Frightning Dangerous Little Beasts in the Hospital. Report by Siegfried van Hoek

Epidemics with resistant micro-organisms are causing more and more problems in Dutch Hospitals as turned out with the recent epidemic in the hospital 'Maasstad Ziekenhuis'. These `super-bugs` are able to spread rapidly and in some cases they are not treatable. In the Rode Hoed Wetenschaps-caf (Science-cafe) on Monday November 28th the doctor and micro-biologist Miquel Ekkelenkamp will explain what kind of `super-bugs` we are now suffering from, what is standing up against us in future and what we can do about it. Source: rode hoed: http://www.rodehoed.nl/nl/programma_details.php?id=1091This is a report of the lecture of November 28th 2011 in the Rode Hoed in Amsterdam about Antibiotics-Resistance held by Dr. Miquel Ekkelenkamp, micro-biologist, physician, and novelist. The lecture was introduced by Mr. Simon Rozendaal medical journalist who in consent took care nicely of the communication with the listeners in the hall (concerning questions and remarks). Differently from what I was at first expecting, was the main part of the lecture being information about the development of viruses and the development of anti-biotic (AB) and the inherent gradual occurrence of resistance against those AB's in reaction upon by the micro-organisms, in stead of the practical issue for hospitals to deal with resistant bacteria's. The fact that a lot of attention is put to the other aspects is understandable, but indeed I was hoping for/ thinking that this was the very thing (with the recent history of at first keeping silent of a MRSA-epidemic in the Maasstad Ziekenhuis in mind) to get to know more about in this very subject nevertheless.

As widely known it is impossible to think a contemporary medical practice without anti-biotics (AB), being a heroic killing remedy against infections. In 1940 Alexander Flemming (bacteriologist) was the discoverer of AB in the form of a molecule excrement-ed by a mold being processed as a medication is called penicillin. AB literally could be translated as 'against - life'; in this case against the life of (infection-) disease-causing mono-cellular organisms (bacteria's). In his days Alexander Flemming was already warning against the development of resistance against anti-biotics by micro-organisms and with that the development of the resistant organism (in evolution). While in 1940 most of the micro-organisms being fought with penicillin were susceptible for the treatment, nowadays 80 to 90 % of the current generations appeared to be unaffected by. Analog to the development of more powerful AB there also arose a variety of combinations of resistance against several up-following kinds of AB under the population of micro-organisms. Likewise -analog to the development of AB- from Penicillin (1943) -> Metillicine (1962) -> Vancomycine (1997) also came different kinds of resistant bacterias in combination with resistances for several kinds of AB or not. At final Dr. Ekkelenkamp mentioned shortly about recent developments in research that are going with the matter mitomycine, but this is a product which is allowed to be prescribed solely by a medical practitioner experienced with treatments of fighting cancer(!) only.

The problem with multi-resistant hospital-bacteria's is that they can live in the hospital environment (anyhow), as well as they can live outside the hospital. Apart from the resistance-issue there is another problem in the use of AB: the intestinal bacteria called Clostridium Difficile may start to predominate the intestinal flora because other to the digestion favorable bacterias have been killed by the AB, by which that mainly remaining kind of bacteria may cause diarrhea or further complications (toxic mega colon) by being in the upper hand. And do notice: That Clostridium is counted under the top-five of the hospital resistant bacterias as number five. On number four we have the so called ESBL (named after the piece of DNA what is residing within the bacteria) which is in appearance under many poultry chickens as a bio-industrial consequence. Dr. Ekkelenkamp made the remark about keeping separated the locations where chickens are held far away apart from the slaughter room in order to fight back bacteriological feedback, so resistant bacterias could not find a new living host in situ, and etc are not able to develop accelerated. On the third place is the Multi-resistant A-Cinto-Bacteria, followed by the CarbaPenemase as number two of the top five of the hospital resistant bacterias. This CarbaPenemase bacteria is the worst ESBL and is resistant against all (contemporary known) AB. Hospitals in Greece and Turkey would have quiet some problems with this kind of bacteria. But on the first place stands the on all sides notorious MRSA which is going around including its evolution starting from the seventies. The latter named is meaning the highest rate of death caused by infection with in consequence.

