Resistance to antibiotics is often described by neo-pagans as
Mother Nature’s vengeance on Man for having had the temerity to interfere in
her natural biological processes. According to the neo-pagans, this vengeance
has left Man (deservedly) worse off than if he had never discovered antibiotics
at all. I do not see the logic of this.
There is no doubt, however, that bacterial resistance to
antibiotics is a serious problem worldwide. It is particularly serious in
hospitals, where patients may pick up infections that they never had before
admission. Many patients die from these infections, which may be of epidemic
proportions.
The most important such infection is MRSA, methicillin-resistant Staphylococcus
aureus. (Methicillin is a semi-artificial penicillin that was developed
when the Staphylococcus first became resistant to ordinary penicillin,
and soon met with resistance itself.) MRSA accounts for most post-surgical
infections; the proportion of patients infected by it is often taken in
research as a measure of a hospital’s hygiene.
An important paper in a recent edition of the New England
Journal of Medicine compares various strategies for reducing the spread of
MRSA in intensive care units, a common place for patients to become infected.
The method of control usually employed is to screen patients for
MRSA on admission to the ICU and to institute special precautions such as
isolation and barrier nursing if they test positive. The authors compared this
method with attempts by means of antibacterial products at “decolonization” of
those who tested positive, and similar “decolonization” practiced on every
patient admitted to an ICU irrespective of whether or not he tested positive
for MRSA.
The authors then compared the overall rate of blood-borne
infections with MRSA between the groups. They found universal decolonization –
the prophylactic use of antibacterials regardless of whether or not patients
were initially infected – was by far the most effective, with decolonization of
those initially infected next best, and the method most widely used around the
world — isolation and special nursing precautions — the least effective.
One of the reasons for the superior efficacy of universal decolonization
might have been that those who were infected with MRSA on admission were
disinfected straight away rather than after a delay while laboratory results
were awaited, and thus the offending organism had no opportunity to spread in
the meantime.
The authors estimated that 54 patients under the scheme of
universal decolonization had to be treated in order to prevent one blood-borne
infection. The cost of universal decolonization was $40 a head: that is to say,
one blood-borne infection was prevented at a cost of $2160. If, as seems likely
(though the authors are hesitant on the point), such an infection involves the
extra expenditure of more than $2160 per patient, then universal decolonization
would lead to economic savings as well as – presumably – to less suffering.
(Additional savings would be made by the need for fewer initial laboratory
tests.) The trial was not large enough, however, to determine whether any lives
would be saved by universal decolonization and if so, how many. It seems to me
likely, though, that lives would be saved.
The neo-pagans, however, could take some comfort from a caveat
issued by the authors. If universal decolonization were instituted, as seems to
be the logical practical consequence of the experiment, the bacteria might develop
resistance to the products (chlorhexidine and mupirocin) used to disinfect.
Indeed, there is already some evidence that this is happening. Thus victory
over bacterial infection is only temporary, not final and probably never to be
final, given the genetic flexibility of bacteria; medicine is thus an aspect of
Man’s Promethean bargain. But temporary victory is to be preferred to perpetual
defeat.
*****
Theodore Dalrymple, a physician, is a
contributing editor of City Journal
and the Dietrich Weismann Fellow at the Manhattan Institute.
His new book is Second Opinion:
A Doctor's Notes from the Inner City.
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