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 As the endoscope is withdrawn from the body those tiny invisible germs adhere to the scope and can then transferred to the next patient the scope is used on.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

Oops.

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