Dr. Kemper Alston explains the “superbugs” that everyone is talking about, how to prevent them and what there really is to worry about. Listen to an interview or read the transcript below.
UVM Medical Center: For many, the term superbug conjures up a science fiction disaster movie, and while these bacteria that are resistant to antibiotics might not spell the end of the world, they do kill millions of people each year worldwide. About 23,000 Americans die each year from these bacteria, but it’s believed that the number is actually much higher, due to under-reporting by hospitals. So, how alarmed should we be, and what can we do to protect ourselves from these and other infectious diseases, and what are the pros doing to control this problem?
Here today with the answers is one of the pros, Dr. Kemper Alston, division chief of Infectious Disease and medical director of Infection Prevention at the UVM Medical Center. He’s also a Professor at the Larner College of Medicine. Dr. Alston is giving a presentation about antibiotic resistant bacteria, as part of the Community Medical School series on Tuesday, April 4th, at six o’clock in the Carpenter Auditorium on the UVM Campus. Thanks for coming.
Kemper Alston: Thank you.
UVM Medical Center: So, do you even like the term superbugs?
Kemper Alston: I think it’s important to realize that I think a lot of people think there’s one superbug, and of course, there’s not. Superbug has been a term that the media has latched onto. There are 10 or 20 different superbugs. You can make a whole long list of bacteria, often, but also viruses and fungi that have developed resistance to antibiotics and can cause life-threatening, invasive infection.
So, when we talk about superbugs, we talk about older things that we’ve recognized for a long time, like MRSA, or clostridium difficile, but we also talk about newer things, like CRE, which is the new player on the block the last few years. So, it’s not a particularly good term, because it describes a whole list of different bacteria.
UVM Medical Center: And, it doesn’t mean they are resistant to all medicines, but they’ve got to be resistant to at least a couple, is that right?
Kemper Alston: There are, I guess, two ways you could think about a superbug, if you will. One would be a bug that may not be particularly dangerous, but it just happens to be resistant to a lot of antibiotics, and we see some of those in the hospital environment. They don’t cause infections very often, but if they were to, it would be a problem because they’re resistant to a lot of things.
Another way to think about a superbug would be that it may still be susceptible to some antibiotics, but it’s very virulent. Meaning, it can be very invasive and cause life-threatening infections. And, of course the combination of those two -having a very virulent, dangerous bacteria which has evolved resistance to lots of antibiotics – would be the ultimate problem.
UVM Medical Center: So, a lot of people have heard about MRSA. Is that one of the most common or just one of the better known?
Kemper Alston: That’s one of the better known, because it’s been around since the 1960’s and has been a big problem in the United States since the 1980’s and that’s been a story of kind of relentless stepwise progress of increasing antibiotic resistance over decades. That will be one of the bugs that I focus on in my talk, if people are interested in hearing that story. It’s an interesting story. But MRSA – the SA stands for Staph Aureus – and that’s a bad bacteria. That’s the most common cause of infections in a hospital setting, and that strain of Staph Aureus has developed resistance to most of the commonly used antibiotics, so that’s a problem.
What people worry about most in this whole thing is this concept of a post-antibiotic era, where we would return to the idea that someone has an infection that’s essentially untreatable. And that’s happening in rare occasions around the world, where you might get a culture report back from the laboratory and all the 10 or 15 different drugs tested against a certain bacteria are resistant. It’s as if you were practicing in the 1920’s when you had no antibiotics to choose from. Mercifully, those situations are very, very rare here in Vermont, but in some bigger cities around the world, I think that’s happening with increasing frequency. And that’s what really got everyone’s attention.
UVM Medical Center: And then what?
Kemper Alston: And then what? You would try to use experimental therapies or perhaps go back to get very toxic drugs off the shelf that we haven’t used in years. That would be something we might try to do: treat people with non-antibiotic measures, supportive care, surgical drainage of an abscess, do everything we could, just like we did 75 years ago, to care for someone without necessarily having an active antibiotic.
UVM Medical Center: So in your view looking out the next few years, 10 years even, how likely is it that you think we’re going to get into this post-antibiotic era?
