The Healthcare Crisis Is Still Not Budgetary: Once More Unto the CRE Breach

One of the most frustrating things about the whole fixation on deficits and budgets is that it ignores the real crises we face, such as carbapenem-resistant enterobacteriaceae (E. coli and relatives that are resistant to virtually all antibiotic therapy):

This is a systemic failure of our healthcare system. Infecting patients with difficult-to-impossible to treat bacteria is not good healthcare. Not only will CREs increase mortality rates, but if carbapenem-resistance establishes itself in the larger E. coli population, a significant fraction of commonplace urinary tract infections will become untreatable. The amount of misery this would cause would be significant–UTIs would be the new STD. And keep in mind, that there are already roughly 36,000 E. coli associated deaths per year in the U.S., which blows U.S. HIV/AIDS deaths out of the water.

At best, I figure we probably have five years, give or take, to get this under control before it spirals out of control (and in the past, I’ve been uncharacteristically optimistic about CREs). Thanks to our political system, which has been utterly warped by deficit reduction hysteria, are we worried about this or any other number of emerging problems (e.g., drug-resistant gonorrhea)?

Of course not. Don’t be silly. Instead, we’re worried about bending thirty-year budget curves like Beckham (as the kids used to say). Rather than worrying about real healthcare problems–that is, improving health and preventing disease–it would appear that the pressing healthcare issue of our age is budgetary.

But like Honey Badger, bacteria don’t care about fiscal crises, they just keep chugging along according to CDC director Tom Frieden (boldface mine):

What I’m talking about today is CRE, carbapenem-resistant enterobacteriaceae. CRE are nightmare bacteria. They pose a triple threat. First, they’re resistant to all or nearly all antibiotics. Even some of our last-resort drugs. Second, they have high mortality rates. They kill up to half of people who get serious infections with them. And third, they can spread their resistance to other bacteria. So one form of bacteria, for example, carbapenem-resistant klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also. E. coli is the most common cause of urinary tract infections in healthy people. So we only have a limited window of opportunity to stop this infection from spreading to the community and spreading to more organisms. We’re calling for a “detect and protect” strategy that we know can save patients’ lives and stop the spread of CRE…

Unfortunately, it appears that CRE bacteria are spreading. We know that in the first half of 2012 alone, nearly 200 hospitals and long-term acute care facilities treated at least one patient who was infected with these bacteria. We’ve tracked CRE from a single healthcare facility in one state in 2001 to healthcare facilities now in 42 states or more. In some of those places, these bacteria are now a routine challenge for patients and clinicians.

Overall, CRE has increased from one percent to four percent in the past decade and the most common type of CRE has increased from two percent to 10 percent during that time. That’s a very troubling increase. It’s a four or five-fold increase in the proportion of these serious infections that are from highly-resistant organisms.

Public health officials very, very rarely use phrases like “limited window of opportunity” or “nightmare.” While not as ‘opaque’ as the Federal Reserve, their language is usually couched in more sedate terms, with the occasional ‘extremely concerned.’ The CDC knows this is bad, and while they know this is the real deal, there’s a problem with the strategy being rolled out (boldface mine):

But an important point is that none of this is required, and none of this is funded. When the Netherlands wanted to beat back the emergence of MRSA, that country passed laws requiring every hospital to test patients before letting them in the door. (That story is told in this book.) When Israel wanted to counter KPC, which was ripping through its hospitals after arriving from the US, it created a national task force and imposed mandatory national measures for detecting and confining the infection. (That program is described in this 2011 paper.) And hospitals are on their own in figuring out how to organize and pay for CRE control. There are no reimbursements, under Medicare, for infection-control as a hospital task

FREEDOM!…to die from an untreatable sepsis infection. Eli Perecenevich is, well, ‘extremely concerned’ (boldface mine):

However, the most important aspect of the Netherlands and Israel examples were that they instituted NATIONAL RESPONSES aimed at MRSA and CRE. There are no such national efforts here in the US targeting CRE. This is what we have in the US per the MMWR report: “six states have made CRE reportable, and three additional states are actively pursuing this option.” This is not a national response. This is a national tragedy. We can’t expect CDC to say they can’t handle the problem and we can’t expect states to say they can’t handle the problem. They are working their butts off with minimal support and no national will for a coordinated response. If we don’t have a national response soon – it will be too late, but I’m not holding my breath.

We are running out of time on this. But instead, our political betters are obsessed with long-range budget predictions that often turn out to be laughably wrong. But even if the sequester madness burns out (and there’s always the debt ceiling!), as Perecenevich notes, where the hell is the money going to come from, even if there were the will to do something?

Cataloging the apocalypse is getting old.

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1 Response to The Healthcare Crisis Is Still Not Budgetary: Once More Unto the CRE Breach

  1. Pingback: Hospital Infection and Profit | Mike the Mad Biologist

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