The Centers for Disease Control and Prevention are warning about the rise of a so-called “nightmare bacteria” in U.S. hospitals. The director of the CDC calls the Carbapenen-Resistant Enterobacteriaceae — or CRE — bacteria a triple threat. They are resistant to almost all antibiotics, they can transfer their invincibility to other bacteria and they are deadly. Infection with CRE has a fatality rate as high as 50 percent. So far, these infections are still relatively rare. They’ve only been seen in hospitals and long-term care facilities. But the fear is that they could soon to spread to the wider community, and the proportion of drug-resistant bacteria has quadrupled in the last decade. Diane and her guests discuss the rise of superbugs and how public health officials are trying to stop their spread.

Guests

  • Dr. Anthony Fauci Director, National Institute of Allergy and Infectious Diseases at the National Institutes of Health.
  • Dr. Neil Fishman Associate Chief Medical Officer, University of Pennsylvania Health System.
  • Dr. Brad Spelberg Associate Professor of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
  • Dr. Michael Bell Associate Director for Infection Control, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention

Transcript

  • 10:06:57

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The Centers for Disease Control warned this week about a dangerous group of superbugs that have become a major health problem in hospitals across the U.S. Joining me to talk about the rise of the CRE bacteria and how public health officials are trying to stop their spread, Dr. Anthony Fauci of the National Institute of Health. Joining us by phone from his office in Torrance, Calif., Dr. Brad Spellberg of the UCLA School of Medicine.

  • 10:07:38

    MS. DIANE REHMAnd from WXPN in Philadelphia, Dr. Neil Fishman of the University of Pennsylvania Health System. I know you'll be interested in finding out more about this. Do join us with your questions and comments. Call us on 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or Twitter. Good morning, gentlemen. Thank you for joining us.

  • 10:08:14

    DR. ANTHONY FAUCIGood morning, Diane.

  • 10:08:15

    DR. BRAD SPELLBERGGood morning.

  • 10:08:16

    DR. NEIL FISHMANGood morning, Diane.

  • 10:08:16

    REHMGood to have you all with us. First, joining us from Atlanta is Dr. Michael Bell. He's associate director for infectious control at the Centers for Disease Control. Good morning, Dr. Bell.

  • 10:08:38

    DR. MICHAEL BELLGood morning.

  • 10:08:39

    REHMDr. Bell, talk about this deadly bacteria that CDC reported on this week. Give us the gist of the report.

  • 10:08:51

    BELLSure. So CRE, carbapenem-resistant enterobacteriaceae is a family of bacteria that are quite commonplace. We carry them normally with us in our bowel. And when they are doing what they're supposed to be doing, they don't cause a problem. If they move into the blood stream, the bladder, other places where they don't belong, they can cause infections. Up until know, those infections have been fairly easily treated with antibiotics.

  • 10:09:18

    BELLBut over the course of time, these bacteria have developed the ability to fight off antibiotics. These are leading to untreatable infections, infections where really even the last resort antibiotics no longer work, and it's taking us back to, really, the dark ages when we didn't have a way to treat infections. This is currently something that is affecting people who have received a great deal of health care, who have had close contact in hospitals and so on.

  • 10:09:48

    BELLBut our concern is that this particular type of resistance has been seen to spread from one type of bacteria to another. In other words, it's able to hand off its blueprint for resistance to other types of bacteria, which raises the possibility that this kind of untreatable infection could become a much more commonplace.

  • 10:10:08

    REHMSo who is getting this infection and how?

  • 10:10:15

    BELLSo right now, as I said, we're dealing mostly with people who have had a great deal of medical care. And this is something related to two factors. One, if you are given antibiotics for even the most appropriate reasons, it has a bad effect on the bacteria that normally reside in the bowel. And when that happens, other bacteria that either shouldn't be there like a clostridium difficile or resistant strains of bacteria can take up residence. So we see the impact of antibiotic use in that setting.

  • 10:10:49

    BELLAnd then also, when you're in a place where other patients are receiving care, the bacteria can be delivered to you either on the hands of health care personnel because of inadequate hand hygiene or from a soiled environment.

  • 10:11:04

    REHMHow do you know that a patient has developed this deadly bacteria?

  • 10:11:12

    BELLSo we at CDC are promoting a detect and protect program, and the detect part of that really boils down to a couple of major things. One is ensuring that the clinical laboratory where you're working, you being physicians, has the ability to accurately identify this type of organism. We have put out methods on our website several years ago, actually, to make sure that everyone knows how to detect this. And then only detecting it, but then notifying your clinical staff that it's present right away is part of the detect piece.

  • 10:11:49

    BELLThe other part of detect is if somebody is transferring the patient to your facility. Having them give you a heads up that that patient carries CRE is very helpful. Likewise, if someone's leaving your hospital going to a nursing facility, letting that facility know that they're receiving somebody with this diagnosis is important as well.

  • 10:12:09

    REHMWhat about the family? How does the family recognize that this bacteria may be present?

