Clinicians Get Smart About Antibiotics Week Storytelling

Infections caused by antibiotic resistant bacteria account for 23,000 deaths per year in the United States and, if left unchecked, could be responsible for more deaths than cancer by 2050. Eighty-five percent of doctors diagnosed one or more of their patients with a multi-drug resistant infection in the past year.

Clinicians see firsthand the effects of antibiotic resistance on patients and public health. Not only are they in a position to prevent detrimental outcomes, but polls show that doctors are among the most trusted professions. Clinician experiences and insight can illustrate the problem in a compelling way that leads to action.

For Get Smart Week 2016, Health Care Without Harm and the Clinician Comprehensive Antibiotic Stewardship (CCCAS) Collaborative have collected stories from clinicians about their experience with antibiotic resistance to motivate transformative policy change.

Each day we’ll post a new story from Clinicians all across the country experiencing antibiotic resistance and working to prevent the misuse, overuse of these critical lifesaving medicines in clinical care and in animal agriculture.

Doctors, nurses, pharmacists and other healthcare providers, we want to hear from you! Submit your story about antibiotic resistance and we’ll share it with the world. It’s time for your voice to count!

Health Care Without Harm and the Clinician Comprehensive Antibiotic Stewardship (CCCAS) Collaborative created the following materials to help clinicians tell their stories:

This story is told by Dr. Scott Weissman, a member of the Clinician Champions in Comprehensive Antibiotic Stewardship (CCCAS) Collaborative who testified to Congress about his battle with a nearly untreatable infection that presented in one his patients.

Early in my career as a Pediatric Disease specialist, I was asked to consult on a patient who had been born with a condition called bladder exstrophy, where her bladder was not fully enclosed at birth. She had had dozens of surgeries in her life to provide her with normal functioning and quality of life. She had suffered urinary tract infections more frequently than other children her age, and had received more than her fair share of antibiotics to treat them, but was being referred to me because the bacteria were increasingly difficult to treat.

For the next three years, we struggled to get these infections under control, but had only brief periods of symptom-free health before infection would return, showing up as stomach pain, flank pain, headache. We tried antibiotics by mouth, antibiotics by IV, antibiotics into the muscle, even antibiotics directly into the bladder. We tried antibiotics one at a time and in combination. We tried probiotics, cranberry juice, and a full array of alternative therapies that I learned about as we went.

This patient taught me much of what I know about managing resistant infections in complicated patients. But being a specialist at an academic referral center, I didn’t fully appreciate how this kind of antibiotic resistance was changing medicine even for the community pediatrician. What I learned during her care was that she was infected with an E. coli strain called Sequence Type 131. First described in 2008, after having already swept the globe, this single nasty, vicious strain has reshaped the treatment of urinary tract infections, just as the community-associated methicillin-resistant Staphylococcus aureus strain USA300 had done for skin and soft tissue infections.

According to data from the Centers for Disease Control, for every 10 residents in Washington state (where I practice), healthcare prescribers give out six antibiotic prescriptions. On average, more than half of us in Washington are getting an antibiotic prescription every year. Kids actually get more than that, on average receiving at least one antibiotic prescription a year through their first decade of life.

If that sounds like a lot, consider that Washington state is among the lowest in all 50 states in terms of prescribing antibiotics. For every 10 residents of southern and southeastern states, the rate is double that of Washington state — some 12 prescriptions per year.

When Antibiotics Stop Working

This story by Dr. Saul Hymes posits a future when routine infections endanger lives due to antibiotic resistance. (Some personal details have been changed to protect the identities and privacy of the patient in this story).

Megan is your average college student. She attends a small school in the suburbs of Long Island where she’s a solid B student. She goes to class, she hangs out with friends, she even drinks a bit despite not yet being 21. And now she has a plastic tube in her arm delivering antibiotics to her, without which she will die of overwhelming sepsisbacteria growing throughout her blood and producing toxins at a rate that can destroy every single one of her organs and kill her in a matter of days.

I know all of this because I am a pediatric Infectious disease specialist at Stony Brook Children’s Hospital and Megan is my patient. For a couple of harrowing days in the intensive care unit, I watched this bacteria try very, very hard to kill her, though thankfully she pulled through.