Kemper Alston: Well, I think it’s likely and my plea – both when I lecture to medical students and doctors in the hospital as well as the community – is just to think of antibiotics as being different. That’s really a key concept. People have to stop thinking that they’re just like any other drug that’s prescribed. Antibiotics have unique attributes. For one, they are all time-limited drugs. They all have expiration dates, and that’s unlike any other class of drug. And, every order we write contributes to their demise, which is unlike any other drug on the market.
There’s no antibiotic we have that targets the single bug that is causing your infection. The problem is, we hope that the antibiotic we prescribe kills what’s ailing you, but remember that it kills lots of other beneficial bacteria that we live with. So, it creates, oftentimes, as many problems as it solves, and clostridium difficile, for example, is an infection that we get because we took antibiotics. People think, “Why don’t we just give antibiotics all the time to everyone, and then we’d never get an infection?” But, of course, by doing that, we would disrupt the normal bacteria we live with to such an extent that it would set us up for more drug resistant infections, like clostridium difficile.
So, both for providers and patients, we have to come to the recognition that antibiotics are a treasured resource. They’re temporary – some are more durable than others and can hang in there for a couple of years or maybe even decades – but the more we order them, the faster they lose their potency. This is happening all over the world, where in some parts of the world, you can get antibiotics without even the doctor’s prescription.
UVM Medical Center: You’re listening to Dr. Kemper Alston. He’s division chief of infectious disease and medical director of Infection Prevention at the UVM Medical Center. He’s also a professor at the Larner College of Medicine. And on April 4th, at six o’clock, he’ll be presenting a talk about antibiotic resistant bacteria as part of the Community Medical School series.
For folks listening out there, it does sound like they should be worried. What can you tell them about what to do to reduce their chances that they’ll get into this situation?
Kemper Alston: One thing is to take general good care of yourself. For example, things like vaccinations. If you get a vaccine for pneumonia and you don’t develop pneumonia, then you won’t need antibiotics to treat that pneumonia. Stop smoking, manage your weight, manage your blood pressure, manage your diabetes, because people with diabetes are very vulnerable to infection. When they get prescriptions for antibiotics from their physician, they should follow those directions and take the full course of antibiotic. Obviously, don’t stop and start them, don’t share them with other family members, don’t take antibiotics on your own when they haven’t been prescribed. Simple measures like that.
The larger burden really is on the healthcare industry itself. We have to do a better job as physicians of prescribing antibiotics, because it’s well-recognized in the United States that a vast proportion of the antibiotics that are prescribed are unnecessary at best. If we could remove all those antibiotics from the environment, that would put less pressure on antibiotics resistance.
And we also have to do something about agriculture because, as you probably have heard, most of the antibiotics used in the United States are actually used in agriculture. They’re not used for human health. And those antibiotics shape the bacteria that animals carry, which then enters the food supply and are, ultimately, transmitted to patients.
UVM Medical Center: In some cases, like MRSA, people acquire it in the community and they walk into the hospital with it. But a lot of this is what happens once they are in the hospital. I want to ask you, as the head of Infection Prevention for such a long time, what are the main strategies that you folks employ to try to contain any infection that might start spreading around?
Kemper Alston: There are certain fundamental things. For example, hand hygiene. We use an alcohol hand rub now, mostly more than soap and water hand washing. We Isolate people with certain significant bacterial infections that are resistant to antibiotics. Meaning, they get a private room, healthcare workers wear gowns and gloves, sometimes masks to care for them, so that they don’t become contaminated, and then take that bug to the next room and contaminate the next patient. Cleaning of the hospital environment and disinfection of all the equipment – computer terminals, the blood pressure cuffs, all the devices, the stethoscopes. Everything that comes into contact with patients. The wheelchairs, the stretchers, the call bells, the telephones, the bedside rails, the toilet handles. Everything that patients come into contact with have to be really decontaminated, or else these organisms will just spread from patient to patient. That’s perhaps the biggest challenge in infection prevention, which has emerged in the last 10 or 20 years, has been cleaning of the environment.
