Deadly 'superbugs' invade U.S. health care facilities | Hacker News Reader

Deadly 'superbugs' invade U.S. health care facilities

usatoday.com

I studied antibiotic resistance when I worked in pharma. It's a fiendishly difficult problem. You have a mix of factors that all conspire to a bad outcome. First, you have natural selection, so any antibiotic safe for human consumption is likely to eventually result in drug resistant bacteria. Secon, you have social practices. In the US you have patients who brow beat their doctors into giving them antibiotics when they don't need them. In other parts of the world, you can buy antibiotics over the counter! This is hugely problematic since the genes for resistance spread globally when they get a foothold (you can actually watch this over time with DNA sequencing and careful collection of samples). Finally, on the economic side, most regulators like the FDA will force any new antibiotic to be held back on the shelf and used only as a "drug of last resort". This reduces incentives to develop new antibiotics since the drug patent will expire before you can sell enough to make back the R&D cost. Much better to throw resources at cancer since your drug might end up as a front line therapy there, than to waste time on antibiotics (so the bean counter thinking goes).

I honestly don't know what the answer is. Most likely, there will need to be some new tech the bugs have a hard time beating. Outside the body we still have plenty of things that kill bacteria which they can't get around (bleach comes to mind). The likely outcome is some kind of new delivery mechanism that is fast, complete, and highly effective.

I wonder if it would be possible to use natural selection and human behavior to our advantage?

imagine a compound that causes bacteria to adapt in a way that makes us easier to control them. like putting fluoride in our water we'd distribute the Trojan biological 'malware' into the wild and make bacteria more susceptible to very specific types of treatments.

This is a clever idea, but likely to end badly in practice given the way genetics works. Any neutral trait that doesn't confer increased survivability will be filtered out rapidly and never spread. So you would need to design something that gives the bacteria carrying the trait a slight survival advantage, but at the same time has a hidden "back door" we can exploit.

Furthermore, the back door has to be intimately tied to increased survival and not just along for the ride. Otherwise, the bacteria will snip the back door part out and keep the part that gives them increased survival. Now you have genetically engineered super-bugs. Oops. Even assuming that you have perfectly designed this new trait to meet the needs of having a back door and increased survivability that are inseparable, you still fail. Eventually, the bacteria all drop your fancy new trait and revert to being plain old bacterium because that state is now the one with the survival advantage that allows them to duck your new fancy antibiotics.

Probably, the only angle that is likely to work is immune system modification and enhancement. Something like a vaccine that causes the immune system to go thermonuclear on the pathogen is likely the best route. The immune system is highly adaptable and extremely well-honed. We've successfully driven many viruses to the brink of extinction this way, but the tech we have is not as good for bacteria (though there are vaccines for some bacterial infections).

yup, I can see my idea being the start to a sci-fi movie.

Even what you describe though is still just building more arms in an arms race.

Natural selection itself needs mutations as fuel. Another crack-pot thought - figure out how to decrease the speed of mutations that bacteria are subjected to. Something along the lines of biological or synthetic error correction on DNA.

At some point (have we crossed it?) human evolution has moved from physical 'fitness tests' to non-physical. When we get colder now we just design thicker clothes and warmer buildings, etc. Heart disease? more pills and surgeries. I've read people make an interesting case that corn is one of the most successful organisms as measured by adapting to fit because over time it became the corner stone of our entire diet as a species. And by that line of reasoning the genetic modification we do as humans on corn is part of corns continued adaptation. A little meta perhaps, but eventually I wonder how much control we'll have over the biology so that the mutations and modifications would seem artificial and human designed by today standards.

There is a rather rude joke that if you want to avoid dying you should avoid hospitals because lots of people die there. What the joke doesn't zero in on is that people that die in hospitals do not always die of what they had when they got there.

Hospitals tend to be very tight lipped towards the people they admit when it comes to admitting mistakes for fear of liability, but in cases like this there ought to be a maximum of transparency so the people that are about to be hospitalized can make informed decisions about the additional risks over and beyond the thing they're going to the hospital for in the first place.

Here's a quote:

"The bacteria made headlines this summer after a CRE strain of Klebsiella pneumoniae battered the National Institutes of Health Clinical Center outside Washington, D.C. Seven died, including a 16-year-old boy. (Hospitals don't reveal victims' names in keeping with medical privacy rules.) But that case was neither the first nor the worst of the CRE attacks."

I'm curious, were new patients notified before admittance that they had a resistant outbreak in their hospital ?

Were existing patients notified that this was happening while they were there ?

I'll bet no, and no.

Another quote:

""We were really frustrated; we hadn't seen anything like this in the literature," says Costi Sifri, the hospital epidemiologist. "The fact that we had different bacteria told us these cases were not related, but the shoe leather epidemiology suggested to us that all these (infections) came from the same patient. ... We realized we might be seeing a mobile genetic event.""

