Outsmarting Resistant Infections - Episode 1

An Overview of Multidrug-Resistant Bacterial Infections

Peter L. Salgo, MD: Thank you for joining us for this Peer Exchange® titled, “Outsmarting Resistant Bacterial Infections.” Multidrug-resistant infections are placing a considerable burden on hospitals in the United States and are associated with significant morbidity and mortality. Fortunately, several new antibiotics have been approved in recent years that are effective against these difficult-to-treat infections. This Peer Exchange® panel of experts in infectious disease will discuss the role of these newer therapies in hospital settings. We will also discuss the importance of antimicrobial stewardship in the battle against resistance.

I’m Dr. Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital. Joining me for this panel discussion are Dr. Sandy J. Estrada, an infectious disease clinical pharmacist from Lee Memorial Health System of Fort Myers, Florida; Dr. Debra Goff, an associate professor and infectious disease specialist from The Ohio State University Wexner Medical Center in Columbus, Ohio; Dr. Jason Pogue, an infectious diseases clinical pharmacist at Sinai-Grace Hospital of Detroit Medical Center and clinical assistant professor of medicine at Wayne State University School of Medicine, in Detroit, Michigan; and Dr. Andrew Shorr, section head, Pulmonary and Critical Care Medicine, MedStar Washington Hospital Center and professor of medicine at Georgetown University in Washington, DC. Thank you all for joining us here today. Why don’t we get started?

I think the best thing to do is take a look at how big a problem this is to begin with. What is the prevalence of multidrug-resistant bacterial infection in the United States?

Debra Goff, PharmD, FCCP: Well, according to the CDC, they estimate about 2 million patients a year are infected with a multidrug-resistant pathogen. Of that, about 23,000 patients die. But that might be actually a little bit of an underestimate.

Peter L. Salgo, MD: Why is that?

Debra Goff, PharmD, FCCP: Well, not every hospital reports their data and not every death certificate lists the infection as the cause of death. Andy would know that.

Peter L. Sago, MD: What are you implying about Andy?

Andrew Shorr, MD: I was an intensivist who filled out a lot of death certificates.

Peter L. Salgo, MD: Oh, OK. That’s an astounding number. Let us assume for a moment that it’s 23,000 deaths, how many 747s? I can’t do the math in my head. If we had that many plane crashes a year, people would sit up and take notice.

Debra Goff, PharmD, FCCP: Absolutely, but they don’t. It’s a number that outside of health care doesn’t generate a lot of discussion unless you frame it as a 747 going down. So, it’s really a challenge.

Jason Pogue, PharmD, BCPS-AQID: And I think the thing to think about, too, when you’re talking about the impact that drug-resistant infections have on our patients is that that number is increasing. Pick your favorite organism. For the most part, if you look at resistant versions of that bug, the numbers are going up over time and that’s why it’s an urgent threat for us.

Peter L. Salgo, MD: You know what I hear? I hear it’s my fill-in-the-blank. Mom, grandmother, friend’s mother was in the hospital, she had pneumonia, they gave her antibiotics and they didn’t work and she died. Shouldn’t antibiotics work? Do you hear that? I hear it all the time.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): I think we do. From time to time, we hear cases where antibiotics had to be switched so perhaps we had to try 2 things, 3 things, 4 things, and then they did eventually work. So, the cases of not working at all are still fairly rare but becoming more common. But the cases where there’s extended length of stay, extended cost, need to stay in the hospital, or have repeat visits are becoming more and more common.

Andrew Shorr, MD: I think another way to conceive of it is if you look at crude mortality rates for some, particularly in highly resistant gram-negative organisms, with what are our best available therapies up until what has recently been approved, the outcomes arrival mortality rate is seen in the pre-antibiotic era, particularly with pneumonia. So, it’s as if we’re back to placebo.

Peter L. Salgo, MD: I think it’s really important to just focus on that for a minute. All medical students and residents that I know give them an antibiotic and say, “Let’s go home.” But we’re facing a real crisis here. Our antibiotics are becoming less effective and we’ve got diseases that we’re having a lot of trouble treating.

Andrew Shorr, MD: Right. And the prevalence, as Jason pointed out, of these infections is going to go up, not only because of the aging of the population, not only because of the epidemiologies of these pathogens, but also because we’re being more and more aggressive with immunosuppression across the board for nearly every disease state. And people are living longer and they’re not dying of their heart failure, they’re not dying of their renal disease. And as Osler said over 100 years ago, “Pneumonia was the captain of death,” and it is for a reason; because you’ve got to die of something. And so, this is not going away, and I think we’ve all lamented it. I think the problem now is we’ve got to figure out how to solve it.