Antibiotic Overuse Threatens Modern Medicine: Experts

Kate Kelland
Tue Nov 10, 2009

LONDON (Reuters) - Overuse of antibiotics in Europe is building widespread resistance and threatening to halt vital medical treatments such as hip replacements, intensive care for premature babies and cancer therapies, health experts say.

Dominique Monnet of the European Center for Disease Prevention and Control's (ECDC) scientific advice unit said the "whole span of modern medicine" is under threat because bugs are become resistant to antibiotics, rendering the drugs useless.

"If this wave of antibiotic resistance gets over us, we will not be able to do organ transplants, hip replacements, cancer chemotherapy, intensive care and neonatal care for premature babies," he told reporters at a briefing.

Antibiotics are needed in all these treatments to prevent bacterial infection. But drug-resistant bacteria are a growing problem in hospitals worldwide, marked by the rise of superbugs such as methicillin-resistant Staphyloccus aureus (MRSA).

Such infections kill about 25,000 people a year in Europe and around 19,000 in the United States

On top of the risks to future treatments, Monnet said the costs of antibiotic resistance were already hurting -- and may hit healthcare budgets across the European Union yet harder if the problem is not addressed.

The six most common multi-drug-resistant bacteria -- often referred to as superbugs -- cause around 400,000 infections a year in Europe, killing around 25,000 people and using 2.5 million hospital days a year.

The ECDC, which monitors and advises on disease in EU, calculates that with a hospital day costing an average of 366 euros ($548), superbug infections are already sucking up 900 million euros a year in extra hospital costs, and a further 600 million euros a year in lost productivity.

"Across the European Union the number of patients infected by resistant bacteria is increasing and that antibiotic resistance is a major threat to public health," the ECDC said.

Britain's government was criticized by a parliamentary committee on Tuesday for failing to tackle the majority of hospital-acquired infections by narrowing its focus to two high profile ones -- MRSA and Clostridium difficult.

The ECDC conducted an "antibiotic awareness" campaign in November to urge doctors to stop overprescribing antibiotics.

Patients demanding antibiotics for viral infections often are not aware that they will not work, it said, but doctors are and should stop giving in to pressure.

Sarah Earnshaw of the ECDC's communications unit, pointed to a 2002 survey that showed 60 percent of patients do not know that antibiotics do not work against viruses like flu and colds.

"Patients often demand antibiotics," she said. And doctors often think, she said, that giving in is a quicker way to deal with a demanding patients than persuading them otherwise.

(Editing by Louise Ireland)

Antibiotic Overuse? Not in Norway

Associated Press Writers

OSLO, Norway (AP) -- Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.

Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospitals of Europe, North America and Asia this year, soaring virtually unchecked.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway's public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world prove that Norway's model can be replicated with extraordinary success, and public health experts are saying these deaths -- 19,000 in the U.S. each year alone, more than from AIDS -- are unnecessary.

"It's a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort," said Jan Hendrik-Binder, Oslo's MRSA medical adviser. "But you have to take it seriously, you have to give it attention, and you must not give up."

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by The Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway's simple solution, there's a glimmer of hope.

Dr. John Birger Haug shuffles down Aker's scuffed corridors, patting the pocket of his baggy white scrubs. "My bible," the infectious disease specialist says, pulling out a little red Antibiotic Guide that details this country's impressive MRSA solution.

It's what's missing from this book -- an array of antibiotics -- that makes it so remarkable.

"There are times I must show these golden rules to our doctors and tell them they cannot prescribe something, but our patients do not suffer more and our nation, as a result, is mostly infection free," he says.

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What's here? Medicines considered obsolete in many developed countries. What's not? Some of the newest, most expensive antibiotics, which aren't even registered for use in Norway, "because if we have them here, doctors will use them," he says.

He points to an antibiotic. "If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail," he says, "and rightly so because it's useless there."

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

"We don't throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better," says Haug.

Convenience stores in downtown Oslo are stocked with an amazing and colorful array -- 42 different brands at one downtown 7-Eleven -- of soothing, but non-medicated, lozenges, sprays and tablets. All workers are paid on days they, or their children, stay home sick. And drug makers aren't allowed to advertise, reducing patient demands for prescription drugs.

