Bacterial Infections Defy Treatment
IRA FLATOW, host:
This is SCIENCE FRIDAY from NPR. I'm Ira Flatow.
For years, public health experts have been warning us that our over-use of antibiotics is going to lead to big problems. Well, that prophesy appears to be coming true. Infections that were once treatable, like staph, are now resistant to antibiotics, and we're running out of drugs to fight them with.
The resistant staph called MRSA was once mainly a hospital-acquired infection, but now it's turning up in prisons, in locker rooms, and it's infecting people who have never been near a hospital.
Meanwhile, hospitals are dealing with much more than just MRSA. Infections from gram-negative organisms, sometimes impossible to treat, are on the rise, and the newest problem for patients, it's a bug called C. diff. Infections from C. diff. have overtaken MRSA infections in some U.S. hospitals, says one new study.
The good news is that we know how to prevent these infections. So why aren't things improving? A report out this week shows most of these hospital-acquired infections are on the rise. Nearly 100,000 people a year die from these largely preventable infections. So where are new life-saving antibiotics? Why don't we have new antibiotics for them?
Joining me to talk more about the problem are my guests. If you'd like to get in on the conversation, our number is 1-800-989-8255. Also, you can tweet us @scifri, @-S-C-I-F-R-I, and you can join the discussion and leave some comments on our Web site at sciencefriday.com.
Stuart Levy is professor of molecular biology, microbiology and medicine at Tufts University. He's also the president of the Alliance for the Prudent Use of Antibiotics and the author of "The Antibiotics Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers." Welcome back to SCIENCE FRIDAY, Dr. Levy.
Dr. STUART LEVY (Tufts University): Thank you, Ira.
FLATOW: It's been a while.
Dr. LEVY: Glad to be back. It has.
FLATOW: Yeah. Maryn McKenna is the author of "Superbug: The Fatal Menace of MRSA." She's also a contributing writer at the Center for Infectious Disease Research and Policy at the University of Minnesota. She joins us from Minnesota Public Radio. Welcome back to SCIENCE FRIDAY, Ms. McKenna.
Ms. MARY McKENNA (Journalist): Thanks, Ira, happy to be here.
FLATOW: Brad Spellberg is assistant professor of medicine at the Los Angeles Biomedical Research Center. That's at Harbor-UCLA Medical Center. He's also the author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them." He joins us from Los Angeles. Welcome to the program.
Dr. BRAD SPELLBERG (Harbor-UCLA Medical Center): Thank you very much.
FLATOW: This is like Stuart, why is this d�j� vu all over again? We talked about this we've been through this for 10 years now, at least.
Dr. LEVY: I think this is the point. Where are we going wrong? We're not educating well. I think that the problem is not going away. It's getting harder and harder, if not almost looking impossible to find new antibiotics for these drugs.
Companies are leaving the field. It's not a good time, and yet it's an appropriate time to take a good look at this and see that we can forward, because we can. It's just a question that we have to have an organized group that will do it.
FLATOW: Tell us about, you know, we've talked about MRSA all these years, and now we hear about gram-negative bacteria. What...
Mr. LEVY: (Unintelligible) significance(ph), because gram is now lowercase, but actually, it stands for Hans Christian Gram, who at the end of the 19th century invented a stain that we still use, and these bacteria that are so-called gram-stain negative have an extra membrane. So it makes it harder for antibiotics or anything to get into them.
So they are hard to treat to start with, and then on top of that they have acquired all these many, many different resistances to antibiotics. So they are what we call multi-drug resistant, and they're hard to treat. That is not a good combination.
FLATOW: Brad Spellberg, do we have any antibiotics for these gram-negatives?
Dr. SPELLBERG: Well, we are very commonly, on a daily basis, encountering bacteria that are resistant to everything except a couple of very last-ditch drugs that don't work very well and are toxic but we have no choice but to use. And unfortunately, not quite as commonly, but already, we are encountering bacteria that are resistant to every FDA-approved antibiotic.
And I think to go back to a point that you made before, you're right. Antibiotic resistance has been around since before there were human antibiotics, because bacteria invented antibiotics about two billion years ago, and they've been using antibiotics to kill each other and coming up with resistance mechanisms to defeat those antibiotics for two billion years.
The thing that's really new, in the last few years, certainly in the last 10 years, is that before every time a new drug came out and resistance developed to it, the pharmaceutical industry would just bail us out by coming out with the next generation of drugs to deal with the previously resistant bacteria, and that is not happening anymore, as Dr. Levy just mentioned.
Dr. SPELLBERG: Well, there's two primary categories of reasons why. Number one is economic. A company is going to make a lot more money selling a drug that you have to take every day for the rest of your life - like a cholesterol, blood pressure, diabetes, arthritis - than a drug that you're going to take for seven days and then stop because you're actually cured of your target disease. So the return on investment of antibiotics is just not competitive with many other classes of drugs.
The second reason has to do with a very complex statistical problem at the level of the FDA, where they've been re-thinking the standards by which trials should be conducted to show that antibiotics work. And right now we don't know what the standards are, and companies don't know, academicians don't know. We don't know how to design clinical trials to meet regulatory standards to get drugs approved anymore.
FLATOW: Maryn McKenna, let's talk about MRSA. I mentioned it's been generally associated with hospital-acquired infections, but you in your book talk about all these other places you can get MRSA. It's shocking to read about.
