Antimicrobial Resistance: Tragedy of the Commons

Over the past few years, many in the infection control community have identified global antimicrobial resistance as the classic economic problem known as ‘tragedy of the commons.’ Tragedy of the commons refers to the situation in which many uncoordinated players, acting in their own self interest, deplete a limited shared resource. Seminal examples include overfishing the ocean and global warming.

Antimicrobial resistance is similar in that health care providers and patients, acting in their own self interest, behave rationally and consume increasing amounts of antibiotics. This drives the unintended, adverse result of increasing antimicrobial resistance, compromising the efficacy of those same antibiotics. 60% of staphylococcus aureus in the US and UK are methicillin resistant. Multi-drug resistance pathogens are emerging in developing countries partially as a result of antibiotic overuse.

Recognizing that antimicrobial resistance is a global economic problem as well as a public health problem better informs strategies and solutions. We begin to think of antibiotic efficacy as a shared limited resource - like the environment and the world's fisheries, and can exercise innovative solutions to promote desirable behavior. Here are experts who've framed the problem in this way:

The tragedy of antimicrobial resistance: achieving a recognition of necessity

Antibiotic Overuse: The Influence of Social Norms

The sounds of silence: Public goods, externalities, and the value of infectious disease control programs

Monday Readings

I want to share two articles from yesterday's New York Times and Wall Street Journal. The first piece from the NY Times talks about FDA's new policy proposal to limit the use of antibiotics in animal feed. There is an apparently an on-going battle between public health and agriculture over the use of antibiotics in animal feed. The prevalent use of antibiotics such as penicillin and tetracycline in water and feed increases the emergence of resistant bacteria, which many believe to be an important public health issue. FDA's new policy calls for limited use of antibiotics. Whether or not the policy can be passed into law remains to be seen.

The second article from the Wall Street Journal describes quantitative measures implemented by many businesses, including hospitals, to evalute performance of employees. The article uses Long Island Jewish Medical Center as an example. Instead of evaluating nurses on qualitative metrics like "leadership" or "respectfulness," the hospital adopted a computer-based performance system that evaluates nurses against quantifiable goals such as keeping infection rates low and patient-satisfaction scores high. One of the key drivers behind the change is that insurers will begin paying hospitals for care based in part on patient satisfaction, which will be collected by surveys after patients are discharged. So hospitals are aligning performance measures to financial incentive.

http://www.nytimes.com/2010/06/29/health/policy/29fda.html
http://online.wsj.com/article/SB10001424052748703964104575334832074865058.html?mod=WSJ_hpp_sections_careerjournal

Emerging technologies in infection control

Infection Control Today published an article detailing several emerging HAI prevention technologies this week. All were interesting, but a few really stood out to me:

1. HandGiene - This company developed an automated hand hygiene technology that uses RFID, wireless, web-based data collection and reporting software to provide real-time monitoring for handwashing activities of healthcare personnel. Given that many believe that more than 50% of all HAIs could be eliminated by handwashing, HandGiene has great potential to help hospitals reduce HAIs through higher hand hygiene compliance rates.

2. Activeion - Activeion's flagship product, the Ionator, uses a process called "irreversible electroporation" to kill germs and bacteria in tap water. The process does not require the use of chemicals and therefore is very environmentally friendly. The company has a cool video that shows how the process works.

3. Agion - I came across this company a couple of years ago. The company makes disinfectants using silver. One of their products, AgionSilverClene24, provides an attractive alternative to traditional surface disinfectants because it keeps surfaces clean longer and is effective against tougher bugs such as MRSA, VRE, HIV, and Influenza.

Finally, I attended the MIT 100K Business Plan Competition Final last month and this year's second place winner is a company called Novophage. They have engineered a bacteriophage that slows the evolution of antibiotic resistance in bacteria and thereby delays the onset of antibiotic resistance. The bacteriophages could be used in conjunction with traditional antibiotics to improve efficacy.

Connected

I’ve been reading the new book Connected by Nicholas Christakis and James Fowler that provides a take on public health through the lens of social network analysis. Christakis and Fowler introduce the “Three Degrees of Influence Rule” that claims we influence and are influenced by people up to three degrees separated from us, a majority of whom we do not know. Several studies have shown, in addition to communicable diseases, conditions such as depression, hysteria, infectious laughter, and even suicide can spread surprisingly quickly through social networks. Particularly relevant to infection control and epidemiology, they described how fellow researchers used the movement of currency, data, and phone calls to predict the movement of pathogens like SARS globally over the course of a several days. The pattern identified was a Lévy flight characterized by many short legs followed by a small number of long legs.

