‘Hospitals should use alcohol for handwash’

Dr John Paul Quinn

Dr John Paul Quinn, Attending Physician for Cook County Hospital in Chicago, is known world over for his outstanding contributions in the field of infectiology. Dr Quinn has written scientific articles on varied topics, which include clinical problems caused by multiresistant gram-negative pathogens, clinical significance of extended-spectrum b-lactamases, strategies to be followed for serious infections and most importantly his work on the infections networks on IDSA, which is the long-term suppressive anti microbial therapy for intravascualr device related infections. He is part of the advisory board for the Merck & Co and plans to carry out trials based on emergence of resistance in VRE as one of his forthcoming projects. On his maiden visit to India, Dr Quinn spoke to Sapna Dogra about his research, various strains in infection and his de-escalation theory in antibiotics.

Tell us what brings you to India.

I have been invited by the ‘Infectious Disease Society of India to share my experience on antibiotic utilisation and antibiotic resistance.

Tell us about your research activities.

My lab is primarily interested in mechanism of resistance in pathogenic bacteria. And majority of our work is with the gram-negative bacteria. In the gram negative world, the antibiotic class that is used most commonly to treat serious infections in a hospital is beta lactam family of drugs. We also do lot of clinical trails with new antibiotics like depthomycin.

What are the common infections on the rise across the world?

We divide infections in two groups; first occurs in a community in healthy people and second one in a hospital environment. People like me, who are involved in research, don’t get involved in community acquired infections, but we concentrate on infections acquired in hospital environments or nosocomial infections. In the US, at my Chicago hospital for the first time this year, we saw majority of strains of staphylococcus. This appears to be a new strain, which is a genetically unique, spreading over the world.

What about the presence of gram negative bacteria in India?

The amount of data published on gram negative bacteria from India is very less to make any kind of general statement. Though extended spectrum beta lactmase (ESBL) has been reported here, an enzyme in the bacteria makes the bacteria resistance to antibiotics. The presence of an ESBL-producing organism in a clinical infection can result in treatment failure, if certain class of drugs is used. ESBLs can be difficult to detect because they have different levels of activity against various cephalosporins. Thus, the choice of antimicrobial agents is critical.

Why resistance to antibiotics is on the rise?

Rampant misuse of antibiotics in India could be the reason. Also, like many other developing countries, here also antibiotics are easily obtainable without prescriptions and people use them indiscriminately, which results in increase resistance. Even in the US, more than half of antibiotic prescriptions are unnecessary. Now there is a growing awareness against the misuse. Another possibility is inadequate hygiene, for example spread of germs from patient to patient from the hands of the medical practioners, which is a problem all over the world. Studies conducted in Switzerland have shown that caregivers forget to wash their hands more than 50 per cent of time from patient to patient. This is also true in the US. Though I am not aware of the situation in India, I assume that if more than 50 per cent of doctors in Europe and the US are not washing their hands properly, then condition in India will be just the same.

Please throw some light on your de-escalation theory with antibiotics.

There should be optimal treatment strategies for multi-resistant pathogens. The emphasis should be on “getting it right the first time.” Here a strategy of de-escalation seems to make the most sense to preserve the likelihood of adequate initial coverage, while avoiding excessive selective pressure with broad-spectrum regimens. An aggressive empiric therapy is selected upfront to cover all likely pathogens, taking into account host, setting and local resistance patterns. Culture results and clinical response are reassessed at 48 hours. Antibiotic coverage is narrowed as appropriate.

Do you think the resistance to antibiotics is going to increase further?

Antibiotic resistance in a community and hospitals are definitely going to increase. Healthcare providers have to make provisions to bring down the infection rates own their own. There are some success stories in communities around the world. For instance, there have been some publications showing national campaigns to try to diminish the rampant use of anti-microbial in the community. It has been successful in Canada. However, for combating antimicrobial-resistant gram-negative bacteria, very limited weapons are coming from medical companies. On the gram positive side, we have a bunch of new drugs like deptomycin for treating resistant gram positive infections. But there is nothing similar in a gram-negative world, therefore, resistance in gram negative bacteria, I am afraid is not going to go away.

How can infections in hospital environment be prevented?

A team at the Johns Hopkins Institute has recently published a paper saying that extremely meticulous attention to the insertion of central venous catheters in ICU can reduce the infection rate to zero. It is an extraordinary work, which is difficult because you have to train every single person and you have to watch them perform and punish them, if they go wrong. It is quite labour-intensive but it woks dramatically. Another low-tech example that is successful in lowering infection is using alcohol while washing hand instead of soap. In the US, alcohol in hospitals is a mandatory requirement because it is a federal requirement. Also, positioning a ventilated patient at a particular angle can also decrease the infection rates phenomenally.

sapna.dogra@expressindia.com