WhiteCoat

Attack of the Superbugs

Antibiotics for viral infections are a big pet peeve of mine. No. Make that a huge pet peeve.

Some doctors prescribe antibiotics for coughs and stuffy noses because the patients want them. If you’re one of those patients who think that antibiotics make your coughs go away, or clear up your stuffy noses, or somehow make your sinus headaches vanish, or if you’re a doctor who prescribes antibiotics for these symptoms, this post is for you.

You’re killing people with your dumb demands and/or your inappropriate prescriptions.

MRSA stands for methicillin resistant staphylococcus aureus. There is regular staph aureus – that bug is pretty much fading into the sunset and being replaced by staph aureus on steroids. Because so many people are requesting/using antibiotics for non-bacterial infections, the bacteria in their systems learn how to beat the antibiotics – in effect, making the antibiotics useless. For example, in our area, Levaquin is frequently prescribed by many doctors for obvious viral infections. Then, when people have a urinary tract infection, almost half of the strains of E. coli – the most common urinary tract pathogen – in our town are resistant to Levaquin and Cipro and all the other drugs in that family that would normally kick E. coli‘s butt. We have had several patients who had simple UTIs turn into serious systemic infections because they were initially treated with Cipro or Levaquin for their urinary tract infection and the antibiotics didn’t help.

Now there’s a super duper bug that’s coming to a town near you. According to a recent article in Lancet Infectious Diseases, bacteria are now picking up a new gene called NDM-1 that makes the bacteria resistant to almost all antibiotics. Most of the bacterial with this gene were E. coli, but the gene can apparently can be relatively easily transferred to other bacteria. The only antibiotics that bacteria with this gene were sensitive to were tigecycline and colistin. Right now most of the isolates are in India and Pakistan, but it is only a matter of time before the super duper bugs have spread worldwide.

A 2007 JAMA article showed that MRSA infections were abundant (.pdf file). An editorial accompanying the JAMA article noted that “The estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000).” In addition, the editorial noted that if the predicted number of MRSA deaths was accurate, the 18,650 MRSA-related deaths in 2005 “would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States.”

Currently, a study by the CDC is claiming that the incidence of MRSA is declining (I wasn’t able to find the study on the CDC’s web site) by between 17 and 27 percent in the past few years.

Even if MRSA goes away – which it won’t – there are still other resistant bacteria out there that are going to become a greater part of our lives. According to this San Fransisco Chronicle article, there’s “extremely drug-resistant tuberculosis” (XXDR TB). Doctors don’t even know how to treat this disease – or if they even can treat it. Less resistant TB can cost $100,000 per year to cure. Patients with XXDR TB will probably just die.

The San Fransisco Chronicle article also notes that drug-resistant infections killed more than 65,000 people last year – more than prostate and breast cancer combined. In excess of 19,000 of the patients who died from drug-resistant infections had MRSA.

So how do we stop the spread of resistant bacteria? It’s actually pretty simple.

1. Patients need to stop requesting antibiotics for nasal congestion, coughs, bronchitis, and “sinus infections.” Doctors need to stop prescribing antibiotics for these diseases. Norway nearly eradicated MRSA just by restricting antibiotic use. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better.” The slogan on a packet of tissues in Norway says “Penicillin is not a cough medicine.” See another article on Norway’s approach to antibiotic resistance here.
If we can’t change the habits of doctors who prescribe antibiotics in this country, then antibiotics need to become controlled substances and regulated by the DEA. It is that serious of a problem.

2. Wash your hands. Patients, doctors, everybody. Wash … your … hands. One friend wrote me and asked whether or not you’ll be viewed as a “trouble patient” if you request that your doctor wash his or her hands after entering your room. My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator. If, on the other hand, you tell them “wash your hands you filthy friggin barnyard animal”, you’re asking for a loogie down your back when you’re not looking.

The video below kind of sums up the whole handwashing idea. I don’t watch TV, but apparently the green on the woman’s hands ends up killing her in the next episode.

Thanks to SeaSpray and to GrumpyRN for the ideas for this post.

Wash … your … hands

44 Responses to “Attack of the Superbugs”

  1. RSDS says:

    What about dentists that prescribe antibiotics before all dental procedures for patients that might (or then again they might not) have heart murmur? Even if it is just a noisy valve. Is it really necessary? Or is that practice just leading to more Superbugs?

