Friday, March 8, 2013

Further thoughts on CRE: "Once in A Lifetime" addition

"You may ask yourself, well, how did I get here?" - the 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.
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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 – 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 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...


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