In fact, most marketing here sends the opposite message: "Penicillin is not a cough medicine," says the tissue packet on the desk of Norway's MRSA control director, Dr. Petter Elstrom.

He recognizes his country is "unique in the world and best in the world" when it comes to MRSA. Less than 1 percent of health care providers are positive carriers of MRSA staph.

But Elstrom worries about the bacteria slipping in through other countries. Last year almost every diagnosed case in Norway came from someone who had been abroad.

"So far we've managed to contain it, but if we lose this, it will be a huge problem," he said. "To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can't prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics."

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics. Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares to 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

In the U.S., cases have soared and MRSA cost $6 billion last year. Rates have gone up from 2 percent in 1974 to 63 percent in 2004. And in the United Kingdom, they rose from about 2 percent in the early 1990s to about 45 percent, although an aggressive control program is now starting to work.

About 1 percent of people in developed countries carry MRSA on their skin. Usually harmless, the bacteria can be deadly when they enter a body, often through a scratch. MRSA spreads rapidly in hospitals where sick people are more vulnerable, but there have been outbreaks in prisons, gyms, even on beaches. When dormant, the bacteria are easily detected by a quick nasal swab and destroyed by antibiotics.

Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway's solutions in varying degrees, and his agency "requires hospitals to move the needle, to show improvement, and if they don't show improvement they need to do more."

And if they don't?

"Nobody is accountable to our recommendations," he said, "but I assume hospitals and institutions are interested in doing the right thing."

Dr. Barry Farr, a retired epidemiologist who watched a successful MRSA control program launched 30 years ago at the University of Virginia's hospitals, blamed the CDC for clinging to past beliefs that hand washing is the best way to stop the spread of infections like MRSA. He says it's time to add screening and isolation methods to their controls.

The CDC needs to "eat a little crow and say, 'Yeah, it does work,"' he said. "There's example after example. We don't need another study. We need somebody to just do the right thing."

But can Norway's program really work elsewhere?

The answer lies in the busy laboratory of an aging little public hospital about 100 miles outside of London. It's here that microbiologist Dr. Lynne Liebowitz got tired of seeing the stunningly low Nordic MRSA rates while facing her own burgeoning cases.

So she turned Queen Elizabeth Hospital in Kings Lynn into a petri dish, asking doctors to almost completely stop using two antibiotics known for provoking MRSA infections.

One month later, the results were in: MRSA rates were tumbling. And they've continued to plummet. Five years ago, the hospital had 47 MRSA bloodstream infections. This year they've had one.

"I was shocked, shocked," says Liebowitz, bouncing onto her toes and grinning as colleagues nearby drip blood onto slides and peer through microscopes in the hospital laboratory.

When word spread of her success, Liebowitz's phone began to ring. So far she has replicated her experiment at four other hospitals, all with the same dramatic results.

"It's really very upsetting that some patients are dying from infections which could be prevented," she says. "It's wrong."

Around the world, various medical providers have also successfully adapted Norway's program with encouraging results. A medical center in Billings, Mont., cut MRSA infections by 89 percent by increasing screening, isolating patients and making all staff -- not just doctors -- responsible for increasing hygiene.

In Japan, with its cutting-edge technology and modern hospitals, about 17,000 people die from MRSA every year.

Dr. Satoshi Hori, chief infection control doctor at Juntendo University Hospital in Tokyo, says doctors overprescribe antibiotics because they are given financial incentives to push drugs on patients.

Hori now limits antibiotics only to patients who really need them and screens and isolates high-risk patients. So far his hospital has cut the number of MRSA cases by two-thirds.

In 2001, the CDC approached a Veterans Affairs hospital in Pittsburgh about conducting a small test program. It started in one unit, and within four years, the entire hospital was screening everyone who came through the door for MRSA. The result: an 80 percent decrease in MRSA infections. The program has now been expanded to all 153 VA hospitals, resulting in a 50 percent drop in MRSA bloodstream infections, said Dr. Robert Muder, chief of infectious diseases at the VA Pittsburgh Healthcare System.