    • Steve says:

      Those guidelines have changed over the past 5 years so that not everyone with the slightest murmur needs antibiotics. Now it’s limited to:

      * Prior infective endocarditis
      * Prosthetic cardiac valves
      * Unrepaired cyanotic congenital heart defects
      * Congenital heart defects completely repaired with prosthetic material or a device
      * Repaired congenital defects with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
      * Cardiac transplants and development of cardiac valvulopathy

      Those antibiotics are given to prevent endocarditis which can be very serious so the cost/benefit of one single dose of an antibiotic is there vs. an entire week-long course for a URI.

      It used to be that anyone with a murmur would get them. Then the AHA and the ADA came together to draft something more reasonable in light of the given evidence and cut down on the number of people who need it. The overall rationale makes sense- everyone gets bacteremic every morning when they brush their teeth and everyone with a murmur isn’t walking around with endocarditis.

      So this is actually one area where we have been successful in cutting down unnecessary antibiotic use.

  2. paul says:

    ahh, yes. the “go away” prescription.

    the first thing we need to do is kill press-ganey.

    • Aaron says:

      In spite of the social costs of giving into narcotic seeking behavior, it shocks me that doctors who have general have at least two years of undergraduate biology so frequently bomb otherwise chill intestinal flora with existential threats for the crimes of viruses.

      My ideas:

      1. If it isn’t a Beta Lactam it goes on Schedule III

      2. More antibiotics go IM or IV, preferably in depot preparations for IM. Most bacterial infections aren’t in the gut except the one you generally want to sustain to avoid worse bacterial colonies like c diff. An added plus is that there are no pills to hoard for unrelated boo boos later.

      3. End veterinary antibiotics for agriculture. Maybe make exceptions for zoo animals and companion animals, but keep antibiotics away from my pork, poulty, beef, and lamb. The increased cost of meat will be worth knowing our nations stable’s, barns, and feedlots are not industrial petri dishes of some of our greatest existential threats.

      I would rather myself and any hypothetical children of mine live within ten miles of any nuclear power plant of US, French, Indian, or Chinese design than for them to take field trips to local meat or dairy farms. The inverse square law is a much more forgiving adversary than selective reproduction pressures.

      • CJ says:

        Why not beta lactams?

      • Aaron says:

        To me they seem to already be a largely lost cause when looking at long term planning when considered as an entire class. While they will be useful for a long time time come in many situations (hopefully), I don’t think they need the strong protections as controlled substances that our antibiotics of later resort need.

        Amoxicillin for strep still makes sense as a first line treatment for strep, but levaquin and cirpo need to be conserved. I would argue tetracyclines, especially doxyxuxline still merit protection and control due to their persisting utility in treating a wide variety of infections including many lesser antibiotic resistant flora.

      • VA Hopeful says:

        Do you include cephalosporins in your beta-lactam list?

      • Aaron says:

        I am not a bureaucrat as much as I would appreciate the income security, but this repentant drunk poster in retrospect sees the error in condemning all of the beta lactams.

        That being said the message of being stingy and selective with all antibiotics preached for a while now seems to have not had the impact of halting antibiotic resistance in the United States. My gut feeling though is that the conversation needs to move in the direction of triage for particular antibiotics as though they are patients at a disaster site. We are far beyond the point where hysteria should be justified.

        I have a feeling though that if agricultural use of antibiotics as growth promoting agents were to end, then community acquired MRSA in rural areas would drop.

  3. aGuy says:

    Is there any research which tracks the development of resistance and attributes it wholly or even primarily to overperscription in people? The majority (I’ve seen figures like 70%) of antibiotic use in the US is for livestock. We’re not talking veterinary use either, but antibiotics which boost growth rates. I wonder what proportion of resistance is caused by this agricultural use?

    • ladyk73 says:

      ditto… I was just going to comment on the sickingly over use of agricultural anti-biotic use. Where do you think e-coli naturally comes from? MMMoooooo MMMoooooooooo

  4. Chrys says:

    Having a family member recently diagnosed with one of these horrible things, it is very frightening. People don’t seem to understand that they can die, if the doctors can no longer kill these bugs. It is very serious.

    I recently went in for surgery, and the list of superbugs has grown. Our hospital gives out sheets on the various bugs and a list of symptoms for patients to be aware of and report. It made me think of my family member and their ordeal.

  5. midwest woman says:

    I lay a lot of this on standard precautions… gloves on, gloves off and the sink is dry as the Sahara desert. I think people have made the erroneous assumption that gloves eliminate handwashing.

  6. Sarah G says:

    I’ve thought about requesting to be sprayed down with Lysol afterward if I ever need surgery.

  7. Nurse K says:

    “I have a cough, I need a z-pack.” —Every ER Nurse and Tech in America

    [Actually not me, but co-workers are the worse for abx drug-seeking]

  8. [...] This post was mentioned on Twitter by Edwin Wise, Sarah Glenn. Sarah Glenn said: The super-duper bugs are here: http://www.epmonthly.com/whitecoat/2010/08/attack-of-the-superbugs/ [...]

