Cut Them Off at the Pass: Obama’s Budget for Bugs Takes the Fight to Them, and it’s About Time

"Just trying to get the bugs out."

First, some background. President Obama unveiled his fiscal 2015 Budget last week and we see that he proposes to double federal funding to fight the emerging problem of antibiotic resistant infectious disease in the United States

The numbers alone warrant the close attention of any budget-meister because antibiotic resistance germs continue to cause more than 2 million illnesses and 23,000 deaths in the United States every year. MRSA alone kills a minimum of over 11,000 people and causes over 80,000 severe infections – again, every year. (Canada, population adjusted, has a similar infection rate of about 200,000 a year, but 2 ½ times the death rate – about 8,000 every year.)

To appreciate the scope of the problem, consider that over the next 5 years there will be more deaths caused by antibiotic resistant germs than there weredeaths by combat in the Vietnam War and the American Revolutionary War, combined (115,000 deaths from resistant disease; 110,848 from the 2 wars).

Given these monstrous numbers, the president therefore proposes (p.82), to double the funding to the Centers for Disease Control and Prevention to $30 million annually for the next 5 years.

The CDC says that with this increased funding they could achieve a 30% yearly reduction in invasive MRSA infections alone, and reductions of anywhere between 25 and 50% for 4 other kinds of infections, for an overall harm reduction of 37%. That would save a lot of pain and a lot of lives.

So how, exactly, does the CDC plan to do all this?

Press reports like this one and the CDC website tell us there will be construction of a country-wide 5-area regional Lab Network that will allow for early detection of outbreaks and thus quicker and more effective treatment. And we’re told that hospitals will be part of this network and they will have new programs to reduce the spread of bacteria.

Now be honest, what does that really tell you?

Here’s the way to think about it, using a war analogy that compares bad bugs to an invading army.

In 1775 the British launched attacks against a loosely organized band of American colonists at various points along the eastern seaboard from Lexington and Concord, Massuchesetts in the north to Chesapeake Bay, Virginia, some 560 miles south. At each point of attack the colonists would rally and do what they could to fight back, each colony operating on their own and largely unaware of what was happening at other outposts. Reports of the fighting would filter back to General George Washington after the event. From there, strategies, such as they were, were hastily cobbled together.

Now imagine, instead, that the colonists were an organized group of professional soldiers with a coordinated chain of command, a sophisticated communication system, and a network of spies. These things would allow them to know when the British were coming, where they were, what direction they were headed, how many there were, what kind of weapons they had, and so on. Such early detection and information immediately shared amongst the colonists would have permitted a coordinated rapid response, precisely tailored to meet each threat as it materialized along with the ability to constantly monitor the invaders. In other words, this enhanced capacity would have told Washington exactly where to attack, when, and with what force and weaponry. And thus a 37% reduction is American casualties would have been reasonable to expect – the same reduction the CDC is looking for based on the changes envisioned in the Budget.

The crucial change is  the proposed Lab Network that would be strung across the bug battleground that is the whole of the United States.  For the  CDC and its partners, now armed with the latest technology, it would mean the ability to engage in rapid diagnoses, a precision and coordinated response, early and more effective treatment, and a continued monitoring of any abnormal bug presence – and a 1/3 reduction in harm to Americans that would otherwise have been caused by bugs that antibiotics can’t touch.

The present system, however, can be described as every man – or hospital – for himself, and is in the sense described in the war analogy, an 18th century throwback..

Dr. Brad Spellberg, author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them," has been arguing for years to enact the measures proposed in the Budget."

Dr. Brad Spellberg is an infectious disease specialist and leader in the field of developing ways to combat drug resistant infections. In a wide-ranging interview with Frontline (in bold) last October he basically indicted the current system:

Is the government doing enough? Is the kind of action that we see up to the nature of the crisis?

“When reporters like you ask me how many resistant E. coli infections do we have, it’s pretty sad that I have no idea what the answer to that question is. It’s not that the government agencies are not aware of the problem and are not doing anything. It’s that we have not had a comprehensive plan for how to deal with antibiotic resistance. We don’t have reporting mechanisms like they do in Europe to know where resistance is occurring. Who is using the antibiotics. Are we overusing them?

You’re telling me we don’t know the answers to the extent of the problem? We don’t have the data?

That is correct, that is correct. I do not know how many resistant infections are occurring right now. I don’t know what the frequency of resistance in different bacteria are. We do not have those data. They are not presented publicly. They are not gathered on a large scale.

There are pieces of data acquisition, but there is not a concerted, coordinated effort to gather the information and make it available. Nor is there a concerted effort to apply financial or regulatory constraints to overuse, either in humans or in animals.

… It is frankly embarrassing that we as a country do not know where resistance is occurring, how bad the problem is for various organisms, or who’s using what antibiotics when. Europe has taken great strides to solve this problem, and we haven’t.”