It’s an interesting book that has a few case studies relevant to infection control and many that are analyzed using similar principles (elections, stock markets, video games). Some food for thought and a potential intersection where those in the infection control profession and those in other professions (marketing, economics, and politics) can share ideas and interventions. Connected shows how materials, ideas, and conditions can spread in a similar fashion to infectious disease.

MRSA and survival

Dr. Dan Diekema recently blogged about a new study published in JAMA that shows that respiratory tract MRSA carriage/infection is linked to high mortality in cystic fibrosis patients. He raises an interesting question about why MRSA, and not MSSA, is associated with worse outcome among cystic fibrosis patients especially since there is no evidence to show that MRSA is intrinsically more virulent than MSSA (Now, this is debatable as there are studies that show that MRSA is more virulent than MSSA, however the justifications behind why this is the case are controversial).

Nevertheless, Dr. Diekema’s question reminded me of an article I read on toxoplasma in last week’s Economist. Toxoplasma is a pathogen that’s a close cousin to Plasmodium, the bug that causes malaria. However, despite its high prevalence, symptoms among people infected with toxoplasma are mild and the bug doesn’t seem to cause a lot of damage, UNTIL scientists discovered that rats infected by toxoplasma exhibit more risky behavior, which suggests that the bug is interfering with the brain.

A separate study on toxoplasma in humans found that people involved in road accidents were almost three times more likely to be infected by toxoplasma than those who had not been. Some are going as far as saying that toxoplasma is altering the culture of entire societies.

So, here is my theory to answer Dr. Diekema’s question, maybe MRSA is affecting patients’ psychology and/or behavior in a way similar to that of toxoplasma? Or could it be that MRSA colonization/infection leads to higher susceptibility to toxoplasma infection, which leads to more risky behavior? i.e. not following hand hygiene compliance. I wonder what kind of study we can do to prove my theory.

First Steps in Our Journey to Zero

It is tempting to declare the “moral equivalent of war” against such global challenges as global warming, oil spills, and healthcare-acquired infections. The metaphor compels and intrigues because it unites disparate parties, focuses them on a singular goal, and demands appropriate resourcing. Many call for a “Manhattan Project-style” effort (referring to the WWII era project that resulted in the creation of the first nuclear bombs) to discover elusive solutions to longstanding problems. In the world of infection prevention, the problem of 99,000 deaths and 1.7 million healthcare-acquired infections annually is one that requires the collective energy of researchers, health care workers, and governments.

We opt, however, for the metaphor of a long journey. The problem is massive and it will require unity, focus, and resources. However, arriving at lower infection rates and establishing an improved patient safety culture will figuratively require us to “be at a different place”. A safe health care system with minimal levels of healthcare-acquired infections will look much different than where we are today.

In the midst of all this, we are already taking the first positive steps. HHS Secretary Sebelius recently declared an early victory with the news of an 18 percent decrease in national CLABIs in hospitalized patients. Success stories such as that in the state of Michigan also bode well for long-term success.

The purpose of this blog is to document our collective journey to zero HAI-related deaths. We’ll explore the varied and innovative efforts of individuals, groups, and governments. We’ll build a supportive virtual community to share best practices, provide moral support, and collaborate. Dr. Atul Gawande of Brigham and Women’s Hospital in Boston recently characterized the HAI problem as “the easiest 100,000 lives we can save.” We share Dr. Gawande’s optimism, and we are excited to document the successes, stories, and challenges in our collective journey.

APIC’s MRSA Census Coming to Your Hospital

How big of a threat is MRSA to hospitals? The recently released APIC survey attempts to answer just that.

MRSA, or Methicillin-resistant Staphylococcus aureus, is responsible for an estimated 19,000 deaths a year in the U.S. and costs hospitals an additional $60,000 per patient who acquires a MRSA infection in the hospital. In October 2006, APIC conducted the first-ever national MRSA prevalence study and found that 46 out of every 1,000 patients in the study were either infected or colonized with MRSA. The rate was larger than previously estimated and led to several concerted efforts by APIC to combat MRSA. The goal of this year’s survey is to update the study results with the current MRSA prevalence rate. The comparison will help evaluate the impact of recent MRSA prevention measures on MRSA prevalence.

The Centers for Medicare & Medicaid Services (CMS) has not yet begun to penalize hospitals with high MRSA infection rates by reducing reimbursement. However, given the current trend that focuses on pay-for-performance, it’s likely that CMS will refuse to pay for preventable MRSA infections in the future.

Therefore, I urge every hospital to participate in this important survey. After all, how do we fight MRSA if we don’t know what kind of problem we are dealing with? The survey results affect the measures and solutions we adopt, the amount of resources we need and receive, the type of care we provide to patients, and the kind of research and innovation that will be necessary to combat the infection.

APIC MRSA Survey