Superbugs

New Round in the Battle Against the Superbugs

By Mary R. Anderlik
Health Law & Policy Institute

Often, progress has a price. To borrow a phrase from Edward Tenner, "things bite back." In the realm of computing, we have the Y2K bug. In the realm of medicine, we have superbugs—multi-drug resistant bacteria. While evidence of the problem is growing, policy solutions remain elusive.

Consider the following:

Each year 16,000 hospital patients become infected with a strain of the enterococcus bacterium that is resistant to antibiotics, including the antibiotic of last resort, vancomycin.

In 1974, 2% of hospital cases of Staphylococcus aureus (staph) were resistant to the antibiotic methicillin (and all beta-lactam antibiotics). In 1997, roughly 50% were methicillin-resistant.

In the August of 1999, the Centers for Disease Control and Prevention published four case studies of community- (rather than hospital-) acquired methicillin-resistant Staphylococcus aureus resulting in death. While all the victims were children from the upper Midwest, they were not from a single community.

Researchers have shown that E. coli bacteria can develop resistance to triclosan, a compound found in many popular antibacterial products such as soaps and body washes.

Researchers have found multi-drug resistant bacteria in chicken feed. Antibiotics are used extensively in agriculture, for example, as food additives to boost growth.

While agricultural uses of antibiotics and the new wave of antibacterial products may hasten the development of superbugs, the primary culprits appear to be doctors and patients. The Centers for Disease Control and Prevention estimate that Americans consume 235 million doses of antibiotics annually, and that 20-50% of those doses are unnecessary (e.g., because infection is viral or because it is minor and would resolve on its own without treatment). This means that many prescriptions are being written with little or no benefit to patients, and big public health risks. Experts suggest that the drug-resistant strains of staph just now beginning to take hold outside hospitals are initially isolated mutations existing alongside other strains of bacteria. Kept in check by their neighbors, they do not pose a threat, even when passed from child to child. However, when one of the children in the chain is treated with an antibiotic, the regular staph is killed off. The resistant strain survives and thrives.

One seemingly simple fix is to speed up the development and approval of new drugs for treating bacterial infections. There is some cause for optimism. On September 21, 1999, the Food and Drug Administration gave fast-track approval to Synercid, a drug effective in treating about 50% of patients with the vancomycin-resistant strain of the enterococcus bacterium. Synercid may also serve as an illustration of the weakness of this strategy: Synercid is a chemical cousin of a common agricultural food additive, and the development of strains of bacteria resistant to Synercid is likely to be rapid.

Another possible policy response is to emphasize prevention. We could have more intensive—and intrusive—regulation of antibiotic use. In the health care context, any attempts at "bureaucratic micromanagement" of prescribing would surely meet with strong resistance. The fallback is always education. Studies of doctors (typically pediatricians) reveal that many attribute overprescription of antibiotics to pressure from patients or parents of patients. But blame can surely be shared; doctors may do little to educate patients (parents) concerning the viral-bacterial distinction or the dangers associated with antibiotic use. These considerations suggest that an effective educational strategy would focus on increasing doctors’ knowledge of the dimensions of the public health problem, and of the importance of allocating precious clinical time to patient and parent education, while seeking to raise the level of awareness of the public at large. At a minimum, a broad-based public information campaign should make people more receptive to explanations from their doctors when they receive them and as ready to challenge a quick prescription as they are to demand one.

09/24/99