We can beat the Superbug

August 25, 2010

Kelvin Teo

Fixing the Superbug

Fixing the Superbug

Most of us might have experience the following scenario at one point of our lives or another: Mr X sneezed onto his palm. He rubbed his wet palm containing the mucus onto his trousers. Finally, he offers you a handshake. Will you shake his hand?

Terms such as Methicillin-resistant Staphylococcus aureus (MRSA), or more rarely Vancomycin-resistant Staphylococcus aureus (VRSA) will send a chill up a General Practitioner’s and an Infectious diseases physician’s spine. These are known as superbugs; bacteria which are resistant to a number of drugs. In fact, the Straits Times reported that a superbug had claimed the life of a Belgian man 2 weeks ago.

Fixing the Superbug

There are two broads approaches towards dealing with these superbugs? The first approach is administering a drug that these bacteria are susceptible to. Having one such available agent is by no means a simple process, but a long arduous one. The process starts with the stage of drug discovery, where chemical agents believed to have a microbial killing or/and growth-retarding effect on these bacteria are identified.

This new agent is then tested on animal models, before being tested on humans in exploratory phase 0 trials (according to Food and Drug Administration [FDA] guidelines AKA First-in-human trials), followed by phase I to III clinical trials on humans again. If the trials are successful, the drug can be approved for use by the regulatory authority, which is usually FDA. There is a phase IV, which is also known as post-marketing surveillance that is the monitoring of the drug after its release into market. This phase is concerned with the safety of the drug in a population-wide context.

It may take up to a decade or more for a drug to eventually hit the market, and many potential drugs fall at the various hurdles, that includes the phases of clinical trials, and were never approved for treatment. For antibiotics, there is always the spectre of the emergence of resistance bacteria hovering and that it will be a matter of time before the new drug is rendered less useful.

This has happened to the drug linezolid. Initially designed to treat MRSA and approved by the FDA in April 2000 (1), a case of linezolid-resistant Staphylococcus aureus was reported in Lancet, a premier medical journal in 2001 (2). As a result, a second approach is required to supplement the shortcomings of administrative hurdles in getting drug approval – preventive measures.

The Superbug is man-made

It has been long recognised that the non-discriminate use of antibiotics resulted in the emergence of antibiotic-resistant strains. Assuming the newly released drug is used non-discriminately; it will kill the susceptible strains of bacteria, but will allow the resistant strains to establish a niche.

It is possible that the resistant strains have always existed within the population of bacteria, as in the case of the linezolid-resistant Staphylococcus aureus, which explains the short span of time elapsing between the market release of linezolid and detection of resistant strain.

Discriminate use of antibiotics involves not prescribing them for viral infections, since they are not useful against viruses. Usually, the viral infection is allowed to resolve by itself. However, our world is far from ideal in terms of achieving discriminate use of antibiotics and some factors are beyond the physicians’ hands.

Some patients stop their course of antibiotics when they feel much better, contrary to the advice of their physicians to finish their course of antibiotics. Although symptoms may resolve, residual bacteria may reside within the body, and stopping the course of antibiotics may give the latter a chance to develop antibiotics-resistance mechanisms, which make them resistant to the antibiotics.

There are also patients who do the unthinkable; they stockpile on the antibiotics that they are supposed to consume, using it later when they get the same symptoms! What they have done may result in a double whammy – not only the bacteria are given a chance to develop resistance mechanisms but the non-discriminate use of antibiotic later down the road results in a selection pressure for the resistant strain.

Another hindering factor is attributed in part to the modern phenomenon of medical consumerism. In the olden days in which “medical paternalism” was in practice, the physician is the one who is the sole decision-maker in patient-care. Nowadays, there is a move towards cooperative models of collaboration between physician and patient in the care of the patient. The other extreme is where the patient acts like a customer who sees the physician as a mere service provider cum technician. Hence, it is not uncommon for a physician to come across a patient who specifically requests for an antibiotic (s).

More alarmingly, it was reported in a survey study involving pediatricians published in Pediatrics journal that 96% of pediatricians who responded had parents requesting for antibiotics for their children when they were not indicated (3). Another piece of damning statistic in a separate study published in the same journal is that 18% of parents had given their children antibiotics at home prior to medical consultation (4)!

Handling patients or parents with such demands can be a tricky one for the physician. At the back of his or her mind, there is always the niggling fear of being thrown into a litigation suit should they not subscribe to the patient’s demand for an antibiotic even when it is inappropriate; there is always this possibility of facing ‘malpractice liability’ (5).