Ms. McKENNA: Yeah, Ira, the MRSA story really shows how very tricky this whole problem of antibiotic resistance is, because as you say, MRSA's been known to be a hospital-associated infection since Methicillin resistance first showed itself in 1961.
But since the late '90s, there's been a parallel, sort of overlapping second epidemic out in what medicine calls the community, which pretty much means anywhere outside the walls of a hospital or a nursing home, and just in the past couple of years there's been a surfacing third epidemic where the bug has taken residence in farm animals that are given lots of antibiotics.
And these all of these epidemics are crossing over and showing up in the places where the other strains used to be so that just in the past couple of weeks up in Canada they found some surgical-site infections, infections in people who had surgery that was caused by the livestock strain. And the Johns Hopkins Hospital has found community-associated infections in their pediatric intensive care unit.
FLATOW: You talk about getting MRSA in a high school locker room. How do you do that?
Ms. McKENNA: Well, you know, so the S-A in the acronym M-R-S-A...
FLATOW: Tell us, what does MRSA stand for?
Ms. McKENNA: Sure, so it's Methicillin-resistant Staphylococcus aureus, and there's a lot of information packed into that acronym. The S-A, Staphylococcus aureus, or staph for short, is an incredibly common bacterium. Drug-sensitive staph, or staph that's sensitive to most drugs, is incredibly common on our bodies and in the environment. Probably a third of us walk around with staph all the time, and it tends to live on our skin, and it really likes the inside of our noses.
The M-R in M-R-S-A stands for Methicillin resistance, which actually Methicillin itself is a drug, is very uncommon now. It goes back to the 1960s, but what that actually designates is that staph has become resistant to a huge family of antibiotics that share a chemical structure at their center with Methicillin.
So why is it that people can pick up MRSA so easily? It's because resistant staph, just like drug-sensitive staph, has that ability to live on our skin and in our nostrils and persist with us for a long time before it somewhat unpredictably causes an infection.
FLATOW: So you could be carrying it around with you, on your clothes, on your carpet...
Ms. McKENNA: Not on your clothes but on your skin or in the inside of your nose. And the CDC estimated a couple of years ago that probably one and a half percent of the U.S. population walks around with MRSA all the time.
FLATOW: So if you're an athlete and you're in a locker room and you get a cut from playing football, let's say, suddenly you're now vulnerable. There's a spot for the MRSA that might be just sitting there harmlessly to get into your body.
Ms. McKENNA: Right, and one of the places where this seems to be sort of a risk factor is places where people are crowded together or where they have skin-to-skin contact or where they have sort of indifferent hygiene.
And there's a lot of overlapping situations where those might be true. It might be a prison. It might be a military barracks. And the conditions under which pro and also student sports teams play also make them vulnerable.
Dr. SPELLBERG: Yeah, I think we need to add to this conversation that these are all - things you're talking about are risk factors for a higher risk, but we clearly see very commonly MRSA infections, deep, invasive infections, in people that have none of these risk factors.
You don't need to have any crowding or contact or anything like you can just be living your life out in the community, and whammo, bammo, you come in with a serious MRSA infection.
Ms. McKENNA: Yeah, Dr. Spellberg's right.
Dr. SPELLBERG: So this is a ubiquitous environmental organism.
FLATOW: And then you bring it into the hospital with you when you're getting treatment.
Dr. SPELLBERG: That's correct.
FLATOW: And then you spread it how in the hospital?
Dr. SPELLBERG: You know, all of these organisms can be spread by contact directly with a source patient who's carrying them but can also be spread by what are called fomites, which are simply inanimate objects someone touches, leaves a trace of the bacteria on it. Somebody comes and touches that fomite and there's a transmission. And that's how they get spread from you know, it's person to person, inanimate object to person and vice versa.
FLATOW: 1-800-989-8255 is our number. And then it could be spread in the hospital in various ways, and the same thing with the gram-negative bacteria.
Dr. LEVY: That's what I think, that important here is the fact that obviously we can't see them. So what happens is that under our very eyes these transfers of bacteria strains or even resistance is occurring, and the community agent that's come out, which is different, has now entered the hospitals, mixing with the one that was in the hospitals, and picked up some of the resistances that it had, so that now the community agent is multi-drug resistant, well-needed for the M, for the multi-drug, as well as Methicillin, and in some hospitals is replacing the hospital one as the critical environmental plague.
FLATOW: What about the bacterial phages, these viruses that are natural enemies to bacteria? Why are we not using those? I know there was one case in Poland, it was reported, where a nurse was cured of MRSA using phages.
Dr. LEVY: It's certainly a possibility, Ira. Clearly it's used now as more topical rather than systemic, although as many know in Russia they were using it as injectable form. But it's made of protein. It can cause allergic reactions, and bacteria can mutate against a single phage. So you have to have lots of phages. But there may be a place and a time now...
FLATOW: If you have nothing left, right?
Dr. LEVY: Yeah, exactly. What Brad was saying, and myself, that if the large pharmaceutical companies have left the discovery field and are not putting energies into it, we're looking for whatever else we can have to cure the patient. That's our goal.