"It's kind of a no-brainer," he said. "You save people pain, you save people the work of taking care of them, you save money, you save lives and you can export what you learn to other hospital-acquired infections."

Pittsburgh's program has prompted all other major hospital-acquired infections to plummet as well, saving roughly $1 million a year.

"So, how do you pay for it?" Muder asked. "Well, we just don't pay for MRSA infections, that's all."

Martha Mendoza is an AP national writer who reported from Norway and England. Margie Mason is an AP medical writer based in Vietnam, who reported while on a fellowship from The Nieman Foundation at Harvard University.

MRSA Leads to Worse Outcomes, Staggering Expenses for Surgical Patients

ScienceDaily (Dec. 17, 2009)

Post-surgical infections significantly increase the chance of hospital readmission and death and cost as much as $60,000 per patient, according to Duke University Medical Center researchers who conducted the largest study of its kind to date.

"We conducted a multi-center study of multiple surgical procedure types among 659 patients to determine clinical and financial outcomes of surgical site infections that are directly attributable to MRSA (methicillin-resistant Stapylococcus aureus)," said Deverick J. Anderson, M.D., MPH, an infectious diseases specialist at Duke University Medical Center and lead author of the study. "We found the impact of methicillin-resistance on surgical patients is substantial and that preventing a single case of surgical site infection due to MRSA can potentially save hospitals as much as $60,000."

Previously published research on surgical site infections provided conflicting conclusions. For the Duke study, researchers looked at the 90-day postoperative period for patients over a five-year period in one tertiary care center and six community hospitals in the Duke Infection Control Outreach Network (DICON). Created in 1997, DICON assists community hospitals in improving quality of care and enhancing patient safety, while minimizing the costs associated with non-evidence based approaches to infection control.

The researchers compared hospital readmission, mortality, length of hospital stay and hospital charges for patients in three groups. Some had surgical site infections due to MRSA, some were infected with methicillin-susceptible Staphylococcus aureus (MSSA), and some were uninfected. The study evaluated deep-incision and organ/space infections, which are more severe than superficial infections at the site of incision. The findings are published in PLoS ONE.

"We found that patients with surgical site infections due to MRSA were 35 times more likely to be readmitted and seven times more likely to die within 90 days compared to uninfected surgical patients," Anderson said. "These patients also required more than three weeks of additional hospitalization and accrued more than $60,000 in additional charges."

The researchers found most of the outcomes for MRSA compared to MSSA were worse, as anticipated, however one finding was surprising, according to Anderson. "Our findings show that methicillin-resistance contributed to longer hospital stays and increased hospital charges but did not increase the risk of mortality," he said. The data shows that patients with surgical site infections due to MRSA compared to MSSA on average required six more days of hospitalization and incurred $24,000 in additional charges.

"For the seven hospitals we looked at, the total estimated cost resulting from surgical site infections due to MRSA was more than $19 million," Anderson said. "That's a staggering amount, which demonstrates an area of cost-saving potential for these institutions and other community hospitals."

The Duke study provides the first cost impact data tied to post-surgical MRSA infection in a large group of hospitals. "Given our estimated cost of one MRSA case, we can conclude that a $60,000 intervention to prevent even one of these infections would be cost-effective for an institution," Anderson said. "With this new financial data, greater emphasis should be placed on an effort to design and evaluate specific preventative interventions."

Other researchers involved in the study include Luke F. Chen, Kenneth E. Schmader, Yong Choi and Daniel J. Sexton of Duke University Medical Center; and Keith S. Kaye, formerly of Duke University Medical Center now at Detroit Medical Center.

MRSA Infections Nearly Doubled Over Last 10 Years: Study

Published: November 27th, 2009

U.S. researchers indicate that there has been a 90% increase in antibiotic-resistant “superbug” infections since 1999, as strains circulating both in hospitals and the community continue relatively unabated.

The study, published in the CDC’s Emerging Infectious Diseases medical journal, pulled data from 300 microbiology laboratories. Researchers at the University of New Jersey found that not only is methicillin-resistant Staphylococcus aureus (MRSA) spreading outside of hospitals as well as within, but that outpatients being admitted to hospitals were major contributors to infections spread within hospitals as well.

