Down at the Courthouse: A Judge Wants to Know Why a Two-Month-Old Infant with MRSA Died

The Judicial Inquest into the MRSA-caused death of two-month-old Drianna Ross is taking place in courtroom 114 of the Law Courts Building in downtown Winnipeg. Presiding Judge Don Slough is nearing the end of his two-year investigation into Drianna’s death in November, 2011, in the northern Manitoba city of Thompson.

The Inquest was struck because Drianna’s mother and father, backed by community leaders, say that northern medical services are substandard and that’s why their child died.

Drianna Ross

Drianna Ross

The case began when they took Drianna, crying, coughing, and with difficulty breathing, to a local nursing station four times over two days. She was never referred to a doctor; instead, she was sent home with Tylenol. Finally, on her fourth visit to see the community nurse, Drianna was medevaced to Thompson General Hospital. The following day she died from a MRSA-induced septic shock.

The purpose of the Inquest is to examine the adequacy of healthcare in remote northern communities and, if that care is found wanting, to recommend changes in government healthcare practices so cases like Drianna’s don’t happen again. (Judicial Inquests, unlike trials, do not assign blame and do not have the authority to hold anyone legally responsible.)

On the stand yesterday afternoon was Dr. Stasa Veroukis, Pediatric Intensive Care Specialist at the Health Sciences Centre in Winnipeg. She wasn’t directly involved in the case but had reviewed the relevant medical documents in order to offer her expert opinion about the quality of Drianna’s medical care.

A half dozen lawyers from various health authorities questioned Dr. Verooukis, trying to pinpoint where it all went wrong after Drianna got to the hospital.

In Dr. Veroukis’s view the moment of truth was Drianna’s first night in the hospital. By 3:00 a.m. her heart rate had risen to 203 beats per minute, her temperature was a “very high” 39.3 degrees C and, most tellingly, when nursing staff poked Drianna to insert an IV she did not respond – which meant she was unconscious. Stunningly, that’s where it was left — no doctor was consulted to see what they should do next.

Those downward-spiraling vital signs meant that septic shock was setting in, said Veroukis, and as brain and heart cells begin to die off the process quickly becomes irreversible and death inevitable.

Dr. Veroukis was clear: “All the symptoms should have been put together by the nurse and [she should] have called the doctor.” Veroukis could only guess why that wasn’t done: a busy night perhaps, poor communication between nurse and doctor, inexperienced staff, and/or a lack of awareness about what the vital signs meant.

When asked how a two-month-old infant could possibly contract MRSA in the first place, Veroukis told the court there’s “More MRSA in the northern communities. The best option I can offer is the people around her have it.”

The research agrees with her, but with one important qualification: It’s not that MRSA frequents the north more than, say, the south, it’s that remote northern areas are home to First Nation communities and it is First Nation people who are disproportionately affected by MRSA.

For example, in a 7-year study ending in 2002, First Nation patients in Canada were found to be 6-fold more likely to have a Community Associated-MRSA infection than non-FN patients. (Community Associated means the patient picked up the MRSA before going to the hospital.)

And it might be getting worse: A U.S. study of Indigineous populations found that MRSA-associated hospitalizations increased from 4.6 per 100,000 American Indians/Alaska Natives in 1996 to 1998 to 50.6 per 100,000 in 2003 to 2005 – more than a 10-fold increase.

In other words, professional red flags have been waving about the increased prevalence of MRSA in First Nation communities for at least a decade.

Drianna’s death reminds us what happens when those warnings are ignored.

Nurses — Educate, Advocate and Treat: SSI’s by: Nicole Gould, Nursing Student, Ontario

surgical nurseAs a nursing student over the last couple years I have gained a lot of knowledge in the field of infections and what to look for in a patient who may be at risk for one. Recently, I was reading an article written by Carolyn Cross about SSI’s and it got me thinking about the problems that are occurring at the hands of the professionals. Some of the major problems that I am seeing when it comes to infections are that the healthcare team is not very knowledgeable about the infections, they are not documented properly and not treated immediately…with the right treatment.