Much of the discussion has been devoted to the discriminate use of antibiotics; yet the irony of it is that this places the pharmaceutical companies responsible for their production in a catch-22 situation. They are in essence producing a drug that shouldn’t be used on a large scale non-discriminately when it is in their commercial interest to capitalize on the extensive sales. In essence, the more of the drug is used, the faster they become obsolete.

A public campaign

Returning to the earlier scenario of hand hygiene, it is easy to see why such a simple task is often overlooked. Yet, it has been shown that poor hand hygiene is associated with the spread of MRSA (6), and an improvement in hand hygiene resulted in a decrease in infections (7). We have been discussing a lot on the problems leading to the proliferation of these superbugs, hence what are the solutions? An educational campaign targeted at the general public with regards to antibiotics use has been a long time coming.

Specifically, the public should be educated to follow through an antibiotic course, and to follow their physician’s instructions instead of self-medicating. They also should be educated on the types of infections that be treated with antibiotics, and the types (viral) in which antibiotics are not useful. It is also essential for such campaigns to reach out to parents. It is important for them to understand that they should neither be requesting antibiotics from the children’s physicians nor should they be giving their children antibiotics without the physicians’ directions.

In addition, an educational campaign should be run on maintaining proper hand hygiene through the use of anti-microbial soap, and the proper hand-washing techniques. On the legal front, options should be explored to provide physicians with an indemnity against ‘malpractice liabilities’ where it has been established according to professional opinion that antibiotics prescription is inappropriate. Such an indemnity will at least ease the physicians’ legal concerns should they not bow down to their patients’ request for antibiotics.

On the pharmaceutical front, the pharmaceutical usage should be tempered with appropriate prescription practices. In order to achieve good prescription practices, two hands must clap in unison, including that of the patient’s. Therefore, the public’s expectations with regards to antibiotics should be managed, and this can be made possible through educational campaigns. Realization of the importance of hand hygiene can double as a preventive measure against the spread of infections. And for physicians, it will be great if they are empowered to make the call that the prescription of antibiotics is inappropriate (in applicable cases) without the fear of legal repercussions.

On an ending note, it will be prudent not to shake Mr X’s hand. Direct him to an educational campaign on proper hand hygiene if there ever was one.

References

  1. American Society of Health-system Pharmacist [LINK]

    Tsiodras, S., H. S. Gold, G. Sakoulas, G. M. Eliopoulos, C. Wennersten, L. Venkataraman, R. C. Moellering, Jr., and M. Ferraro. 2001. Linezolid resistance in a clinical isolate of Staphylococcus aureus. Lancet 358:207-208.Bauchner H, Pelton SI, Klein JO. Parents, physicians, and antibiotic use. Pediatrics. 1999 Feb;103(2):395-401.Palmer DA, Bauchner H. Parents’ and physicians’ views on antibiotics. Pediatrics. 1997 Jun;99(6):E6.Coleman CH. Do Physicians’ Legal Duties to Patients Conflict with Public Health Values? The Case of Antibiotic Overprescription. Journal of Bioethical Inquiry Volume 6, Number 2, 181-185, DOI: 10.1007/s11673-009-9155-4Girou E, Legrand P, Soing-Altrach S, et al. (October 2006). “Association between hand hygiene compliance and methicillin-resistant Staphylococcus aureus prevalence in a French rehabilitation hospital”. Infect Control Hosp Epidemiol 27 (10): 1128–30.Swoboda SM, Earsing K, Strauss K, Lane S, Lipsett PA (February 2004). “Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit”. Crit. Care Med. 32 (2): 358–63.

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2 Responses to We can beat the Superbug

  1. Paul Ananth on August 25, 2010 at 22:32

    Hi Kelvin

    Patients are taking steps to combat drug-resistant infections.

    Check out http://www.cancerstory.com/

    Paul Ananth

  2. Kelvin Teo on August 26, 2010 at 16:15

    hi Dr:

    Actually good to have such patients around.

    Hmmm do you think it will be a public health concern to have packed public transport during peak hours. Not sure if anyone did a comparative epidemiological study say between populations of singaporeans who own private transport and those who take public transport..and the incidence of infections..esp airborne types.

    Had someone close to me..fell sick because she thought someone sneezed into her face in a crowded bus…

    I saw the synopsis of the book. Apparently the author was also advocating for an affirmative action amongst healthcare workers. Well..good to have such like-minded fellows around!

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