FLATOW: All right. We have to take a break. We'll come back and talk lots more about these antibiotics and the bacteria that are resistant to them. Stuart Levy, Maryn McKenna and Brad Spellberg are here. Also be joined by another guest. So stay with us, 1-800-989-8255. Tweet us, @scifri, @-S-C-I-F-R-I, and go to our website and get a discussion going there. Stay with us. We'll be right back after this break.
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FLATOW: You're listening to SCIENCE FRIDAY from NPR. I'm Ira Flatow. We're talking this hour about superbugs that are they're not stuff in your lawn. These are infections that are hard to treat in a hospital or wherever you can find them. They're showing up in many different places.
I'm talking with Stuart Levy. Maryn McKenna, author of "Superbug: The Fatal Menace of MRSA." Dr. Levy is author of "The Antibiotic Paradox." And also with us is Brad Spellberg. He is author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them." 1-800-989-8255 is our number.
What if you or someone you knew was going to the hospital, you're listening to this program now, as my producers are, and we're all washing our hands with antibiotics. It's a scary thing. Maybe you're going to have a baby. Maybe you're there for surgery. Is there anything you can do to prepare? Can you find out beforehand if your hospital has a good track record of keeping infections low?
Well, joining me now to talk more about what you can do is my guest, Elizabeth, or Betsy, McCaughey. She's former lieutenant governor of New York and chairman and founder of the Committee to Reduce Infection Deaths. She joins us here in our New York studio. Welcome to SCIENCE FRIDAY.
Ms. ELIZABETH McCAUGHEY (Committee to Reduce Infection Deaths): Well, thank you, and I'm so glad to be able to tell all our listeners that there is a place to come for the information that you need on what you can do to protect yourself, to reduce your risk of a hospital infection, or to protect someone you love who's going into the hospital. So come to hospitalinfection.org.
We have 15 steps that patients can take to reduce their risk of getting a hospital infection, and by the way...
FLATOW: Is that a free thing? You can just...
Ms. McCAUGHEY: Oh yes, absolutely free. We're happy to send it to you if you want a hard copy to bring to the hospital with you, and it's also up on the website. And just as an aside, since Maryn was talking about community-acquired staph earlier, we also have a brochure for parents and teachers on how to reduce the risk for students of picking up this nasty bug, community-acquired MRSA, at school.
FLATOW: So what do you tell people? What are the top three hints? You haven't been asked this before, I'm sure.
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Ms. McCAUGHEY: Number one actually, I should say number one, two and three: Ask anyone who's going to touch you in the hospital to clean their hands first. And if you're worried about being...
FLATOW: You have to ask them that?
Ms. McCAUGHEY: Oh, yes, you do have to ask. The research shows that doctors, for example, fail to clean their hands before treating a patient 52 percent of the time, and so it's very important.
If you're worried about being too aggressive, just remember your life is at stake. and don't be misled if someone comes in wearing gloves, because if they pulled those gloves on without cleaning their hands first, the gloves are contaminated. And it's really important to see caregivers clean their hands because so often, for example, I'll stand in an emergency room and I'll see the most well-intentioned physician or nurse clean their hands and glove and then they reach up and they rip open the privacy curtain to see the next patient.
Well, that curtain is seldom cleaned. So automatically already their hands are re-contaminated.
FLATOW: Brad, do you agree with that?
Dr. SPELLBERG: Well, I do agree that patients should definitely feel confident and empowered to, if someone approaches them in the hospital without washing their hands, to ask them: Would you mind please washing your hands?
And no one is perfect, and even the best of us forget sometimes. So yes, I totally agree.
FLATOW: Let me go to the phones because there are some questions that our listeners can probably that you probably can answer, Betsy. Mandy in Sacramento, hi.
MANDY (Caller): Hi, how are you?
FLATOW: Yes, go ahead.
MANDY: Yes, I'm actually an intensive care nurse, and one big piece of the puzzle that I see missing a lot of times, because we are required to do extensive education about hand washing and isolation precautions with our patients and their families, but it seems to me like I educate people every day, multiple times a day, about isolation, and then nobody listens to me.
So I think it's important for family members to take their own responsibility. If you have MRSA, if you have a superbug, and you're people are coming to visit you in the hospital, or you're going to visit someone, follow those instructions and don't just say: Oh, yeah, whatever; well, I don't need to wear the gown because it doesn't affect me.
Ms. McCAUGHEY: I want to hug this lady. I'm so glad you called because it is really important to respect those rules, and let me just weigh in and add that I wish that more hospitals in the United States right now it's only about 17 percent screen incoming patients for the MRSA bacterium, because what the research shows very convincingly is that you cannot control the spread of this bug if you don't know the source, and the hospitals that are screening incoming patients - it's a simple, non-invasive nasal swab - can then take the proper precautions to prevent the bug from spreading.
It also is very effective at reducing the risk for the patient who is MRSA-positive, because we can take precautions like putting mupirocin it's an antibiotic cream in their nose and also having them bathe with Chlorhexadine for three or four days before surgery, and there are just so many studies now, including a very compelling meta-analysis in Lancet that shows that the patients who are identified as being MRSA-positive ahead of time and given those extra precautions have a substantially lower risk of contracting a post-surgical wound infection.
FLATOW: Brad Spellberg, you agree?