Next to the resistance of the bacteria by the bacteria itself in evolution, there are three other mechanisms to be called to spread resistance: next to the natural selection within the patient which bacteria will survive with its host and also next to the resistance-exchange of bacterias 'inter-club' mutually, there also is the opportunity of spreading the bacteria under patients mutually, with a profit (in survival) for the travelling bacteria with its increased resistance in comparison to other bacterias.

In order to be able to fight the bacteria and its resistance it is essential to study the development, function and the composition of the bacteria in itself. Likewise it is known that a bacteria is carrying a circular bound of a little piece of DNA, being actually extra-chromosomal (comparison: a human being has 46 complete chromosomes (in 23 pairs with DNA strings). That little piece of DNA may contain a gen with information on AB-Resistance. The exchange of that little piece of DNA is very part of the development of AB-resistance. Dr. Ekkelenkamp in here made also the comparison with viruses concerning the exchange of gen-information. (ie: an interesting efficient little piece with further explanatory information is on: http://www.platformgentechnologie.nl/genetech/thema_intro/cursus_genmanipulatie.shtml {On this Dutch site they are also telling about how Genetically manipulation manipulation is possible either with a promoter coming from viruses or with the plasmid (ESBL) of the bacteria that is allowing to be copied and exchanged easily. And in our story namely the plasmids (exchange) are the cause of the rapid spreading of resistance (information) against AB under bacterias.} This also points out immediately that the spreading of resisting-gen-information is not limited to the hospital related environment.) In comparison about resistance as a process there was also referred to Ernest Hemingway: a slow development of resistance, which all of a sudden is showing itself with a decrease of the effective function of the AB. That silently sneaking development unfortunately and however can only be noticed as a signal afterwards by/because of in result.

Anti-Biotics are not only applied to fight an (acute) infection, they also can be applied because of for a preventive motive, but also then the choice of the correct AB is important and the treatment may become more complex because of the intention of preventing complications infection (at risk) as with tissue/organ transplantation, placing appliances including pacemakers, or even in the support against immunity-lowering diseases as for instance the intestinal disease of Crohn. Dr. Ekkelenkamp gave another very practical example to apply AB preventive, namely at trans-rectal punction of the prostate (biopsy), (via the rectal path through (the anus) the prostate is reached best over the shortest distance), because such a punction in the utmost consequence could even cause blood poisoning easily.

Whereupon Dr. Ekkelenkamp showed some schemes and diagrams in order to make the development of the resistance visible, a problematic issue that in history showed an exponential acceleration (, the euphoric days from before the seventies that we were master over all bacteria was far behind us, because in a decennium of time after resistance started to be visible exponential), followed by an overview of financial costs of AB (cure). It is unnecessary to mention that the 'big boys' were also (also with scale enlargement) the most expensive ones. (Out from the hall the critic then appeared that the graphics about the effective activity of a kind of AB also contain a subjectivity of marketing and that the effectively could be actually even much more marginal before resistance is recognized then is suggested.) The issue is to choose the correct AB, because the appliance of the correct AB is also slowing down the process of developing resistance against AB. For it is not preferable to put in the strongest AB available, because this otherwise would just help to increase the development of a resistance on/in scale. Therefore it is necessary to define what kind of infection we are dealing with, and to what AB that bacteria is/or is not resistant. There above, resistance-infections are additional to regular infections that may occur at the same time. Resistance is coming by horse and by foot. Being thrifty with AB treatment is nowadays the starting point, but in the case of complex operations and situations of a serious life-threatening endangerment like the risk of blood poisoning etc of course directly is applied for the (very strong) sufficient AB.