  9. Karol says:

    My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator

    Glad to hear, from a professional, that we shouldn’t feel badly about asking for this.

    My 83-year old mom had a bad fall and is currently in a care/rehab center. She had a UTI (previous to admission) and developed a staph infection in her injured leg. We have observed some careless infection control procedure in this place, like CNAs washing body parts with towels and putting the dirty/infected towels on the footboard of the bed. Then just taking the dirty towels away and not sanitizing the place they rested it (which they shouldn’t have done in the first place).

    We do speak up, and in fact have taken on some of the care. Thank God we can be there at least 12 hours a day, who knows what would go on if we couldn’t.

  10. throckmorton says:

    Did anybody notice that the superbugs began to emerge at the same time the FDA banned mercurochrome? It is extremely active against all strains of staph and gram negs. In fact, it is one of the most effective topical agents. The FDA banned it because of the mercury which was never shown to be absorbed to any degree or to lead to any problems. Just like the thermosol scare, mercurochrome became the enemy.

  11. Carol says:

    Can I just have my script for the real Psuedoephedrine? Just one box.. Love the law, hate that I have to see a Dr. for a bad cold.

    • G says:

      Do you really need a prescription? My state only requires that you show the pharmacist your ID. All you have to do is ask for it. I think the law stinks. All it does is create more work and tedium for the rest of us.

      • Carol says:

        Yes, I live in Oregon.

        I’m on my way to one of the other states in November, I’ll pick myself up some cold medication with my trip.

    • throckmorton says:

      Carol:

      What you really need is phenylpropanolamine. This was the agent in many decongestants that worked great. It was taken off the market because it had a side effect of appetite suppression. People would take too much of it to lose weight and becuase of this there was a chance of stroke. So in its wisdom the FDA removed it from the market. It is actually far safer than psudedoephedrine, safer and you can make meth out of it.

      It is still sold over the counter everywhere except in the US.

      • Aaron says:

        The US has the wierdest exceptions for things it excludes, but other countries are much more permissive on things they allow. Gaza and Egypt allow Tramadol over the counter. Weak government gets worse though when Afghan national Army soldiers eat opium seed out of the pod in front of American patrols (disclosure: I am not a witness).

      • Karol says:

        I still do better with pseudoephedrine. No side effects. Phenylpropanolamine caused me severe tachycardia that sent me to the ER once.

        Sadly the pseudoephedrine is only available by prescription in my state. I just have my husband bring it home when he travels for his job.

  12. Ian Random says:

    Simple, make the insurance copay proportional to the strength of the anti-biotic. :-)

  13. Long term, we’ll have to move towards antibiotic rotation, similar to crop rotation. Entirely stop production and use (worldwide) of entire classes of antibiotics for a decade or so. The bugs resistant to that class of antibiotics generally pay a metabolic price for that resistance, and will lose out to their non-resistant colleagues if that class of antibiotic isn’t in use anywhere.

    In a decade or so, that class of antibiotic probably starts becoming useful again, and we can rotate out other classes of antibiotics.

    Of course, the global coordination required to achieve the above is probably beyond us – not to mention the screams of “but that antibiotic is the only one *I* can tolerate, you can’t stop using it!”.

  14. Nick says:

    Parents are the worst for demanding antibiotics when their child is sick. Just say no!

  15. BinkRN says:

    I have a few coworkers who get ABX for everything…it is annoying. Also, a couple of docs who hand out prescriptions all the time…many to fill if this or that occurs…I think people likely just fill those no matter what.
    One of my children was on their first ABX last winter- at age 5. No ABX for ear infections or sniffles. I feel my kids’ immunity is pretty good…even if schools are a beanpot of germs.
    I actually respected my primary MD more than I already did when she felt I didn’t need an antibiotic for the sinus issue I had for 4 weeks already, but prescribed a nasal steroid instead, which worked wonders.

  16. ERP says:

    My big pet peeve is staff memebers curbsiding me for a Zpack for a cough for a few days. URGH!!!!!!!!

  17. Roberto says:

    This is a great post, I think the claims by Aaron and aGuy about the use of antibiotics for livestock need to be addressed side-by-side with the issues of Abx prescription for humans. I enjoyed the link on policies adopted in Norway 25 years ago. Unaddressed is also the fact that many antibiotic resistant plasmids and genetic material get dumped in regular trash in most labs doing this kind of work (not the bugs which get killed by an incinerator just the material like plasticware carrying the plasmids). I do it almost every week!!. I recall this being an an issue back when genetic engineering became possible but suddenly it stopped being such. …don’t know the reasons.

