Wrong Directions: Pathogens are up, specialists are down

The hot paper we reported on yesterday said that you can reduce the 30-day mortality rate for hospitalized MRSA patients by more than half (from 23% to 10%) if you involve an infectious disease specialist in your care (along with your GP). According to the study’s lead author, having an ID consult is an absolute game changer: If there were a medicine that had such a dramatic effect, he said, “every patient would be on it.”

But there’s a problem – a lack of ID specialists. This has been reported on for several years now and various reasons are offered. Then just last week a report in Medscape addressed the issue again, identifying yet another reason for the shortage – a difficult diagnostic coding system used for tracking antibiotic-resistant infections is missing nearly 9 out of every 10 cases. And this has a domino effect: Grossly understating the problem of resistant infections means funding for research and treatment isn’t provided, which in turn “creates a strong disincentive for physicians to specialize in infectious diseases.”

So the researchers used a different method for identifying resistant infections – looking at evidence of treatment failure, defined as use of two or more therapeutic subclasses of prescription antibiotics to treat a bacterial infection – and found an 88% increase in the number of cases.

 

Rise in ABR infections

 

Looking at this new data over a 14-year period beginning in 2000, the authors conclude:

  • Rates of antibiotic-resistant infections have roughly doubled since 2002. “That while the overall number of [susceptible] bacterial infections remained relatively constant between 2002 and 2014, rising from 13.5 million to 14.3 million annually, the proportion that were antibiotic resistant rose dramatically, from 5.2% to 11.0%.”
  • The cost of care now tops $2 billion per year in the US. “Antibiotic resistance added $1,383 to the cost of treating a patient with a bacterial infection. Using an estimate of the number of such infections in 2014, this amounts to a national cost of $2.2 billion annually.”

They admit that even this is an undercount because they didn’t include data for institutionalized patients, such as those in nursing homes (a huge source of resistant infections), other long-term care facilities, prisons, and military or Veterans Affairs facilities, all of which typically have higher rates of antibiotic-resistant infections. Nor did the analysis include children, who, they say, “are the primary carriers of methicillin-resistant Staphylococcus aureus and pneumococcus in the community.”

In other words, resistant infections are on the rise, yet the very people who are able to cut by half the 30-day mortality rate in MRSA cases are on a relative decline, especially when you factor in one huge demographic: the aging thus increasingly vulnerable-to-disease baby boomer generation.

 

Hospital patients with a MRSA infection require an infectious disease specialist

ID consult

 

If you’re a hospital patient under the care of a GP and have a MRSA infection, your chance of dying or being sent to hospice within a month is just over 23% – that’s almost 1 in every 4 patients. And further, within the first year of a MRSA infection that risk of mortality goes up to 44% – approaching 1 in every 2 patients.

But here’s the crucial bit: You can cut the risk of death in the first month by more than half; and the 1-year mortality figure by 13% – if you involve an infectious disease specialist in your care (in addition to your primary care doctor).

That’s the new and important finding by researchers at the Washington University School of Medicine in St. Louis, Missouri, in their 10-year retrospective study involving 4,214 adult patients in 13 academic medical center hospitals (they have sicker patients) in and around St. Louis.

In addition to the MRSA numbers, they also found that an ID consultation was associated with similar reductions in 30-day and 1-year mortality for drug-resistant Enterobacteriaceae infections (a family of microbes that includes E. coli and Salmonella) and for drug-resistant polymicrobial infections – infections caused by more than one bug.

Lead author of the study, Jason Burnham, MD, offered his perspective in an interview with Consumer Reports: If there were a medicine that had such a dramatic effect “every patient would be on it.”

He explains why you should be seen by an infectious disease doctor:

They do more than simply suggest that a particular antibiotic would work well for particular bacteria. While a nonspecialist can, for example, write you a prescription for an infection you pick up in the hospital, an infectious-disease doctor can help you launch a more comprehensive treatment plan – using multiple antibiotics in combination when needed, draining abscesses where infections can hide, removing infected central lines, checking for pernicious complications such as endocarditis (an infection of the heart valves), and monitoring you for potential side effects to potent antibiotics.

But there’s a problem of invisibilty.

As patient advocate Lisa McGiffert told Consume Reports, people with resistant infections often “don’t know to ask for a specialist…. [as they] probably don’t even know these kinds of doctors exist.” But “[i]f you have a heart condition, you’re going to want a cardiologist. This is the same kind of thing.”

And so asking for a specialist, McGiffert says, could “make a difference in a person living or dying.”

 

 

 

 

 

 

 

 

 

 

 

When a skin infection is as deadly as a heart attack

In an epic webinar last week on why it’s important to focus on antibiotic stewardship and why it’s important to save these “frankly miraculous therapeutics” (antibiotics), Brad Spellberg, MD, Chief Medical Officer at the Los Angeles County-University of Southern California Medical Center, began his address by reminding us, using a true story, of how bad things were before we had these miracle drugs.

In December of 1942 a healthy 4-year old girl tripped while going downstairs. She cut her cheek and developed a Staphlococcal infection on her face which spread to her blood. The infection on her face spread relentlessly over 3 days. The evening of the third night her face and neck became so swollen she couldn’t swallow her own saliva. On the morning of the fourth day when she was gasping for breath her parents in a panic rushed her to the Mayo Clinic. This is what she looked like on arrival at the hospital. These are the actual photographs taken on admission to the Mayo Clinic.

Spellberg W3

Her admitting physician told her parents she would be dead within 2 days and there wasn’t anything anybody could do to stop that. Imagine, said Spellberg, being told that about your 4-year old who 4 days earlier had been perfectly well.

But she was very lucky because the treating doctor was one of the very few people who could access penicillin before the end of WWll. It was all going to the army. But he had experimental vials in his lab and so he grabbed those vials and began to treat her with penicillin. And you can see in the bottom pictures what she looked like after a few days of penicillin therapy.

Antibiotics, Spellberg emphasized, are the only drugs, the only medical intervention, that can take a girl that looks like this on the top panel and turn them into a patient who looks like the little girl on the bottom panels, in just a few days.

In fact, in the pre-antibiotic era a simple cellulitis (a skin infection) had an 11% mortality rate – an 11% chance of death. By comparison, a 1988 study found that death by myocardial infarction (a heart attack) was 12%. Which means, Spellberg says:

[T]hat the death rate from cellulitis in the pre-antibiotic era was the same as the death rate from myocardial infarction. Who remembers that? Who remembers that a simple skin infection was as deadly as an MI? That the reduction in death you get when using a beta-lactam to treat a skin infection is far greater than the reduction in deaths you get from aspirin or clot-busting drug treatment of MI.

Just think about how insane that is compared to what we see today with effective therapy. And the reduction of death that you got with penicillin was immediate and dramatic.

Drug resistance was always with us, but Spellberg warns it has caught up with us now that we’ve stopped coming out with the next generation of “gorillacillin.” So much so that with respect to some gram-negative pathogens:

We have organisms that have become resistant to almost all available therapies and, in some cases, quite literally to all available therapies.… [T]he reality is…. [w]e are making things up. We are putting together regimens that we know will not work individually and hoping by some magical combination phenomena that we can treat an otherwise untreatable infection. And that’s not the way medicine is supposed to be in the 21st century …. This is 1934 medicine. We have set the clock back 80 years to the pre-antibiotic era.

An era when a skin infection was as deadly as a heart attack.

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