Dr. SPELLBERG: Well, I think actually the data on the utility of screening are extremely mixed and that many of the studies are of very poor quality. There is one good study showing an effect and one good study showing not an effect, and this is an issue that is widely debated.
There is no doubt there is a very compelling, very recent study showing that use of Chlorhexadine before surgery reduces post-operative infections. It is not at all clear that the screening was at all relevant. If they had given the Chlorhexadine to everyone, irrespective of screening, it may well have had the same effect. We don't know because they didn't use that as a control.
So one of the things that's really important is that we not mandate by law activities that we don't have very clear, crisp, convincing data to support. That's not to say people shouldn't do it in the absence of that data, but when we set policy standards in the absence of consensus based on data, it can create problems, drive up costs that then steal resources from other things that need to be done at hospitals. That would be my only...
Ms. McCAUGHEY: Let me just emphasize that Ira asked me about the 15 steps before, and step number five is, if you're going into the hospital and you're having surgery, begin bathing with Chlorhexadine four or five days before your operation.
FLATOW: But he doesn't agree with that.
Ms. McCAUGHEY: Yes, he does. He just said Chlorhexadine is effective.
FLATOW: Do you agree with that?
Dr. SPELLBERG: Well, I think if you're saying pre-operatively, the answer is yes. We have very good data now that pre-operatively that that is effective. Now, when you say to do it outside the hospital, you are now extrapolating from the study a little bit. I'm not going to quibble on that point. I think if you say anyone who's going in the hospital for any reason should do it, then you're going beyond the available data.
Ms. McCAUGHEY: No, this is for pre-surgical patients.
FLATOW: Pre-surgical patients. Maryn, where do you come down on this? Do they do this in Europe now routinely, pre-screening?
Mr. SPELLBERG: They have to do it...
Ms. McKENNA: They do it in certain countries, and it has definitely shown an effect in those countries. In fact, this third epidemic of MRSA, the livestock-associated one that's now causing human infections, was actually discovered in Holland because a six-month-old who was going in for repair of a heart defect was checked.
And there are some health care systems in the United States that are using it with a lot of success. The largest one is the VA. But it's, as Dr. Spellberg said, it's very disputed. The problem with the dispute is that it's keeping a lot of health care institutions from moving forward on doing something, and the most important thing may be to do something aggressively rather than to do this one thing.
Dr. LEVY: I was just going to say it also has to be proven to be cost-effective, because hospitals are lean in terms of personnel, and you've got to be sure that what you're doing is really worth doing if you can't do something else.
And I also think it's a segue also into the topic we began with, which is the gram-negative bacteria, which are also a threat and also get transferred from person to person and in hospitals. And I think that this is you know, it's an important concept that one should wash their hands anyway.
FLATOW: Well, do you all agree, and Betsy, do you agree, that it should be mandatory that people should be screened for MRSA and these other gram-negative...
Ms. McCAUGHEY: No, I don't believe in legislating it, and I'll tell you why. Because the science on any medical issue evolves so quickly that once something like this is put into black and white in law, it doesn't change as rapidly as scientific knowledge.
But I do find it Lancet, for example, the 2006 meta-analysis, found that it was not only effective but cost-effective. Now, scientists disagree on that. So I'm not calling for legislation. I'm calling for best practices in the hospital.
FLATOW: You seem to be, you know, so and you're handing out your steps to do this, they should be screened. Why not just make it mandatory that people should be screened if you're really thinking of everybody's health?
Ms. McCAUGHEY: Because legislatures don't respond to new scientific information as quickly as they should, and once something is put in writing, then we come up with a new way of preventing infections or protecting patients, and perhaps the old method will be stuck in stone because it's been legislated.
One thing we haven't talked about at all yet is cleaning, and yet there is so much compelling evidence now that effective cleaning in hospitals can prevent the transmission of bacteria from patient to patient.
I'm thinking of another nasty bug, vancomycin-resistant staphylococcus.
FLATOW: Cleaning like the - like what kinds of things?
Ms. McCAUGHEY: Wound cleaning, for example. A study at Tufts that came out two years ago showed that the number one predictor of which patients pick up vancomycin-resistant enterococcus, another nasty drug-resistant bug, was who occupied that patient's room in the preceding two weeks. Because the terminal cleaning that supposed to go on when one patient is released from the hospital and another is admitted to that room is inadequate.
In fact, Philip Carlin, another researcher at the Boston University, took a look at rooms in 20 hospitals up and down the Eastern Seaboard and found that over half the surfaces in the patient's room that are supposed to be clean, were left untouched by the cleaners. They (unintelligible)...
FLATOW: They did that between patients?
Ms. McCAUGHEY: Oh, yes.
Prof. LEVY: But you have to admit that that cleaning has to be - we have to learn a lot more about how to clean, because one can pick it up off the telephones, off the tables. And the question is how do you clean it? How rapidly can you clean it? I think there's a lot of room there, although the concept is - certainly important.
Ms. McCAUGHEY: Well, you know what amazes me is that hospitals should be very clean. But, in fact, in almost every municipality now, restaurants are inspected for cleanliness, but not hospitals.
Dr. SPELLBERG: Well, but you don't go swab restaurant surfaces to culture and determine density of bacteria.
Ms. McCAUGHEY: Well, they do, in fact, cutting boards and other food preparation surfaces in food processing plants and restaurants. And believe it or not, there was time when they did it in hospitals.