    • Aaron says:

      One of the problems with research ethics is that the people making the rules aren’t always the people who know enough to cover all the risks, but often just as in industry cost wins anything where rules aren’t explicitly raised. I truly pity future archaeologists that might investigate our landfills.

  18. SeaSpray says:

    Wc ..I used to be one of those patients that thought I needed antibiotics. Not for a cold ..but if it progressed into bad cough or sinus smell or green sputum, It was the doctors who told me I needed antibiotics ..I never asked. They said green and/or infected type odor I described was indicative of a bacterial infection. And I could feel it in my body and I did get better after a few days.

    But thanks to you ..back in Nov/Dec 07 (I think), I waited 2 weeks with a bad uri before going in to doctor. Than I told him I didn’t want antibiotics if I didn’t need them and he didn’t give them to me and I was secretly worried I’d never get over it and was sure I would need them because I was so sick and coughing and nothing would stop the cough but hot tea, lemon and honey. I was living on it. he told me to sit in a steamy bathroom a few times a day for 10-15 minutes. It WORKED! I never got antibiotics and started feeling better not long after that visit. Thankfully ..I have not had anything like that since… but will keep it in mind.

    You had also mentioned netty (sp?) pots and they helped too.

    I have a question for you or anyone that could answer. back in 06 I had a ureteral stent in me and had a urinary tract infection. I didn’t have symptoms, but my doc had good follow-up and checked on me. I became resistant to all oral antibiotics he gave me and had to be admitted for to hospital for stronger antibiotics and have stent out. It worked.

    Did that happen because of antibiotics I had in my life for other things? I always finished them and i think I had things like amoxicillin, penicillin and z-pak.

    And ..does it mean that once resistant ..always resistant or was it just that particular infection? I never thought much about it after I got better. Does it matter?

    The other stuff you discuss is frightening ..the idea that such serious things are resistant to anything we have.

    • Roberto says:

      Seaspray, there’s not such thing as a strong antibiotic. You should know that by this time. If anything you could talk about MIC (minimal inhibitory concentration) but ‘antibiotic strenght’ belongs to the layman.

      • SeaSpray says:

        But I am a layman Roberto. :)

        I’ve always thought that when pts were admitted for cellulitis, sepsis,pneumonia, etc., that the docs wanted the patients on heavy duty/stronger antibiotics.

        So .. if not stronger, than is it because of how they are administered?

      • Roberto says:

        SeaSpray, a good explanation of why there aren’t strong or weak antibiotics can be found in Dr. Mark Crislip fascinating podcasts (gobbet o’pus) that I’m sure you’ve heard of. However, I can’t recall exactly the edition in which he explains this concept in a very funny way.

        Alternative explanations can be found in any textbook. Antibiotics like any other ligand that binds a high affinity binding site follows the rules of pharmacology. Although there might be differences in affinity among the different antibiotics and thus potency could be used as a criterion for their ‘strength’ (http://en.wikipedia.org/wiki/Minimum_bactericidal_concentration), therapeutically useful classifications use SPECTRUM rather than potency. So if you’re going to kill a resistant bug instead of hitting it harder with the same weapon (say, increasing the concentration of the same Abx), you take advantage of different weapon by targetting a different ‘Achilles heel'; say, switching to another Abx that instead of inhibting cell wall synthesis will inhibit DNA gyrase, or inhibit protein synthesis. And they call it the big guns, and it’s just ‘different guns’.

      • SeaSpray says:

        Thank you Roberto, for taking the time to explain.

        No ..never heard of Dr Crislip.

  19. SeaSpray says:

    WC – I very much appreciate what you said about speaking up to staff about washing hands. It should be a no brainer for them, but they probably get so busy they forget.

    I don’t see myself assertive enough to call someone though. I don’t like to make waves and I know that is not the smart thing.

    I had a particularly disturbing thing happen to me at the hospital one afternoon. I will never let it happen again. I had requested a percocet. I could have two, but usually only took one and that is what I did that day.

    The nurse walked up to me and took my unwrapped percocet out of her nurse’s jacket/scrubs.

    I was in there being treated for an infection..although going home next day.

    She looked at me and for a split second ..I could see in her eyes that she knew she was breaking protocol and I am sure my eyes told her I knew it and was hesitant.

    No wrapper on the pill. No little cup to dispense it in after unwrapping it in front of me.