  • 10:12:19

    BELLOh, my. I don't know that the family is necessarily going to be the one doing the detection. I think having close conversations with the clinical care team is one way of knowing that. The good news is that family members who are healthy, who are not on antibiotics, who are not receiving medical care don't have a lot to worry about it in terms of transmission from a loved one.

  • 10:12:41

    REHMNow for quite a long period of time, we heard about the MRSA virus, and I'm wondering how different this is.

  • 10:12:54

    BELLSo it's a great comparison. MRSA is very concerning, and it's certainly something that we worked very hard to prevent. But a striking difference between that bacteria and the CRE is that there are usually second and third-choice options for treating MRSA infections. So we haven't been backed against the wall the way that some of the infections with CRE have had us. With CRE, we're in a situation, in some cases, where there is literally no treatment. And aside from supportive care, there's nothing we can do to directly stop the infection.

  • 10:13:28

    REHMSo you are telling your health care providers what?

  • 10:13:35

    BELLSo I mentioned the detect part of detect and protect. The protect part is a combination of things. One, it's ensuring appropriate hygiene, paying attention to clean hands, making sure that the environment is appropriately cleaned and then also keeping patients who have CRE in a private room with dedicated equipment that doesn't move from one patient to another, having staff dedicated to that patient so that there's as limited a possible -- as possible a risk of transferring CRE bacteria from that patient to other patients.

  • 10:14:08

    BELLThe last piece here is antibiotic use. We know that the more antibiotic exposure you have, the more likely you are to have these kinds of resistant organisms. And while we've been warning about this for many years, we're yet again at a point where the latest antibiotics are starting to fail us. You know, we've seen this back through penicillin, gentamicin, ciprofloxacin and now CRE. And so before we max out this latest credit card, we're saying, you know, let's be as careful with our medications as we can so that they will last.

  • 10:14:41

    BELLWe're several years away at best from a new antibiotic type that would supplant the drugs that we use currently. And so between now and then, we need to make sure that what we have left continues to work.

  • 10:14:55

    REHMBefore you leave us, Dr. Bell, Dr. Anthony Fauci wants to pose a question.

  • 10:15:03

    FAUCINo, not a question, just to underscore what Dr. Bell had said. As you know, Diane, we had a very unfortunate experience at the NIH where we had an outbreak of klebsiella, carbapenem-resistant klebsiella, and that was really a very difficult issue. And everything that Dr. Bell said about what we had to do of everything from isolation, hygiene, hand washing, use of instruments, designated staff, being very careful about antibiotics was a very, very trying experience for us. Thankfully, it's under control now.

  • 10:15:38

    FAUCIBut one other thing that's really important to underscore is that we have a window of opportunity now to control this because, remember -- in fact, we spoke on this show sometime ago, a long time ago when MRSA was fundamentally a hospital-acquired infection. And then it went out into the community and now we have community-acquired MRSA. Luckily, the CREs are not yet community-acquired.

  • 10:16:02

    FAUCIThey are fundamentally hospital, particularly long-term care hospitals and long-term care facilities. So if we can get our arms around this and suppress it, hopefully it will not then spread to be a community-acquired infection.

  • 10:16:15

    REHMHow could it spread to the community, Dr. Bell?

  • 10:16:22

    BELLWell, so I mentioned that these bacteria can pass on the blueprint of resistance. A closely related bacteria, just as one example, would be E. coli. This is something that everyone carries. And I can't tell you how many people have come into my clinic through the years with an E. coli bladder infection, a very commonplace thing. We rely on the fact that, you know, oral antibiotics can be prescribed that will treat an E. coli bladder infection.

  • 10:16:48

    BELLIf E. coli becomes resistant to the way CRE is resistant right now, then that changes from a prescription and four days of treatment at home to the possibility of, A, having to have intravenous antibiotics for even routine infections or even having untreatable infections. This is something that could completely change how we receive medical care. I think, you know, Dr. Fauci is exactly right.

  • 10:17:12

    BELLWe don't want to be crying wolf, but at the same time, we feel it's our obligation to give everybody a heads-up before it's too late that this needs to be contained now.

  • 10:17:23

    REHMDo you think it can be contained, Dr. Fauci?

  • 10:17:27

    FAUCII think it can. In fact, there have been several pilot studies that the CDC has been involved with of implementation of this detect and protect protocol that Dr. Bell has spoken about, and there has been some decreased incidents in certain places. For example, Colorado and Florida and others have actually worked very closely with the CDC in some outbreaks and had been very successful. We had a successful containment in our own hospital, but you need to go beyond that.

  • 10:17:56

    FAUCIYou need to have a broad awareness of it. And I think one of the important things is to make sure that the detect part of it as well as protect, and that is when you transfer a patient from one facility to another and you know the patient has CRE, you've got to let the receiving facility know about it and the lab has got to let the clinicians know about it when they find it.

  • 10:18:19

    REHMDr. Anthony Fauci, he is with the National Institutes of Health. Dr. Michael Bell, he's associate director for infection control at the Centers for Disease Control. Thank you, Dr. Bell, for joining us.

  • 10:18:40

    BELLIt's been a pleasure. Thank you.