Dr. SPELLBERG: Well, I think - well, I think one of the really important concepts here is everybody agrees that we should be preventing these infections, the hospital-acquired infections.
What we really need is funding for research to determine how to do that. I don't think it is fair to say we know today how to stop all these infections. I think we know some of the answers to reduce them, but we need much more research to - how should we terminally clean. What's the best mechanism to do that?
Prof. LEVY: Exactly my...
Ms. McCAUGHEY: Well, we - more and more...
FLATOW: Hang on a second. Let me (unintelligible) - Stuart, did you want to jump in there?
Prof. LEVY: No, no. I just said it was precisely my point is the concept is there. How it's done - there aren't enough studies and the funds are not - been required. If this is so important - and we dont disagree on that point - then there should be a support of studies in how to clean, where to clean, what agents to clean. And we have to be careful in terms of the toxicity of any agents we want to use.
So bacteria, you know, are not all of the same type. Some may be spores that sit around and are resistant to a lot of the cleaning agents, and others are more easily treated. So it's not straightforward, but I do think - as we've all sort of agreed, here - that it requires funded studies to determine what is the best way to do it.
FLATOW: We're talking about superbugs this hour on SCIENCE FRIDAY from NPR News. I'm Ira Flatow, talking with Betsy McCaughey, Stuart Levy, Maryn McKenna and Brad Spellberg.
Betsy, cleaning, do we know - I mean, critics have said that you're in the business of selling cleaning products and products that would help the hospitals.
Ms. McCAUGHEY: Not at all. I don't know why anybody would say that. I've never advertised a cleaner or been involved in that. But I do think that there is - I can tell you that there are many compelling studies already out there that demonstrate the efficacy of cleaning.
And since we were talking about C. diff before, let me underscore that with C. diff cleaning is the first line of defense. One of the studies, I think, that's so important, was done at Case Western Reserve and the Cleveland, VA, which found that after terminal cleaning - what's supposed to be done when a patient is discharged and before the next one comes in - 78 percent of the surfaces in the room were still contaminated with these C. diff spores.
But then, when the researchers went back and worked with the cleaning staff to show them the frequently overlooked objects and also the importance of bleach, any kind of bleach, in destroying C. diff spores, they were able to bring that level of contamination down to single digits.
And that's really important with C. diff because we found that most people who contract C. diff do it to themselves. As a patient, they reach out and they touch surfaces around their bedside, whether it's over the bed table, the bedrails or the doorknob. And then without thinking, they touch their lips, or their meal tray comes and they pick up their sandwich and eat it without cleaning their hands, and then they've swallowed those spores.
FLATOW: Okay. Let's go to the phone. Sheila(ph) in St. Louis. Hi, Sheila.
SHEILA (Caller): Hey, thanks. I'm really happy to have this opportunity because I had a major surgery a couple of weeks ago in a very reputable, accredited hospital. But I observed at least three new sources of contaminations, thanks to modern technology. And the first is cell phones. The nurses and aides all carry hospital cell phones. And every single time, without exception, someone came in the room to do - give me a pill, give me a shot, take some blood, they were interrupted. After washing their hands, they were interrupted by a phone call and they took the call. The phones are not sterile. None of these calls was urgent enough to make them have to excuse themselves before they've completed whatever they were there to do for me. That's number one.
FLATOW: Quickly, Sheila. Were running out of time so.
SHEILA: Okay. Number two. There's a computer in the room. Everyone charts by using the computer. The keyboard, which is covered by a plastic thing, was never wiped down, and dozens of people use that computer.
FLATOW: Number three?
SHEILA: Number three. Only one person actually washed their hands. Everyone else used a sanitizing gel and I'm not sure that's as effective.
FLATOW: All right. Let me start...
Ms. McCAUGHEY: Well, it certainly doesnt kill C. diff.
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Prof. LEVY: The sanitizing gel is fine except for C. diff.
Dr. SPELLBERG: Except C. diff, that's correct.
Prof. LEVY: Except C. diff.
FLATOW: Last words, Betsy?
Ms. McCAUGHEY: All right. So cleanliness is the aspect of this problem that really hasn't been emphasized enough. And I'd like to see much more attention to making sure that the surfaces in patients' rooms are clean because you see doctors and nurses come in, and the first thing they do is put their hands on the bedrail while they're talking to the patient. Then, of course, they touch the patient, and whatever bacteria has been on the bedrail...
Ms. McCAUGHEY: ...or on the privacy curtain, then can be transferred...
FLATOW: Would you be in favor of more research about the best way to clean things?
Ms. McCAUGHEY: Oh, of course, more research is always good. But the fact is we already have a tremendous amount of information. What has been lacking is not the knowledge - it's the will to do it.
FLATOW: All right. We're going to take a break. Thank you, Betsy, for joining us. Elizabeth "Betsy" McCaughey is a former lieutenant governor of New York. She is chair and founder of the Committee to Reduce Infection Deaths, and she was joining us here in our studios in New York. Thank you for taking time to be with us today.
We're going to take a break, come back and talk lots more about the science of infection, what - and these superbugs, how we might prevent them, what - we'll talk more about antibiotics.