According to the U.S. Centers for Disease Control and Prevention (CDC), there are more than 2 million hospital infections acquired each year, resulting in about 90,000 deaths annually. Another 1.5 million long term care and nursing home infections occur every year.

Methicillin-resistant Staphylococcus aureus, commonly referred to as a MRSA infection, has accounted for more than 60 percent of hospital staph infections in recent years. The CDC reports that about 126,000 hospital MRSA infections occur each year, resulting in about 5,000 deaths. But the researchers suggest that the number of deaths from MRSA in the U.S. is closer to 20,000 annually.

The rate of community-acquired infections (CA-MRSA) increased by about 33% annually, researchers found, resulting in an overall MRSA increase of 10% every year. And those infected individuals often made their way into U.S. hospitals, where they then infected hospital staff and other patients, even while hospitals slowed their own rate of infection, the study found.

“Outpatients, who outnumber inpatients by [about] 3:1, may play a major role in the spread of CA-MRSA strains from the community to the hospital through their interaction with hospital staff or use of similar hospital resources, such as surgical rooms,” researchers stated.

As more hospitals and medical facilities have begun to follow protocols designed to reduce the risk of hospital infections, those that have not established the standards or enforced the rules have been found by juries in medical malpractice lawsuits to be providing care that does not fall within the ordinary standard of care for the industry.

University of New Jersey researchers said that the community strains now entering hospitals are not replacing hospital strains, but instead are adding to the numbers of people infected, and said that strategies for prevention of infection and treatment of patients needs to be coordinated at the local level.

“Infection control policies should take into account the role that outpatients likely play in the spread of MRSA and promote interventions that could prevent spread of MRSA from outpatient areas to inpatient areas,” Researchers concluded.

Staph infections have risen by more than 90 percent, study finds


Published: Monday, November 30th, 2009

The number of cases of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased by more than 90 percent over the last decade, according to recent research led by University scholars.
Ramanan Laxminarayan, a visiting scholar at the Princeton Environmental Institute, and Eili Klein, a visiting specialist in the ecology and evolutionary biology department, co-authored a paper on the spread of MRSA infections from 1999 through 2005.

In 2006, there were 278,203 reported cases of MRSA-related infection, more than double the number in 1999, according to the paper. As many as 17,280 people infected with MRSA died in 2005, more than the number of people who died of AIDS that year. The paper, published in the December 2007 issue of the journal Emerging Infectious Diseases, stressed that MRSA should be “considered a national priority for disease control.”

These infections are caused by the bacterium Staphylococcus aureus, which usually lives on the skin and in the nasal passages and can be harmful if it enters the body through a sore or cut.

The growing number of MRSA cases reflects the increasing resistance of Staphylococcus bacteria to antibiotics over the last few years. The researchers discovered that resistance to various antibiotics like ampicillin and erythromycin increased by more than 20 percent between 1999 and 2005, and the researchers said the widespread use of antibiotics in the past few decades has made their use less effective.

Klein explained that the increase in MRSA cases has consequences beyond health risks. People who have infections resistant to treatment face a number of extra costs because they “tend to stay longer in hospitals and may need more expensive drugs,” he said. For instance, the cost of treating MRSA infections can range between $3,000 and $36,000 more than a methicillin-sensitive infection, according to his research.

Klein added that he believes there is a need to reduce the inappropriate use of antibiotics, which helps the bacteria develop their resistance. For example, instead of prescribing antibiotics to patients who are sick and insist on being prescribed drugs to “make them feel better,” doctors should explain to their patients when they don’t need antibiotics, Klein said.

“Every time somebody uses an antibiotic, that reduces the number of times the antibiotic can ever be used because it’s going to create resistance,” he explained.

Laxminarayan referred all requests for comment to Klein.

The researchers also discovered another important trend in their data. Hospital-associated MRSA infections, occurring mostly in patients with weakened immune systems, have been more common than community-associated MRSA infections, occurring among those who pick up the bacteria in fitness centers, common restrooms and other public places. The researchers found that the percentage of hospital outpatients who reported community-associated MRSA infections had jumped drastically from about 10 percent to roughly 50 percent between 1999 and 2005. They concluded that community-associated MRSA infections are currently spreading more rapidly, and that they are possibly making their way into hospitals.

