Tuesday, April 05, 2011

Superbugs and Seasons

Besides MRSA, other superbugs are now vying for our attention. A few months ago, NDM-1, from India, was creating a furor. A new article, by Maryn McKenna, focuses attention on Carbapenem resistance in Klebsiella pneumonia and clearly outlines how this form of resistance occurs. But there is one element fueling this growing problem of resistance that is not often touched upon—that of the public’s unreasonable expectations about care.

For example, I saw another patient last month who was minimally responsive, with little likelihood of recovery. This patient was colonized with a carbapenem resistant Acinetobacter baumanii which, like the KPC, was susceptible only to colistin, a highly toxic antibiotic. Years ago, when I started practice, families understood when doctors said, “Nothing can be done.” Patients were allowed to die in peace, with the emphasis being on comfort. Now, many families appear to believe in the immortality of their loved one and want “everything” done—no matter the cost in money, pain for the patient, or the danger to others. In the current U.S. environment, families have a sort of magical thinking in the ability of technology to prolong life, and an inability to accept death as a part of life. This leads to their demands for care beyond what seems reasonable for both the patient and from a public health perspective. And all of this is fueled by conservative religious groups. These demands—based on wishfulness—contribute to the increasing bacterial resistance to antibiotics, which in turn is putting the viable segment of our population at risk for unnecessary death from multi-resistant bacteria.

While some might be shocked at the idea of “rationing” antibiotics, or feel that we might head down a slippery slope to euthanasia, I would suggest that consideration be given to the public health aspects of squandering antibiotics on what is widely agreed to be futile care. Is it reasonable to continue antibiotic treatment of such end-stage patients, who have no likelihood of recovery, knowing that they are a breeding ground for multi-resistant organisms that threaten the community? How else might this be addressed? Keep in mind that there are almost no antibiotics in development; many pharmaceutical companies, such as Pfizer, have forsaken antibiotic research as not being adequately profitable. After all, who needs antibiotics when you can have Latisse or Viagra?

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