Delivering evidence-based medicine is a deceptively elegant and simple goal. But new findings about the increase in antibiotic resistance challenge us to consider just how complicated and challenging it is to actually define and deliver evidence-based care.
"Are we ready for a world without antibiotics?'' A recent paper, in Lancet Infectious Diseases, documented the spread of a gene (NDM1) that passes between certain types of common bacteria such as E. coli and Klebisella pneumonia and makes them resistant to all the powerful last-line antibiotics available to treat them. Apparently, this gene is widespread in India and has arrived in the UK, thanks to the popularity of global travel and medical tourism for such procedures as pregnancy, cosmetic surgery and transplants. Next stop, big cities in the US, no doubt.
Tim Walsh, one of the authors of the study in an interview with The Guardian, said, "In many ways, this is it," Walsh tells me. "This is potentially the end. There are no antibiotics in the pipeline that have activity against NDM 1-producing enterobacteriaceae. We have a bleak window of maybe 10 years, where we are going to have to use the antibiotics we have very wisely, but also grapple with the reality that we have nothing to treat these infections with."
Well, that will send a chill up your spine, even when it is 97 degrees outside.
We have heard this news before. Or news like it. Why has so little changed?' Are we as individuals responsible for this? If we act differently, can we affect it?
The answers to these questions are not simple, but they vividly illustrate the complex paths through which science shapes (and does not shape) health care, even in the face of the imperative of evidence-based medicine.
Start with the assumption that while resistance to antibiotics is impossible to prevent, it is possible to slow its progression that would allow for the development of effective new drugs. Consider also that there are two major contributors to antibiotic resistance:' poorly conceived and enforced public policies and individual practices related to the production of food, and health care practices. Both patients and doctors fail to follow evidence-based guidelines on the appropriate use of antibiotics, and our excessive and unnecessary use of them promotes the development of antibiotic-resistant strains of bacteria.
Here are just a few of the factors that complicate the straightforward implementation of evidence-based approaches to antibiotic use:
Doctors believe their primary obligation is to the patient in front of them, not to the general public, so many of them will prescribe an antibiotic if there is a remote chance of it being effective for this patient today.
The incentives for us as patients to refuse antibiotics are too weak to make us care about the effects of our behavior on others. Our actions and the undesirable consequence of increased resistance are separate in time, so we don't remember or recognize the connection. Or, thinking of our own self-interest, we realize that no single act on our part can stop the growth of resistance. After all, why take the chance of missing out on possible benefit? So we take the drug on the off chance it will help.
Quality improvement efforts for doctors such as pay-for-performance may inadvertently contribute by providing an incentive for doctors to prescribe antibiotics for infectious diseases without penalizing their inappropriate administration. For example, one initiative focuses on early prescription of antibiotics for lower respiratory tract infection, particularly community-acquired pneumonia. So emergency department physicians prescribe antibiotics for any infection that might possibly fit that description, regardless of its location or that a specific bacterium is causing it.
Reports of health-related behaviors and clinician practices that persist in the absence of evidence (and even in the presence of contradictory evidence) are fairly common. Medical regimens related to antibiotic use are among them. For example, physicians continue to order bowel cleansing that contains antibiotics prior to surgery despite lack of evidence of effectiveness and the possibility of harm. And despite a weak scientific foundation, physicians routinely direct patients to 'finish the course of antibiotics. The popular press supports this notion. And we tend to believe it.'
Many of us still believe that an illness sufficiently serious to warrant the time and expense of a trip to the doctor should be treated by prescription of an antibiotic, and good number of us are willing to express our dissatisfaction with a physician who refuses to participate either directly or by finding a clinician who will.
We 'us, our doctors, those who make and enforce clinical policies' are caught in a web of interdependence in which we act on the basis of inadequate information in the service of our individual interests, reinforced by the incentives, social norms and traditions of both American society and the health professions. As it stands, neither we nor our providers will make a change without the other, and while I'd like to think that an advance in diagnostic technology will soon make the accurate prescription and use of antibiotics a slam-dunk, I'm not hopeful. Until then, I fear that none of us will change our behavior without an immediate, compelling equivalent of a whack upside the head.
I wonder what form that whack will take?