To prevent transmission between people in the outpatient and inpatient units, Laxminarayan and Klein, in their paper, called for stringent hand-washing and other infection-control practices in hospitals.

Let Me See You Wash Your Hands


One of the heroes of SuperFreakonomics is Ignatz Semmelweis — who crunched numbers in the 1840’s to champion the benefits of doctors washing their hands.

“The reason why unusual interventions are necessary is simply because voluntarism wasn’t working.” (I’ve written a bit about him myself and, for some odd reason, I just love to pronounce “Ignatz” out loud.) It has taken the medical profession a long, long time to get religion on hand sanitization.

But there is good news: Clean Hand programs are now the norm at hospitals. SuperFreakonomics explains how hand-hygiene compliance at Cedars-Sinai Medical Center “shot up to nearly 100 percent” after the hospital started using disgusting pictures of the bacteria found on the palm prints of physicians as screensavers. I can verify that other hospitals are copying this solution.

A couple of weeks ago, one of my coauthors had a health scare and was hospitalized for a night in New Haven. Her hospital ward was plastered with color photocopies of disgusting, bacteria-laden palm cultures.

I’m also impressed with the increasing practice of hand-sanitation in front of the patient. Many health care workers show you that they have just applied hand gel as they are coming in to examine you. We’re slowly getting to the point where patients might start calling out doctors who don’t sanitize in their presence.

Indeed, in addition to the disgusting hand cultures, hospitals might do well to post notices asking patients to challenge anyone who tries to treat without sanitizing in their presence. (This idea is a bit like the restaurants that say “your food is free if you are not given a receipt.”)

The reason why unusual interventions are necessary is simply because voluntarism wasn’t working. Giving health care workers the unaided choice resulted in too many people bypassing the hand-washing opportunity. Sadly, hand sanitation is a classic non-durable precaution. To be effective, it needs to be done repeatedly. Psychologically, it needs to become routine for us to have a chance of making the practice stick. (That’s how I finally got in the habit of using a seat-belt.)

Having won the day with hospitals, we should turn our attention toward schools. Sadly, most schools are at best stuck in voluntary regimes where students can wash their hands if they want to. My concern is that not enough students avail themselves of this option. Even if 80 percent regularly choose to sanitize (a pipe dream), the persistence of a recalcitrant 20 percent might undermine the public health benefits of sanitation.

If your school or place of business has public hand-sanitizers, I’d love to learn how often you have to refill the dispensers. If we know the rate of use and the number of people in the building, we can know the average rate of sanitation. I bet we’d find that the rate of sanitation would be very low. (I bet we’d find a similar result if we compared toilet paper use to soap use in school toilets. We should be very scared if there are 100 sheets of toilet paper used for every dose of hand soap.)

Schools should experiment with mandating routine, public hand sanitation. As a beginning, they might put hand gel dispensers in science class and ask the teachers to make sure that their students dose their hands at the end of class.

Mandating hand-sanitation might reduce sick days by as much as 20 percent. In fact, that’s what this 2002 study of 18 elementary schools (located in Delaware, Ohio, Tennessee, and California) found. The study protocol required multiple sanitations per day:

[T]he students were instructed to also use the waterless alcohol gel hand sanitizer when entering and leaving the classroom, especially first thing in the morning, before and after lunch, after recesses, after use of the restroom, and before going home. Students were also encouraged to use the sanitizer when they sneezed or coughed. Crucially, the study made teachers responsible for ensuring that the protocol was followed.

Compared with paired control group schools, students who were forced to clean their hands ended up with 19.8 percent fewer sick days (the full article is behind a firewall here; similar studies are abstracted here). And teachers’ absenteeism dropped by 10.1 percent. These figures ignore the beneficial effects on moms and dads and others who probably got sick less too.

As our nation suffers through another flu season, the spirit of Ignatz Semmelweis calls out to us across the decades for less discretionary hand sanitation.

