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 As the endoscope is withdrawn from the body those tiny invisible germs adhere to the scope and can then transferred to the next patient the scope is used on.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.

The Day the Earth Stood Still

Last week we wrote about the new British report that said drug resistant infections will cause more deaths than cancer by 2050.

We focused on how untreatable infections will fundamentally change how we practice medicine, citing 3 examples: an increased inability to treat cancer; an increase in deaths during child birth – to mother and child; and how surgery will become too dangerous to perform in most cases.

There is, crucially, a whole other aspect to the global rise of drug resistant infection that is stressed in the report. It is summed up in one sentence by the lead author, former Goldman Sachs economist Jim Nill, in the video below, where he says:

“Something like this which is going to affect everybody; you know it could have a devastating impact on international trade and travel and globalization.

A devastating economic and social impact – what does he mean?

Remember the great American Ebola freakout of 2014? The one where, in the US, 1 person died and a half a dozen or so were sick but recovered. Well, what if the number of deaths in the US and Canada was not 1, but, as the report predicts concerning drug resistant infection, over 300,000? What if the number of infected people were several multiples of that? And what if these infections, unlike Ebola, are airborne – meaning you catch them easily, the way you catch the cold or the flu?

Deaths attributable to drug resistant infections every year, by 2050

A partial answer to these questions has been before our eyes for the past 6 months or so with Ebola virus disease in West Africa. As of yesterday, the US Centers for Disease Control and Prevention reported more than 8,000 deaths and over 21,000 cases.

As a consequence, life over there has stood comparatively still. Take just 2 brief examples.

The World Bank reported this month that in Liberia “The Ebola virus has tempered our economy. It has hurt our economic investments. Our businesses have been closed down and our country has been abandoned.”

And from the Financial Times in October: Airlines, hotels, tour operators and cruise businesses are resigned to a period of crisis management as investors retreat from their stocks on fears that the Ebola threat will blunt people’s willingness to travel.”

Now imagine that scenario playing out over here and in Europe and you have the kind of “devastating impact,” from the rise of drug resistant infections “which is going to affect everybody,” that the conservative, experienced, elite economist Jim Nill is warning us about.

In other words, closed businesses, truncated trade and travel, investment crises, and other globalization effects will be such that the world could virtually end up at a stand still — and don’t forget the fear that will accompany it all.

Here’s the brief video where Mr. Nill and a few others voice these stark concerns:

Drug-resistant infections are going to cause more deaths than cancer

Deaths caused by untreatable infection will overtake deaths caused by cancer by the year 2050. So says the first report produced by UK Prime Minister David Cameron’s working group on antimicrobial resistance, formed last July. As you look over the graphic keep this warning from the Cameron group in mind: “Despite the staggering size of the figures set out … they do not capture the full picture of what a world without antimicrobials would look like.”

The “full picture” of a world without these drugs means we will be forced to stop practicing medicine the way we do now. Stuff we have long taken for granted will be taken from us. The report gives us 3 concrete examples: surgery, cancer treatment, and child birth.

On surgery: “When most surgery is undertaken, patients are given prophylactic antibiotics to reduce the risk of bacterial infections. In a world where antibiotics do not work, this measure would become largely useless and surgery would become far more dangerous.”

On cancer treatment: “Modern cancer treatments often suppress patients’ immune systems, making them more susceptible to infections. Therefore without effective antibiotics to prevent or treat infection, chemotherapy would become a much riskier proposition.”

On childbirth: “Rising drug resistance would also have alarming secondary effects in terms of the safety of childbirth, including caesarean sections, with consequential increases in maternal and infant mortality. The 20th century saw childbirth in high income countries move from being something that carried significant risk to something that we take for granted as being safe: the world witnessed a 50-fold decrease in maternal deaths over the course of that century. Much of this progress could risk being undermined if AMR is allowed to continue rising significantly.”

Here’s the most important point: You and I have a role to play. We are are not meant to be mere bystanders. Since the problem is driven by the overuse of antibiotics our job is to lessen the demand. How so? Stop asking for antibiotics. That’s the message that people such as the Harvard School of Public Health are trying to get across. It’s well worth watching their presentation – meant for the public – by clicking on the preceding link.

How Concerned Should We Be With the Continuing Deadly Outbreak of Antibiotic Resistant ‘Superbugs’ That Killed 58,000 Infants in India Last Year?

How we assess threats depends on where we live in the world. For example, a Pew Research Center report from last month tells us that if you live in Sub-Saharan Africa you see Aids and disease as our greatest threat. In the Middle East it’s religious and ethnic hatred, and in the US and Europe it’s inequality.