We'll also take your phone calls. Our number: 1-800-989-8255. You can tweet us: @scifri, @S-C-I-F-R-I. And also, join us on sciencefriday.com where you can leave some comments and questions. We'll be right back after this break.
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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY from NPR.
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FLATOW: You're listening to SCIENCE FRIDAY from NPR. I'm Ira Flatow.
We're talking, this hour, about superbugs and the infections they cause. My guests are Stuart Levy, author of "The Antibiotic Paradox: How the Misuse of Antibiotics Destroys their Curative Powers," Maryn McKenna is author of "Superbug: The Fatal Menace of MRSA," and Brad Spellberg is assistant professor of medicine and he is also author of "Rising Plague: The Global Threat from Deadly Bacteria and our Dwindling Arsenal to Fight Them." Our number: 1-800-989-8255.
Brad, I want to go back to the point we were talking about before, about why there are so few drug companies - I mean, if the drug companies aren't going to be doing them - and I do see that Pfizer has an effort to create some antibiotics. If - so few drugs companies, don't we need another tact here? Do we need a nonprofit way of making these antibiotics?
Dr. SPELLBERG: Well, I think the first thing that we need to do is - about creating antibiotics is to have some economic incentives so that the return-on-investment calculation for for-profit companies changes.
FLATOW: Don't we - but don't we have something like that called orphan drugs?
Dr. SPELLBERG: Orphan drug does not apply to antibacterials. We have tried to work that for years. It has been definitively adjudicated that it is not applicable to antibacterials for a variety of reasons - we wish it would be. In the absence of that, we need other mechanisms to change the return on investment calculation.
Having said that - your question is about nonprofits - I have become, recently, more interested in this idea. Stuart and I have actually discussed this concept. The real problem with doing it - it's a great idea - is how would you pay for the cost to develop, successfully - a new drug is over $1 billion now. That includes the costs of all the failures that go in along the way. And so...
Dr. SPELLBERG: How are you going to capitalize this nonprofit organization so that it has enough operating capital to conduct the pre-clinical discovery, pre-clinical development, clinical development and then get the drug manufactured and marketed?
FLATOW: That's one-tenth the cost of a - one bank bailout, you know?
(Soundbite of laughter)
Dr. SPELLBERG: Well...
Prof. LEVY: It might seem that way.
FLATOW: If you look at it that way, it doesn't cost that much anymore, does it?
Dr. SPELLBERG: Well, that's an interesting perspective, and there are ideas out there about how it could be funded. Just realize, that of the 150 or so antibiotics - antibacterial drugs that have been developed over the last 70 years - not one has ever been developed by a nonprofit. All of them have been developed by private companies. So you would be inventing a totally new system for developing drugs.
FLATOW: Well, on the other hand, a lot of the basic research that goes into drugs comes from tax money. The NIH, people like that, doing the basic research.
Dr. SPELLBERG: Yeah. Let - let's hit this one head on. That's true of all drugs.
Dr. SPELLBERG: And NIH doesn't develop drugs. That's not in their mission. They don't know how to do it. They don't have the money to do it. They fund the basic science that creates the foundation of knowledge atop which technology can be developed. You have to distinguish technology from basic science. Stuart is someone who knows a lot about that transition since he's done both, so I don't know...
FLATOW: Segue to Stuart.
Prof. LEVY: Yeah, the point is that my frustration at trying to bring technology that I had developed here at Tufts University, was answered by starting my own company. So I co-founded Paratek Pharmaceuticals to get a new drug out, which we have. We've perfected in the tetracycline series, a new drug which is not subject to resistance by any.
We've been through the first two major phases - we're in the third phase. And I've learned the hard way and the important way how difficult it is to take a idea, take it through discovery and to pre-clinical studies and then into human patients' test because it certainly has to be safe and be effective.
And what's nice about antibiotics are, if they're effective in your mouse model, they're greater than 90 percent going to be effective in people. The really critical thing is the toxicity and they should be safe.
But as Brad was intimating, I've been on both sides and I'm still on both sides, because I got to put in both - academic and in - as chief scientific officer now in Paratek Pharmaceuticals.
FLATOW: Mm-hmm. Let's go to Linda(ph) in Myrtle Beach, South Carolina. Hi, Linda.
LINDA (Caller): Hi. How are you?
FLATOW: Hi, there. Go ahead.
LINDA: I was wondering - I think it's relevant to say that in other countries, they've tackled this problem as well. And I know I was reading about the Norwegian model where they have essentially eradicated most deaths by resistant drugs. And they've done it, from what I understood, by investigating each case and extensively, including going to the home or going to the situation where it first occurred and trying to get to it that way. And, uh, certainly that's...
Prof. LEVY: Do you know which organisms? Do you know which kind of infection because it sounds - I mean, I've heard of bits of that, but not that it was done in a total - for any infection.
Dr. SPELLBERG: Yeah. You're talking largely MRSA.
Prof. LEVY: I think it's mostly skin infection.
LINDA: Yeah. MRSA. Yeah.
FLATOW: Maryn, can you chime in on this?
Ms. McKENNA: So that thing that I think is most important here, and it's so great that the caller mentioned this, is to think where that - where this program happens. She's talking about her program as antibiotic stewardship, of reserving antibiotics that they created at the national level.
All the places where these schemes have worked, whether it's antibiotics stewardship or the sort of surveillance and testing of patients that we were talking about earlier, are in health care systems, they're really different from our health care system.