Drug Resistant MRSA has Increased by 90% Over the Past Decade

Featured TNM Health Update

A recent study conducted at the Princeton University has revealed that cases of the drug resistant bacterial infection MRSA have rapidly increased by as much as 90% over the past decade, and are still spreading at an alarming rate outside hospitals.

Researchers, led by Ramanan Laxminarayan, analyzed data on laboratory tests of a countrywide network of 300 microbiology laboratories across the US for the sake of study, and reported that two new strains of MRSA have been recently found circulating in patients, which are completely different from those discovered earlier.

"We found during 1999-2006 that the percentage of S. aureus infections resistant to methicillin increased more than 90 percent, or 10 percent a year, in outpatients admitted to U.S. hospitals. This increase was caused almost entirely by community-acquired MRSA strains, which increased more than 33 percent annually", shared the researchers.

Researchers discovered that a large number of people were now being diagnosed with MRSA, and the strains found in those patients were not replacing their older counterparts, but simply adding to them, thereby making the infection worse and more difficult to combat.

It has been estimated that nearly 20,000 people die every year in the US after contracting MRSA, and the infection's treatment can cost anywhere from $3,000 to over $35,000 per case.

Rougly 50% Of Patients In Intensive Care Suffer Infections

Washington (SmartAboutHealth)

According to a new study, roughly 50% of patients who are in intensive care units suffer from infections.

The new study was carried out by researchers led by Dr. Jean-Louis Vincent of Erasme Hospital in Belgium.

The study analyzed data from one single day, May 8, 2007. The day consisted of looking at data on adults who were 18-years-old an dup from over 75 different countries.

There were over 13,000 patients involved in total that were put in over 1,250 intensive care units around the world.

Researchers confirmed from this data that 51% of those patients in an ICU were suffering from an infection.

32% of patients who were in an ICU for a day or less suffered from an infection, compared to 70% who spent seven days or more.
On top of that, they found that 71% were being treated with an antibiotic for an infection.

Breaking down the infections further, researchers confirmed that the majority of the infections, 64%, took place in the lungs.

South America was found to have the highest rate of infection.

The study has been published in the December 2nd issue of the Journal of the American Medical Association.

Lawmakers set to make healthcare changes

The Washington Times
By Jennifer Haberkorn
December 2, 2009

Bracing for a lengthy debate that has been rambunctious since day one, lawmakers are preparing dozens of additional changes to Democrats' health care overhaul legislation.

Everything from the major flashpoints -- government-run insurance, Medicare spending and abortion -- to lesser-known topics such as hospital reimbursements and an in-home insurance plan are likely to face intense scrutiny on the Senate floor in the form of amendments.

Sens. Susan Collins, Maine Republican, and Joe Lieberman, Connecticut independent, plan to offer amendments to reduce the rate of hospital-acquired infections and change the way the small-business tax credits are structured, according to a Senate aide.

"I'd like to see more of a penalty for [government-backed] reimbursements to hospitals that have high rates of hospital-acquired infections," Ms. Collins told reporters on Tuesday.

Ms. Collins discussed both issues with White House health care "czar" Nancy-Ann DeParle in her Senate office on Monday, signaling just how closely Democrats are listening to her in hopes of getting bipartisan support for their bill.

Mr. Lieberman is also a swing vote, meaning that his and Ms. Collins' amendments are likely to get more than a glance from Democratic leaders. He is an independent and caucuses with Democrats but said he would support a Republican filibuster if the legislation contains a public insurance plan at the end of the debate.

Any amendment that significantly changes the legislation could change the dynamic of attracting 60 votes. Changes that pick up the support of some members could come at the cost of others. For instance, if an amendment to remove the public option passes, one or two moderate Republicans could come on board, but it could make liberal Democrats revolt.

The debate over the first two amendments has already been contentious. The Republicans' first amendment -- a proposal to eliminate nearly $500 billion in Medicare cuts -- was dubbed a "huge big belly-flop flip-flop" by Senate Majority Leader Harry Reid of Nevada.

Mr. Reid said Sen. John McCain's amendment was merely "one big earmark to the insurance industry" and not in line with the Arizona Republican and former presidential candidate's disdain for members of Congress favoring specific companies or industries in legislation.