What horrifying bacteria or type of infection must this have been? MRSA? A horrible heart or bone infection? No. Megan nearly died because of a simple E. coli urinary tract infection. A UTI that was resistant to nearly every antibiotic.Megan’s UTI started out like mostsome burning and pain when she used the bathroom. She went to her doctor and got a prescription for Bactrim, a pretty standard antibiotic that is commonly used for UTI’s. “Three days of this and you’ll be better,” her doctor and told her. But she didn’t get better. In fact her lower belly pain, around her bladder, had become so severe she had stopped going to class. So her doctor switched her to Cipro, a broad antibiotic that ought to stop this in its tracks. But still no luck.

By this point, Megan was having fevers and chills and pain that extended up to her flankaround the kidney, a sign the infection had spread there. Because what she was doing clearly wasn’t working, she managed to get a ride with a friend and showed up in the Stony Brook ER on a Friday night. She was having shaking chills so bad her teeth chattered uncontrollably when she talked. She was pale. Her heart was racing. Her temperature was 105, she was burning up. She was septic.

The ER suspected the bacteria had spread to her blood and when they called me to discuss her case we decided to start her on a broad antibiotic called cefepime that we usually only use in cancer patients, and Megan was whisked up to the ICU. But we had seen patients like this before get better fast. We figured she would improve with some fluid, the antibiotics would kick in (she probably just needed IV antibiotics, right?) and she would be just fine. But that’s not what happened. Megan’s heartbeat continued to climb faster and faster and her blood pressure dropped lower and lower. Overnight she needed continuous medicines to keep her blood pressure up. She needed to have a breathing tube inserted down her throat because she was drifting in and out of consciousness and was starting to not be able to breath reliably on her own.

The next morning we switched the cefepime to one of our last resort antibioticsmeropenemand added a second last resort antibiotic, Vancomycin. If these didn’t work, we didn’t have a lot else that would. And finally, slowly, she turned the corner. She started to breath on her own more strongly; she was able to control her own blood pressure and heart rate. The amount of machinery and equipment next to her bed began to dwindle to just an IV pole. The antibiotics were working. Finally her urine culture and blood culturetests to grow bacteria in the lab to see what was causing her infectionshowed us the culprit. She had an E coli that was resistant to all but 3 antibiotics on the testing panel, and of course resistant to all that we had tried before the meropenem. And most impressively, resistant to every single oral antibiotic.

Every single drug that she could take by mouth for this bacteria would never even touch it. After a few more days to make sure Megan’s blood and urine were finally clear of bacteria, her antibiotics were tweaked to a once-daily drug called ertapenem (a member of the same family of drugs meropenem is in), she was given a semi-permanent IV called a PICC line to go home with, and she was sent home with nursing care for her 2 week antibiotic course.

Today Megan is doing fine, she has graduated, and is thinking about becoming a nurse, she says because of the fantastic nurses she met while in the hospital. So this was a success story. And if you’re anything like me, you’ve seen a few such patient stories published in columns in the New York Times, or your local paper, or even on the evening news. Perhaps you’ve donated money to a GoFundMe for a family member or friend with cancer. And you’ve had your emotions tugged at by these touching success stories or the melancholy failures.

But Megan is not like those patients. Megan does not have an unfortunate but horrible condition that makes her more likely to get infections. Megan has not received tens or hundreds of antibiotic courses over her life. Megan got the occasional ear infection, the occasional throat infection as a child. She has had 1 or 2 UTI’s before. She is a completely ordinary patient just like any of us. What happened to Megan could happen to all of us.

What exactly did happen to Megan? Why did Megan get an infection with a bacteria that was so resistanta ‘superbug’? I don’t know the answer to that is her specific case, but we have some ideas. We know that antibiotic resistance is increasing at an alarming rate. The Center for Disease Control (CDC) estimates that 23,000 deaths occur yearly due in some way to antibiotic resistance. The World Health Organization (WHO) has said that if nothing is done, by 2050 antibiotic resistance will be the single biggest killer worldwide, responsible for 10 million deaths a year. This resistance is caused by us. All of us.

Certainly we physicians bear some responsibilityevery time a child is given a drug like Omnicef for an ear infection or Azithromycin (a “Z-pak”) for a sore throat, the bacteria that cause the infection and the ones that normally live in their body become a little bit more resistant to those antibiotics. And we in medicine are trying to do more to reduce our inappropriate antibiotic use.

