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:

The Fear Factor: A Leader in the Field of Infectious Disease Says Doctors Habitually Over-Prescribe Antibiotics Because They’re Too Afraid Not To. What is it They’re Afraid of?

Brad Spellberg, MD: Physicians need to stop being afraid to do the right thing. Sometimes you have to just say no.

Yesterday we reported on the Harvard School of Public Health’s plea to the public to please stop asking their physicians for antibiotics. In their view “They [the public] need to be a partner in using antibiotics properly,” and “We’re all in this together.”

Fair enough. But of course there’s someone else involved in this illicit relationship of over-prescription – our friendly neighborhood physician. And so the question arises: Why are they doing it? Why are they giving out antibiotics when they shouldn’t? Presumably they know better, so what’s going on?

Enter Brad Spellberg, MD; physician, researcher, and a leader in the field of infectious disease and antibiotic resistance. As far as doctor’s go this guy is not your average bear. Extremely well-credentialed, he stood in front of a select audience this year at the prestigious Institute of Medicine and revealed this uncomfortable truth:

The root cause of why antibiotic [over] prescriptions occur is simply fear. Fear of the unknown. We as treating physicians do not know what our patients have with certainty. We make our best guess. And that guess is haunted by the fear that we could be wrong. And that’s what leads to this ‘Well, what if it’s bacterial, how much harm could one prescription do?’ And so we need to deal with that fear. Everything else is putting a band aid on the problem.

Ouch.

Here’s what he’s talking about. Antibiotics don’t work for the common cold, the flu, most ear infections and respiratory problems, because they’re typically viral-based illnesses. Physicians know this. But they’re overrun with patients pleading for antibiotics, often-times for their sick kids. So the physician has a choice. She can order a diagnostic test to see what germ they’re dealing with, knowing that it will take 3 days to get the result. Or she can take 10 minutes to explain bacterial vs. viral-based disease, which the patient may or may not understand, and if they don’t they’ll leave the office disappointed and may well change doctors. Or she can cave in to the demand on the basis of “What’s the harm? Besides, who knows, maybe it’ll do some good.” It’s this faulty last choice that Spellberg is saying is too often made.

And we know that that choice does damage. An inappropriately prescribed antibiotic puts patients at risk for allergic reactions, super-resistant infections, and deadly diarrhea caused by Clostridium difficile. These practices also drive antibiotic resistance, further endangering the future of antibiotics and the patients who need them.

Notwithstanding this huge downside a report in the New England Journal of Medicine estimates that 50% of antibiotic prescriptions may be unnecessary. Health care providers prescribed 258.0 million courses of antibiotics in 2010, which translates into over 8 prescriptions for every 10 people. Prescribing rates were higher with kids under 10 years of age and persons 65 years of age or older. In other words, we’re getting it wrong half the time and it’s the vulnerable among us that are most hurt by this.

All we want to do is give the right antibiotic to the right people and not give it when it’s not necessary. However, before we can realistically think of getting there, Spellberg is saying his colleagues need to first fill this prescription: Physician, heal thyself.

Here is Dr. Spellberg’s talk:

A Message From the Harvard School of Public Health: Please Stop Asking for Antibiotics!

Dr. Stuart Levy: Because of antibiotic resistance "We're in danger of not being able to save lives. I think that's the issue," he says.

So now we know. Antibiotics are not what we thought they were, a miracle drug with no downside. As it turns out antibiotics have a huge downside. And that’s the message a panel of infectious disease experts wanted to get across in a public forum, “Battling Drug – Resistant Superbugs: Can We Win?” held at the Harvard School of Public Health this year.

Here’s the thing. Antibiotics don’t work for the common cold, the flu, most ear infections and respiratory problems, because they’re typically viral-based illnesses. So not only does the antibiotic not help, it turns out there’s an unintended consequence we didn’t anticipate: antibiotic use drives resistance. That means the more we use them the less effective they become, not just for the person taking them but for everybody else too. In that sense antibiotics are a “societal drug,” because individual use affects others in the community. No other class of drugs does that.

The upshot is a lot of unnecessary harm. In the US alone, for example, over 2 million people a year succumb to infections that are resistant to antibiotics ; over 23,000 of whom die, almost half of them because of MRSA. Even when MRSA doesn’t kill it does very bad things to you . You may face having to amputate a limb as happened to this NFL player, or it could leave you blind as happened to this robust teenage boy from north Detroit.

