Many hospitals have made impressive strides in preventing health care-associated infections; some have seen a 70 percent reduction in the rate of bloodstream infections, thanks to safeguards such as checklists of steps to take before and during medical procedures and stepped-up hand-washing. But the problem continues to worsen. Now the White House has asked Congress for $1.2 billion to fund an effort to cut the rate of dangerous infections in half by 2020. The plan includes steps to prevent and slow the spread of infection, improve surveillance of resistant bugs, develop better diagnostic tests and new antibiotics and curb the misuse of currently available drugs – the main driver of drug resistance.
This is no fleeting crisis. Experts warn that the loss of antibiotics would roll back medical progress by 70 or 80 years. Without them, people could die of everyday dental abscesses and strep throat. Just inserting an IV could have lethal consequences. “Medical practice developed in a way that presumes the ability to treat infection in order to allow other things to be done like major surgery, cancer chemotherapy, transplants and joint replacement,” says James Johnson, senior associate director of the Infectious Disease Fellowship Program at the University of Minnesota in Minneapolis.
In terms of their power and importance, “almost nothing else in medicine comes close,” says Brad Spellberg, chief medical officer and professor of clinical medicine at the Los Angeles County and USC Medical Center. He is also the author of “Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them.”
The trouble is that “any time we use antibiotics, we’re contributing to their future ineffectiveness,” Johnson says. It’s natural for an organism to eventually become resistant to that drug. And too often, bowing to the demands of patients, doctors prescribe antibiotics when they’re not needed; the drugs aren’t effective against viral illnesses.
Another problem: Because it takes time to determine precisely which organism is the culprit, doctors frequently prescribe “broad spectrum” antibiotics that work against a wide range of bacteria when a more targeted drug would do. “The consequence,” Johnson says, is that “we’re using our last-reserve antibiotics with increasing frequency.” The CDC estimates that at least 50 percent of antibiotic use in humans is unnecessary or inappropriate.
At the same time, 80 percent of antibiotics in the U.S. are used in livestock feed to prevent or control infection and promote growth, which fuels outbreaks of drug-resistant organisms such as Salmonella, E. coli and Campylobacter that spread through the environment. The end result: “There are patients in hospitals in the U.S. today suffering and dying from infections for which doctors have no antibiotics to give,” says Arjun Srinivasan, associate director for Healthcare Associated Infection Prevention Programs for the CDC. “They are completely resistant to all therapies.” Experts agree that no single intervention will solve the problem – and are exploring a number of needed solutions:
Under the president’s plan, hospitals would establish antibiotic stewardship programs to focus doctors on “prescribing the right antibiotic at the right time at the right dose for the right duration,” says Ann McIntyre, clinical associate professor in internal medicine at Nova Southeastern University and director of the infectious diseases fellowship program at Palmetto General Hospital in Florida. Only about half of hospitals currently have such programs. But the Centers for Medicare and Medicaid Services is expected to make them a requirement for eligibility for reimbursements by 2017. Typically led by a multidisciplinary team – infectious disease doctors, pharmacists, microbiologists or epidemiologists and nurses – stewardship programs involve keeping careful control over how the drugs are dispensed. They include such strategies as frequently reviewing patients’ status to make sure they still need an antibiotic, and if so, reassessing the drug, dosage and type of delivery (switching from IV to oral antibiotics, for instance, eliminates a potential source of additional infection), and restricting the use of certain broad spectrum antibiotics until an antibiotic expert weighs in. “Physicians are used to practicing for the patient in the moment and not having to think about all patients globally,” says Neil Fishman, an infectious disease specialist and chief patient safety officer at the University of Pennsylvania Health System. That, he says, has to change.
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