XJ/R308

HITTING GERMS WHERE THEY LIVE
Hospitals, acting together, can control drug-resistant bacteria

[The Partnership Policy Center seeks to involve the business community in key sectors

of New York’s economy where we believe our engagement can make a positive difference.
On December 12, 1997, the Policy Center held a forum on the spread of drug-resistant
infections within hospitals, an issue of great consequence to our medical institutions

and public health. Participants in the forum agreed that a collaboration of business,
medical, public health, and government leaders would be the most effective way to

address this emerging health problem, and that the Partnerhsip Policy Center should

lead the effort. The following is adapted from the proceedings of the forum, convened

at Manhattan’s Sky Club and cosponsored by the Albert and Mary Lasker Foundation.]

[Participants included: Ira Millstein, Joshua Lederberg, Robert J. Rubin, Stuart
Levy, Alexander Tomasz and Barry Kreiswirth ]

J Lederberg comments:

The development of those wonder drugs we take for granted today, antibiotics, is actually

a phenomenon within my own lifetime. I can recall as a kid reading about this great wonder
drug, prontosil, which had been developed by German chemists on a totally erroneous theory.
It was one of a number of dyestuffs that had been tested for antibacterial activity following
Paul Ehrlich’s notion that if a chemical can stain something specifically, maybe it can kill

it specifically. Well, it turned out that wasn’t the case. Prontosil was really sulfonamide
cloaked in a dye capsule, but it provided very important help in a number of infections. You
may recall World War II action movies. in which sulfonamide was dusted into the wounds of
soldiers and prevented them from getting gangrene. About ten years from the time of its
introduction, one began to see the first glimmers of sulfonamide resistance appearing in a
variety of organisms.

Alexander Fleming discovered penicillin in 1928, but then it was a laboratory curiosity

because of the difficulties of extracting and purifying a rather unstable molecule. Develop-

ing the drug became a very high priority, a war-related technology and an exercise in British-
American cooperation. Had it not been for World War IJ, there might never have been the level
of investment needed to carry it off. Penicillin was the next great wonder drug, and became
common currency.

And again, it wasn’t quite ten years before we began to see the first significant signs of

the development of resistance in a variety of places. It was not a major problem to start
with, but it was an escalating one, and through the 1950s it became sufficiently serious

that new generations of beta-lactam had to be invented in order to keep up with the develop-
ment of resistance. It’s been a constant race because -- surprise, surprise! -- bacteria

are not sitting targets, they’re evolving. They’re part of an evolutionary process in which
we’ve become the major ecological actors by altering the environments in which they operate,
most notably by pouring tons of these very potent materials, sometimes productively, sometimes
unproductively, into an environment that is full of bugs of all kinds. We do this because we
want to select out dangerous pathogens, yet then we discover to our dismay that it’s very,

very difficult to eradicate any bacterial species. They fight back.

And it’s been a somewhat latter-day discovery that drug resistance is not simply a question
of natural selection working on a targeted pathogen, but that pathogenic bacteria and non-
pathogenic bacteria exchange plasmids with one another, so the development of resistance in
one species can promote the spread of resistance in others.

The problem has become more and more serious. It’s especially focused in hospitals because
of the concentration of antibiotic drugs there. Hospital staff and patients themselves are
moving around, and even when they take moderate precautions against further spread, they’re
acting as the vectors of disease.

So in a number of respects a hospital is getting to be a rather dangerous place to go. We
obviously have to shake that image and reality if hospitals are to perform their necessary
social function and continue to enjoy public confidence and support. For that to happen, we
need more information, and one of the main thrusts behind this meeting is to try to find a
fair way to facilitate the recording, the indexing, and the sharing of information so there
can be an effective, collective answer to the development of drug resistance -- which, if

left unchecked, will frustrate us mortally in our ability to use these agents for protection
against disease.

JL:

If these dangerous organisms had different names and were reportable diseases, we’d be sending
up red flags of the most urgent kind. Contrast the first patient who comes along with a high
level of vancomycin-resistant staphylococcus and a patient labeled as having the Ebola virus.
But the threat to the community from an individual with vancomycin-resistant staphylococcus

is probably substantially larger than Ebola. Despite all the publicity, Ebola can be contained

by standard infection control procedures. Outbreaks have not spread to other continents. But
unless we change our practices severely, we’re not going to contain the spread of the next
occurrence of vancomycin-resistant staph.

Infection control practices in hospitals are one point of consideration. [’'m not an expert on
this matter, but I read quite alarming things from time to time in the medical literature about
the frequency with which health care workers at every level -- and I’m not sure that docs aren’t
the worst offenders in this regard -- neglect to wash their hands when they go from one patient
to another. Then there’s the mythology that if you put on gloves, they’re going to protect the
next person you’re going to see. They obviously won’t if you don’t change them.

Can we find the sources of new infectious agents among health care attendants, among visitors,
in the ambient environment of a hospital? Very few places have ever done that. You track the
bugs that are sent down to the diagnostic laboratory because there’s a problem in the patient.
We don’t have a lot of insight into the detailed traffic, into where the perps are hiding and
where they’re moving around. We’re never going to get it unless we adopt a concerted attitude
that this information has to be gotten.

Do any of us want to advertise ourselves as a place with a high level of methicillin-resistant
staph? We’d better watch out about that. Can we rely on the confidentiality of the system

if we share information? Reasonably but not perfectly. Nobody can give absolute guarantees
that that kind of information isn’t going to get out.

But there may be a negative side to keeping it as a secret. I think of a Libby Zion kind of
case. Imagine an infection-oriented scenario where the plaintiff is able to bring out that a
hospital did have information that might bear on the spread of resistant organisms, but didn’t
share it with the rest of the community. That might not bear directly on culpability in an
individual case, but it sure could make a hell of an impact on a jury pondering whether to

add punitive damages to the compensatory ones if there was knowledge about what might have
been done to minimize the opportunities for the spread of infection, and that was not only
neglected but actively resisted.

There’s an act that’s got to cleaned up here. Although all of us would greatly prefer an

effective voluntary system, it’s only a matter of time before compulsion of the ugliest
sort enters in.

JL comments:

Everything has to be considered, but only when we have the data to understand what the
patterns of spread are and what draconian measures are going to accomplish.