Re: those awful superbugs

From: Carol Tilley (
Date: Sun Aug 12 2001 - 16:47:43 MDT

From: "Damien Broderick"
my point remains: `superbugs' aren't an especially virulent
novelty, just a reversion to how things were *before* we had the
`low-hanging fruit' off the metaphoric antibiotic tree, and wasted it
improvidently. Is that correct?
Well, best to harvest the fruit that comes off easily in the hand and allow
the rest to ripen, no?
For a more staid overview of the situation, three googURLs:

Basic Background:
In addition to its adverse effect on public health, antimicrobial resistance
contributes to higher health care costs. Treating resistant infections often
requires the use of more expensive or more toxic drugs and can result in
longer hospital stays for infected patients. The Institute of Medicine, a
part of the National Academy of Sciences, has estimated that the annual cost
of treating antibiotic resistant infections in the United States may be as
high as $30 billion.

A key factor in the development of antimicrobial resistance is the ability
of infectious organisms to adapt quickly to new environmental conditions.
Microbes generally are unicellular creatures that, compared with
multicellular organisms, have a small number of genes. Even a single random
gene mutation can have a large impact on their disease-causing properties;
and since most microbes replicate very rapidly, they can evolve rapidly.
Thus, a mutation that helps a microbe survive in the presence of an
antibiotic drug will quickly become predominant throughout the microbial
population. Microbes also commonly acquire genes, including those encoding
for resistance, by direct transfer from members of their own species or from
unrelated microbes
Improving antimicrobial utilization is not only important from a
cost-containment perspective, but from a patient-care perspective as well.
Increasing appropriate antimicrobial usage can help avoid the potential for
adverse reactions and excessive selection of resistant organisms.

A perceived need to implement ongoing monitoring of antimicrobial use and
physician prescribing habits has led to the development of an Antimicrobial
Education Program at WVUH. Again, the objective of the program is to
maximize patient outcomes with respect to antimicrobial therapy while
minimizing costs to the institution. This program was developed by the
Pharmacy and Therapeutics Committee and approved by the Patient Care Review

The thrust of the program is to divide antimicrobials into two categories:

1. Open Use - antimicrobials that may be utilized upon the discretion of the
prescribing physician.
2. Criteria-Based - antimicrobials that must be utilized according to
approved criteria.

Education and intervention will be conducted by the pharmacist on a
per-patient basis. To obtain an institutional perspective on antimicrobial
usage, one antimicrobial from the criteria-based category every quarter will
be selected to assess compliance through the Drug Utilization evaluation
(DUE) process.

Specific antimicrobials that pose documented risks to patients, in terms of
toxicity and emerging resistance, will also be considered criteria-based
antimicrobials. If utilization outside of the criteria is inappropriate, the
pharmacist will intervene. If usage of this agent continues despite pharmacy
intervention, the Infectious Disease attending physician will review the
case. Note: This will not generate a formal ID consult. The goal, at this
point, is to provide peer-peer recommendations.

It is, of course, acknowledged that antimicrobial usage outside of approved
criteria may be appropriate for a given patient. Both pharmacists and ID
physicians will be open to such cases.
Vancomycin-Resistant Enterococci: Approach to Treatment and Control
Treatment options for VRE are limited to various combinations of
antimicrobials, none of which has been found to be absolutely effective. A
review of 69 cases of VRE found that 42 different combinations of
antibiotics had been used,[16] which illustrates both the extent and the
limitations of the treatment options now available. Since successful
treatment for VRE and multidrug-resistant enterococcal infections are yet to
be defined, current therapies are guided by microbiology laboratory reports.
Caution is needed by pharmacists and physicians when reviewing studies of
treatment of VRE. The usefulness of any regimen in a particular institution
is affected by local factors such as the presence of other resistances
besides vancomycin resistance, levels of resistance, phenotypes, and species
being studied.

Studies documenting patient outcomes are needed as new therapies are
developed. Since the organism is so adaptable, the answer to controlling
these difficult and resistant infections may lie not in the development of
new antibiotics, but rather in research that focuses on methods to overcome
the resistance. A national group is currently addressing these problems.[21]
At present, the most effective control measures are the prevention of the
spread and development of infection
The second reference has an excellent graphic (at the end of the article)
that illustrates the interrelationship between pharmacokinetics,
pharmacodynamics, and pharmacoeconomics. Hospitals in the US are under
increasing pressure to meet economic performance goals. Profitability
delimits research and treatment availability and utilization. Note the
dramatic decline in the production of many vaccines that cannot match demand
in today's market. But I am getting sidetracked here.
Take a look at Kaminuma's work at the NIHS in Japan: the right dosage of the
right drug for the right client at the right time.
His goal is currently unattainable. Too much data being churned into
information without sufficient computational soft/hard power at this
point-in-time to complete the perquisite individualized knowledge base.

But The Spike Cometh. Let's hope it beats out rampant necrotizing fasciitis,
the leprosy of the privileged man.
Here, I picked another apple for you...

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