When a patient comes out of surgery they look to the nurses and doctors to take care of them and help get them on their feet again. They trust that we know what we are doing and trust that if something were to go wrong we would notice right away. Throughout my schooling I have come across many articles talking about how there is a lack of knowledge within the healthcare team when it comes to monitoring for infections, specifically surgical site infections. It is our duty and responsibility to be highly educated on infections, how they start and the time period in which they start to develop. I also believe that it is equally important to teach our patients about the signs and symptoms to look out for so they are aware when something does not feel right.  We need to remember that our patients know their body and they know when something is not right. Far too often we ignore what our patients complain about for whatever reason and by the time it is taken seriously, they are dead. No matter how silly or how often our patients voice problems we need to listen immediately and be proactive before it is too late.

There are patients dying every day from what was supposed to be a minor surgery that turned into a horrible infection. We, as nurses need to take responsibility and educate ourselves on infections because they happen more than we think. We need to document properly and efficiently so this problem around the world can be stopped. No improvements, no new technology or new skills can help fight this problem without proper documenting and proper accountability. If we don’t document about how often infections happen in the hospitals, how will we ever find the proper solution? How will the healthcare system know what they need to focus their attention on? How will we stop innocent patients from dying from these infections? Are we just going to keep throwing antibiotics at them that no longer work?

These infections require immediate treatment and the RIGHT treatment. We are running out of treatment options. The antibiotics that use to combat these infections no longer have the same effect due to overuse, improper timing and misuse of the drug. “An estimated 40–60 percent of Surgical Site Infections (SSIs) are preventable with appropriate use of prophylactic antibiotics.” Imagine the amount of money, time and most importantly lives we could save if we just used the proper treatment. It is so easy to fall back and use the same antibiotics hospitals have always used but when it no longer works…who are you helping? We need to be more cautious and treat infections the proper way because our patients are dealing with those consequences.

We need to educate, advocate and treat.



It’s Not the Crime it’s the Cover-Up: A MRSA lawsuit against the Tampa Bay Buccaneers illustrates the principle

In the Circuit Court of Broward County, Florida, this past Monday, former National Football League kicker Lawrence Tynes filed suit against his former team, the Tampa Bay Buccaneers.

TynesHe says he contracted a methicillin-resistant staphylococcus aureus (MRSA) infection from the Tampa Bay Buccaneers’ Training Facility, One Buccaneer Place, during the summer of 2013, which, among other things, caused him to: (1) have 3 surgeries to remove infected tissue (2) live under the threat that doctors were going to have to amputate his toe as the infection worsened (3) endure six weeks of intravenous antibiotic therapy which involved a central line catheter inserted into his arm and placed above his heart (photo) (4) live with persistent pain which he is reminded of every time he gets out of bed and his feet hit the ground, and (5) sustain permanent damage to his kicking foot thus ending his career which cost him over $20 million in expected future earnings.

A crucial component of Mr. Tynes’s complaint against the Bucs is found in paragraph 23 of his 57 paragraph Statement of Claim which reads, in part: “… Defendants failed to disclose, and actively concealed, ongoing separate incidents of infection amongst individuals who used and visited One Buccaneer Place.” (My emphasis)

What, exactly, did they cover-up? It was the fact that 6 other members of the Bucs – 4 players, an assistant coach, and the head trainer – were also battling bacterial infections that summer. That these people “used the same hot and cold tubs, soak buckets, and other therapy devices, equipment, and surfaces used by Mr.Tynes.” And that as a result Lawrence Tynes contracted his life-threatening career-ending infection.

But why the cover-up? What reason would the Bucs have for keeping this critical information from him? The answer, according to Mr. Tynes, is the Bucs’ effort to gain advantage in the very competitive NFL marketplace in order to attract the best available players and coaches.