But our recent experience with Ebola may have changed that. This Wednesday the New York Times ran the story ‘Superbugs’ Kill India’s Babies and Pose an Overseas Threat. It was on the front page and two days later at 8:00 this morning it was still on the most viewed and most emailed lists, reaching as high as number 3 yesterday. That’s a first. Apart from Ebola, stories on infectious disease in the US and Canada are generally ignored.

But not the Times report, which says 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.”

So are Times readers right to keep this story front and center?

Let’s ask one of our foremost experts on infectious disease, Tom Frieden, MD, Director of the US Centers for Disease Control and Prevention. You may recall Dr. Frieden as the guy who, in the midst of the great American Ebola freakout, was telling the President, the Congress, the media, and the public, that “I have no doubt that we’ll stop this in its tracks in the U.S.” And as we know he was proven absolutely right.

But this past July in a talk to the National Press Club in Washington, DC – a talk that got zero publicity – Tom Frieden told us what we will not stop in its tracks in the US:

But the next pandemic is not likely to be MERS … But maybe the next thing that we are most at risk for is not the thing that we don’t know, but something that’s hiding in plain sight, something that could kill any of us, something that could undermine our ability to practice modern medicine, something that could devastate our economy and something that could sicken or kill millions … Antibiotic resistance…

I’m an infectious disease physician. I’ve treated patients for many infections and I’ve also treated patients for whom there are no antibiotics left. I felt like a time traveler going back to an era before antibiotics. We talk about the pre-antibiotic era and the antibiotic era. If we’re not careful we’ll soon be in a post-antibiotic era. And, in fact, for some patients and some pathogens, we’re already there.

And what does this post-antibiotic era look like? It looks like India, right now; that’s the compelling story in the Times that its readers, rightfully, aren’t letting go of. They seem to intuitively grasp, perhaps because of our recent Ebola experience, what Frieden says explicitly: “A disease outbreak anywhere is a disease risk everywhere.”

Riddle Me This: What’s an Infectious Disease?

Infectious disease?

I came across this brain-teaser in David Quammen’s masterful book Spillover: Animal Infections and the Next Human Pandemic.

In general terms, we’re pretty comfortable with what a disease is. And we certainly know the difference between an attack by bacteria versus that of a lion, say. But not so fast. Here’s Mr. Quammen’s take:

Infectious disease is all around us…. It’s one of the basic processes that ecologists study…. Predators are relatively large beasts that eat their prey from the outside. Pathogens (disease-causing agents, such as viruses) are relatively small beasts that eat their prey from within. Although infectious disease can seem gristly and dreadful, under ordinary conditions it’s as natural as what lions do to wildebeests and zebras, or what owls do to mice.

So are a pack of wolves – or human cannibals – the functional equivalent of a bunch of pneumonia bugs?

Perhaps after dinner and over a glass of wine we could discuss it. Oh wait … how would we characterize what we just did to that side of beef?

What’s safer: a stint in your local hospital or a stint in the Iraq war?

A nursing group in Texas sent us a compelling (disturbing?) chart on hospital safety which we’ve posted below (original source: http://www.accelerated-nursing.net/hospital-safety/ ). Notice how it refers to preventable deaths and that a full 25% of these are due solely to infections you pick up simply because you’re in a hospital.

And no, this isn’t just a U.S. phenomenon. In fact, Canadian numbers may be worse. For example, a CBC Fifth Estate investigation found that about 1 in 10 patients admitted to hospital in Canada contract hospital-acquired infections (versus 1 in 25 in the U.S.), and that between 8,000 and 12,000 of these patients die from them each year.

So it turns out that we’re not as safe in hospitals as we think. But that we’re even less safe in our hospitals than in the entire Iraq theater of war … what’s going on?

A Tour of A Hidden Universe

“Most of life is invisible. 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.

But here’s the thing: we’re immensely affected by this hidden universe of tiny creatures. Look no further than the front page news these past few months and witness the effect that the Ebola virus is having on us.

The Tree of Life depicts every living organism that we know about on Earth. The only ones we are able to see, however, are depicted at the top right – the animals (that’s us), the plants, and a few of the molds and fungi. For all the rest we need magnified pictures.

But those magnified pictures can fool us because they typically don’t provide contrast. Instead, they represent all micro-creatures to be roughly the same size. Which is akin to showing a child similar size pictures of ants and elephant’s, thus leaving the impression they’re roughly the same dimension! What you need of course is contrast, i.e. a picture of the ant (standing!) beside the elephant.

