World Health Organization Warns of a Post-Antibiotic Era

When I was ten, my life was saved by antibiotics when I had pneumonia and pleurisy simultaneously. So this story has personal resonance for me.

It’s worth noting that 80 percent of the antibiotics used in the United States are used as a routine part of raising animals for meat, dairy, and eggs, on factory farms and other non-organic agricultural operations. That’s where the problem most urgently needs to be addressed. The private sector isn’t doing anything about it, which means it will require regulatory action at the federal level. The sooner the better.

The ‘post-antibiotic’ era is near, according to a report released today by the World Health Organization (WHO). The decreasing effectiveness of antibiotics and other antimicrobial agents is a global problem, and a surveillance system should be established to monitor it, the group says.

There is nothing hopeful in the WHO’s report, which pulls together data from 129 member states to show extensive resistance to antimicrobial agents in every region of the world. Overuse of antibiotics in agriculture — to promote livestock growth — and in hospitals quickly leads to proliferation of drug-resistant bacteria, which then spread via human travel and poor sanitation practices.

“A post-antibiotic era — in which common infections and minor injuries can kill — far from being an apocalyptic fantasy, is instead a very real possibility for the twenty-first century,” writes Keiji Fukuda, WHO assistant director-general for health security, in a foreword to the report.

Perhaps the most worrying trend is the spread of resistance to carbapenems, the ‘antibiotics of last resort’, says Timothy Walsh, a medical microbiologist at Cardiff University, UK, who was an adviser for the report. “That’s taken us by surprise,” he says. “All of us are rather like rabbits in front of the headlights in how quickly this has taken off.”

 

Organic Chicken Has as Many Antibiotic-Resistant Bacteria as Conventional Chicken

Tom Philpott has a post at Mother Jones today about a Consumer Reports finding that, surprisingly, certified organic (and therefore antibiotic-free) chicken has as many “superbugs” (antibiotic-resistant bacteria) as chicken raised conventionally with antibiotics. The finding is clear but the reasons behind it aren’t at this point.

What got me was that chicken samples labeled “organic” or “no antibiotics” (list of all brands tested here) were just as likely to contain these potentially deadly, drug-defying pathogens. Notably, organic and antibiotic-free chicken both carry substantial premiums over conventional—at my local H-E-B supermarket in Austin, organic boneless chicken breast is fetching $7.97 per pound—vs. $4.99 for no-antibiotic and $1.97 for regular.

My surprise wasn’t based on some romantic notion that organic food is cleaner. Bacteria develop the ability to withstand to antibiotics by being exposed to them regularly. US Department of Agriculture code forbids antibiotics in organic meat production, and the “no antibiotics” label means just that, and is also regulated by the USDA.

Eighty percent of antibiotics used in the United States are given to animals raised for meat, dairy and eggs. Nearly all are given routinely, with the intent of preventing disease in these farmed animals, rather than as treatment for sick animals. The remaining 20 percent are used in human medicine.

Public health officials fear that if antibiotic resistance continues to accelerate at its current trajectory, we may find ourselves in a post-antibiotic age in the near future. If and when this happens, many infectious diseases that were fatal or caused permanently damage before the invention of antibiotics will be much more difficult to treat, as was the case prior to the 1940s.

The routine use of antibiotics in animal agriculture is an area ripe for reexamination.

Prescribing Antipsychotic Drugs to Kids

Consumer Reports looks at current practices and finds them alarming:

The number of children taking powerful antipsychotic drugs has nearly tripled over the last 10 to 15 years, according to recent research. The increase comes not because of an epidemic of schizophrenia or other forms of serious mental illness in children, but because doctors are increasingly prescribing the drugs to treat behavior problems, a use not approved by the Food and Drug Administration (FDA). And a disproportionate number of those prescriptions are written for poor and minority children, some as young as age 2.

Doctors are prescribing antipsychotics even though there’s minimal evidence that the drugs help kids for approved uses, much less the unapproved ones, such as behavioral problems. And to make matters worse, the little research there is suggests the drugs can cause troubling side effects, including weight gain, high cholesterol, and an increased risk of type-2 diabetes.

This pattern repeats itself throughout the medical system. A drug that may be helpful for certain severe cases is prescribed for vastly greater numbers of people. As we move down the severity scale, the risk-benefit ratio gets worse and worse. Milder cases (even assuming the diagnosis is correct) are those least likely to benefit from drug treatment and most likely to have a cost-benefit ratio that’s underwater.

$500 Per Stitch

This sums up the bizarre economics of the hospital business in the United States as well as anything I’ve seen. Oversimplification? Sure. But what a clarifying example!