  • 10:18:41

    REHMAnd we'll take a short break. Right back.

  • 10:20:05

    REHMAnd now, we add two other doctors into our discussion. Dr. Brad Spellberg, he's assistant professor of medicine at School of Medicine at UCLA. His research focuses on using the immune system to prevent and treat infections. And joining us from WXPN in Philadelphia, Dr. Neil Fishman, associate chief medical officer with the University of Pennsylvania Health System. Dr. Spellberg, let me start with you. This is not a new bacteria, I gather. So how come it's making news now?

  • 10:20:56

    SPELLBERGWell, I think the thing driving the news is the spread and the fact that we, you know, the CDC has gathered data that has helped us understand better how rapidly it's spreading. And when you see the numbers coming out of the CDC, it really puts an exclamation point on the need for us to really stop the spread of the organism.

  • 10:21:17

    REHMWhy is it that you've called the lack of action so far on dealing with CRE a conspiracy of silence? You're suggesting that hospitals, nursing care facilities really wanna hide this?

  • 10:21:37

    SPELLBERGOh, I don't -- I've been misquoted if somebody said that. No, no, no. There are certainly has not been a lack of action on CRE. There's been a lot of action on CRE. Unfortunately, these bacteria are very tricky, and they find ways to do what bacteria is supposed to do, which is grow and replicate. And the conspiracy of silence is not anybody doing anything wrong. It's that hospitals don't wanna talk about it. Nobody wants to be associated with something like CRE.

  • 10:22:07

    SPELLBERGSo when the NIH Clinical Center came forward publicly last year, I think we all should be applauding them for doing that. They were really the first medical health care system or hospital system that came forward in a public way and said, hey, we have a problem with this organism. It's really a problem. And, you know, this is something that have been around for 10, 12 years before that, and hospitals generally just don't wanna talk about it.

  • 10:22:31

    REHMDr. Fishman, how is your hospital dealing with CRE? What do you see as this so-called window of opportunity to deal with it before it becomes a community-borne illness?

  • 10:22:50

    FISHMANWell, I think we've missed one opportunity and that it has spread across the country. Antibiotic resistance, as you've heard, is a very complex problem and you need to tackle it from a lot of different angles. We need to be able to diagnose or detect these infections. We need drugs to treat these infections. We need to make sure that we use the drugs that we have wisely. We need infection control to prevent transmission.

  • 10:23:22

    FISHMANWe need research to prevent the spread of these organisms into the community and to prevent their development. And we need public policy to fund that research and also to fund our public health infrastructure so that we can detect these problems before they become -- before they begin to have national implications.

  • 10:23:47

    REHMSo if this particular problem has been around for 10 years and is just reaching public awareness and has not yet had that kind of research, Dr. Fauci, where does that leave us?

  • 10:24:08

    FAUCIWell, we have a lot research on this, and we're spending at the NIH now a total of about $375 million a year. We can do the research, but there really is a spectrum of what should be done from the fundamental basic research to the early clinical trials to the development of a product and then to partnering with the pharmaceutical companies.

  • 10:24:32

    FAUCIAnd that's what we've had to do more aggressively because in general -- and it's sometimes difficult, if not dangerous, to generalize, but if you can grant me that in general, pharmaceutical companies don't have an overwhelming enthusiasm of developing new antibiotics.

  • 10:24:47

    REHMWhy not?

  • 10:24:48

    FAUCIWell, because the cost of developing a new drug is measured in several hundred million to $1 billion.

  • 10:24:54

    REHMBut if you are ratcheting up the need...

  • 10:24:59

    FAUCIRight.

  • 10:25:00

    REHM...for one new drug to heal the remnants of...

  • 10:25:04

    FAUCISure.

  • 10:25:05

    REHM...one last drug, wouldn't you think that that would be pushed?

  • 10:25:09

    FAUCIBut antibiotics are not the kinds of drugs that are major profit-makers for the following reason, is that they're generally used in short courses, number one. After a period of time, they become -- the bugs...

  • 10:25:21

    REHMRight.

  • 10:25:22

    FAUCI...become resistant as opposed to an investment in something that a person will use every day for their rest of their life. So I'm not saying that there's no company that's doing that. But the point I'm making, Diane, is that part of our research agenda is to do public-private partnerships so that we can partner with the pharmaceutical industry and take some of the risk of discovery away from them to give them the advantage of being to then put more investment into developing a product.

  • 10:25:51

    REHMDr. Spel

  • 10:25:51

    REHMberg, who is most susceptible? And are there concerns that we're just scaring the American public?

  • 10:26:04

    SPELLBERGWell, I think Dr. Bell and Dr. Fauci described the populations of patients who tend to pick up these infections currently. There are people that are undergoing extensive medical care often in intensive care units and often have been in skilled nursing facilities. It's not because their immune systems aren't working per se. It's because we're providing very intensive care in, for example, putting plastic catheters into their blood stream so we can give life-saving medicines or putting tubes into their lungs so that we can have mechanical ventilators breath for them, tubes in their bladders.