In a single-payer health care system, it's a lot easier to say to all your hospitals you will not use this drug or to say to your doctors or hospital you will practice this particular behavior. It makes it much more complex, as that AHRQ report you've mentioned that came out just two days ago says to get the system started that actually create prevention in a system as complex as ours.
FLATOW: You are in Washington, Maryn, yesterday at a congressional briefing and you spoke about antibiotic use in farm animals. And please tell us little bit about that.
Ms. McKENNA: Sure. So, you know, I was talking a little while ago about this third epidemic of MRSA which was first identified in pigs and now has been identified in a number of livestock and in retail meat in Europe and in North America and is now being traced to a number of really difficult human infections.
Small numbers, at small complete numbers at the moment, but it may be that we're at the beginning of the epidemic curve. What that really points to is something that Dr. Levy's been talking about for years now. Is that we vastly overuse antibiotics in both human medicine and even more in agricultural. And we're putting those out there in a way that stimulates resistance. And we also don't do a very good job for surveilling for the emergence of resistant bugs, particularly in animals.
Prof. LEVY: I absolutely second and third that. I mean, that point is, for, I guess, more than 30 years I've been campaigning to remove low-dose antibiotics, non-therapeutic antibiotics from their use in animals. We've surpassed any of the efforts or - that they had given in the old days of farming. This goes back to the '50s, and we're still doing this practice here. And it's - more antibiotics being used this way, creating lots of resistance. So here again, though, it's an example of how we can make corrections without having to change the antibiotic - just how to use it. Get rid of it for this practice, and allow bacteria to come back to their normal sensitive selves.
FLATOW: Well, are we then - if I - I heard you saying in this discussion, that the large - the pharmaceutical companies are not jumping on this bandwagon. We don't have an alternative source of antibiotics. We're not looking into any other virus solutions. We're not I'm hearing, you know, we're just going to devolve into the 18th century. People are going to die of simple bacterial infections.
Prof. LEVY: I think that's one of the reasons...
Ms. McKENNA: There are people who already are.
Prof. LEVY: That's one of the reasons we're happier talking about it here, Ira. I mean, let's get the audience involved. There should be. I mean, these large pharmaceutical companies have merged. They've left the field. The difference now, in terms of antibiotic discovery, is going to come from the smaller biotech companies that are filling in this void left by the large companies. But they have to be encouraged. And I think this is critical. And I don't think that all of us take a dire look at, this but certainly it's in a crisis.
FLATOW: Do you agree, Maryn?
Ms. McKENNA: You know, Don Berwick, the founder of the Institute for Healthcare Improvement, has a saying: The system is perfectly designed to produce the results that it does. And in many, many ways, we have designed our society and designed health care without really intending to, so that antibiotic resistance is the natural result. It's the same for agriculture, as well. There are so many things that combined to produce this problem that we need to change.
Prof. LEVY: But Maryn, you had also said that it isn't so pessimistic. I mean, that we see ways through, don't we? I mean...
Ms. McKENNA: Oh, I do think there's hope.
Prof. LEVY: I always say the optimism, Ira, is that we are...
FLATOW: All right, but you...
Prof. LEVY: ...we think of them so badly that at least we know where we can make big differences...
Prof. LEVY: ...if everything was perfect.
FLATOW: Well, let me play devil's advocate, because to me, it sounds like you're just rearranging the chairs on the Titanic. I mean, if you look at the cold facts that you all presented today...
Dr. SPELLBERG: Yes
FLATOW: ...that there are these drugs that getting - there are these bacteria, they're getting stronger, they are we're getting fewer drugs. We dont pay attention enough to cleanliness of all these drugs out there. I don't see where the good news is in you know?
Dr. SPELLBERG: Well, okay. So let's quote Joshua Lederberg, Nobel laureate, who in 2000 wrote that the future of humanity and microbes would likely evolve as episodes of our wits versus their genes.
This is what bacteria do. They're just being bacteria. They become resistant to stuff, they adapt. We have to accept that's never going to stop. No matter how perfect our stewardship is, no matter how prefect our infection control is, they're always going to adapt. So, yes, we are never going to win in the end. But as Stuart's saying, there are - we know steps that we can to get back ahead in the race.
Prof. LEVY: It's a - and I would say those who were using these antibacterial products in the homes and those that are saying I'm going to sterilize my home - that's impossible. And in fact, I don't even like the image anymore, Ira, of a war between bacteria and people. I mean, what it has to be is a coexistence.
Dr. SPELLBERG: Yeah.
Prof. LEVY: And I think that we do need new drugs. It's critically important. That's one of the reasons I co-founded this smaller company is that we need new drugs. And if the large pharmas are leaving here, are we going to just throw up hands and what are we going to do? We have to offer incentives, but there are lots of small biotech companies that are filling the void.
We have to encourage them in ways that make them able to reach their goal of getting it out to the public. The public needs new drugs. And the public needs new understanding of how to use the older ones. And I've said many, many times, organizations out there, the critical thing is education of the public - how to use the drugs, not to demand them, not to stockpile them. There are so many ways that we can make a difference to resurrect what I was saying before, the sensitive bacteria. If you get infected with a sensitive bacteria, I can use whatever antibiotic I want. It'll be terrific.