Prevention (of spreading of resistance) is therefor nowadays the keyword. A hospital with a weaker prevention also has an exponential larger increase of resistance (factors) then a more 'cleaner' hospital. In earlier days they were thinking that resistant bacterias were to be found in hospitals only. Nowadays we know that ESBL is also to be found at home, also urine cultures are showing out. ESBL is also to be found in chicken food. The Netherlands is using the highest amount of AB in animal-meat-production, because it is not allowed to radiate the meat. The reasons for this are including and also of economical kind. But at the same time with regards to its human inhabitants the Netherlands is carrying out a more stringent awaiting policy (with quarantine) with regard to the appliance of AB (then for instance Scandinavia) in order to counteract on the development of resistance. Nowadays there is even a standard protocol for each hospital, while in the past there were indeed large differences among according to. And now, when an infection with resistant bacterias is found at two patients at the same time/place or more this is already seen as an epidemic situation. The incident in the hospital 'Maasstad ziekenhuis' with neglect of duty is in this contemporary time therefore seen as a condemnable business because they did not undertake any action at first, not just towards the victims, but also against the spreading of the bacteria and its resistance. Isolation of resistant bacterias is thus a very important point. Abroad they are faster in applying AB. In the prevention (of spreading) , in the Netherlands, quarantine (in a hygienic situation) is seen as the most important. Inspection of the patient for the existence of the bacteria has to be done at the very patient first, and thereafter upon the surrounding environment. If the surrounding is not contaminated, the patient has brought the bacteria with. So isolation can act effectively, but what is happening outside the spheres of higher levels of care? Next to the financial cuts in the healthcare budgets this is also showing out in the cuts on cleaning facilities next to the increased pressure of work by which in care techniques hygiene also is getting under pressure... etc. Hereupon a former (retired) surgeon made the remark out from the audience that there is also an issue of care-inertia. Not washing hands before entering the OC was indeed a clear example of already, but the surgeon also mentioned the forsaking of the medical obligation to wax the nose with desinfecting creme. ( The noise is the biggest carrier of bacterias next to the throat and the intestines.) A good antisepsis is of importance got Dr. Ekkelenkamp to know, but a 100% achievement is impossible. The patient nowadays as part of the food-chaine is carrying the stronger bacteria with. But the reputation is that hospitals indeed act too late, and Dr. Ekkelkamp is therefor thinking that commercial hospitals would better because next to money lifesaving is defining. (ie: In that case first something has to change with the cult of silence around medical injury of harm and the right to refuse answer questions at the court in front of the judge..., for otherwise this measurement would even result contrarily).

AB (in gaining heavier weight for treatment) is according to Dr. Ekkelenkamp thus not the answer but preventive handling and care-efficiency are, where with at the same time the pharmaceutic industry keeps on working on the development of new AB in order to give answers with policy too a continuous development of AB-resistance. But a a new AB however is a short term effect, next to that there is a financial issue on the financing of the costs for research and the market forces of the product to be sold, where with the investments have to be earned back, which may take a selling-trajectory of twenty years and what may create a delaying/postponing effect / or either another effect on developing out a medication to the end due to the financial perspective in relation the issue of resistance.

Dr. Ekkelenkamp also made some closing remarks, like as the proposal that the WHO could take over the inspection of hospitals, by which on a macro-level-scale likewise more insights are to be gained on the development of resistance of bacterias. At last he pointed out a remark about also the relativity of the issue that is turning pale with the urgency that in India is going on where a thousand children die each day, while over here we are worrying about a man with a pacemaker (after -in general- having had lived a life of a far more higher quality) and the risk of a resistant bacteria in consequence of his treatment. In back view I think that the lecture mainly was showing the issue of anti-biotic-resistance being complex, but also stressing on the issue of the importance of handling prevention, care-efficiency, and the counter acting on care-inertia, they all have to stand at front, because in due course AB will become as dangerous for ourselves as for the little beast that started its power-gym from 1940....

Concluding: The most dangerous frightening little beasts are to be recognized wearing a white coat having a rather casual attitude with problematic concern around anti-biotic-resistance..., followed with notification by the mono-cellular (meanwhile AB resistant) varieties of.