  • 10:26:35

    SPELLBERGAnd when you break those kinds of anatomical barriers, it allows bacteria that normally don't get into those parts of your body to get in there. So, you know, I think that the worry is is it going to escape from the hospital like MRSA did? We really didn't -- we still don't really understand why MRSA decided to escape from the hospital into communities when it did. And that's what we've been talking about, as to how can we make that not happen.

  • 10:27:02

    REHMAnd what you have said is that you need better drugs to treat. And yet Dr. Fauci is saying that the pharmaceuticals are less than enthusiastic about developing new antibiotics.

  • 10:27:23

    SPELLBERGYeah. Well, there -- that is absolutely true. There has been a massive egress or leaving from the field of antibiotic development by large pharmaceutical companies for the reasons that Dr. Fauci mentioned. In addition to the fact that there -- the regulatory environment for getting new drugs approved is not friendly and has become much less friendly over the last decade. So the cost of doing trials to get new antibiotics approved has skyrocketed.

  • 10:27:50

    SPELLBERGBut there is good news. Congress really has recognized that this is a problem. We had legislation passed and signed into law by President Obama last year called the Generating Antibiotic Incentives Now Act or GAIN, which is a good first step. It's not strong enough to get really big companies back in the field, but it's a signal that Congress has understood and the president has understood that this is a big problem.

  • 10:28:13

    SPELLBERGAnd I think one of the big solutions Dr. Fauci touched upon, the traditional business model of pharma companies taking all the upfront risks and spending $1 billion to develop a drug, which -- that isn't gonna make them much money downstream, that's probably not sustainable for antibiotics. And what we need are expansion of public-private partnerships.

  • 10:28:33

    SPELLBERGAnd so what that means is we need, for example, Congress to money into NIH programs and other programs within the Department of Health and Human Services that will de-risk development of these critically needed public health compounds from pharmaceutical companies.

  • 10:28:50

    REHMOf course, there you are, Dr. Spellberg, out in California. We here in Washington have been doing little more than following this stupid sequester, where no money for anything. How does that affect the possibility of a public-private partnership, Dr. Fauci?

  • 10:29:16

    FAUCIWell, I think every aspect of a biomedical research enterprise, when you have cuts, particularly when the opportunities for science are greater and more likely productive that they've ever been, will have a dampening effect not only on individual things, but on the long range. We are very concerned at the NIH about the signal that sent to young investigators about even going into the field of biomedical research when they see that there are many scientific opportunities. Everyone's appreciative of the fiscal constraints.

  • 10:29:50

    FAUCIIt isn't that we're so naive that we don't realize that. But when you're thinking about biomedical research and the short-term approach to it, not really fully realizing the long-term benefits of enhancing it and the long-term detriment of not supporting it, that's what we're concerned about when you're talking about sequester.

  • 10:30:09

    REHMDr. Fishman, how many patients have shown up at your own hospital with these kinds of infections?

  • 10:30:22

    FISHMANWell, again, this is, as you've heard, this is still a relatively rare infection, and we have had several individuals with these infections. We generally see them as very -- see very sick, complicated individuals with very severe infections. One important thing that Dr. Bell pointed out is that you really also need to think beyond the four walls of your institution. So, in Philadelphia, we know that there are at least two long-term care facilities that have large outbreaks.

  • 10:31:00

    FISHMANSo we are cognizant of where these institutions are and track the patients if they -- those individuals if they come into our -- any of our facilities and actually treat them as though they are infected with one of these organisms until we can prove otherwise.

  • 10:31:21

    REHMNow, does that mean they go into quarantine immediately?

  • 10:31:27

    FISHMANWe put them -- we place them in what we call contact precaution. So they're in a private room, and we make sure that people practice diligent hand hygiene, that they clean their hands well and they wear some personal protective equipment to prevent the spread of the organism beyond the room where the patient is located.

  • 10:31:50

    REHMWhat about visitors? What about family? Are they allowed, or are they kept at a distance?

  • 10:32:00

    FISHMANOh, no. Of course they're allowed. It's critical for patient care to have family visiting, but we do educate the family about the organism and make sure -- certain that they also take precautions to prevent the spread of this organism outside of the room where the patient is located.

  • 10:32:19

    REHMHow can that be done with certainty, Dr. Fishman?

  • 10:32:26

    FISHMANWell, primarily, the most important thing that we can do is the same for any type of infection, and that's practice good hand hygiene. Beyond that, we have individuals wear protective gowns that -- while they're in the room, that they take off when they leave the room, and also gloves if they're going to be touching their family member.

  • 10:32:50

    REHMDr. Neil Fishman, he's at the University of Pennsylvania Health System. And you're listening to "The Diane Rehm Show." I'm going to open the phones now, 800-433-8850. First, let's go to Thomas in Ann Arbor, Mich. Good morning to you.

  • 10:33:15

    THOMASHi. Good morning, Diane. Love your show.

  • 10:33:17

    REHMThanks.

  • 10:33:17

    THOMASThank you so much for doing this. I had a couple of questions, but I'll try to limit them. So the good doctor, I think, dodged your question when you asked how many patients have actually been seen. And my question was everyone's calling this a deadly virus. How many patients have actually died of this?

