Outsmarting Resistant Infections - Episode 2

Understanding the Causes and Impact of MDR Infections

Peter L. Salgo, MD: My point was not, is it a big problem and are you hearing about this in the hospital, is there a drum beat? My point is it’s actually beginning to percolate into the population. People are beginning to understand that not every antibiotic works, not every infection can be cured with what we’ve got. And to some degree, I’m not sure they have the sense that it’s our fault. But it is, isn’t it, to some degree?

Jason Pogue, PharmD, BCPS-AQID: It’s not necessarily our fault. It is, to some degree, because the simple answer is yes, but even appropriate use of antibiotics is going to lead to resistance development. Sure, we could mitigate it a little bit by more appropriate use, limiting unnecessary antibiotic use. And I would say that infection control plays a big piece of that story as well. But it’s natural selection, right? We would expect this to occur. And as Andy pointed out—and I think it’s an important thing to keep in mind—we keep people alive longer now for things that they used to not be able to survive. And they end up becoming the poster children for getting these drug-resistant infections.

Andrew Shorr, MD: I’m going to disagree with you a little bit, Jason.

Jason Pogue, PharmD, BCPS-AQID: How dare you.

Andrew Shorr, MD: I know this shocks you and all.

Jason Pogue, PharmD, BCPS-AQID: We’ve never disagreed once.

Andrew Shorr, MD: In the last 7 minutes.

Peter L. Salgo, MD: You’re so easy to get along with.

Andrew Shorr, MD: It’s fascinating. But to bastardize Shakespeare, I disagree. I think the fault does lie with ourselves and not with the stars. This is not something where we should have stepped back and said, “This was inevitable. There was nothing we could do.” This has been like watching a slow-motion car crash for a generation, and we’re still playing catch-up. We’ve created the problem, we have to fix the problem. And each one of us in our roles as clinicians, whether they’re in the SICU, the MICU, ER, on the floors, as a PharmD, we have all contributed to this, and it is incumbent upon us to figure out how to solve the problem, period!

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): I think getting back to the question about more information in the community, with the increase in C. diff, a lot of people are aware of C. diff and they are starting to be aware that it’s associated with overuse of antibiotics. So, this is starting to very slowly be a topic that’s discussed outside of hospital settings. But while we’ve worked on antimicrobial stewardship a lot over the last decade in the inpatient setting, it’s really just starting to even be discussed as a need in the outpatient setting.

Peter L. Salgo, MD: This gets back to what I was saying. This is a lot of deaths, 23,000.

Debra Goff, PharmD, FCCP: It’s a lot, and I think I have to piggyback on Andy’s comment when he said we’re to blame. It has been occurring over decades. But there’s a bigger issue called One Health. About 70% of antibiotics in the United States are actually prescribed to animals, and so when you look at the animal-to-human transmission of resistance, there’s a big component right now of who’s to blame. So, yes, health care providers are part of it, but responsible use in the animal sector is another part. And it’s becoming a blame game, which we’ll never solve. It’s a responsibility amongst all of us.

Peter L. Salgo, MD: How about we just accept the fact that there’s enough blame to go around.

Debra Goff, PharmD, FCCP: Right.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): Absolutely.

Peter L. Salgo, MD: And we’re all in the same boat. Let’s take a look at the impact. Yes, it’s beginning to percolate and the point is, if everybody realized that was a lot of 747s crashing, maybe there would be some outcry here. Until that happens, people have to understand the impact. First of all, what are the clinical and the economic impacts here on the hospitals, per se?

Jason Pogue, PharmD, BCPS-AQID: I think the clinical impact is best described on the patient. Again, pick your favorite resistant organism and look at outcomes in patients who have an infection due to the resistant form compared to the susceptible form. What you’re going to find across the board are twice as worse outcomes: mortality rate doubles, and if the patient survives, length of stay is double, as is the need for extra care afterwards. And again, from the hospital standpoint, there’s a cost associated with every single one of those things.

Peter L. Salgo, MD: How many of these resistant bugs are hospital acquired? How many out in the community?

Jason Pogue, PharmD, BCPS-AQID: I don’t know. In my opinion or based off of what we see, the majority of them are some exposure to the health care industry. But there are certain versions of these that have transmitted out into the community. MRSA is a good example of that. You can certainly see patients with purulent skin infections from the community that’s community-acquired MRSA. We can see it in community-acquired pneumonia from time to time as well. And even in the gram-negative space we’ve started to see that occur, and ESBLs are the real example there. That was a traditionally nosocomial pathogen, and as the epidemiology changed, you saw this push out into otherwise healthy individuals.

Debra Goff, PharmD, FCCP: You know, Jason, a good example of that is young women who acquire their first urinary tract infection and everybody thinks, “Oh, no big deal. You give a couple days of Cipro and call it a day,” except when it doesn’t work. And so, we’re seeing patients who have never had health care exposure acquire their first E. coli UTI, multidrug resistant. I think the best example is a 23-year-old model from Brazil who was exactly that scenario, got her first UTI, got 3-day course of Cipro, except it was resistant to everything and she ended up dying. And that put it on. She was the face in Brazil for that statement of, “We’re in a crisis,” and so that’s a big problem.