Ebola and the cult of vitamin R

This week saw the appearance of Ebola virus disease in a Liberian visitor to the United States. Active transmission here is not expected and public health authorities have done extensive contract tracing. Fifty individuals who were potentially exposed to the virus are being monitored and a small number are in isolation. 

First, a brief description of the episode. A man who had direct contact on September 15th with a woman suffering from advanced Ebola virus disease in Monrovia, Liberia, traveled to Dallas, Texas, to visit relatives. He flew from Monrovia to Brussels on the 19th of September and took a connecting flight to Washington DC before catching a final flight to Dallas, arriving on the 20th. He was screened for fever and exposure at the airport before departing Liberia; apparently, his answers to a screening questionnaire were inaccurate. After arriving in Dallas he remained asymptomatic for several days and began suffering symptoms on the 24th. On the 26th he presented to the hospital. (Note: some news accounts report the date as the 25th.) At this first visit he was evaluated, prescribed antibiotics, and sent home to the relatives with whom he was staying in Dallas. He subsequently deteriorated and was transported to the ED by ambulance on the 28th. The positive test for Ebola virus was received on the 30th.

Many details about this event are unsettling. To me, especially disappointing is that the man's travel history was not a factor in the clinical diagnosis on the 26th, although a nurse was informed that he was visiting from Liberia. The nurse entered the information into the electronic health record (EHR), following protocol, but that didn't trigger suspicion. The hospital has since clarified why: There are separate physician and nursing workflows, and patient travel history did not automatically appear in the physician's standard workflow. The doctor never saw the information.

I think it's also interesting that the man was prescribed antibiotics for what turned out to be a viral illness. In a sense, this is a familiar story: change the name of the virus and it's a scene that occurs daily in many clinics and office visits. It seems ironic that, a week after the White House released its National Strategy for Combating Antibiotic-resistant Bacteria, this physician-patient encounter resulted in the apparent inappropriate prescription of antibiotics. As the National Strategy tells us, 

. . . a growing body of evidence demonstrates that programs dedicated to improving antibiotic use, known as "antibiotic stewardship" programs, can help slow the emergence of resistance while optimizing treatment and minimizing costs. These programs help providers prescribe the right antibiotic for the right amount of time and prevent prescription of antibiotics for non-bacterial infections. It is imperative that such programs become a routine and robust component of healthcare delivery in the United States. (emphasis added)

To be fair, the man may have had a bacterial infection at the first hospital visit, in addition to the unsuspected Ebola virus infection. We don't know; it's a matter of his private health record. However, I am reminded of how a physician colleague once described the pervasive inappropriate, and often rushed, use of antibiotics,

It's a common problem. Patients present with vague complaints that are plausibly due to bacterial infection and there is a very low threshold for prescribing antibiotics. The patients often request or insist on it, and it often seems harmless to acquiesce. In fact, many doctors view prescribing them as a protection mechanism in case there is an infection or one develops. It's so common that in many clinics and EDs ceftriaxone is referred to as "vitamin R".

Perhaps the antibiotic prescription dimension of the encounter on the 26th is all too understandable.

One can hope that a thorough, transparent investigation and analysis of this entire episode can produce helpful knowledge on how to harden healthcare systems for routine healthcare as well as extraordinary events like this one. In the meantime, the CDC has produced clear guidance for evaluating patients with a history of traveling to epidemic regions.

Acknowledgement: The title is inspired from a Medscape Connect item entitled "The cult of Vitamin R", which no longer appears to be available online.

(image source: Wikipedia)

New antibiotics on the horizon: Are we ready?

A previous blog asked:

Who wouldn't agree that we need an invigorated pipeline of new, effective, and safe antimicrobial drugs to help us counter the specter of resistance? But it does make me wonder: Is it really a good idea to place new weapons in our arsenal when we have demonstrated few reasons to think that we will use them responsibly?

A reinvigoration of the drug pipeline may be starting, given news that a major drug company is re-engaging its research on antibiotics. Moreover, this week we learned about a new highly potent drug, and another one that was just approved by the FDA, for skin infections. Other new drugs are under development as well.

It seems poignant to think about how to make it safe to employ new antibiotics on a wide scale so as not to risk the emergence of new resistance. It's a complex issue, but here are some thoughts.

• Antimicrobial stewardship programs need to implemented across all healthcare settings. Using antimicrobials in a targeted, appropriate fashion is important for preventing acquisition of new resistance. Progress is being made in some settings (notably children's hospitals), but programs need to be instituted across the board.

• HAI rates need to be reduced to very low levels across institutions and patient populations. Low rates are important for preventing the spread of resistant infections once they emerge. Substantial opportunities remain to improve infection prevention programs in hospitals.  

• Patient expectations for drug therapy for common ailments need to be managed. Patients often pressure doctors for antibiotics for common symptoms (e.g., sore throat, congestion), even when etiology (viral versus bacterial) is unclear. Public health messaging, including the use of social media, is important for changing this. 

Undoubtedly, additional things are important as well. I haven't mentioned, for example, the issues surrounding the intensive use of antibiotics in animal farming, the emergence of antibiotic resistance organisms surrounding those practices, and the potential for causing human colonization and disease. If you have additional thoughts, please comment.

An important question is how we can measure progress in these areas. Surveillance for antimicrobial stewardship policy compliance and HAI rates within an institution seems more straightforward than monitoring these across regions. Likewise, monitoring public perception and expectations for antibiotic prescribing practice is complex. Perhaps this is an area where social media monitoring can play a role. Regardless of the difficulties, measuring such things is critical if we are to manage drug resistance moving forward.

(image source: CDC)

How to avert an antibiotic apocalypse: We need more than new drugs alone

Forbes magazine ran a story recently entitled "How to avert an antibiotic apocalypse". It begins with a simple proposition:

Want to protect your kids from drug-resistant bacteria? Open your wallet. Governments and insurance companies need to commit to paying 10 or 50 times more than they already do if industry is going to put resources into fighting the threat of superbugs.

Who wouldn't agree that we need an invigorated pipeline of new, effective, and safe antimicrobial drugs to help us counter the specter of resistance? But it does make me wonder: Is it really a good idea to place new weapons in our arsenal when we have demonstrated few reasons to think that we will use them responsibly?

Of course new antimicrobial agents are desperately needed to treat infections resistant to currently available drugs, and understanding the reasons for the stalled pipeline is key to to achieving development goals. However, it seems to me that the question of whether, given our current practices and the state of research, we are doomed to repeat the past with a new set of effective drugs -- assuming they can be and are developed -- is fair game.

The problem of resistance is complex and has been reviewed several times (see, e.g., here, here, and here) but the ultimate solutions remain unclear. Almost certainly they include a combination of new antimicrobial drug and vaccine development, antibiotic stewardship, better hospital infection prevention, and management or elimination of environmental reservoirs of resistance such as those produced by large farms and wastewater treatment facilities, among others.

Hopefully, by comprehensively addressing these and related issues, we can avoid repeating the past when new drugs do appear. If we don't improve in all areas, it stands to reason that we run the risk of seeing resistance develop against new drugs, too.

(image source: Wikipedia)