The reason for the “resistance movement” by bacteria – the ability to render antibiotics ineffective – is that they are “born” with the ability to fight antibiotics. Their only job in life is to survive, and they’ve done that quite well now for some 3 billion years. In order to have survived that long they had to develop ways – “resistant mechanisms” – to fight the people in their world that threaten them; other bacteria, viruses, fungi, and so on. And that they did. Then along we come in the 1940s and try and knock them off with what we naively think are these invincible antibiotic drugs, and their response is like, “Whatever dude, we’ve seen all this stuff before.”

These critters are clever. Not only will the bug fight off the antibiotic you’re taking, penicillin say, but at the same time the bug will develop the ability to fight off other antibiotics too; for example, methicillin, amoxicillin, and tetracycline. The bug will then transfer the resistances it developed to those 4 antibiotics, to all his little bug buddies. This transfer will take place not just within a single species, E. coli to E. coli for example, but also between species, say from E. coli to Salmonella to Shigella (a bug that causes dysentery). In other words, when you take an antibiotic a whole other world of bugs that become resistant to multiple antibiotics develop inside you, thus leaving you more vulnerable to disease than ever.

But here’s the wicked part. Guess what you do with all these bugs you’re growing that are resistant to multiple antibiotics? You give them away, although not just to anybody. You’re most likely to give them to those closest to you, your family and friends. So when they get sick and need an antibiotic it won’t work for them. And it’s because of you: you’ve given your family and friends bugs that are already resistant to multiple drugs – you have effectively “immunized” them against antibiotics – not a good thing.

Dr. Aaron Kesselheim: The number 1 thing his patients say to him is "I want an antibiotic." That public sentiment has to change, he says, because it drives the rising threat of antibiotic resistance.

So what’s the answer? Stop asking for antibiotics. One of the panelists, Aaron Kesselheim, MD, of the Brigham and Women’s Hospital, Boston, says his number 1 patient complaint is “I want an antibiotic.” That is the very attitude the HSPH is trying to change. So if your doctor prescribes an antibiotic for you be sure to ask her why. Ask how she knows you have a bacterial-based illness and not a viral-based illness. Because unless she has swabbed for the bug and taken it to the lab for analysis you cannot know for sure what germ is making you sick.

Stuart Levy, MD, another panelist, and author of the book “The Antibiotic Paradox,” (the paradox is that the more you use them the less effective they become), wound up the discussion with this thought: If I had $800,000 to spend on fighting infectious disease, he said, I’d spend $700,000 of it on educating the community: “They need to be a partner in using antibiotics properly.”

As Kesselheim points out, “We’re all in this together.”

Here’s the video of the enlightening panel  discussion:

A Date With Brad Pitt

Sometimes words just aren’t enough. Such is the case with the landmark report released 5 weeks ago by the World Health Organization that warned us we’re entering a post-antibiotic era in which common infections and minor injuries will once again kill us. The WHO says this is not an apocalyptic fantasy, it is now a very real possibility.

But reading about a “post-antibiotic era” is one thing, actually seeing it play out right in front of you is quite another. This is where Brad Pitt comes in. He narrates the Emmy-winning 6-part PBS documentary series, “RX for Survival – A Global Health Challenge,” that makes you an eyewitness to a world without antibiotics.

Watch, how without antibiotics, a simple scratch to a policeman’s face turns into a horribly disfiguring life-threatening condition where the bacteria eats through his body like a worm eating through an apple. Watch the raw emotion in Seattle teen Ryan Woerth as both antibiotics and surgery fail to fight his stomach infection and how his only option is to try an experimental antibiotic only available for “the most desperate patients.” Watch live footage of a 10 month old infant with pneumonia struggle to breathe, while his mother and doctors rush to find an antibiotic that could save the child’s life.

The Youtube video below is part 3 of the series, “Rise of the Superbugs.” Just after the 36 minute mark Brad Pitt says “Perhaps the most alarming threat is from the common Staph aureus.” We’re then introduced to Ricky Lannetti, a star college football player in Pennsylvania who just 1 week after winning his ninth game of the year is in the hospital fighting MRSA with heart, kidney, and critical care specialists at his side. And his disbelieving father who tells us, “He’s Ricky Lannetti. No little bug is gonna kill him. Not a bug. Not something that we can’t see.”

It’s harsh viewing. But it’s real. And it’s exactly what the WHO says we’re headed for because we’re losing our antibiotics.

Here’s the video:  Rise of the Superbugs

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