Modern medicine is rapidly approaching a crisis state. The antibiotics that we have depended upon for 65 years are losing their effectiveness, and death from drug-resistant pathogens are increasing in frequency.
"More than 63,000 patients in the United States die every year from hospital-acquired bacterial infections that are resistant to at least one common antibiotic…" says a new report released March 22, "Extending the Cure: Policy Responses to the Growing Threat of Antibiotic Resistance."
The research was conducted by Resources for the Future (RFF), a nonpartisan organization that conducts research in public health issues. This number is more deaths than from either AIDS, traffic accidents, or influenza. And the actual number is probably higher because many deaths attributed to other causes, may be really due to antibiotic-resistant infections.
In 1941 penicillin was first introduced, and since then the medical system has increasingly relied on antibiotics to control infectious diseases. Moreover, the successes of new procedures, such as kidney and heart transplants, as well as chemotherapy and surgery, were made possible by the crucial role that antibiotics play in preventing surgical site infections and saving the lives of patients with weakened immune systems.
Treating Resistant Infections
The best example of this problem of antibiotic resistance is the case of Staphylococcus aureus ( S. aureus ), better known to lay people as "Staph" infection. Its mortality rate was reputed to be as high as 82% in the days before antibiotics. Then the "wonder" drug, penicillin was introduced in 1941 and saved many lives and limbs from amputation during World War II.
However, resistance to penicillin emerged, and people began to die again from this infection. So, in 1960, penicillin was replaced with methicillin, which was effective against the penicillin resistant S. aureus. But by the 1970s, unfortunately, a methicillin-resistant S. aureus (MRSA) had evolved just as had happened to penicillin.
In 1974, only 2.4% of patients in U.S. hospitals with the "Staph" infection failed to respond to methicillin, the penicillin replacement, according to Ramanan Laxminarayan, Ph.D., who is a senior researcher at RFF and one of the primary authors of the report.
Dr. Laxminarayan cites data that says that the MRSA prevalence increased to 29% in 1991, and to nearly 60% by 2003. The latter data is from the Centers for Disease Control and Prevention (CDC). MRSA prevalence rates in U.S. hospitals have grown more than 12% per year.
Note that even though methicillin—the "M" in "MRSA"—was found ineffective long ago and has been replaced, "MRSA" is still retained by the health professionals as the acronym used for the general phenomena of resistant S. aureus to a penicillin derived antibiotics.
The latest and possibly the last drug that can treat MRSA infections is vancomycin. But its massive use has given rise to vancomycin-resistant enterococci (VRE) and strains of MRSA resistant to vancomycin, according to Dr. Laxminarayan. The U.S VRE rate of 12.6% is one of the highest in the world.
Drugs like penicillin and methicillin were inexpensive. Penicillin cost pennies a dose, but the most recent antibiotics "can run as high as a few thousand dollars for a course of treatment," says Dr. Laxminarayan. The chief reason for this huge expense is that the newer drugs are under patent. As our medical system has to rely more on very expensive treatments, this will have a profound of effect on the poor and uninsured.
Moreover, patients typically have to be treated with two or more drugs to ensure the treatment will be successful. This is certainly an incentive to use multiple drugs rather than take a chance on a sequential drug treatment and jeopardize a patient's life.
New Policies for "Extending the Cure"
"Extending the Cure" addresses the problem of antibiotic resistance, not by trying to eliminate it which the report says is impossible. Instead, it assesses the pros and cons of various policies designed to protect antibiotic effectiveness by (1) delaying the emergence of resistant bacteria and (2) controlling better the spreading of the antibiotic-resistant bacteria.
The problem is that each of the main players in our health care system—health care providers, consumers, insurers, and pharmaceutical manufacturers—has an interest, such as maximizing company profits, avoiding lawsuits, or fighting off a life-threatening infection, which lead to actions that are detrimental to the common good of all. The report considers new incentives that hopefully will have as an outcome, the keeping of the antibiotic drugs effective as long as possible.
One set of policies that the report would like to put in place involve reducing antibiotic prescribing. Every time antibiotics are used, the "effective lifespan of that antibiotic and perhaps related drugs has been shortened," says the report.
The United States has one of the highest rates of antibiotic prescribing in the world. Educating physicians and patients can help here, but reducing prescribing is an instance of choosing between the good of the individual versus society.
The need for antibiotics can sometimes be reduced by community vaccination campaigns. Presumably then there would be less sickness and fewer number of infections. The report suggests a national requirement for childhood pneumococcal vaccinations, which "could greatly reduce the need for antibiotics in children under the age of five, who consume a significant proportion of antibiotics used in the community," says the report.
Another way to reduce the need for antibiotics is to reduce transmissions in the hospital settings. Some methods discussed in the report are doing a better job in isolating patients who have the beginnings of a resistant infection, restricting the nursing staff with access to patients with such infections, and more rigorous attention to hand-washing and changing of caps and gowns.
The Netherlands stands out in Europe as a country with stricter controls of their MRSA infected patients—isolating the patients in private rooms and taking care not to infect other hospitals—and the result has been an extremely low rate of MRSA infections.
The Dutch, known for their war strategy of "search and destroy," are especially vigilant in controlling their MRSA problem. Patients from foreign hospitals and suspected MRSA carriers are screened and isolated, according to the Eurosurveillance Monthly (Mar 2000).
The Dutch form ad hoc MRSA teams to control the problem, and the board of directors, medical specialists, nurses, and other health care workers of the hospital may be required to cooperate with additional measures, including closure of wards. As a result, the above source states, "older antibiotics continue to be first line drugs in the treatment of serious infections."
However, it is difficult to persuade U.S. hospitals to the above actions when the use of antibiotics is less expensive. Moreover, the costs of staff time and other expenses related to infection control are borne by the hospital, while antibiotics are paid by health insurers.
Also, many patients use more than one hospital and so if one enlightened hospital makes the investment for better controls, it could result in a waste because the other area hospitals are not doing the same. In the Netherlands all the hospitals share the costs and benefits of superior infection control.
The complete report, "Extending the Cure," can be downloaded from Extendingthecure.org.
Feeds