These, then, are exactly the problems that the proposed Budget aims to correct. It could be a game changer. Of course there is one obstacle that remains – our friend, the Congress – perhaps the greatest bastion of resistance that we have today.


CDC Report Alleges Nation-Wide Hospital Misuse of Antibiotics

Will doctors listen to what's in the CDC report?

Poor prescribing practices are putting patients at unnecessary risk for super-resistant infections, and errors in prescribing decisions also contribute to antibiotic resistance, making these drugs less likely to work in the future, says a report released last week by the U.S. Centers for Disease Control and Prevention.

Those strong words are based on the following specific findings by the CDC:

1. About 1 out of 3 times, prescriptions for the critical and common drug vancomycin, which is used to treat MRSA, included a potential error – given without proper testing or evaluation, or given for too long.

2. Antibiotic prescribing practices vary widely. For example, doctors in some hospitals prescribed up to 3 times as many antibiotics as doctors in similar areas of other hospitals. This difference suggests the need to improve prescribing practices.

3. Patients getting powerful antibiotics that treat a broad range of infections are up to 3 times more likely to get another infection from an even more resistant germ.

4. Although antibiotics save lives they can also put patients at risk for a Clostridium difficile infection, a deadly diarrhea that causes at least 250,000 infections and 14,000 deaths each year in hospitalized patients.

5. Decreasing the use of antibiotics that most often lead to C. difficile infection by 30% (this is 5% of overall antibiotic use) could lead to 26% fewer of these deadly diarrheal infections.

The second most common type of infection for which hospital clinicians wrote antibiotic prescriptions were for infections caused by drug-resistant Staphylococcus bacteria, such as MRSA (17% of the total).

The reason this matters is that the more you use antibiotics the less effective they become. This is the problem of antibiotic resistance and it means that future patients will pay with their lives for today’s overuse of antibiotics.

Dr. Brad Spellberg is an infectious disease specialist and leader in the field of developing ways to combat drug resistant infections. In an interview with Frontline last fall he gave us uncommon insight into the problem of resistance and how it’s beating us in our fight against infections:

Frontline: Was there a moment when you came to this realization about resistance? Tell me a little bit about your own personal discovery.

Dr. Spellberg: Antibiotic resistance is something that all infectious disease practitioners think about, know about and deal with. But the moment I guess where the power of the resistance was brought home to me was when I was a fellow in training and for the first time encountered a patient that was infected with bacteria that was not treatable, that was resistant to every antibiotic we had.

Do you remember that moment? What was it like?

This was a young woman who had leukemia, and she had gotten an infection, and you look at this computer screen, and what you see on the computer screen, or what I saw, was all the names of the different antibiotics we have, and then next to the names [was] “R” for “resistance” — R, R, R, R, R. And I kept looking down going, “Where is the ‘S’ for ‘susceptible’?” But there wasn’t any “S” for “susceptible.”

And so what do you say to that patient’s family member? There was nothing I could do. That was a very difficult conversation.

How did you feel then?

Sort of astonished that in the 21st century we could run out of drugs, that we had bacteria running around that had developed resistance to everything. We had nothing left.

Bugs Without Borders

How MRSA gets around - no boarding pass required!

Suppose we find a huge increase in MRSA someplace in the world, far away from us, in Ireland, say. We would obviously be concerned for their health, but would an outbreak there have any bearing on our life here, thousands of miles and an ocean away?

I ask the question because a report out of – you guessed it, Ireland – yesterday tells us they have discovered a huge rise in MRSA over a 10 year period ending in 2011.

The report is based on a study by researchers at University College Dublin who have documented a 44-fold increase in the prevalence of MRSA – identifying 16 distinct clones (different types) of MRSA – as well as finding a six-fold increase in the number of MRSA samples resistant to multiple antibiotics.

In other words, they’re discovered a greater overall number of Bad Bugs, more different kinds of Bad Bugs, and more Bad Bugs that antibiotics won’t work on.

Prof David Coleman of UCD, one the authors of the report, says their findings constitute an “unprecedented level” of change that is a “worrying development” and therefore it is “vital to ensure that these strains do not spread and become more established.”

Spread where, here?

You betcha. And the explanation is globalization – we are One World now – and specifically, this includes the country-to-country spread of MRSA.

Professor Coleman puts it this way: “It is not a phenomenon unique to Ireland,” because “international travel increases the mixing of different community strains, helping to cause the very high level of [MRSA] diversity.”

Dr. Thomas Frieden, Director of the Centers for Disease Control in the U.S. agrees. He expressed his concern in an editorialSafer Countries Through Global Health Security, in The Lancet. The title itself tells the story: health, now, is viewed from a global perspective.

Look at SARS (severe acute respiratory syndrome), he says. What began as an outbreak in 2002 and 2003 in southern China caused an eventual 8,273 cases and 775 deaths in multiple countries around the world including Canada.

“Disease is just a plane trip away, and an outbreak anywhere is a threat everywhere,” says Dr. Frieden.

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