... all the while continuing to admit new patients ...

this isn't anything new... hospital acquired infections (HAIs) are the 4th leading cause of death in the U.S.

nearly 1 in 20 hospitalized patients will acquire a HAI killing 270 people/day

hospitals... scary place

Yes, it is scary. But you forgot to add that give or take half the time doctors don't have the slightest idea of what they're dealing with.

However, the thing gets even hairier when you talk to med students. Most of the one I've talked told me their main reason to learn the craft was the money.

Take good care of yourself, exercise, eat healthy, and don't forget to have sex. Otherwise you're gonna end up in their books as just another entry.

Good advise. If you can at all stay out of a hospital, the better your chances of avoiding these highly selected bugs. It makes sense that feeders are nursing homes or establishments that have some palliative care, as many patients there have somewhat weakened immune systems, whether from age related illnesses or otherwise, and the prescription of antibiotics is, as it is in many other scenarios, excessive. [1]

Stay as strong and as healthy as you can, and condition your immune system as best you can is good advise.

http://www.sciencedaily.com/releases/2008/02/080226092810.ht...

>However, the thing gets even hairier when you talk to med students. Most of the one I've talked told me their main reason to learn the craft was the money.

I lived with a persistent and occasionally debilitating health problem for nearly a decade while being brushed off by clueless doctors.

Finally, I wound up in the ER (again) being served by a guy who actually took the time / had the ability to interpret a blood test.

Not long after that I was having a large, old and thankfully benign tumor removed.

As I understand the issue, a blood test would have revealed this at any point and likely even before the 10 or so years I'd been having symptoms.

Personally, I'm given to thinking that we tend to give folks in medicine too much credit.

Sure, I think it reasonable to expect that someone who has made it through medical school and successfully practices is above average in some regards - relative to the broad population.

However, within the field, I expect that incompetence / apathy is just as prevalent as it is in any other profession.

I'm currently dealing with similar issues. New symptoms started for me this summer, my GP and all the tests and specialists I've seen have no ideas.t

When I do my own research my GP brushes it off. I try to take that in stride -- I do recognize that I am uneducated in the field. But it's disheartening when a specialist comes up with my researched conclusion as one of their top possible explanations.

If you don't tick all their boxes on a list of precisely described symptoms -- which you must self-report -- for a condition that they've looked up moments prior to your appointment you won't get diagnosed correctly unless you are lucky and have managed to find a competent and caring doctor.

Then there are those that claim to have injected themselves with these and then performed surgery on others.....There was a TED talk on this..... scary and reckless stuff.

I used to write code for medical devices. One of the things I learned during my time at the firm was that some hospitals are better than others. Like.. significantly better.

So the question then becomes: How do I, as a consumer of healthcare, tell them apart? Well, patient survival rate and causes of death are never published (hospitals hide behind HIPAA to avoid revealing this info, even in aggregate). But one way we found (empirical & anecdotal evidence, so treat accordingly) is to look down the ward and see if the nurse-call lights flashing for more than a few minutes. If the patients are pushing the bedside button and not getting attention from the care-givers, find yourself another hospital.

Another good way is to see if the staff are frequently washing their hands and cleaning the equipment that can be moved from room to room (the plastics used typically have silver ions in them, but that's only partially effective at killing the wee beasties).

Family involvement is also critical. If you're wonked out on drugs, you really need someone in the room watching the staff to ensure they do things correctly, and that the bill doesn't get padded with goods & services that weren't used in your care.

hospitals... scary place

I think there are some advocacy groups that overestimate the role of hospital-acquired infections (nosocomial infections) as a cause of death. The ranking I find in one source that is readily looked up

http://www.cwru.edu/med/epidbio/mphp439/Hospital_Acquired_In...

is lower. A general ranking of causes of death in the United States by the standard WHO definitions

http://www.scientificamerican.com/article.cfm?id=longevity-w...

gives a different picture of which causes of death rank highest, and which have declined the most in recent decades. Life expectancy is up at all ages in the United States, even though most people have a hospital visit at some time in life.

Every time I hear about hospital acquired infections I cross my fingers for the narrow band UV lights I remember hearing about. Even if we could just have those in hospital hallways or elevators... Man, what a difference that could make.

http://www.popsci.com/science/article/2010-11/researchers-us...

It's unfortunate that regulatory environment in the US is not more favorable for advancing phage therapy. It could be a promising alternative to antibiotics for treating infections caused by multi-drug resistant organisms.

From what I've read. You're probably right. They're worried that mutations make it hard to lock down the exact properties of any given phage treatment, but that would be a risk I'd be willing to take. Especially since they're in wide use in some countries with no horror stories that I've heard.

Assuming it is correct to say that antibiotic-resistant bacteria evolve in response to the (over-/ab-)use of antibiotics -

I wonder to what extent opposition to teaching evolution improves the chances of these kind of bacteria evolving. Disbelief in, and/or ignorance of how a process works is effectively giving that process a green light.

Conversely, might the appearance of CRE bacteria might sway the evolution debate?