  • 10:33:34

    THOMASAnd my second question -- I'll take it off the air -- if all bacteremia with patients with hardware devices and who are in the hospital is deadly, so what are the comparison statistics? Like how more deadly is this compared to your run-of-the-mill, you know, hospitalized patient with hardware? Because I think we have to put this in context before we get everybody really scared.

  • 10:33:54

    REHMAbsolutely. Thomas, thanks for your question. How many have died, Dr. Fauci?

  • 10:34:00

    FAUCIWell, you know, since it is not yet -- though it is in at least six states -- reportable, it -- we don't have a precise number, but...

  • 10:34:09

    REHMWhere are those six states?

  • 10:34:12

    FAUCIIt's Tennessee, Oregon, Wisconsin, Minnesota, Colorado and North Dakota, or now it's reportable. But I think the important point to directly answer the caller's question, when -- there's virtually no treatment for CRE. The death rate is 50 percent. That is extraordinary. That's the reason why there's the alarm in addition to the concern about being -- about spreading. As Dr...

  • 10:34:40

    REHMBut is there an actual number of those who have died?

  • 10:34:46

    FAUCII don't have the exact number because I think the number -- since it isn't a fully reportable disease, but I can give you some numbers to get an idea of it, OK? So, right now, in the first six months of 2002, 4 percent of hospitals have reported at least one case of CRE, of the whole group of Enterobacteriaceae. Eighteen percent of long-term care facilities have reported at least one case within the first six months of 2012.

  • 10:35:24

    FAUCISo if you just sort of take a look at that, you're talking about a considerable -- even though it's still -- relatively speaking, when you compare it with MRSA, it's really not widespread. That's the reason why when I told you before, the real concern is that we wanna make sure it doesn't spread.

  • 10:35:41

    REHMExactly. He also asked about comparisons to those who have some hardware and whether that compares favorably, unfavorably.

  • 10:35:56

    FAUCIWhen you say hardware, what are you talking about?

  • 10:35:58

    REHMSome kind of device that one wears permanently.

  • 10:36:02

    FAUCIWell -- no, that is not -- for example, somebody has a pacemaker.

  • 10:36:07

    REHMYeah.

  • 10:36:08

    FAUCIThat's not what we're talking about. We're talking about things like ventilators and indwelling catheters.

  • 10:36:11

    REHMRight. OK. Let's go to Arlington...

  • 10:36:16

    FISHMANMay I...

  • 10:36:17

    REHMOh, sure. Go right ahead.

  • 10:36:18

    FISHMANOK. It's Neil Fishman...

  • 10:36:20

    REHMSure.

  • 10:36:20

    FISHMAN...in Philadelphia. So I think the caller does make -- point out one good problem, that another way to attack this organism and all organisms that cause infections is to make certain we don't lose our focus on preventing all health care-associated infections. And the CDC has recently reported on our successful efforts nationally in preventing or decreasing the numbers of central line-associated bloodstream infections and catheter-associated urinary tract infections. And we certainly can't lose focus of those efforts for this organism or for any other organism.

  • 10:37:04

    REHMDr. Spellberg, do you wanna add to that?

  • 10:37:07

    SPELLBERGWell, the only thing I'll add is that it is a telling commentary on the infrastructure that we have funded in the United States that we don't know the answer to the question how many people have gotten it. We can give you...

  • 10:37:20

    REHMThat's pretty scary. Yeah, yeah.

  • 10:37:20

    SPELLBERG...pretty good data of how many died at one unit. You know, Dr. Fauci said that's 50 percent.

  • 10:37:25

    REHMFifty percent.

  • 10:37:25

    SPELLBERGBut in Europe, they would be able to answer that question...

  • 10:37:27

    REHMWhoa.

  • 10:37:27

    SPELLBERG...much more definitively because they have a more developed public health network.

  • 10:37:31

    REHMDr. Brad Spellberg, he's at the UCLA School of Medicine. We'll take a short break. More of your calls, your comments, when we come back.

  • 10:40:05

    REHMAnd we'll go right back to the phones. To Trevor in Arlington, Texas, you're on the air.

  • 10:40:15

    TREVORHey, good morning. How are you doing?

  • 10:40:16

    REHMGood. Thanks, Trevor.

  • 10:40:18

    TREVORThe topic today is really been all about antibiotics and the strains. Our company works with antibodies specifically, and the -- most of these doctors are probably aware of how the most common form or easiest way to get antibodies is possibly from an egg yolk. They call it IGY. These antibodies can be specific or general in nature.

  • 10:40:41

    TREVORBut in relation to some of these issues that superbug is going on in the hospitals in third world, we actually have patented products and there's actually product around the world that has specific antibodies to things like this H. pylori (unintelligible) et cetera. You know, so -- and as well as the CDC is looking at antibiotics as a solution, the most searched out possible solution has been the science IgY which is immunoglobulin yoke specific that is related to the human IgG and IgE.

  • 10:41:16

    REHMAll right. You're getting very technical on me. But I wanna ask, Dr. Fauci, if you get that.

