Steering the Antibiotic Enterprise

Today there have been multiple media stories regarding the misuse of antibiotics in hospitalized patients and the risk that this practice poses. Not only does it waste money, it sets up a scenario in which infections such as Clostridium difficult thrive. 

C.diff, as it is colloquially known, is a bacterium that can cause a range of symptoms from diarrhea to life-threatening intestinal perforation. It also adds significant days onto a hospital stay, can spread to other patients, and is expensive. 

The media attention is focused on a report from the CDC which studied the use of antibiotics in hospitals. What the CDC found is alarming:

• Over 50% of hospitalized patients receive an antibiotic of some sort
• Scrutinizing the use of vancomycin and the treatment of urinary tract infection revealed that treatment could have been improved in close to 40% of cases 
• Antibiotics prescribed for urinary tract infections were particularly egregious with many being prescribed without a definitive diagnosis (i.e. no symptoms, no culture ordered)
• Using mathematical tools, it was found that a 30% decrease in antibiotic use would decrease C.diff rates by a similar amount

The bottom line of this report is that antibiotic stewardship--something that is part of the daily routine of every infectious disease physician--is a key component of controlling the rates of C.diff, improving cost-effectiveness, and improving patient care. 

Vaccine Education Can't Cure Irrationality

A recent study on vaccine education yielded a paradoxical result. In those less likely to vaccinate their child, information aimed at illustrating the benefits of vaccines and debunking the fantastical "link" to autism actually strengthened their resolve against vaccines.

What this illustrates to me is that once one has committed to an irrational fixed belief, rational persuasion is not something that can be effective. Anti-vaccinationists, by their very position,  have declared that reason, logic, and evidence hold no sway with them. Because the benefits of vaccines are unequivocal and manifest for all to see, willful evasion must be occurring on some level. 

The anti-vaccine movement began, not in the modern era, but with the 1st vaccine (Jenner's smallpox vaccine). Today's movement is nothing more than an extension of that primitive phenomena which has, since its inception, stunted mankind's progress.

Nazi Mosquitoes?

When people discuss historical uses and development of biological weapons, much emphasis is rightly given to the Soviet, US, and Japanese bioweapon programs. However, there are some other efforts that are very notable but little discussed, including those of Germany.

While most know of Germany's efforts, led by Anton Dilger, to infect American horses bound for the war with glanders (in Baltimore) not much is known about further German efforts. There is a general consensus among scholars the German Chancellor Hitler's experience with chemical weapons as a solider in WWI largely biased him against chemical and biological weapons.

A recent news article, however, reports National Socialist Germany's efforts under Heinrich Himmler to use malaria-infected mosquitoes during WWII. The article reports that the mosquitoes were bread, but not deployed.

As a bioweapon during a war, I tend to think mosquitoes would be a poor choice given the unpredictability of their flight patterns which could easily place one's own soldiers at risk. Moreover, malaria is a treatable and recognizable condition making it less attractive. 

However, entomological warfare with the covert release of mosquitoes infected with, for example, dengue (as Fidel Castro accused were used against him) might work to create havoc and make a region inhospitable for living. As such, it is a concern that merits consideration.

Don't Fear the Leper

Leprosy, or Hansen's Disease, is a term that strikes fear into the heart of everyone, almost exclusively in those who know little about the disease. Since biblical times, lepers were casted outside of society and interaction with them was minimized. Leper colonies were created, even in the US. 

One of the most infamous of these colonies was on the island of Molokai in Hawaii. This colony, which was the result of a forced segregation policy, lasted for over 100 years until 1969. This colony has been the subject of at least two books and a film focused on the experiences of Father Damien, a  Catholic priest who resided there and ultimately became infected, was also made. I saw the film last night and found it interesting and instructive to those interested in the history of this disease.

However, leprosy is not easily spread between humans and since the 1940s--prior to the ending of forced segregation--effective antibiotic treatment has been available. In my experience, I have only known of one case in the Pittsburgh area in an immigrant, who did not spread it further. 

Like HIV thousands of years later, leprosy illustrates that fear of infectious disease has been a recurrent theme and will likely continue so long as novel infectious diseases continue to appear--a safe bet.

Your Friendly Neighborhood Live Vaccine

A really intriguing study suggesting a non-specific general health effect of live vaccines was just published in JAMA. 

The study compared a half million children immunized with the MMR vaccine as their most recent vaccine compared to DTap-IPV-HiB. The hypothesis tested was that MMR, with its live components, would have a non-specific immune enhancing effect due to greater immune stimulation than with the killed vaccine. To assess this the incidence of hospitalization for any infection was determined.

The researchers found a statistically protective effect (IRR 0.86) with those who received MMR as their most recent vaccine.

What this study may have uncovered is a non-specific immune boosting effect of live vaccines. If true, it may mean that live vaccines should be placed in the immunization schedule at the times most opportune to provent childhood morbidity, as suggested by an accompanying editorial.

Further, the animus that the anti-vaccine movement has against live vaccines has again shown to be completely unfounded and not reality based.