Lawrence Tynes, an integral part of the New York Giants 2007 and 2011 Super Bowl Championships, was a sought after free agent when he signed with the Bucs in the summer of 2013. What induced him to sign was the Bucs’ highly-touted superior medical and rehab facility, as laid out in para 9 of his Claim:

“Defendants represented to Bucs players, prospective Bucs players, including Mr.Tynes … that the Bucs Training Facility is a world-class facility at which ‘state-of-the-art’ physical training, medical care and treatment, and other rehabilitative services are provided … that the ‘gleaming new team headquarters,’ which it calls ‘One Buccaneer Palace,’ ‘is the largest facility in the NFL. Equipped with every modern tool to help produce a successful team on the field, the facility is also a major draw for potential free agents.’”

This had particular appeal to Tynes because as a kicker he has “a podiatrist perform a toe-nail procedure on his great kicking toe” in the summer before the start of each season. This requires a strict rehabilitation regimen; the use of “hot tubs, cold tubs, and a soak bucket for his toe, and included dressing changes to the open wound on his toe” – the functional equivalent of a quarterback’s arm.

Knowing this, the Bucs told Tynes’ agent that they had “the best of everything” and “procedures designed to prevent the spread of infection were in place … at the Bucs Training facility.” And that’s what Tynes relied on.

Now, Lawrence Tynes only feels betrayed: it’s not so much that he contracted MRSA; rather, it’s the cover-up that led to the infection that bothers him most. In a recent interview he told ESPN: “You expect this billion-dollar enterprise to protect you at all costs, and obviously, they didn’t do a lot of right things. I’m standing up for what I think is right, or what I know is right. I’m in this thing ’til the very end. I’m not going away.”



Greater Global Co-ordination is Needed to Address SSI Prevention and Antibiotic Resistance

SSISurgical Site Infections (SSI) are a significant risk factor for patients undergoing surgeries. In fact, 77% of deaths among patients with SSI are directly attributable to SSI. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI. Each SSI is associated with approximately 7-10 additional postoperative hospital days, resulting in significant financial burdens to the healthcare system.  SSIs are classified as superficial incisional (involving only skin or subcutaneous tissue of the incision), deep incisional (involving fascia and/or muscular layers) and organ/space. 1 The cost of each SSIs ranges from $1,000 to $100,000. SSIs are believed to account for up to $10 billion annually in healthcare expenditures in the US, and up to $1billion in Canada…before including the cost impact on families and the economy.

Significant reductions in SSI rates have been realized due to adoption of protocols involving prophylactic use of potent systemic antibiotics like Vancomycin. Long term Vancomycin resistance generation resulting from more widespread use is the trade-off for these significant reductions in short term SSI rates. Vancomycin, long considered one of the potent “last resort” class of antibiotics, has become a prophylactic medical tool to keep surgical site infections in check. The challenge is that there are too few new classes of last resort antibiotics being developed to replace Vancomycin should significant resistance evolve, due to the $1-1.5 billion cost and over a decade required for new drug development.

In light of this challenge, there should be a global coordinated effort to develop new classes of powerful replacement antibiotics as well as a global coordination of antibiotic rotation to preserves the ones that we do have. More emphasis should be taken on screening for at-risk individuals as well as health care workers, at times, the vectors of the spread of infection. Non-antibiotic antimicrobial therapies, such as Photodisinfection, Ultra-Violet Robotic Sterilization, etc. should be quickly advanced and integrated into healthcare associated infection prevention protocols. The superior patient outcomes would be well received around the world and the economics easily justified.

Reference: Infection Control Hospital Epidemiology/Volume 29/Supplement S1/ October 2008, pp S51-S61

The CRE Infections: No One Warned the Patients

“I want to know what the hell is going on and I want to know right now,” Sheila Adamczyk said. “They had two deaths. They knew this had taken place.”