  • 10:41:24

    FAUCIWell, yeah. I think what the caller is saying is that there are alternative ways when antibiotics don't work. It relates back to the fundamental principal what we call passive immunization where you give someone an IgG antibody or a particular type of antibody against a microbe if you have no other way of treating it, particularly, for example, when you get exposed to something. Whether or not -- this is not ready yet for primetime in what we're talking about here, but it's not something you just discard.

  • 10:41:54

    REHMOK.

  • 10:41:54

    FAUCIYou got to consider all possibilities.

  • 10:41:55

    REHMAll right. And here's an email from Debby who is a physician, "Is it possible," she says, "that facilities might refuse to accept transfer of patients with known CRE infection, and what will be those ramifications?" Dr. Fishman.

  • 10:42:22

    FISHMANI don't think it is ethical and certainly not legal in certain instances to refuse to care for these patients. We haven't seen that with other resistant organisms yet, and I don't suspect that we'll see it with this organism. I certainly hope that we would not see it with this organization.

  • 10:42:42

    REHMDr. Fauci.

  • 10:42:43

    FAUCIOh, I agree. I mean, obviously, to take a transfer from one facility to another would be, in some respects, causing the receiving facility to have to do a lot.

  • 10:42:53

    REHMExactly.

  • 10:42:54

    FAUCIAnd they may be some concern. But I think it would be unethical if that's the place where the patient could be best treated and the person is not allowed to come to the facility.

  • 10:43:03

    REHMAll right. To...

  • 10:43:05

    FISHMANThe important thing, as Dr. Fauci has said, is to make certain that we know when one of these individuals is coming in to the hospital so that we can take appropriate precautions.

  • 10:43:14

    REHMYes. To Bowie, Md. Good morning, Michael.

  • 10:43:21

    MICHAELA very interesting show. Unfortunately, it's very sad to hear this 'cause my dad died on January 4 at Laurel Regional Hospital of ESBL urinary tract infection and C. difficile colitis. He was discovered to have found that he had the ESBL UTI at John Hopkins Bayview Medical Center only a few weeks before he died. He had an unknown type of dementia that no doctor could figure out what's wrong with him.

  • 10:43:55

    MICHAELHe did have urinary tract infection and was treated at Georgetown Hospital December of 2011, and they gave him Cipro for that. And he had recurring episodes of excessive sweating, coordination and balance problems. I read that there's also a problem where the doctors think a person has dementia, but actually they have this urinary tract infection. I just want to point out, he was treated with Ertapenem at Johns Hopkins where they were very confident. They said easily treatable. There's a very low risk of infection.

  • 10:44:30

    MICHAELThey never told us about possible side effects of Ertapenem which, as you're probably aware of, are aspiration pneumonia, septic shock and C. dif which is what my dad contracted.

  • 10:44:41

    REHMMichael, I'm so sorry about the loss of your dad. I'm sure that, you know, hospitals are fighting with everything they've got, Dr. Fauci.

  • 10:44:56

    FAUCIYes, that's the case. And unfortunately, people get very sick. And sometimes, when they get sick, complications compound each other. So again, I also express my sorrow for the loss of your father.

  • 10:45:06

    REHMAll right. To Little Rock, Ark. Hi there, Tom.

  • 10:45:11

    TOMHello, Ms. Rehm or Diane.

  • 10:45:12

    REHMYes.

  • 10:45:12

    TOMI suppose I should just call you Diane.

  • 10:45:14

    REHMPlease.

  • 10:45:15

    TOMYes. I was a registered nurse at the only teaching hospital in the state for over 25 years. And during that time, I'd notice that there was something we started referring to as white coat syndrome where the doctors would go into the rooms without gowning up or even putting gloves on, examine the patients and then go straight to another room. And this would be -- even if there was an isolation sign and the cart for gloves and the masks and the gowns and all that on the outside.

  • 10:45:41

    TOMAnd I asked several of them. I was friendly with them, and I asked them several of them. They said, well, they don't, you know, we don't transmit the diseases like the nurses and the, you know, and the staff and the family members do. And I was wondering if this is wide-spread, you know, because, you know, they'd be frequently to have a number of residents following along behind them and trailing from one room to another.

  • 10:45:59

    REHMSure. Dr. Spellberg, do you wanna comment?

  • 10:46:04

    SPELLBERGWell, you know, all health care providers have a responsibility to, most importantly as Dr. Fishman said, wash hands. And that includes whether you're wearing gloves or not. And that's doctors, nurses, respiratory therapists, doesn't matter, anybody going in the room. And with the patient contact isolation, you need to do it. You need to follow the appropriate precaution.

  • 10:46:25

    FAUCIRight. Or you'll lose your accreditation.

  • 10:46:29

    REHMUltimately.

  • 10:46:30

    FAUCIYeah, yeah.

  • 10:46:30

    REHMBut an awful lot of people can get sick in the meantime.

