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Thursday, April 4, 2013

Further thoughts on CRE: "Once in a Lifetime" edition

"You may ask yourself, well, how did I get here?"
--Talking Heads

It's been a busy week in antibiotic resistance. From Tuesday's MMWR early release identifying terrifyingly large increases in CRE until today, there has been non-stop media coverage. This morning, I had a long discussion with a colleague about CRE and it got me thinking about how we got to this point. As Maryn McKenna so astutely said this week, "It will be interesting to see whether the news sinks in this time." So, how did we get here?

1981: What we now call AIDS was recognized as a clinical syndrome. Thus began the cascade of infectious diseases research towards a full-scale and massively-funded response to the AIDS crisis. This has been an incredibly successful, if not yet complete effort. At the 2011 IDSA meeting, Cornell's Trip Gulick said that we now have 10,000 possible combinations of antiviral therapy agents for HIV. Thirty years after the virus was discovered in 1983, the progress has just been incredible. Sure, we've not yet achieved a significant number of cures and an effective vaccine remains just out of reach, but if you'd asked most of us in 1990 if we'd wanted to switch places with 2013, we would have said yes in a heartbeat.

2013: Most ID research efforts still target HIV and other viral pathogens. As we published last year, 2009 NIAID funding for HIV was $1.3 billion, while funding for all ESCKAPE pathogens was around $49 million. When we reported this disparity, it seemed quite obvious that we needed to fund more research of antibacterial resistant pathogens. However, nothing is ever that easy. One of the peer-reviewers of our paper made the excellent point that the "historically poor funding for antimicrobial resistance over the years along with the exit of pharma from the field has led to a lack of significant infrastructure. There may not be enough productive labs to send more money to at this point." So, even if the US wanted to fund more research, it may take time to train or retrain investigators to undertake the relevant research.

Now that I've shared some brief thoughts on why we are where we are, I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail.

This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequencing stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE.

My recommendations:
(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics.
(2) Invest in studies to improve compliance with hand hygiene. There have been only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands.
(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors?
(4) Undertake studies to further optimize environmental source control
(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other messaging techniques that have a chance to be effective.

Oh, and no more ridiculous hand hygiene song and dance videos, unless they include folks like the Talking Heads.



Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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