Preventing Infections With Universal Decolonization is the Smart Way to Extend the Useful Lifetime of AntibioticsBy
Eight days ago, the United States government rolled out its National Strategy to fight the growing crisis of antibiotic resistant bacteria. It is a crisis because at least 2 million Americans are severely wounded and at least 23,000 are left dead (about half are due to MRSA alone), every year, by infections that antibiotics no longer cure. As antibiotics continue to lose their usefulness, these numbers will grow.
A key component of the White House Strategy is to try and extend the useful lifetimes of the antibiotics we have now by restricting their use – this is called “stewardship.” We’re familiar with the principle from our own lives.
For example, antibiotics are just like a community car: the more everybody uses it the more run down it gets until eventually it’s no good to anybody. So to extend the useful lifetime of the car restrict its use to necessary things like going to work, but no more drag racing and trips to the beach. With antibiotics, continue to use them to treat serious infections but stop prescribing them for things they don’t work on like the common cold and the flu, or because patients pressure you for them.
Back in July, when the president’s science advisors tabled their report that became the basis of the National Strategy, it received unanimous and enthusiastic approval. There was, however, one elegant and very subtle partial dissent from Christine Cassel, MD, a member of the President’s Council of Advisors on Science and Technology (PCAST).
She began : “… [M]y congratulations … on a masterful and really thorough look at the original literature about this. I just wanted to – and this is not really I think in the report yet … – add to the definition of stewardship in two ways. One is we think of stewardship as not prescribing antibiotics unnecessarily. But there’s another kind of stewardship which is reducing the risk of infection so the person doesn’t need the antibiotic … if you think about American hospitals … Medicare & Medicaid, and in particular the innovation center programs have incentives in place … to reduce HAIs, which is where some of the more dangerous ones are.
And we learned just in the last year that’s down 10%. You may say 10% is not a lot, 10% is half a million adverse events and 15,000 lives. Not to mention lots of dollars, but also lots of avoided need for antibiotics in the first place, and for exposing those bacteria to more antibiotics. So I think there’s a way in which looking at prevention is an important thing.” (My emphasis.) (Webcast, Antibiotic Resistance Report Discussion, 39 minute mark.)
In other words – less elegantly – we need to double down on prevention. A prime example of prevention in action was just reported in The Journal of Hospital Infection. In a study led by Elizabeth Bryce, MD, the Vancouver General Hospital, concerned about the overuse of antibiotics yet needing to reduce infections that arise during surgery, replaced the standard antibiotic ointment with a universal decolonization method using a novel light-based disinfection therapy. They found a “significant reduction” in the overall surgical site infection rate and the greatest decreases were a 42% drop in orthopedic and spinal patients. (This work received an international innovation award.)
Given that one of the controls was the 12,387 surgery patients over the 4 years prior to the study who received the standard antibiotic therapy, the reduced infection numbers would have translated, over those years, into a lot of saved lives, needles trauma, and antibiotics that needn’t have been dispensed.
Indeed, as The Lancet reported yesterday, “findings from large randomised trials show that decolonisation of nasal carriers of S aureus, irrespective of sensitivity to meticillin, can reduce postoperative wound infections, and that universal decolonisation is more effective than targeted decolonisation on intensive care units.” (My emphasis.)