Or to be more blunt, does a disbelief in evolution increase a nation's chances of collectively qualifying for a Darwin award?

If bacteria can modify the host's behaviour (this is proven), perhaps your hypothesis is a certain type of bacteria's survival vector?

> Conversely, might the appearance of CRE bacteria might sway the evolution debate?

No. It seems like an easy political point, but there's a lot more to the story.

First, there are far easier and more visible examples of evolution. In UK schools, possibly because it's a nearby example, it is taught that the color of moths in London changed dramatically during the Industrial Revolution because light-colored moths were easy snacks for birds on newly soot-covered walls. There are more colorful examples closer at hand: most of the domesticated animals in the world are examples of evolution by artificial selection: cows today share little with cows 10,000 years ago, and corn today looks nothing like 10,000 years ago.

Second, thanks to #1, the belief is often that "humans (special) didn't evolve from apes (animal)" --- not that species never change. The belief is based on an idea that either evolution started after humans were created, or that even if evolution has been running for 100 million years, there's no way that natural selection could cause the leap from animal to human. It doesn't preclude belief in evolution among animals.

Third, antibiotics are all prescribed by doctors, who are plenty aware of the work of Sir Charles.

And, last, antibiotic misuse is largely a tragedy of the commons. Rational patients who are very aware of the risks of antibiotic-resistant phages will still request antibiotics: they feel the benefit (even if the chance of a benefit to them is small) but the pain of antibiotic resistance is felt by other people.

So, no, it's easy political point but it has more to do with enthusiasm than fact.

I agree with the tragedy of the commons point, but I think it might be a smaller piece of the puzzle than industrial farming. Pretty much every chicken that is raised industrially is given regular doses of antibiotics to "prevent" rapid spreading of disease through large chicken stocks. Which would happen easily since the chickens are kept in such close quarters. Just about any non organic chicken you buy has antibiotic resistant bacteria living on it.

A nitpick, a phage is a virus that targets bacteria. They pretty much have no risk to humans, and are antibiotic resistent almost by definiton.

> Assuming it is correct to say that antibiotic-resistant bacteria evolve in response to the (over-/ab-)use of antibiotics -

Keep in mind that this class of antibiotic is always administered by IV, so if there is overuse or abuse, it is by doctors who likely already believe in evolution.

I think that what is important to note is that their only evolutionary advantage, and thus the main reason they spread, is their resistance to antibiotics, in normal conditions they would have a quite big chance of losing in competition with other bacteria. As soon as antibiotics are used, the competition dies and they can proliferate. This means that the best prevention method is to use antibiotics as rarely as possible. Let's remember that the same bacteria that cause infections, can ordinarily live on our body quite harmlessly.

It is amazing how this bacteria interchanges genes with ease. Could it be possible to use this strength as a weakness? Inoculating a modified bacteria to act as a trojan horse?.

edit: missing letters.

I believe this approach normally doesn't work because any gene that leads to weakness with be removed via natural selection.

I think the goal might not be to make a bacteria that's easier to kill, but one that's less likely to kill us. There's generally a strong evolutionary pressure not to be fatal for your host.

4 in 10 chance that if you get infected with CRE bacteria you will die...

That's one nasty bacteria. According to the article, the worst part is that it contains a resistant strain that started migrated to other types of bacteria. So far, contained mostly at hospitals, might get outside and merge with more common bacterias. The plague is near?

The plague has never really left us. It's just being held at bay (barely) by anti-biotics and basic hygiene.

On a long term scale bacteria have won over every other kind of life, there is little reason to assume that this will change in the future. This holds whether you look at them by mass, by number or by just about any other metric.

Not precisely. 4 in 10 chance that if they notice you're infected, you'll die - doesn't count all the countless people who are infected but not immunocompromised, so their bodies keep the infections in check or actively destroy them.

What's the sample size behind that? Because it doesn't seem like there have been that many CRE cases yet, and we don't know the condition of patients before CRE infection.

People who get sick from CRE usually have lots of other medical issues, and are weaker.

They don't necessarily die from CRE itself.

Also remember that CRE are not more virulent than non resistant forms of enterobacteriaceae, and those certainly don't kill 4 in 10 (although that family seems to have all the really bad bacteria like E. Coli, Salmonella, Plague and others).

It actually does. Healthy people who get MRSA often end up fighting a long uphill battle. If you are in a hospital you are going to have a compromised immune system. When someone gets sepsis it is really nasty.

10 in 10, the way you've phrased it

I've come across some mentions of MDR (Multidrug Resistance) pumps, and MDR pump inhibitors:

I assume there's a reason we're not mixing in Oregon Grape root into our antibiotic cocktails? http://en.wikipedia.org/wiki/Oregon-grape http://www.ncbi.nlm.nih.gov/pmc/articles/PMC26451/ http://www.ncbi.nlm.nih.gov/pubmed/11321580

My mother died from a hospital acquired superbug (MRSA) earlier this year......this is nasty stuff.

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