PHOTO ILLUSTRATION BY KIP AOKI / KAOKI@STARBULLETIN.COM Can we win Hawaii doctors and patients are being enlisted in a war against enemies closer to home than Osama bin Laden, al-Qaida or Saddam Hussein.
the war on bugs?
Infection-causing germs prove
increasingly resistant to drugsBy Helen Altonn
haltonn@starbulletin.comThey are germs that fight back against drugs and multiply, creating the potential for untreatable illnesses.
Resistance of infection-causing bacteria to antibiotics is increasing at an alarming rate, warn infectious-disease specialists, calling it a national public health emergency.
Hawaii is worse off than many mainland areas for spreading bacteria because the organisms thrive in the hot, moist climate, water and beaches, the doctors point out.
"This is a form of biological warfare we are waging against microbes," said Dr. Alan Tice, associate professor at the University of Hawaii medical school and consultant in infectious diseases at Queen Emma Clinics. "The bacteria seem to be winning an escalating battle."
Dr. Thomas Hooton, infectious-disease specialist at the University of Washington School of Medicine, said some experts predict that "we may be entering a post-antibiotic era where we have limited ability to treat some of these infections."
Used correctly, antibiotics are powerful, lifesaving drugs, but overuse of the "miracle drugs" has led to multiple, drug-resistant bacteria, the doctors say. Already difficult to treat with antibiotics are tuberculosis, gonorrhea, malaria and childhood ear infections.
About 30 island health leaders and infectious-disease specialists, including Dr. Paul Effler, state epidemiologist and chief of the Health Department's Communicable Disease Division, recently alerted island doctors and health-care administrators to the "urgent health issue." They asked for help in increasing public awareness of the situation.
Of greatest concern, they said, is the increase of penicillin-resistant Streptococcus pneumoniae bacteria, which cause pneumonia, inflation of the ear, meningitis and other invasive infections. The greatest impact is in young children, they said.
Recent reports of infections caused by resistant strains of Staphylococcus aureus also are a critical concern. Once largely confined to hospitals, Staph aureus has spread throughout communities, the doctors said.
"It is a terrible human pathogen, probably the worst," Tice said, predicting "more and more resistance" to antibiotics. "We may have to hospitalize more patients or give them Zyvox (a new antibiotic) at $100 a day (for two pills).
"We're investing billions of dollars in systems to try to defend ourselves from biological agents like anthrax," Tice said. "How many died from anthrax so far? Five. How many die every day of MRSA (Staphylococcus aureus)? A hell of a lot more than that."
As bacteria once easily treatable become antibiotic-resistant, infections begin occurring that "you need to pull out big guns on," Effler said. "That involves potential side effects."
Patients often are part of the problem because they demand antibiotics that may do no good and could be harmful, the doctors said.
"When a person is ill, they want something that's going to make them feel better," Effler said. "If the doctor says it's only a virus that will get better on its own ... the patient's perception a lot of times is, the doctor doesn't know what he's doing ... so there is a lot of pressure on doctors to make sure the patient is happy and well treated.
"It's a big job educating the public that antibiotics may not be the best thing for you."
Patients should know that antibiotics do not work for viral illnesses, such as a common cold, flu (influenza) or mononucleosis. They are only effective for bacterial infections, such as suspected pneumonia, strep throat and a prolonged cough that may suggest a specific illness like sinusitis.
But viral symptoms can resemble those caused by bacteria, so doctors often are confronted with a "gray zone" in diagnosing an illness, the specialists say.
There is no swab test to distinguish between viral and bacterial infections, "and we'll probably never have one because we're all colonized with bacteria," Hooton said.
What is the difference between viruses and bacteria?
Viruses are genetic material in a capsule that have to live inside a cell of the body, Effler explained. "They have to use the cell's machinery to replicate themselves. They can create lots of copies of themselves and spread one to another."
Bacteria, on the other hand, are "free-living organisms" that use their own machinery to make copies, which is why antibiotics can work on them, he said. "We can design things to disrupt their growth processes."
The Hawaii Medical Service Association sponsored a two-day seminar for doctors last week with Tice and Hooton discussing "Appropriate Antibiotic Use."
Hawaii is a gateway for resistant organisms from Asia, where antibiotics are sold over the counter and resistance is much higher, said Dr. John Berthiaume, medical director of HMSA's Health Plan Hawaii.
"There is a concern that pharmaceutical companies won't be able to keep up with new antibiotics to stay ahead of bacteria," he said.
Tice said HMSA showed "remarkable foresight" with a 1998 project collecting data on respiratory infections among 600,000 members.
It showed antibiotics were given in 10,336 cases out of 29,020 office visits for what were theoretically nonbacterial problems, he said. HMSA followed with information to doctors in 1999-2000 about appropriate use of antibiotics.
The Health Department has a variety of free educational material about antibiotics to doctors and health-care providers. For further information, call Effler at 586-4586 or e-mail epi1@mail.health.state.hi.us.