Sheila is talking about the endoscope-caused CRE, or carbapenem-resistant Enterobacteriaceae, superbug outbreak at the Ronald Reagan UCLA Medical Center this winter that killed 2 people, seriously infected 5 more, and put 179 other people on notice that they, too, might become infected.

informed consent 4Her worry is that her 16-year-old daughter, Bailee, whose recent cancer screening involved a scope similar to the ones involved in the outbreak at UCLA, is now at risk. The problem is, no one told her this could happen. Sheila learned about in news coverage and has been trying to reach her doctor ever since.

And this is the position approximately 500,000 people across the country find themselves in, the number of people who annually undergo the procedure.

But there’s an even deeper story. According to specialists like Dr. Andrew Ross, head of gastroenterology at Virginia Mason Medical Center in Seattle “You have to understand that this issue dates back to 2011 – 2012.”

For example, we saw the emergence of the CRE deadly pattern of illnesses in 2012 – 2013 at hospitals in Seattle (11 deaths, 32 infected), Chicago (38 infected) and Philadelphia (8 infected). In each case investigators identified the same source of transmission: a specialized endoscope, threaded down the throat of patients to treat GI tract illnesses.

The agency responsible for oversight of these outbreaks, the U.S. Food and Drug Administration, also knew about them. In a March 4 letter from Congress to the head of the agency, demanding answers, they write: “It appears that the FDA has known for at least two years that the design of [endoscopes] could result in CRE outbreaks.”

Remarkably, the knowledge trail is actually decades long. “We have known about this even as early as 1983 or 1984,” says John Allen, of the Yale School of Medicine. In 1987, Allen wrote in an academic journal about 10 of his patients in Minnesota mysteriously becoming infected with a bacteria that they traced to a single endoscope.

And in this case, knowledge is power. Because in hospitals where outbreaks occurred they immediately fixed the problem, preventing any further infections.

For example, at Seattle’s Virginia Mason Hospital they put used scopes in quarantine for 48 hours after disinfecting and then retested them to make sure no bacteria had regrown before reuse.

So what we have here is everybody knew – the hospitals, the Feds, and the scientists – everybody, that is, except the patients.

The National Law Review, commenting on the pending CRE lawsuits in California and Pennsylvania, issued a clear warning: “Health care personnel should … thoroughly explain associated risks to patients when using reprocessed endoscopic devices.” (My emphasis.)

This is not only how you avoid lawsuits, it’s also how you keep innocent people like Sheila, young Bailee, and others across the country from feeling they were sucker-punched by a “nightmare bacteria.”

So now – and only now – are we seeing places like Cedars-Sinai Medical Center in Los Angeles, also the scene of a recent outbreak, issuing directives that physicians will discuss with the patient “the current unresolved national questions regarding [endoscopes] and CRE.”

While that may be a start, Lisa McGiffert, consumer advocate and director of the Safe Patient Project at Consumers Union in Austin, Texas, says this comes too late for some patients: “It’s really horrific to know so many people underwent these procedures when they could have known the danger beforehand,” she said. “They went in trusting the system, and the system broke down.”

It came too late for Lori (a nurse) and Glenn Smith, the adoptive parents of 18-year-old high school student Aaron Young. Aaron has been in the UCLA hospital since January, bedridden, trying to overcome his CRE infection. We know how Sheila Adamczyk feels because she told us. Here’s a picture of Lori and Glenn taken at their home last month.

How do they feel?

aaron 7



Here Come the Lawyers

Over the past month, 5 lawsuits have been filed in California Superior Court, Los Angeles County, over the deaths and debilitating infections caused by the superbug CRE (carbapenem-resistant Enterobacteria) to patients at the Ronald Reagan UCLA Medical Center. The harm resulted from the use of CRE-contaminated scopes that are threaded down the throat into the intestines of patients to diagnose and treat various GI tract illnesses.

The plaintiff’s argue – and virtually everybody agrees – that these scopes have a design flaw: they are such intricate devices that they can’t be properly cleaned between procedures, thus CRE bacteria are transferred from one patient to the next. Accordingly, the makers of this device have been sued on the grounds that they knew their scope had this problem yet they failed to correct it. These lawsuits are a big deal because the scopes are used in about 570,000 procedures each year across the country. And because once CRE enters your bloodstream there’s a 1 in 2 chance you will die.

