A colleague just called me to advise him about treatment options for treating a patient he has diagnosed with a "superbug." Superbugs are ordinary bacteria that no longer respond to our usual antibiotic armamentarium. They are drug-resistant. The conversation led to a discussion about the NIH superbug debacle this past summer. In August, there was public ire directed at NIH over "lack of transparency" about the deadly drug-resistant bacteria. As I told him, it is an ire that is misplaced and misguided. In an editorial response to the situation, a citizen wrote, "NIH had an ethical obligation to inform the public about this dangerous threat to the public health." If this were the barometer by which people gauged their willingness for hospital admission, most would elect to convalesce at home. The NIH is no guiltier than hundreds of top-notch hospitals across the nation that don't alert the community to similar struggles with containment of increasing prevalence of drug-resistant bacteria. The accusing finger should not be specifically leveraged against NIH but against community members and health-care providers across the U.S.
The death toll from the NIH superbug was six but in 2011, the CDC published data attributing 98,987 deaths nationwide to these health-care-acquired infections. The truth is, for over a decade the CDC, health educators and a variety of other health mavens have been warning the public about the urgent need for behavior change in antibiotic prescription and usage, but this information has fallen on deaf ears. Antibiotic overuse by patients and overprescription by health-care providers are largely to blame for the emergence of drug-resistant bacteria. Therefore, lest the community continue to express outrage about the NIH's lack of transparency, may I suggest an examination of the primary behaviors that have led to this urgent public health crisis.
First, health information about appropriate antibiotic usage is largely ignored by the community. Patients often feel entitled to antibiotics, and demand them regardless of whether or not they are medically warranted. During my residency in the mid-90s, while moonlighting in an urgent care center, I remember an interaction with a patient who arrived knowing exactly what she wanted. She told me she had come to get a prescription for amoxicillin because she could feel a cold coming on. She wanted to take the antibiotics pre-emptively to thwart the cold or, in her words, "knock it out" before it was full-blown. I told her antibiotics were for bacterial infections and because colds and flu are caused by viruses, the antibiotics were not warranted. She continued her argument, relating that all of her illnesses start in the same manner; she would later develop colored phlegm, signifying a bacterial infection; and the only thing that would help was taking an antibiotic at first symptoms. When I refused to relent, she told me about the other doctors who had prescribed the antibiotic in the past, and said that if I didn't give her a prescription she would simply return and get the prescription from another doctor. I am sure she did.
Second, many health-care providers across the U.S. prescribe broad-spectrum antibiotics aimlessly and carelessly. Antibiotics have become a safety net as evidence of tangible health-care delivery. Patients want doctors to "do something." In a society now accustomed to pharmaceutical remedies for every malady, when faced with an elusive or unknown diagnosis, an antibiotic prescription mollifies both the patient and the doctor. This cavalier approach is now pervasive in the health-care industry, and has helped create a culture of widespread availability and accessibility to antibiotics, which are the largest contributors to emergence of drug-resistant bacteria. When a patient first arrives with an unknown illness, understandably a provider may elect to cover as many bacteria as possible with an antibiotic, i.e., broad-spectrum. The problem arises when health-care providers are not diligent and thoughtful about the scientific and laboratory evidence supporting or refuting their decision to continue this broad coverage. It's a perfect storm for bacteria crafty enough to reconfigure themselves to ignore and evade the threat of broad spectrum antibiotics. This behavior has perpetuated the continued emergence of multi-drug-resistant bacteria like the superbug at NIH and many hospitals across the U.S. I was once consulted by another doctor to see a patient who appeared to have an infection. Upon review of the information, I discerned the patient did not have an infection and recommended antibiotic discontinuation. The doctor thanked me for my consult and discharged the patient on antibiotics "just in case" the patient had an undetectable infection.
The emergence of multi-drug-resistant bacteria is a challenge that will be with us for years to come. The solution demands a strategic, thoughtful and collaborative team approach. Scientists can contribute to the team by developing new antibiotic agents to treat drug-resistant organisms or "superbugs," and I am confident they will. However, once these agents are available, what will prevent us from witnessing emergence of resistant "superbugs" to new, more powerful antibiotics if we don't initiate behavior change in antibiotic overuse and prescribing patterns? Behavior change is never a popular remedy to a health crisis, but in this case it's vital. Health-care providers and the community members have a critical role to play in in addressing this public health crisis. Each can consider adopting one of more of the following actions:
- Review the CDC health information on appropriate antibiotic use. The vast majority of upper respiratory infections result from viruses like influenza. Viruses do not respond to antibiotics and are therefore not necessary. Community members can refrain from demanding antibiotics. Keep an open mind when engaging your health-care provider about an unknown illness or infection. Antibiotics may not be the solution, and you may leave the office with only health advice rather than a prescription. Maintain close -- and truthful -- communication with your health-care provider about changes in your symptoms. Health-care providers can trust clinical judgment to discern appropriateness of antibiotics and devise practical ways to educate patients about responsible antibiotic use.
Finally, reduced community demands and provider prescription will be impactful, but the solution will likely also require quality control programs, restriction and evaluation of antibiotics prescription by infectious diseases experts, particularly in hospital settings. This strategy will undoubtedly be unpopular and controversial, and may invite resistance from health-care providers who shun the oversight. However, the status quo is unacceptable and demands action. Anything less will mean waiting for the next sensational story about the wrath of a new superbug. Only then the death toll will likely be much, much higher.
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