not surprisingly, the answer seems to be income security – theirs.

This brutally honest admission came to us last month by way of NPR’s On Point, in their show titled “A Wake-up Call on Antibiotics Resistance.” A guy who has been an ER physician for over 20 years, in addition to being a private practitioner, called in (at the 25:35 mark) and explained what I will call the Doctor’s Dilemma. It goes like this. A “major issue,” he said, “is that a patient will come into the ER and demand from the physician an antibiotic. And if they don’t get it they’ll complain to the administration who’ll complain to the doctor and say either make our patient happy or you’re fired!”

He described a similar circumstance faced by doctors in private practice. The pattern is that “a patient will come in to the office and say ‘I’ve got a cold, the sniffles,’ or whatever, looking for antibiotics. So you try to educate them and say sinus infections are usually viral, and they will go to some other physician and may not come back to your office, and so it becomes a business issue.”

Dr. Michael Bell, from the US Centers for Disease Control was a guest on the program and said this is common behavior across the board. Unfortunately, Bell went on to say, we live in a “pill for every ill” society, and made the interesting observation that while we trust doctors when they say we should take something, we apparently don’t trust them when they say we don’t need something – like an antibiotic.

And so the systemic failure of physicians to properly resolve the Doctor’s Dilemma is what led Spellberg to offer this solution in his address last month at the Institute of Medicine:

“How do we deal with that fear? [i.e. the Doctor’s Dilemma]. We need technology. Relying upon asking people to behave differently [think hand washing] in a sustainable way is not going to get the job done. [W]e need regulators and payers, especially payers, to help us push these technologies into the clinic so that doctors don’t have the fear that creates the inappropriate antibiotic prescription. We need to hold these healthcare systems accountable for implementing these technologies as they become available.”

Writing in the New England Journal of Medicine earlier this year, Spellberg was more specific about what we need technology to do: “Infection prevention eliminates the need to use antibiotics. Traditional infection-prevention efforts must be buttressed by new technologies that can more effectively disinfect environmental surfaces, people, and food”.

Canada’s Vancouver General Hospital is ahead of the curve on using technology to “disinfect” people. They’re the first hospital in the world to adopt a new light-activated disinfection method that is expected to reduce infections in surgical incisions by 39 per cent and save almost $2 million a year. A trial of 5,000 patients reduced average re-admissions for surgical site infections to 1.25 cases a month from 4 and shortened hospital stays for surgical patients.

“What we’re doing now isn’t working,” says Spellberg. “If we want to have a future state where we’re not living with a crisis of antibiotics resistance we need to think disruptively. Incrementally tweaking what we’re doing is not going to get the job done.”

Vancouver General leading the way:

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