A hundred hands shot up when epidemiologists at a March meeting were asked if they made restraining antibiotic resistance a priority.
Every hand fell when Donald Goldmann, M.D., an infectious disease expert, rephrased his question. "How many of your hospitals," Dr. Goldmann asked, "have made control of antibiotic resistance a strategic priority?"
For decades, hospitals have been fighting a hard battle against the rise of drug-resistant bacteria. They watch the use of antibiotics, track resistant organisms, prod caregivers to wash their hands and take other precautions against the spread of disease.
Now, haunted by the specter of rampant, untreatable disease, experts are asking hospitals to fight harder.
"You can't just delegate this," said Dr. Goldmann, director of quality improvement at 349-bed Children's Hospital in Boston. "We should use quality improvement methods to look at the system issues that get in the way of control. This is something the whole staff must participate in."
About half the 2 million infections acquired in hospitals each year involve bacteria that resist some of the drugs that once vanquished them. And more hospitals are seeing patients who acquired resistant bacteria in the community or in other healthcare facilities, experts said.
The problem is age-old: Bacteria evolve to defeat their enemies, and the more often they face antibiotics, the more likely they will adapt to resist them. What's changed is that enough new antibiotics aren't forthcoming.
"Executives have got to be aware of the potential for changes in hospitals' ability to look at a simple infection as a relatively quick procedure," said Mike K. Roark, a pharmacist and vice president of medical affairs at Houston-based Owen Healthcare, which runs 250 hospital pharmacies.
Physicians' fears. In the nightmares of infectious disease experts, Staphylococcus aureus-the culprit most often behind skin and wound infections-will do in hospitals what it has done so far only in laboratories. It will learn to defeat its main foe, the antibiotic vancomycin, by picking up resistance from another common cause of hospital infections, enterococcus.
"If that occurs, it's a crisis," said David Schlaes, M.D., chief of infectious disease at the 752-bed Veterans Affairs Medical Center in Cleveland. "And I think that it's going to occur."
His conclusion is drawn from the growth of vancomycin-resistant enterococci, or VRE. The percentage of hospital-acquired enterococci that withstood vancomycin-as well as many other drugs-rose to 7.9% in 1993, from 0.3% in 1989, according to the national Centers for Disease Control and Prevention in Atlanta.
Last month, the CDC released draft guidelines urging hospitals to develop strategies to control the spread of VRE. It recommends education, infection control and prudent use of vancomycin. The CDC plan also asks hospitals to routinely test enterococci and S. aureus isolates for vancomycin resistance.
On their own, many hospitals are trying to use antibiotics, especially vancomycin, more cautiously.
One reason is cost. Antibiotics consume 40% to 50% of pharmacy budgets. Some U.S. hospitals spend one-fourth of that on vancomycin.
New guidelines. Concern about drug-resistance also is driving new antibiotic guidelines. For example, 290-bed Mount Zion Medical Center in San Francisco no longer recommends vancomycin as a treatment for infectious diarrhea because it fears that intestinal-tract enterococci will learn to resist it.
Yet, bacteria have outwitted years of guidelines and drug formularies. In the critical hours before the attacking microbe is identified, physicians treat patients based on their best guesses and their worst fears.
Better use of antibiotics might come from more communication between pharmacists and physicians. A few weeks back, Owen taught 380 of its pharmacists how to interview physicians about their reasons for prescribing drugs-an essential step to finding the best drugs. "Physicians don't use these types of drugs because they're trying to destroy your budget," Mr. Roark said. "They do it because they think it's right."
Other healthcare firms are grappling with antibiotic use outside the hospital, a more difficult task.
When cold and flu season brings a flood of prescription claims, Albuquerque-based benefits manager Diagnostek will watch how well physicians follow its recommendation to use the most specific antibiotic. Broader spectrum antibiotics cost more. They also teach more microbes to resist them through evolution or chemical changes wrought by the drug, said Terrance Killilea, a pharmacist and Diagnostek's senior vice president of clinical services.
"We want to be on the ball early," Mr. Killilea said. "If we overuse the advanced cephalosporins, we're going to render them less potent."
Other action prescribed. Controlling the use of antibiotics is but part of the cure.
Dr. Schlaes of the Cleveland VA wants behavioral science data on healthcare workers because they've defied infection-control recommendations for years. Scientists also want better data on the spread of resistance. Experts meeting at New York's Rockefeller University this year suggested that health systems and managed-care organizations might finance a more thorough tracking system.
U.S. hospitals might someday be forced to test patients for drug-resistant bacteria when they're admitted, a practice of some Australian hospitals, said Stuart Levy, M.D., of Tufts University School of Medicine in Boston. Dr. Levy is a longtime crusader for prudent antibiotic use.
His counsel raises this question: Is it enough for hospitals to do what they've always done, but better?
"This is a question we should be asking," said Frank Rhame, M.D., an epidemiologist at 553-bed University of Minnesota Hospital and Clinic in Minneapolis. "Should we be wearing gloves for all patient contact? Should we be taking more vigorous steps to assure compliance with hand-washing recommendations? Should we be changing the culture of patient care?"