Democrats say the proposed cuts would merely eliminate waste and fraud and not have an impact on benefits. But Mr. McCain and Republicans say there is no way to make such cuts without reducing seniors' care.

The Democrats' first amendment, from Sen. Barbara A. Mikulski of Maryland, was co-sponsored by Sen. Olympia J. Snowe, Maine Republican. It would give the health and human services secretary the authority to require insurers to cover additional preventive screenings for women. Just last month, controversial recommendations to limit screenings sparked worry that the Democrats' plan would ration care.

The debate is expected to last at least through the end of the year, with dozens of amendments offered by both sides.

Sen. Ben Nelson of Nebraska, one of the Democrats most skeptical of the legislation, said he plans to introduce amendments to insert abortion restrictions, strip the CLASS (Community Living Assistance Services and Supports) Act -- a program to fund in-home care for disabled Americans that some say has questionable funding -- and "deal" with the public insurance plan.

He declined to say how he plans to address the public plan, but said he prefers a state-based approach and would consider a plan in which states can "opt in" instead of opt out, as the bill currently is written.

Mr. Nelson said he would have a hard time voting for a health bill that doesn't have abortion restrictions similar to what the House passed last month. Their plan, with an amendment from Rep. Bart Stupak, Michigan Democrat, would prohibit patients on the public insurance plan from obtaining abortions without separate insurance. It sparked a firestorm from supporters of abortion rights who said the language went too far.

Other expected amendments include a repeal of the insurance companies' antitrust exemptions, from Sen. Patrick J. Leahy, Vermont Democrat, and cost-cutting measures from a group of moderate freshman Democrats.

Hospital infections disturbingly common worldwide News Staff
Date: Wednesday Dec. 2, 2009 7:23 AM ET

A huge new study finds that about half of all patients in intensive care wards around the world are battling some kind of infection.

The study, led by Dr. John Marshall of St. Michael's Hospital in Toronto looked at data from 1,265 intensive care units in hospitals in 75 countries.

It found that in one 24-hour period in 2007, more than half of the over 14,000 patients in ICUs that day had infections. Of those infected:

60 per cent had pneumonias
20 per cent were infections inside the abdomen
15 per cent were infections of the urinary tract
The longer the patients stayed in intensive care, the bigger their risk of becoming infected, the study findings suggest. The infection rate increased from 32 per cent for patients with an ICU stay of one day or less, to more than 70 per cent for patients with an ICU stay of more than seven days.

Not surprisingly, infected patients had longer ICU and hospital lengths of stay than those not infected.

Patients in ICUs who were battling infections were more than twice as likely to die than non-infected patients (25 per cent vs. 11 per cent). Their in-hospital death rate overall was also higher than non-infected patients (33 per cent vs. 15 per cent).

It's been well-documented that infections can increase the risk of death in the hospital. But the authors estimate they also account for about 40 per cent of total ICU health care costs.

"One of the things that this study actually allows us to do, is to begin to get a sense as to how much of the burden of infection is an added burden on a patient who is already at risk of dying because of the underlying diseases that led them to be in the intensive care unit," Dr. Marshall said in a statement.

Countries in Central and South America had the highest infection rates while more developed countries such as Australia and New Zealand had the lowest rates.

There are a number of things doctors could do to limit infections in hospital, write two doctors in an accompanying editorial, Dr. Steven M. Opal, of Warren Alpert Medical School of Brown University in Providence, R.I., and Dr. Thierry Calandra, of Centre Hospitalier Universitaire Vaudois and University of Lausanne in Switzerland.

Firstly, doctors should work to combat antibiotic resistance by limiting the use of antibiotics to patients who clearly have bacterial infections and then discontinue their use when their possible benefits have been obtained.

But even more important, new drugs need to be developed to replace the increasingly obsolete classes of antibiotics that currently exist, they insist.

"A 'post-antibiotic era' is difficult to contemplate but might become a reality unless the threat of progressive antibiotic resistance is taken seriously," the authors write.

GOP lawmaker wants tougher penalties for hospital infections

By Matthew DoBias
December 1, 2009

A key Republican being courted as a possible swing vote on healthcare reform by Senate leaders and the White House said she would press for stricter penalties against hospitals that have high rates of hospital-acquired infections.