As the escalating number of CRE infections become known to the general public, more lawsuits are likely to be filed nationwide. What’s more, we are learning that researchers have issued unheeded warnings to the medical community about these scopes since at least 1984. In other words, we’re entitled to ask how much of this pain and suffering could have been avoided. For instance, to 18-year-old high school student Aaron Young, 1 of our 5 plaintiffs.

Lori (a nurse), and Glenn Smith, are the adoptive parents of Aaron Young.

Lori Smith, who is a nurse, and husband Glenn, are the adoptive parents of Aaron Young.

Aaron is still in the hospital fighting his infection. Though he’s expected to eventually return home he will do so with this knowledge: the CRE bug will remain in his body for the rest of his life forever putting him at an elevated risk for infection. And just because he’s beat it so far is no guarantee he will again, especially if he becomes immunocompromised by age or disease.

Aaron is not alone. We’re learning of more cases like his in Seattle, Chicago, Pittsburg, Philadelphia, Tampa, and Charlotte. And there’ll be more to come: “Most hospitals that do these procedures are not even looking for this problem, or they may not be aware, and that’s got to change,” says Jeffrey Duchin, an infectious disease expert in Seattle. Thus, these infections “may go unnoticed.”

The reported cases of CRE are “probably the tip of an iceberg,” says Marcia Patrick, of the Association for Professionals in Infection Control and Epidemiology. “But we don’t know how big that iceberg is.”

But we know when the iceberg began forming – some 30 years ago:

“We have known about this even as early as 1983 or 1984,” said John Allen, a professor at the Yale School of Medicine who is president of the American Gastroenterological Association. In 1987, Allen wrote in an academic journal about 10 of his patients in Minnesota mysteriously becoming infected with a bacteria known as Pseudomonas. He and his colleagues traced the infections to a single [scope], whose small crevices harbored bacteria despite repeated cleanings.

An investigation this month by the LA Times offers further evidence of years of red flags:

“Since 2007, ECRI Institute, a nonprofit group that evaluates medical devices for hospitals and other organizations, has listed the risk of contaminated endoscopes and other surgical instruments among its top 10 health hazards.

In 2008, the U.S. Centers for Disease Control and Prevention urged that endoscopes be redesigned so they don’t represent a ‘potential source of infectious agents.’

Last year, the Joint Commission, which accredits and inspects hospitals, raised alarms about tainted endoscopes and other equipment posing an immediate threat to patients’ lives.

The FDA said it has received 75 reports of contaminated scopes causing possible infections in 135 patients who underwent [the scope procedure], from January 2013 to December 2014.”

But there’s more. Where the LA Times really earns its stripes is in showing us that there are deep, often hidden institutional structures that drive disease – it’s not as simple as bug bites boy:

“Three years ago, [the maker of the scope] Japanese electronics giant Olympus Corp. was in crisis amid a massive accounting scandal and plunging sales of its signature cameras.

Executives vowed to save the 93-year-old firm by turning aggressively to healthcare and selling more medical scopes to doctors and hospitals in the U.S. and worldwide.

The bet paid off: Medical sales soared 25% last year, and Olympus boasts a commanding 70% share of the global market for gastrointestinal endoscopes … a record breaking performance.”

The Times also questions doctors and their conflict of interest:

“One key part of that success has been the company’s close ties to doctors, industry analysts say.

Olympus is a major donor to the American Society for Gastrointestinal Endoscopy. The company also contributed more than $1 million to the society’s new Institute for Training and Technology.”

