The future: Health care without antibiotics?
Palm Beach Post (FL)
It reads like a how-to from the pre-antibiotics era, though it was published in 2012.
Its core recommendations: Make nurses wash hands every time they should. Keep the sick in their own wards, isolated from the uninfected. Make sure the infected are treated by separate staff with separate equipment. Avoid invasive devices. Retrain all hospital personnel on the new normal.
Faced with the growing threat of antibiotic resistance, health care is rediscovering 19th century germ-fighting strategies, while exploring the promise of 21st century tech. At stake is the ability to continue providing many life-saving surgical advances to older and sicker patients -- joint replacements, organ transplants, heart surgery.
A bouquet of germs has become resistant to many antimicrobial drugs at a time when the drug industry has little else to offer. Beyond MRSA, there are gut germs like CRE and C. difficile, soil bacteria called CRAB, and sexually transmitted diseases including gonorrhea that won't respond to most of the drugs long used to fight them. A few are gaining resistance to everything and killing high percentages of sick patients.
The infections are typically hitting the most frail and vulnerable -- those in long-term acute care hospitals, on ventilators and in intensive care units, with open wounds and long-term antibiotic use.
If precautions aren't taken now, doctors warn, these germs will become widespread in the community, as MRSA already has.
Old habits, new tools
Fighting their spread requires rededication to time-tested methods such as disinfection and isolation, experts say. But it also requires more: Computer-driven solutions like data analytics, hospital-wide microbe tracking, regional information-sharing, molecular studies, new testing technologies and whole-room disinfection.
New technologies are hitting hospitals seemingly every month. There are devices that emit ultra violet light to sanitize patient rooms; machines that vaporize hydrogen peroxide to sterilize surgical suites; laser tools that recognize and analyze germ samples, and sensors that know whether a nurse washed hands before touching a patient.
Meanwhile, a few small biotech firms are striking out in different directions from antibiotics. They are attempting to develop drugs that can disable the enzymes that cause resistance. They are exploring the bacteria-killing powers of a subset of germs called phages, which live to infect other germs.
Those drug solutions -- if they work -- are years or decades away. The change that matters most now is a change in attitudes, doctors said. That goes for consumers, doctors and health care administrators.
Sea change on antibiotic use
"We have a generation of people who grew up with the idea that if one shot is good, two shots are better," said Dr.
With antibiotics, that's rarely true, he said.
"We have to stop the use of antibiotics that aren't necessarily needed," said Dr.
In 1843, before it was widely accepted that germs caused infections, physician and author
Holmes' argument was angrily attacked by obstetricians. But only after attitudes changed -- after disinfection of hands and instruments became commonplace -- did infants stop losing their mothers to the infections.
Over a year and a half, they said, 18 patients at the NIH clinic tested positive for CRE, carbapenem resistant Enterobacteriaceae, and seven immune-compromised people died.
They described how challenging it was to stop the 2011 CRE outbreak. As in Holmes' day, strict hand washing proved key, they said. But with no margin for error, they went so far as to hire full-time minders to shadow nurses and stop them if they were about to do something that might spread germs.
But it took more: The NIH scientists devised a way to use lasers and a technique called mass spectrometry to profile the types of germs infecting a patient, a tactic that was expensive, but enabled same-day identification of the nightmare germs. That enabled precautions to be taken before other patients became infected.
Tools like that aren't widely available outside the
Testing takes days
Instead, the process of identifying a nightmare germ takes days. Hospitals that are actively looking must first collect samples with swabs. They send the swabs to their labs and literally wait for days for the germs grow on dishes. If they are treated with an antibiotic and keep growing, it means they're resistant.
By the time they send results back to doctors and nurses, staff may have spread the germs all over the hospital.
Rapid, inexpensive tools are needed to spot the CRE germs in minutes, instead of days, scientists said.
The drug industry says the
For now, the CDC urges, everyone must practice stewardship of the antibiotics we still have.
There aren't expected to be new antibiotics able to kill CRE for many years to come. Stewardship programs place tight protocols on when the most valuable drugs can be prescribed, to ensure they aren't used unless absolutely necessary. And they impose standards on what to do when one type of antibiotic isn't doing the job after 48 hours.
Delray Medical works hard
Given Delray's patient demographics, it should have some of the highest rates of infection anywhere in the region. But it doesn't.
According to data reported to the CDC and released by the
It's no accident, said Dr.
"Anytime a patient is admitted to the ICU, they are screened for MRSA, VRE, active TB, if suspected, and C. difficile, just to see if they are colonized," Dardano said. "A person colonized would automatically be isolated."
Delray Medical has adopted most of the "toolkit" recommendations, and beyond, he said.
"We have an automatic order to remove that catheter on day one or two after surgery. The longer that catheter remains in a person's body, the greater the likelihood of infection," said Pharmacy Director
"We go on rounds with the doctors and make sure to use the right antibiotic at the right time for the shortest duration possible."
They also use their electronic medical record on a weekly basis to look for doctors with outlier prescribing or infection patterns.
And, importantly, they are thinking regionally. They look for problems among the nursing and long-term care hospitals that their patients go to for longer recoveries, and they alert those facilities when it's clear there's a problem.
"When they leave here, they are clean, and then they come back with an infected wound? That's just terrible," Dardano said. "We have periodically pulled in nursing home directors to tell them which ones are sending us the most patients with complications."
It's clear from the 12 known
Once they asked, they learned that eight of 10 of
It didn't happen. One state official confided that hospitals here didn't care to participate. They were coping with new data reporting demands about health care associated infections from the
"The data burden seemed overwhelming to the hospitals at that particular time," said
Instead, she found 12 hospitals in other parts of the state willing to participate.
The CDC says it's important that hospitals and nursing homes to create regional collaborative groups, because information sharing is critical to prevention. They've created forms they want hospitals and nursing homes to use when moving patients from place to place, so that proper precautions are readied if needed. Few places are using them.
The workaround, one that's not especially nice for patients, is for hospitals to assume that all transferred patients are infected with nightmare germs until testing proves otherwise. That means putting them immediately under what's called "contact precuations," an isolation protocol that requires washing hands, and putting on gloves and gowns for each entry into the patient's room, even from visitors. It involves using disposable food trays and medical equipment wherever possible.
It's hard on patients and it's hard on nurses, Bush said.
"It does not make them happy," he said. "It ostracizes you. People are less likely to go into the room when you need something. It's cumbersome."
But it's the new normal.
"Things are very different from when I started out 30 years ago," said Dr.
He's eager to see what the data shows now that
"We need to better understand the transmission patterns in the community, so we don't think about it only when there's a patient dying of a God-awful infection," Morris said.
"We are in a window of opportunity," he said. "We are really going to need to think of creative, out-of-the-box solutions."
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