The same holds true for us and our understanding of the Hidden Universe. So here’s a really neat animation that solves the problem. It lets us peek into the unseen universe of bugs and things and see not only what they look like and how they compare in size to each other but – and here’s the trick – it lets us compare them to something we’re very familiar with as all the various life forms are sitting side-by-side on the head of a pin.

So explore the secret world of Ebola, E. coli, staph aureus, blood cells, and so on, and notice how many thousands of times bigger, or hundreds of thousands of times bigger, one is from the other.

Click on “Start the Animation …” and enjoy the tour!

The Hospital’s Duty of Care

Arlene Wilgosh admits that hospitals have a duty to protect their patients from acquiring "super bacteria."

Twenty people died in Canada today – but they didn’t have to. They were all in healthcare facilities, hospitals mostly, and the reason they died had nothing to do with what brought them there. They died because of an infection they picked up while in care. And they picked up the infection because the hospital wasn’t following its own hygiene rules – and they admit it.

These preventable deaths happen every day in Canada, all across the country. By the end of the year – and every year — more than 8,000 people die in care, making Hospital-Acquired Infections (HAIs) Canada’s fourth leading cause of death. But it doesn’t stop there as more than 200,000 people are made sick by these infections, often seriously, as lifelong scars or a missing limb attest to.

This past Tuesday, Winnipeg’s Health Sciences Center held it’s (18th) annual “Bug Day,” an event that brings together experts from across the country who publicly address various aspects of HAIs. It played to an attentive and overflow crowd of healthcare workers. The take-home message was the same as it was last year: “Wash your damn hands,” as Winnipeg Regional Health Authority CEO Arlene Wilgosh put it, as 80% of these infections are spread by healthcare workers, or patients and their visitors.

But there’s a problem: the golden rule of washing your hands between every patient visit isn’t followed. Around 70% of nurses comply and a paltry 38% of doctors – if that. It’s been suggested that even these numbers are inflated because staff know when the hand washing police are watching and will thus “buckle up.”

Then came the stunning bit: Arlene Wilgosh said she didn’t know why these compliance numbers are always so low. The admission was stunning because even the nursing student seated next to me said: “We just don’t have the staff. There’s too many patients for each nurse to look after and there’s just too much to do.”

And that’s the dirty little secret that none of the presenters at the day-long event were willing to give voice to.

Not even Arlene Wilgosh, who seemed so compassionate. A former frontline nurse herself, she admitted that staff have a duty of care to their patients and candidly asked the audience: “If these patients were our loved ones, would we still not wash our hands and take proper precautions?”

According to Ms. Wilgosh, the hospital infection issue “poses a … very significant risk to those we care for,” and therefore “Something new has to be done to address it.”

But what is that “something new”? Because if our healthcare leaders aren’t even willing to acknowledge a major cause of HAIs, then where are we supposed to look for a solution?

Is this where we're headed?

How about the law. A sharp-eyed CBC report filed this month put it this way:

Our concern about the WRHA … is the lack of acknowledgement of the systemic nature of the true solutions, apparently devoid of a plan to marshal the required resources.

Under the Manitoba Workplace Safety & Health Act, Sec. 43(1): “A worker may refuse to work or do particular work at a workplace if he or she believes on reasonable grounds that the work constitutes a danger to his or her safety or health or to the safety or health of another worker or another person.”

Who … will be the first health care provider to draw the line and say, “I have too many patients, and

not enough time to follow proper hand hygiene protocols. I am refusing this work on the grounds that it constitutes a danger to the health of another person.”

Will it then be labor legislation that ultimately compels the minister of health and the WRHA to properly resource a systemic solution that will keep patients safe?

The CBC may be on to more than it knows. When professionals breach their duty of care to their patients, and serious, foreseeable, and preventable harm results, year in and year out, there’s a name for what happens next – it’s called a lawsuit. And a class action suit filed on behalf of close to 250,000 patients would not be out of the question for an imaginative and resourceful law firm.

Arlene Wilgosh began her address to us with these words about hospitals and infections: “It’s like going to war every day,” she said. She, too, may be on to something. Because if hospitals carry on shirking their duty to their patients, they will find themselves engaged in yet another theater of war, only this time they’ll be the ones in need of help. And they will dearly hope that the legal professionals in whose hands they’ll be in will properly discharge their duty of care.

Look at it this way. Suppose Ebola was killing 8,000 Canadians a year, every year. And on top of that our healthcare leaders publicly admit we could avoid those deaths if only hospital staff would bother to follow their own hygiene protocols. Yet they don’t, and so the deaths of innocent people continue to pile up. How would we feel about a lawsuit in that case? And so to our issue – how is the runaway train of hospital-caused/associated infection any different than that?

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