And now the feds are on the case:

“The company’s relationship with medical providers has already come under scrutiny. Last month, Olympus said federal investigators are looking into whether it violated laws that ban improper kickbacks to doctors and other customers.”

aaron 9The Times report ends with a cruel observation. As hospitals replace the contaminated scopes with new ones it’s generating more business for Olympus. In Seattle, Virginia Mason Medical Center bought 20 additional scopes, at a price close to $1 million. Dr. Andrew Ross, the hospital’s section chief of gastroenterology, said placing such a big order with Olympus “certainly seemed ironic from our perspective.”

None of this is pretty. But neither is this photo. It’s Aaron, hardly visible, in the bed where he lives these days.







The Personal Side of the Current CRE Outbreak

ricci“I just thought it’s just an infection, you know? I really didn’t realize what they meant by infection.” Those are the words of Cheryl Perron, mother of then 19 year old David Ricci (“reach-y”) who was struck down by the superbug CRE. (p.53)

David’s story began one morning on his way to work. Walking along side railway tracks he got sucked underneath a speeding train by its backdraft. His right leg crushed, he was rushed to hospital. Still conscious, he watched a doctor take out a machete-style knife and begin “hacking” his leg off. His friends, standing outside the room, could hear him screaming before he passed out. David never made it to the Mother Theresa Orphanage in Calcutta where he worked as an HIV/AIDS volunteer.

Then things got worse. Some of his amputated leg became infected with CRE. “They said I don’t have that much longer,” says a weakened David on what looks like a cell phone video taken by one of his friends. His family got him home to Seattle as soon as they could but the ordeal continued. David was placed under quarantine. His infection continued to spread. Multiple antibiotics were tried but failed. Then a doctor remembered one from the 1940s that was shelved because it was too poisonous. But it was the only one left so they tried it. As David put it, “It started to eat away at my organs on the inside, you know? I could just feel it, just— just this poison rushing through my blood.” One option remained – cut off the rest of his right leg to within 6 inches of his hip and maybe, just maybe, they’d get all the CRE. But they wouldn’t know for months, so in the meantime all they could do was wait …

That was 2011. David’s story was told 2 years later in the outstanding PBS Frontline episode “Hunting the Nightmare Bacteria.” We’re presenting it here because CRE is now on the move across the United States. As we reported 2 weeks ago, it was an outbreak at the University of California hospital system in Los Angeles this year that brought the problem to the public’s attention. But with a little digging we found out that CRE had also surfaced in Illinois, Pennsylvania, and Washington, dating back to 2012. And since our last report we’ve learned of more outbreaks occurring this year in North Carolina, Wisconsin, and a second hospital in California, Cedars-Sinai.

The unique feature of the US outbreak is they’re all caused by the same thing, a medical device called an endoscope. It’s threaded down the throat deep into the intestines to diagnose and treat people suffering serious illnesses of the GI tract. It’s the only tool we have to do the job and so it’s used all the time, in about 500,000 procedures every year across the country. The problem is, the endoscope has a design flaw. It’s such an intricate complex device that it can’t be properly cleaned between procedures and so the CRE from one patient will sometimes transfer to the next. Nevertheless, because it’s an indispensable tool in the treatment of life-threatening disease we continue to use it.

The total number of people affected so far is probably less than 1,000. But the story doesn’t lie in the numbers. It lies in the lives of the people afflicted and everyone close to them. And what it does to the ones that survive changes them forever.

David’s story begins at the 12 minute mark and resumes again at 46 minutes. Our hope, though, is that once you meet David you’ll want to see the episode in its entirety.

Our Current CRE Outbreak is Probably Just the Tip of an Iceberg

We have a problem and it will probably get worse before it gets better.

CRE (carbapenem-resistant enterobacteriaceae) is a superbug picked up in hospitals – for now – that kills about half the people it infects, roughly equivalent to the vicious Ebola virus.

For the past few days media outlets across the U.S. have been reporting on a CRE outbreak at the University of California hospital system in Los Angeles. So far 2 people have died, 5 more have become infected, and a further 179 are suspected of having been exposed to it and are being monitored.

endoscope 4But the real story isn’t in the numbers – at least not yet – it’s in how these people became infected, i.e. through the use of a medical device called an endoscope. The scope has a long fiber-optic cable with a light and camera at the end so doctors can see inside the body. It’s inserted down the throat into the stomach and then into the intestines. It’s used to treat digestive-system problems from cancer to gallstones, and it does a very good job.