With blood oozing from deep lacerations, the two patients arrived at California Pacific Medical Center’s tidy emergency room. Deepika Singh, 26, had gashed her knee at a backyard barbecue. Orla Roche, a rambunctious toddler on vacation with her family, had tumbled from a couch, splitting open her forehead on a table.

On a quiet Saturday in May, nurses in blue scrubs quickly ushered the two patients into treatment rooms. The wounds were cleaned, numbed and mended in under an hour. “It was great they had good DVDs, the staff couldn’t have been nicer,” said Emer Duffy, Orla’s mother.

Then the bills arrived. Ms. Singh’s three stitches cost $2,229.11. Orla’s forehead was sealed with a dab of skin glue for $1,696. “When I first saw the charge, I said, ‘What could possibly have cost that much?’ ” recalled Ms. Singh. “They billed for everything, every pill.”

There is little science to how hospitals determine the prices they print on hospital bills.

“Charge master prices are basically arbitrary, not connected to underlying costs or market prices,” said Professor Melnick, the economist. Hospitals “can set them at any level they want. There are no market constraints.”

Prices for any item or service are set by each hospital and move up and down yearly, and show extraordinary variability, health economists say. The codeine that costs $20 and the bag of IV fluid that costs $137 at California Pacific are charged at $1 and $16 at the University of California San Francisco Medical Center, across town. But U.C.S.F. Medical Center charges $1,600 for an amniocentesis, which costs $687 at California Pacific.

 

 

New Cholesterol Calculator Tells Healthy People They Need Statins

The cholesterol guidelines released last week are already poised to drastically increase the number of people prescribed statin drugs, and this calculator that the American College of Cardiology just unveiled will help people miscalculate their risk (substantially upwards, of course) even more.

This is beyond the beyond. Worth reading this whole article if you or a loved one are considering taking statins.

“[It] overpredicted risk by 75-150%, depending on the population. A man whose risk was 4 percent, for example, might show up as having an 8 percent risk. With a 4 percent risk, he would not warrant treatment…..  Miscalibration to this extent should be reconciled and addressed before these new prediction models are widely implemented. If real, such systematic overestimation of risk will lead to considerable overprescription.”

“Something is terribly wrong,” Dr. Nissen said. Using the calculator’s results, he said, “your average healthy Joe gets treated, virtually every African-American man over 65 gets treated.”…

Despite Practice Guidelines for Back Pain, Prescriptions for Narcotics Rise While Those for NSAIDs Fall

Medical practice guidelines are voluntary. Sometimes, this leads to clearly dysfunctional outcomes.

This interview with the author of a new article in JAMA Internal Medicine underscores the conclusions reached in the 2010 study by Bishop and colleagues at the National Spine Center in Canada, published in Spine Journal, which found management of low by pain by primary care medical physicians (PCPs) to be highly “guideline-discordant” with regard to medications. (Bishop’s article also found that for low back pain, guideline-based care that includes spinal manipulation by chiropractors is significantly more effective than usual care by PCPs).

The new JAMA Internal Medicine article’s lead author is John N. Mafi, MD, chief medical resident and fellow in general medicine at Beth Israel Deaconess Medical Center in Boston:

We saw a decline in use of NSAIDs that was discordant with the guidelines. The guidelines recommend it as a first-line treatment. What we are seeing instead is a rise in narcotic prescriptions. The guidelines are cautious about narcotics and say to be cautious and recommend them only as second- or third-line therapies.

There is also discordance between the guidelines and physician use of imaging. In patients with new-onset back pain, ordering an MRI or CT scan is not indicated in most cases. Finally, we saw a rise in referrals to specialists, though primary care clinicians are usually able to manage patients with routine cases of back pain themselves with minimal treatment.

news@JAMA: What do you think is driving physicians to pursue these more aggressive treatment approaches?

Dr Mafi: We are a society that demands instant solutions, but back pain doesn’t play by these rules. It takes time, and unfortunately, the fancier treatments haven’t been shown to decrease patient’s pain or increase their quality of life. That’s why we have to rely on the less-is-more approach.

news@JAMA: What do you think is driving the shift from NSAIDs to narcotics?

Dr Mafi: It is in part patient expectations and a sentiment that emerged in the 1990s physicians weren’t paying enough attention to patient pain. The Joint Commission made pain the fifth vital sign. In response, there has been an overcorrection and now narcotics are reached for first. Since that time, there has been a 300% increase in narcotic prescriptions and rise in narcotic overdoses and deaths. In 2008 almost 15000 people died—more than for cocaine and heroin overdoses combined. There are huge public health implications.

References:

1. Mafi JN, McCarthy EP, Davis RB, Landon BE. WOrsening trends in the management and treatment of back pain. JAMA Internal Medicine. 2013 (epub before print).

2. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal. 2010;10(12):1055-1064.

Arthritis Drugs May Trigger Shingles

Because arthritis affects so many people as they age, this finding is important for health practitioners to add to their diagnostic radar screens. This is particularly true for those who deal primarily with musculoskeletal conditions.

Patients with rheumatoid arthritis (RA) undergoing treatment with agents such as Enbrel (etanercept), Remicade (infliximab) or Humira (adalimumab) appear to have a significantly increased risk for developing shingles.

The incidence of shingles among patients on anti-tumor necrosis factor (TNF) treatment was 1.6 per 100 patient-years, compared with an incidence of 0.8 per 100 patient-years among those receiving traditional disease-modifying anti-rheumatic drugs (DMARDs), according to Kimme L. Hyrich, MD, of the University of Manchester in England, and colleagues.

 

NY Times Article: Flu Shot Benefits Substantially Overrated

I have never found the hype behind flu shots convincing. Here’s new evidence supporting that skepticism.

It’s flu-shot season, and public health officials are urging everyone over 6 months of age to get one. Many businesses provide on-site flu shots, and some hospitals have told staff members that they have to wear masks if they do not get the vaccine. By 2020, United States health leaders want 80 percent of the population to get yearly shots.

For vaccine manufacturers, it’s a bonanza: Influenza shots — given every year, unlike many other vaccines — are a multibillion-dollar global business.

But how good are they?

Last month,, in a step tantamount to heresy in the public health world, scientists at the Center for Infectious Disease Research and Policy at the University of Minnesota released a report saying that influenza vaccinations provide only modest protection for healthy young and middle-age adults, and little if any protection for those 65 and older, who are most likely to succumb to the illness or its complications. Moreover, the report’s authors concluded, federal vaccination recommendations, which have expanded in recent years, are based on inadequate evidence and poorly executed studies.

“We have overpromoted and overhyped this vaccine,” said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy, as well as its Center of Excellence for Influenza Research and Surveillance. “It does not protect as promoted. It’s all a sales job: it’s all public relations.”

It’s my impression that it’s people over 65 to whom these vaccines have been most strongly promoted. And those are the folks who derive “little if any protection.”

 

 

Preventing Unintended Pregnancies and Abortions Through No Cost Contraception

Research evidence confirms beneficial effects of Obamacare’s contraception mandate.

Here’s the abstract of the article from Obstetrics and Gynecology, along with news and commentary from Think Progress Health:

A new study focusing on low-income women in St. Louis, MO concludes that expanding access to free contraception — just as the health care reform law does through its provision to provide birth control without a co-pay — leads to significantly lower rates of unintended teen pregnancy and abortion. Researchers found that when women weren’t prohibited by cost, they chose more effective, long-lasting forms of birth controland experienced much fewer unintended pregnancies as a result.

Researchers from the Washington University School of Medicine in St. Louis worked in partnership with the local Planned Parenthood affiliate to track over 9,200 low-income women in the St. Louis area, some of whom lacked insurance coverage, during a four-year Contraceptive CHOICE study. The CHOICE project simulated Obamacare’s birth control provision by allowing teens and women to select from the full range of FDA-approved contraceptive options and receive their preferred method at no cost. They found that birth rates among the teens who received free birth control in the CHOICE project were less than a fifth of the national teen birth rate — just 6.3 births per 1,000 teens, compared to 34.3 per 1,000 teens nationwide in 2010 — and abortion rates were less than half of both the regional and national rates.

Reality Check on Claim That Obamacare “Raids” Medicare, Lowers Benefits and Adds to Deficit

From today’s Washington Post, a reminder that the Medicare Board of Trustees reports that Obamacare extends the solvency of Medicare and does so without any lowering of benefits to patients.

Repeal of Obamacare, as proposed by the Romney-Ryan ticket (and already passed by the House) would bring insolvency closer. It would also take insurance away from over 30 million people, eliminate the ban on pre-existing conditions, eliminate the new preventive care provisions for Medicare, re-open the prescription drug donut hole, etc.

 The $716 billion in savings helped free up funds to pay for other health programs, like the expansion of insurance to 32 million Americans.

That was the primary purpose, at least. There was also a really important side effect: The health care law extended the solvency of Medicare’s Trust Fund. If the program pays hospitals less, each dollar stretches a little bit further. Earlier this year, the independent Medicare Board of Trustees estimated that with these cuts the trust fund would remain solvent through 2024.

Without those cuts, however, the budget gets a little tighter. Medicare keeps paying providers at the same rates it does now, but each dollar buys less. And that means, according to these trustees, that the trust fund would no longer be able to cover Medicare’s costs as soon as 2016.