But the problem is also bigger than just antibiotic use in humans. Every year animals are given 80 million tons of antibiotics as part of a standard use in farmingand most of that is either for growth promotion or infection prevention, situations that do not require antibiotic use in animals grown in normal, healthy conditions. We know that antibiotic use in these animals leads to resistant bacteria in those animals as well as in the environment around them; the antibiotics they are given get from them, to their urine and stool, and then to the water we drink and the soil we touch. Cases of E coli UTIs just like Megan’s as well as other E coli infections have been linked directly to antibiotic use on the farm.

What can we do about that? Aside from lobbying for stricter rules and regulations, hospitals and other institutions are starting to come forward and pledge to purchase meat and poultry raised with more responsible use of antibiotics, or without antibiotics important for human medicine, or any of a whole host of other possible methods to reduce our overuse in animals of these lifesaving drugs.

We are also almost all individual consumers of products that this animal antibiotic use is relevant inchicken, beef, pork, milk, eggs. And we can all do our part to try to make more responsible shopping, purchasing, or dining decisions when it comes to that chicken breast or hamburger, and it may not even cost us more to do so. In restaurants, Chipotle and others are starting to promise to only use meat raised with more responsible antibiotic use. And in the supermarket, many producers, like Perdue, are starting to phase out human-medically-important antibiotic use across all their product lines.

So go back and re-read this and as you do, imagine, in Megan’s place, your friend, your daughter, your sister, your mother. And think: the next time your doctor wants to give you a broad antibiotic for a cold or earache; the next time you buy beef, or chicken, or pork raised with standard antibiotic practicesis that antibiotic really worth it? Is the price paid by Megan and an ever-increasing number like her worth it? Because none of us, especially not Megan, want the antibiotic we get for a UTI to almost be our last.

All Natural Beef In Hospitals and Antibiotic Stewardship

As I progressed through my career as a staff pharmacist, Director of Pharmacy, Hospital COO and CEO, I always had a keen interest in appropriate antibiotic usage and resistance. (I guess that was the ingrained pharmacist/scientist in me that never left). It was always of concern because of the potential for adverse patient outcomes. I always fully supported a strong hospital-wide antibiotic stewardship program and was proud of our efforts. But, upon reflection, this was just one of many competing interests in ensuring the safest outcomes for our patients.

After retiring, I had the opportunity to become involved with sustainable agriculture. I have become friendly with, and learned some of the trials and tribulations of a small dairy/beef farmer in rural upstate New York. This opportunity allowed me to observe many aspects of farming that one can only learn by being personally involved.

As I got more involved, I had more opportunities to interact with other beef farmers and their operations. I quickly realized that I had come full circle with respect to antibiotic utilization and resistance. It seems that smaller farm operations (farm-to-table/farm-to-institution) can produce, in this case, beef, without the routine use of antibiotics (and growth hormones). And this is considered a breakthrough in “all natural” food.

Well, I thought, how can this “all natural” food get into routine hospital use. My first foray was to discuss the issue with some colleagues in hospital administration. And, as anticipated, the first concern was “price point”. I asked how they personally purchased meat and all said “all natural” was preferential and the price was not of concern. After further discussion, all were of interest, but it was once again one of many competing priorities.

All that being said, significant effort is required to get hospitals to take the lead in ensuring “Healthy Food in Health Care.” That means “all natural meat” (antibiotic and hormone-free) must be available for in-hospital use. In addition, with hospitals taking the lead in population health, they need to ensure availability of such products to the communities they serve. It’s time to shift the healthy food paradigm.

A Baby’s Last Hope

Our Pediatric Infectious Diseases group was intimately involved in the care of an infant who developed life-threatening antimicrobial resistance right in front of our eyes, and this almost cost her life.

She is now 6 months old, but when we first met her, she was a two week old full-term baby girl born via uncomplicated C-section had previously presented at six days of life to an outside hospital emergency room with purple discoloration of her hands and feet, but was without a fever. She was discharged home, but returned to the same ER the following morning due to a fever to 102.5 and non-reassuring mental status.

A workup to rule out sepsis was performed, she was started on the antibiotics ampicillin and ceftriaxone at high doses empirically and transferred to our hospital for further care. A cerebrospinal fluid test came back positive for Enterovirus PCR and she was discharged the following day with a reassuring clinical exam.