  • 10:46:33

    FAUCIWell, no. Actually, it -- well, this may have happened some time ago. But right now, the attention to washing hands when you go in and when you come out of the room no matter what the patient has and certainly when a patient is on isolation that you follow all the isolation procedures. I mean, that's the right thing to do. It's the ethical thing to do. But there's a considerable amount of enforcement about that. If you don't do that and someone's inspecting you and you don't know that, you could lose your accreditation.

  • 10:47:00

    REHMAll right. To Atlanta, Ga. Good morning, Wayne.

  • 10:47:06

    WAYNEHi, Diane. Great show.

  • 10:47:07

    REHMThank you.

  • 10:47:09

    WAYNEI share a similar story of the previous caller. My dad died on January 7 from complications of MRSA. And I can tell you, people should be scared of these superbugs. He was given -- once diagnosed, he was given less than 50 percent chance to live. And he had a lot of pain, had a lot of issues. But what I'm -- my question is, there's been a lot of talk on the show today and good discussion about the clinical and pharmaceutical side effects.

  • 10:47:38

    WAYNEI just thought the government should be doing more to educate the public and to perhaps put more restrictions on the use of antibiotics. I know that's going on in Europe, and I'm just wondering why that's not happening here.

  • 10:47:50

    REHMWhat about CDC, Dr. Fauci?

  • 10:47:53

    FAUCIWell, Diane, the caller brings up a very good question. But this is exactly what the CDC is trying to do and is really aggressively doing. They came out just the day before yesterday with their Vital Signs, which is the first Tuesday of every week, they pick out a very hot topic associated with their morbidity, mortality weekly report.

  • 10:48:15

    FAUCIAnd they spell out very, very clearly the kinds of things that need to be do, the extent of the problem, and they even have a toolkit which they provide for prevention guidelines for doctors, nurses, hospitals, health departments, as well as the general public. So they're really, really being very aggressive about it.

  • 10:48:33

    REHMBut, Dr. Spellberg, isn't it a problem that only six states require hospitals and health care facilities to report the CRE infection to state officials?

  • 10:48:50

    SPELLBERGYeah. Well, you know, I think I alluded to this before. The bottom line is if we want to really tackle this problem, we need to put resources into it. You can't expect the CDC to do everything with insufficient resources. And as Dr. Fauci said, we realize we're in a tough budget environment. The question is just where you prioritize this problem. And I would say that the problem 10 years ago certainly was public education.

  • 10:49:16

    SPELLBERGI'm not sure that's true anymore. I think that a lot of people -- you talk to people on the street, a lot of people know what a superbug is, or they've heard of superbugs. They know MRSA, and they're starting to learn these new bugs. It's made it into movies and books. We're at the point of what's called implementation science at this point.

  • 10:49:32

    SPELLBERGI think we're sort of passed the, hey, everybody. We have a problem. We're at the point of, are we going to be able to generate the will to help politicians act to implement policies that affect change?

  • 10:49:45

    FISHMANAnd one of these issues is the issue that the caller just brought up, which is what the -- we've called having good antimicrobial stewardship or that doctors need to use antibiotics wisely. They have to make certain that the correct patient gets the correct antibiotic at the correct time, at the correct dose for the correct duration. And that the caller is absolutely correct that that is critical.

  • 10:50:13

    FISHMANWhat we haven't seen yet is any legislation or accreditation standards focusing on the issues of the way physicians use antibiotics either in the in-patient setting or in the ambulatory setting.

  • 10:50:29

    REHMCould we be entering into something...

  • 10:50:29

    SPELLBERGAnd to add to that -- well, let me add to that. Diane, I'm sorry. Let me add to that really quickly.

  • 10:50:35

    REHMSure.

  • 10:50:36

    SPELLBERGEighty percent of the antibiotic use in the United States is in animals, primarily in livestock to make the animals grow larger so farmers make more money when they sell the animals. There is no political will to stop that like they've done in Europe. So again, it's an example of we know -- we kind of know what the issues are, and I think the public has been greatly educated over the last decade, it's do we have the will to act.

  • 10:50:57

    REHMNow, do you, Dr. Spellberg, believe that the animal use of antibiotics is exacerbating this entire problem?

  • 10:51:12

    SPELLBERGWell, there is no question that it contributes to the transmission of resistant infections in the communities, that's been very well-documented. It has not been directly link to CRE, and it may well not contribute directly to CRE but other resistance patterns that absolutely contributes to. And I would say that if you want to control antibiotic use, it doesn't make sense to focus only on the 20 percent. We should be having a conversation about 100 percent of antibiotic use, not just the 20 percent that goes into humans.

  • 10:51:42

    FISHMANAnd just to extenuate something Brad said a little while ago. Europe has tackled this problem already and removed or mandated that antibiotics cannot be used as growth promoters in the animal industry.

  • 10:51:57

    REHMThat's...

  • 10:51:58

    FISHMANSo it's another example the way Europe is ahead of us in tackling this problem.

  • 10:52:02

    REHMHow do you feel about this, Dr. Fauci?

  • 10:52:05

    FAUCIYeah. I think the inappropriate use of antibiotics anywhere, any time is something that needs to be carefully scrutinized and tried to be avoided.