FLATOW: So you say bring back the other bacteria that could fight the bad bacteria.
Prof. LEVY: Exactly. That's why - because...
FLATOW: You know, the fair fight between bacteria.
Prof. LEVY: That's...
(Soundbite of laughter)
Prof. LEVY: That's true, on their own playing field.
FLATOW: And that'll work.
Prof. LEVY: It should work. It works experimentally. We did - we've done work on farms and you can bring in sensitive bacteria with resistant ones, and the sensitive ones will take over. This is E. coli in some farm chickens that we rose a number of years ago. It was a dramatic demonstration that it's a population situation. Remove the advantage to the resistant strains of having the antibiotics there, just remove it.
Prof. LEVY: Now, everybody has - there's no antibiotic to make them any better. And the susceptible strains can take back over, 'cause there's always a consequence of being resistant, even if it's very, very tiny. In those situations, the susceptible strains will come back.
FLATOW: Talking about superbugs this hour on SCIENCE FRIDAY from NPR, I'm Ira Flatow. And, Stuart, one of these things we could talk about in this vein is something called triclosan. Tell us about it. The FDA is looking - this is an ingredient in antibiotic soaps, is it not?
Prof. LEVY: It's in everything you can think of.
FLATOW: There's a campaign to get it out of the soaps, now.
Prof. LEVY: It could be at, you know, your bed clothes. It could be in your sheets. It could be anywhere, Ira. And I'm happy to say the FDA is looking at it - I have testified in front of them as well. But I know that Congressman Markey has a whole group looking into this issue, because the drug does not self-destruct, and it goes out into the environment, and it is an endocrine-breaking drug. It infects endocrine systems of animals and - well, we don't think people, but depending on the dosing, we worry.
FLATOW: Mm-hmm. And endocrine disruptors are ubiquitous now.
Prof. LEVY: Yeah. And it's - there are large amounts found in municipal waters downstream, because this drug was used effectively in hospitals at a high dose that was useful in the brushing - the hand washing of surgeons, and it was fine. Once it was then diluted down, and it is diluted, to be used as a substitute for good soap and water or even the alcohol-based disinfectants, it began to be naked(ph) throughout household. People picked it off the shelves. It's difficult to even find those without it. And I think there's a time where recognition of the consequences, the negative consequences, has got to be understood.
FLATOW: Mm-hmm. You all agree with that?
(Soundbite of laughter)
Prof. LEVY: I Don't know if they disagree with me. But I - there's very little disagreement on that point. I think that where you need these disinfectants is certainly where they should be used at the right percentage, and not used in any different way in these household products where theyre not needed. So it's kind of the same kind of idea of throwing antibiotics to - in animal feeds to animals to help them grow when, in fact, that whole process no longer works.
FLATOW: All right. Are you saying, (unintelligible) you're still believing that just good soap and water is the best?
Prof. LEVY: Good - a good soap and water, there is no substitute for it in terms of general cleanliness and of environmental impact. If you can't find soap and water - and this is what - at our hospital, we have all over and it works great, and it answers what Betsy is saying as well, it's a form, it's alcohol based. I always make a difference between those so-called antiseptics or cleaning - which have a chemical in it that leaves a residue, because we have shown that these residues can select for resistant bacteria - antibiotic-resistant bacteria. I put them against things like alcohol, bleaches, peroxides which dissipate into the environment almost immediately, but they do their job.
FLATOW: But C. diff, is it not resistant to alcohol-based?
Prof. LEVY: Bleach. It's resistant to alcohols and peroxides, but bleach is the answer. And I think that, really and truly, we can use some other forms of bleach activities so that it can be used more effectively with less damage to furniture and other areas.
FLATOW: Well, will ultraviolet light do anything to kill these bad bugs.
Prof. LEVY: Not much at the spores. I mean, it'd be pretty heavy. I mean, that's - the spores are like case - encased in a thick wall that you can't get through, and then the germinate like a tool of germinates. But when they germinate, they germinate into bacteria that then start producing toxins and you have these terrible diarrhea which takes lives, as what has been called C. diff
FLATOW: All right. We're...
Dr. SPELLBERG: But this gets to the point of we don't know the best way. We need to know the best way. There is a company out there called Zimmick that has a technology where they can aerosolize an antiseptic to cover an entire room and then suck it back into the machine in an hour.
Prof. LEVY: There you go.
Dr. SPELLBERG: Every surface in the room...
Dr. SPELLBERG: ...so that's the kind of stuff we need to start exploring, is new technologies.
FLATOW: All right, there's the hope we've been looking for in this hour. Thank you for joining us today. Brad Spellberg is assistant professor of medicine at the L.A. Biomedical Research Center at Harbor-UCLA Medical Center, also author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them. Also with us is Maryn McKenna, she's author of "Superbug: The Fatal Menace of MRSA." She's contributing writer at the Center for Infectious Disease Research and Policy at the University of Minnesota. Stuart Levy, professor of molecular biology, microbiology and medicine at Tufts University, he's author of "The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers. Thank you all for taking time to be with us and for a great conversation. Have a good weekend.
Prof. LEVY: Thank you, Ira.
Dr. SPELLBERG: Thank you.
FLATOW: You're welcome.
Ms. McKENNA: Thanks, Ira.
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