The Government’s Antibiotic Resistance Plan by Stella Fitzgibbons MD
I see that the federal government is unveiling a plan to prevent and counter antibiotic resistance. Pardon me while I look at the factors that brought it about.
In the hospital we are under constant pressure to shorten patient stays. Giving an antibiotic that only covers 95% of the pathogens likely to cause our new admission’s infection–horrors, we might have to change it after the cultures come back. And we do that even if the patient is clinically better, forgetting that most of our dehydrated elderly with UTIs would get better with IV fluids alone and that many of those respiratory cultures represent colonization rather than disease. A much more expedient choice is to give Gorillacillin or Megaquin right there in the ER, since it covers a whopping three percent more of the possible bugs even if it does cost ten times as much.
Hospitals all over have countered by sending out e-mails, restricting use of Gorillacillin and stressing isolation procedures. But at the same time they use their beloved electronic records to see which doctors get those UTIs discharged fastest. And if your patient satisfaction rating dropped because Grandma was still confused on Day Two, you get a black mark for that too.
We can’t open a medical journal without hearing what a big advance these medications are.. Less nephrotoxicity! Once daily dosage! Ingenious cartoons to help us remember the name! (Remember that picture of a tiger?)
Meanwhile we are seeing more and more resistant bugs, more C. difficile raging through ICUs and GI tracts…and complaints from financial officers about the price of these wonderful new concoctions.
I thought that evidence-based medicine was supposed to be the gold standard for treatment. Too bad nobody’s looking at all the pressure to ignore it.
What about the 95-99% of antibiotics (tetracyclines and fluoroquinalones) used in the meat industry. Next time you tuck into some deep fried southern goodness, look on the packet “Hormone free”. Hormone free doesn’t mean low dose antibiotic free. Chickens get to market size 2-3x as quick when fed low dose antibiotics, in squalid crowded conditions. Hmmmmm if I was going to try to generate antibiotic resistance to a gram negative bug, lets see, I’d need fecal matter (fecal oral transmission), cramped hot and crowded conditions, long term use of under-dose antibiotics….. Where could you get such an environment????
Our friends and role models the prokaryotes have been about the world for a billion or so years before us, and have laid down a terrific evidence base to show us that you get what you select for.
Behavior adaptation by regulation pretends to bypass this truth, insisting that one can progress in all directions simultaneously. A thing can only move in one particular direction in one moment in time – that is the characteristic of physical mechanics. We cannot progress in all ways; we are merely likely to progress in the direction which all the forces sum up to.
In the experienced practice of medicine, one apprehends one clear thing to do next. That thing may well be individual to a particular patient; or it may be a path held in common in the treatment of many patients. By disempowering the physician, one sets the compass in the direction of the fastest rate of increase of healthcare expenses. If there is no best practice for one patient, there is merely a Best Practice for all patients; or merely dozens of conflicting Best Practices, each of which, if violated, can result in punishment for the chooser. To a rat in a cage, it is obvious – do not choose, and merely await the punishment that is inevitable. That is is the compass heading for American medicine – overreaching high costs with even higher costs, and bad outcomes with worse ones. We may assuage ourselves that we have the highest of intentions; nevertheless, we are heading straight for the shoals, no matter how loudly the captain shouts that sinking is unacceptable.