  • 10:52:12

    REHMAnd again, government action would be needed.

  • 10:52:15

    FAUCIRight. Right.

  • 10:52:17

    REHMAll right. And you are listening to "The Diane Rehm Show." Let's go to Miami, Fla. Good morning, Bernard.

  • 10:52:29

    BERNARDHello?

  • 10:52:29

    REHMHi.

  • 10:52:30

    BERNARDYeah. Listening to your show is always a pleasure. One of the questions that I have, you -- one of your panelists is an expert in the area of the human immune system. What is the findings -- I mean, we talked about the antibodies and pharmaceutical companies. But what is he trying about how the body is able to deal with some of these diseases? And how can that help us to better reinforce our whole human immune system?

  • 10:52:58

    REHMDr. Spellberg.

  • 10:53:00

    SPELLBERGWell, it's -- I have to say it's amusing for me to be considered the immune expert in the presence of Dr. Fauci, who's one of the most famous immune experts in the world.

  • 10:53:09

    REHMI thought I'd toss it to you anyhow.

  • 10:53:12

    SPELLBERGPlease, please add Dr. Fauci. Of course, my laboratory is directly interested in this. In fact, we have a program to look in my lab at antibodies for KPC, one of the CRE bacteria specifically that we're trying to get funded through NIH. And the issue I think really is, as I mentioned before, most patients that get these infections, they don't have compromised immune systems per se. Their white blood cells are working OK. The problem is that we have created orthosis in their body that didn't used to be there.

  • 10:53:42

    SPELLBERGWe put holes in their body to put catheters into their blood. We put tubes into their lung to breath for them. We put tubes in their bladder. So it isn't so much that their immune systems are not working. It's that we are practicing intensive medicine that can make bacteria enter parts of the body that they're not normally supposed to be in.

  • 10:53:59

    SPELLBERGHaving said that, we do have proof of concept at least in my lab and I think there are others out there that have shown this as well that you can raise antibodies against this bacteria that can help clear them. So there is -- as Dr. Fauci, this isn't ready for primetime, but this is an area we should be investing R&D resources into.

  • 10:54:19

    FAUCINice job, Brad.

  • 10:54:21

    REHMAll right. And here's a final question. How does sequestration affect the work of the CDC and the superbug fight, Dr. Fauci?

  • 10:54:34

    FAUCIWell, that's related to the question, Diane, that you asked me before. I mean, obviously, when you curtail resources and even cut resources in organizations that have a long-term mandated commitment for the public health in science, see, it isn't like you're gonna built four bridges instead of five bridges or you're gonna make 20 planes instead of 25 planes. The investment in science, you have to think in terms of the long term.

  • 10:55:00

    FAUCISo when you have something like sequestration, which cuts the amount that you were planning to spend, it has a chilling effect that might not be immediately realize tomorrow. But in the long run, it really dampens that ability to be able to make the kind of scientific advances that we need to make in the long run, not...

  • 10:55:18

    REHMWhat's the dollar amount that's going to be cut from NIH?

  • 10:55:23

    FAUCIThe NIH will have approximately 5 percent sequestration of what we were expecting to do in 2013.

  • 10:55:29

    REHMSo how do you -- how is that going to affect personnel? How is that going to affect work going forward?

  • 10:55:37

    FAUCIWell, what it does is that certainly it's going to slow down the process of the scientific enterprise with the numbers of grants, the new initiatives. I mean, at the NIH, we have grants that come in from investigators that are very creative. You certainly are not gonna fund as many as you did if you didn't have the cut. And then there's the other issue of new initiatives, things that we were talking about on the show.

  • 10:56:00

    FAUCIYou might slow them down, do it at a slower pace, so the -- its dampening effect unfortunately at a time when the scientific opportunity is the greatest it's been in the long term.

  • 10:56:11

    REHMWill there be layoffs?

  • 10:56:13

    FAUCILikely at the NIH, not, in the sense of people who are government employees. But there will some -- be some agencies that would have to fare a little bit. But...

  • 10:56:23

    REHMBut there will...

  • 10:56:24

    SPELLBERGCan I -- let me add to that, and Dr. Fauci alluded to this earlier. It isn't just an issue of intramural science, scientists employed directly by NIH, but Dr. Fauci made a comment earlier. There has been a chilling effect over the last decade as the NIH budget has not kept pace with inflation, and this is gonna exacerbate it. People -- scientists, very successful scientists, are leaving the field.

  • 10:56:46

    SPELLBERGAnd young investigators are simply saying, well, I'm just not gonna do that. I'm gonna go see patients for a living because I can't make a living doing the research...

  • 10:56:54

    REHMAnd on my downer note, I'm afraid we'll have to end. Dr. Brad Spellberg, he's at the UCLA School of Medicine, Dr. Neil Fishman, he's associate chief medical officer with the U of Pennsylvania Health System, and Dr. Anthony Fauci, he's at the National Institutes of Health. Thank you all so much...

  • 10:57:24

    FAUCIThank you.

  • 10:57:24

    REHM...for being with us. Thanks for listening. I'm Diane Rehm.

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