But there’s a problem. The GI tract is lined with a host of different germs. As the endoscope is withdrawn from the body those tiny invisible germs adhere to the scope and can then transferred to the next patient the scope is used on.

But isn’t the scope cleaned between patients? Yes, and according to FDA-approved manufacturer’s guidelines which the hospitals have apparently followed. However, the issue is more insidious: parts of the scope are so small and intricately designed that you simply can’t access all the areas you need to to properly clean it. So the bugs remain on the scope ready to be transferred to some unsuspecting patient down the line.

But that’s just the beginning of the story. Two more facts bring us to the heart of it.

One, the endoscope is used across the country on about 500,000 patients every year, so why would the problem arise only in L.A.?

Two, if the GI tract is lined with oodles of different germs why would the scope only pick up one of them, CRE?

A little digging reveals that the endoscope-induced CRE problem isn’t confined to L.A. For example, at Virginia Mason Medical Center in Seattle, between 2012 and 2014, at least 35 patients fell ill and 11 died after contracting a CRE infection via the contaminated endoscopes.

Similar cases involving a half dozen outbreaks and about 150 patients have also occurred in health facilities in Chicago and Pittsburgh.

And we’re learning that “almost certainly,” the endoscope is transmitting other kinds of infections as well. Infection control specialist Marcia Patrick says these cases tend to go unnoticed because doctors simply prescribe antibiotics and don’t give much thought to where or how the illness was contracted.

That’s why Patrick says the reported cases of CRE are “probably the tip of an iceberg,” and adds, ominously: “But we don’t know how big that iceberg is.”

The More Doctors You Have in Your Community the Better off You are, Right?

doctorsIf you’re a poor or underserved community then the answer is yes, get more doctors in there. However, for “wealthy” communities, you have to be careful because the business side of medicine can hurt you.

It goes like this. More doctors in your area means more competition for patients; one way to please patients is to give them what they want, and what they too often want is … antibiotics. That’s the conclusion of researchers at Princeton University and the Johns Hopkins University School of Medicine, published online yesterday.

What drew their attention to the issue is the explosion of the so-called “Doc-in-the-Box” establishments across the US – which are attracting a growing Wall St-type investor interest. These are the retail, walk-in, and urgent care clinics that are open nights and weekends when many doctor’s offices are closed and don’t require appointments.

What concerns the researchers is the rising plague of antibiotic-resistant bacteria. They know that the reason these bacteria have become a problem is because we take too many antibiotics. In the US for example, in 2010, 258 million antibiotic prescriptions were written nationally, which is almost 1 prescription per person.

They also know that the more physicians there are per person in an area, the more prescriptions per person there will be. So with this background in mind, they wanted to know if the rise in Doc-in-the-Box establishments, i.e., if an increased competition among providers, leads to more prescriptions for antibiotics.

In finding that that is indeed the case the authors explain it this way: “The second reason is that physicians are competing for business either by increasing the number of patients they see by adding walk-in hours and same-day scheduling or by prescribing antibiotics more readily – even if they wouldn’t do any good – to maintain good patient relationships or to help retain patients.”

The idea of having to please patients in order to keep them was also investigated by the online journal Medscape, last summer. They specifically looked at why physicians cave-in to patient demands for antibiotics.

Physician responses show them feeling pestered endlessly for unnecessary antibiotics. One provider put it this way: “I often have patients, sometimes multiple times each day, get quite upset when an antibiotic prescription is denied to them. Even after explaining my rationale, some [patients] argue with me or head straight over to an urgent care center and obtain their antibiotics there instead.” (My emphasis.)