That’s really a challenge, because as anyone who’s visited or been in a hospital lately knows, you know that it’s crowded with people and it’s crowded with equipment, and a lot is happening very quickly to allow the person to go home as soon as possible. And all of that stuff in the healthcare environment can be a source of contamination.
UVM Medical Center: One thing that we do here -in addition to having a great Environmental Services staff which has been trained and they’re monitored and they have some actually low-tech ways of knowing whether or not the room is clean – we also have a little thing that you wheel in there and it blasts rays of ultraviolet light. Now what’s the story with that?
Kemper Alston: Yes, it’s referred to as The Robot. And of course, that’s a terrible name, because it’s not a robot, but it looks a bit like a robot. It emits ultraviolet light, and ultraviolet light kills bacteria. So that’s used for high-level disinfection of a room, where a patient with a bad bug, like clostridium difficile is discharged home.
In addition to standard room cleaning before the next person is admitted to that room, we can bring this machine into the room and it emits ultraviolet radiation, which essentially can kill every bacteria in the room and essentially sterilize the room before the next patient is admitted. We have a couple of these machines that we deploy throughout the healthcare environment to try to add that extra measure of disinfection and safety for our patients.
UVM Medical Center: In terms of all of this detail that people have to pay attention to – with all these surfaces you’re talking about, and the gowning, and gloves – how do you do that? Because you’ve got more than 1,000 nurses here. You have all kinds of other clinicians. How do you make sure that people have that top of mind and actually do it?
Kemper Alston: Well, you can’t. We can’t be at every patients’ bedside, monitoring every encounter with a healthcare worker all the time. It’s impossible. So we do a lot of training and a lot of education. Then we do monitoring. We walk around and make observations and we record those observations and feed those back to try to see where there’s unsatisfactory practice, and try to improve that practice. But, the problem is, all of this is microscopic. None of it’s visible to the naked eye. It’d be easy if you touched a patient and didn’t wash your hands, and there’d be a red mark left on the patient’s arm or something. Some visible evidence of what had happened. But, of course, it’s not like that.
If it’s a medication error or something like that, you can look at the whole chain of events in the medical record and figure out where system broke down, and what system failed that might be fixable. With infection prevention, that’s impossible because we never know who brought them that bug, and how that happened, and who failed to wash their hands. So, it really takes tremendous discipline, because employees have no immediate feedback and no way of knowing whether they’ve contaminated a patient or not.
It’s up to their training, and their discipline, and their absolute dedication to their patient safety that they wash their hands every time. And that the equipment they’re bringing to the patient bedside to use on that patient has been properly disinfected. That’s the challenge of modern infection prevention and healthcare safety, and we all struggle to maintain that discipline and that perfection of practice.
UVM Medical Center: You guys have a good track record here.
Kemper Alston: We do. I mean, I think for an academic medical center, we do well. And when we benchmark nationally and benchmark against other hospitals – I think we’ve had our successes and we’ve had our shortcomings – but I think we have a good program. We’re blessed here that the administration and the Jeffords Institute for Quality are really strong supporters of our group, and that’s huge. We have eight people directly working on infection prevention here, which for a hospital this size is a lot.
Obviously, we collaborate with departments throughout the hospital, and ultimately we work with all employees, but those dedicated to working just on infection prevention here, we have about eight people. We get tremendous administrative support, and when we’ve asked for something or asked for help from the administration, we’ve always gotten that support. That’s very satisfying and gratifying, that the hospital is dedicated to that program, but it’s an ongoing challenge.
UVM Medical Center: You have your hands full — your very clean hands are full with infection prevention. If you want to learn more about this fascinating topic of antibiotic resistant bacteria, you can go to the Community Medical School presentation on Tuesday, April 4th. That’s in the Carpenter Auditorium on the UVM Campus at six o’clock, and you’ll be able to hear from Dr. Kemper Alston, who has been our guest today. He is the chief of Infectious Disease and medical director of Infection Prevention at the UVM Medical Center. He’s also a professor at the Larner College of Medicine. Thanks very much for joining us.
Kemper Alston: Thank you.
UVM Medical Center: If you want to learn more, by the way, about that lecture, you can go to uvmhealth.org/medcenter and you can do a quick search on Community Medical School.