Following discharge, she was noted to be excessively sleepy with decreased appetite and a temperature of 96.6. She was advised by her pediatrician to return to our Emergency Department, where she was noted to have a slow heart rate, hypothermia, low blood pressure and gray coloration. A repeat workup to rule out sepsis (A life-threatening complication of an infection) was done, including the addition of three antibiotics; ampicillin, cefotaxime, and acyclovir. She was admitted to the Pediatric Intensive Care Unit. The EKG was notable for complete heart block and lab work demonstrated an elevated risk for congestive heart failure.

She was diagnosed with enterovirus sepsis and heart inflammation and treated with IVIG (Intravenous Immunoglobulin) to help with her immune system and control the inflammatory process. Antimicrobials were discontinued when sepsis workup was negative. Although her heart block resolved, her heart function remained markedly depressed, and she was placed on Extracorporeal Membrane Oxygenation (ECMO), the maximal of all life support measures. A heart surgery was performed due to severe mitral valve regurgitation that did not recover.

While on ECMO, she developed disseminated intravascular coagulation, a serious disorder that occurs in response to infection and inflammation causing overactive blood clotting. This required transfusion of multiple blood products. Her extremities became discolored and she was in shock. Blood and sputum cultures were obtained, and she was empirically started on vancomycin and pipercillin-tazobactam (Zosyn).

A blood culture grew Enterobacter cloacae complex (an antibiotic-resistant bacterial infection). Vancomycin was discontinued, gentamicin was added for double coverage and Zosyn continued. Zosyn was changed to meropenem once susceptibilities revealed an Amp-C producing organism, which indicates extended antimicrobial resistance even to very broad-spectrum antibiotics such as Zosyn. Her sputum culture grew Stenotrophomonas maltophilia resistant to ceftazidime but susceptible to levofloxacin and trimethoprim-sulfamethoxazole (Bactrim). Bactrim was added to her regimen. No further blood cultures were positive. She completed 14 days of meropenem, gentamicin, and Bactrim. She was extubated and taken off V-A ECMO due to improvement in cardiac function.

While she survived this nearly-fatal multi-drug resistant infection, she had suffered diffuse tissue death of her extremities. Her left leg progressed to wet gangrene, which required amputation along with several of her fingers. Her wound cultures grew yeast and skin flora. For her amputation she was treated with a perioperative course of vancomycin, meropenem, and fluconazole.

This baby’s case demonstrates how even some of our most trusted antibiotics can fail us when we are dealing with life-threatening invasive bacterial infections. We fortunate to have been able to save this baby’s life in this case, but not without significant consequences that will affect her for her whole life.

The Unthinkable

In the United States, 23,000 Americans die from an antibiotic resistant infection each year. Unfortunately, as a Pediatric Infectious Diseases physician, I have cared for children who have died from such infections. While these instances are rare, they are moments you never forget.

One of these children was a previously healthy child who was admitted to the Pediatric Intensive Care Unit. The child was quite active playing numerous sports and having a zest for life. In interviewing the family and examining the child I could see my own three children. I could feel the hopes and dreams these parents had for their child and their intense fear and sadness of having their child in the intensive care unit.

When I first evaluated this child, I never thought death would be the ultimate outcome. Even though it was evident this child had a serious bacterial infection, I did not doubt that the antibiotics we would use would be unable treat this infection. Unfortunately, I was wrong. This beautiful child had methicillin resistant Staphylococcus aureus (MRSA) in the bloodstream and in the lungs. Despite utilizing both old and new antibiotics that were tested and were shown to be effective against MRSA we were unable to get rid of this bacteria from these places. As one of the physicians, I did not know what to do next as we had added and changed antibiotics to try and provide the best antibiotic regimen possible. All the healthcare providers were doing everything they could in providing the medical care and support to this child and their family. Unfortunately, this antibiotic resistant bacteria had caused such a severe infection and was so difficult to treat that we could not get ahead and we lost. We lost a thriving child to an antibiotic resistant infection. While the loss we felt cannot compare to that of the family, the disbelief and despair was realized by all of us caring for this child.

I asked my father, a family practice doctor for 30 plus years, if he ever thought we would have bacterial infections we couldn’t treat with antibiotics. He confirmed what I thought, not in his lifetime. Unfortunately, antibiotic resistant infections are all too common and now many of us clinicians have cared for and watched people die of what previously were treatable infections. I ask all of you to remember this case and to think what you can do to assure we use antibiotics appropriately so we can maintain these life-saving therapeutic agents.

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