Dr. Bartlett would subscribe to the "you-have-to-sometimes-be-cruel-to-be-kind" school of medicine

Dr. Bartlett subscribes to the “sometimes-you-have-to-be-cruel-to-be-kind” school of medicine

This Medscape survey of almost 800 clinicians found that 28% of them prescribe antibiotics simply because the patient asked for them. Their thinking is that if you don’t keep the patient happy not only will you lose their business, you risk falling out of favor with administrators, and this in turn affects both your job satisfaction and, indeed, whether you will keep your job. And how do administrators know what patients think? The increasingly ubiquitous patient-satisfaction surveys.

Just how far down the customer-is-always-right road have we gone? Here’s what one equity firm manager who has invested in a chain of Doc-in-the-Box facilities has to say: “We borrow a lot from the restaurant industry,” therefore, “We have to be good, fast, and kind to be successful.”

But there’s a crucial difference between the guy who wants to know what you want for dinner and the guy who wants to know what’s wrong with you. John G. Bartlett, MD, Professor Emeritus at the Johns Hopkins University School of Medicine, offers us this sobering observation: “The use of patient satisfaction scores to evaluate physicians is just plain wrong, not to mention the fact that there is a direct correlation between patient satisfaction scores and mortality.”

And just what is this link between happy patients and dead patients? “The happier the patients, the more likely they are to die,” says Bartlett.


President Obama Doubles Down on the Fight against Superbugs

Calling antibiotic resistance “one of the most pressing public health issues facing the world today,” the President’s FY 2016 Budget, announced Tuesday, proposes an historic investment – almost doubling the current budget to an unprecedented $1.2 billion – to combat antibiotic-resistant bacteria.

A meeting of PCAST members with President Obama, 2014

The Budget is Obama’s effort to pay for the game plan on antibiotic resistance, announced in September, drawn up by his eminently qualified President’s Council of Advisors on Science and Technology (PCAST).

Eric Lander, PhD, founding director of the Broad Institute of MIT and Harvard, and co-chair of PCAST, assessed the state of play at the time: “There is no permanent victory against microbes. If you use antibiotics, whether in human health care or in agriculture, you will over time see resistance. If we fail, if we fall behind in our stewardship, in our creation [of new antibiotics or equivalent therapies], or if we fail to surveil to understand what’s going on, it’s a very real risk to see a resurgence of what life looked like a century ago when we had bugs we could not treat. It’s a terrifying prospect. Now … it doesn’t help to do scare tactics around these things but it’s just plain scary.”

Since then, there have been two notable events.

One, the announcement in December by UK Prime Minister David Cameron’s working group on antimicrobial resistance that deaths caused by untreatable infection will overtake deaths caused by cancer by the year 2050.

Two, the report in the New York Times that India’s infants are born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died last year as a result. That if these “resistant infections keep growing … it would be a disaster for not only India but the entire world.”

Quoting health officials, the Times reports that the infections are in fact growing rapidly: “Five years ago, we almost never saw these kinds of infections. Now, close to 100 percent of the babies referred to us have multidrug resistant infections. It’s scary … And these resistant infections have already begun to migrate elsewhere … reaching just about every country in the world … including … the United States.”

Migrate here? The recent Ebola scare in the US is a useful reminder of a bedrock principle of infectious disease: “A disease outbreak anywhere is a disease risk everywhere,” says Tom Frieden, MD, Director of the Centers for Disease Control and Prevention.

Of course, there is a crucial difference between Ebola and antibiotic- resistant infections: Ebola is transferred only from the very sick through their body fluids. Most ABR infections, on the other hand, travel through the air and are therefore as easy to catch as the common cold. So imagine then, if Thomas Eric Duncan, the only person to die in the US from Ebola, was left wandering Dallas for 5 days with an undiagnosed case of MRSA, say, as he was with Ebola. What then?

That is just one scenario that would constitute Dr. Landers’ “terrifying prospect.” And that is why President Obama rightly calls antibiotic resistance one of the most pressing public health issues facing the world today.

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