    She just took the pill out of her pocket and handed it to me ..her pocket ..with God knows what contaminating it (see video above), to her fingers ..no gloves (were they washed? – I don’t know) and handed the percocet to me. I took it with my fingers and drank it with water and she left.

    She had NO idea how much that *bothered me*. I was seriously wondering why she did it that way and was secretly squirrelly about germs and what I had taken ..which seemed so much stronger to me. I really liked her and we had a good rapport and so I didn’t say anything. It bothered me all afternoon. I know I probably overreacted.. but admit to being a slight germaphobe.

    Ha! I never was until having the mandatory in services at the hospital. Then I became as careful as I could ..even at home.

    “wash your hands you filthy friggin barnyard animal” – that’s HILARIOUS! :)

    LOVE SCRUBS! :)

  20. medrecgal says:

    This post should be handed to every patient that comes into a physician’s office with a URI or similar (viral) problem that they request antibiotics for. (Or even perhaps some limited bacterial infections, which the immune system can get rid of.) As someone who survived a nasty tangle with MRSA that got me more than a week as an inpatient, I cringe every time I see physicians giving in to patient demands for antibiotics when they are not warranted. I silently cheer when I read the comments that say “no antibiotics are warranted, this infection is viral” or something along those lines. Keep up the good fight, Dr. WhiteCoat!

  21. Shalom (R.Ph.) says:

    Amen, brother. You could float a boat in the amount of amoxicillin and cefdinir that goes out of my store in a week. There’s even a doctor in town, an old-timer, who prescribes zpaks to anyone who asks for them, or so it seems from my end. Hell, he puts refills on them, and I’ve even had him call in for antibiotic suspensions with instructions not to reconstitute them so the patient can save it for when they (think they) need it. Drives me nuts.

    Worst case I’ve had yet was someone who’d been on oral vanco for some reason or other, who wanted me to call his doctor for a refill on it. I asked him why he was taking it, and he said because he noticed that when he took it he had a real good bowel movement! I told him, sorry buddy, there are cheaper laxatives out there, and the People of the State of New Jersey ain’t paying a thousand dollars a week for you to have a better bowel movement. I mean, sheesh, talk about inappropriate abx use…

    I am convinced that the reason Zyvox is so damn expensive (runs about $65 a tablet last I checked) is specifically to discourage casual use. Last thing we need for the drug of last resort for VRSA is for some dufus to walk into his doctor’s office and say “Hey doc, I got this terrible cold, I want you to gimme the STRONGEST ANTIBIOTIC THERE IS!!1!” and you know there are some docs who’ll prescribe it just to get the patient out of their hair.

    My son is three and a half; he’s had one course of abx in his whole life, and that was when he went in for his 2-year well visit and the paediatrician said he had an asymptomatic ear infection. Yet I see patients (kids) in my store who have been on abx more than they’ve been off them. What gives?

    • Roberto says:

      I wonder if this complacency has anything to do with our ‘customer service’ culture, which is also engrained in our ‘market’ culture, especially the propaganda-type ‘free market’ that even Mr. WhiteCoat seems to advocate.

      The people yell free market!, I want free market!, Yes, that’s what I want, and nobody notices that just a few companies rule the world. Just a few banks control the whole economy (with different names of course) and when the free market, the invisible hand of the free market has to show its claimed self-regulating abilities, pum! that’s when it fails and suddenly it needs a multibillion tax-payer bailout, a golden parachute paid by the most humble of the servants. Yes, we want free-market, and we physicians and pharmacits want it to serve our customers. Yes, free market in a monopolized economy!!.

      I wonder if you could comment on Codex Alimentarius.

    • KT says:

      Someone correct me if I’m wrong, but vancomycin is a hospital-use only drug in Australia. In any case, I’ve worked in retail pharmacy for 3 years and have NEVER seen it prescribed. And they’re giving it to someone so they can have a BOWEL MOVEMENT?

  22. Karol says:

    How about the proliferation of anti-bacterial hand soaps? Everyone is using them (not my family).

    Does this not contribute to superbugs?

    • G says:

      I’m curious about this too. About 5-8 years ago (before they were so abundantly used)my pediatrician told my mother not to use them because they cause “super bugs.” I’ve never used them and strongly discourage my husband from using them, but are they really part of the problem??

    • WhiteCoat says:

      No resistance to alcohol-based cleansers has been documented.
      Minimal resistance occurs with antibiotic hand cleansers containing triclosan, but those cleansers are no better than regular soap in killing bacteria.
      See here: http://www.cdc.gov/ncidod/EID/vol11no10/04-1276.htm

  23. SeaSpray says:

    I forgot to thank you for the link.

    Thank you for the link WC. :)

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