Sen. Susan Collins (R-Maine) is readying an amendment that would subject hospitals to a higher penalty—and earlier on in the process—than is currently included in the Senate's health reform package.

Under the current bill, starting in 2015, hospitals in the top 25th percentile of rates of hospital-acquired infections would be subject to a 1% penalty under Medicare. Collins' provision, however, would move up the penalty date two years to 2013 and could increase the actual penalty as well.

Collins discussed the measure with White House officials. “That's one specific idea that we requested that they seemed interested in helping us on,” she said, referring to administration officials Nancy-Ann DeParle and Jeanne Lambrew.

Additionally, Collins said that she's considering amendments that deal with affordability, small-business tax credits and a raft of other provisions.

Collins' recommendations, however, could have added traction. A moderate, Maine Republican—like her counterpart Sen. Olympia Snowe—is seen as a possible swing vote for a legislative package that so far is backed only by Democrats. Having a handful of Republicans on board would give Democrats more wiggle room to pass a bill that requires 60 votes in the Senate.

Collins said she continues to oppose the legislation as it is currently written but left the door open for a change of heart. “There would have to be substantial changes, but I certainly hope that would be possible,” she said. “I think there is unease on both sides of the aisle about specific provisions in this bill and that it's possible that we can come up with alternatives that will garner bipartisan support.”

Half of World's ICU Patients Have Infections: Study

By Maggie Fox, Health and Science Editor
December 1, 2009

WASHINGTON (Reuters) - Half of all patients in intensive care units around the world have infections, and more than 70 percent are being given antibiotics -- a trend that could help more drug-resistant superbugs emerge, researchers reported on Tuesday.

Patients who had infections were more likely to die, especially of bloodborne infections known as sepsis, the survey of more than 13,000 patients found. They also spent more time in the ICU at greater expense to hospitals and patients.

But one of the biggest concerns was the widespread use of antibiotics in patients who were not infected -- a practice that has been shown to lead to antibiotic resistance, when germs defy common drugs.

"Importantly, the incidence of sepsis is increasing, as is the number of consequent infection-related deaths," Dr. Jean-Louis Vincent of Erasme University Hospital in Brussels, Belgium and colleagues wrote in the Journal of the American Medical Association.

For the study, Vincent's team surveyed 13,796 adults in 1,300 intensive care units in 75 countries on one day -- May 8, 2007.

The analysis took some time and revealed that 51 percent of the patients had infections and 71 percent were receiving antibiotics, either as treatment or to prevent infection.

In 64 percent of cases, the lungs were infected, and infections of the abdomen and bloodstream were also common.

The most common bacteria was Staphylococcus aureus, but E. coli and a family of bacteria called Pseudomonas were also common.

"Infection and related sepsis are the leading cause of death in noncardiac ICUs, with mortality rates that reach 60 percent and account for approximately 40 percent of total ICU expenditures," the researchers wrote.


Dr. Steven Opal of Brown University in Rhode Island and Dr. Thierry Calandra of Vaudois Hospital Center in Lausanne, Switzerland, who were not involved in the study, saw several troubling trends.

For instance, a type of bacteria known as gram-negative now account for 63 percent of infections. "This is not a favorable trend, because resistance among gram-negative bacteria is increasing and the number of therapeutic alternatives to treat these infections is diminishing," they wrote in a commentary.

The heavy use of antibiotics in ICUs can make such units into epicenters for bacteria to mutate into drug-resistant forms and to spread, they added.

But critical care doctors have little choice, they noted.

"Early intervention with appropriate antibiotics is lifesaving in patients with severe infection, yet the profligate use of antimicrobial agents contributes to progressive antimicrobial resistance," they wrote.

Doctors are penalized if they fail to treat with an antibiotic, but little happens if they over-treat patients.

And few good tests are available to tell if a patient is really infected or just carrying a germ. "With few alternatives available, it is understandable why intensivists opt for liberal antibiotic use and rely heavily on these therapeutic agents to carry patients through critical illness to recovery," Opal and Calandra wrote.

Without some "radical" new technology, such as vaccines or immunotherapy, there is little hope for the situation to improve, they added.