Pioneering Ideas

C. diff Infections: Worse Than We Thought

BY RAMANAN LAXMINARAYAN, PROJECT DIRECTOR, EXTENDING THE CURE

Infections caused by the dangerous microbe Clostridium difficile, or C. diff, are much more prevalent in hospitals and health care facilities than previously reported, according to an investigative front page story in last week’s USA Today. This bug is most often seen in hospitals, nursing homes, and other medical facilities. It causes severe diarrhea and intestinal problems that can worsen and even be fatal. The story cites a scientist from the Centers for Disease Control and Prevention who says annual fatalities may be as high as 30,000 per year, more than twice as high as some recent estimates.

The article accurately points to many reasons for this problem. Many hospital infection control programs aren’t stringent enough and C. diff reporting rates are poor. Hospitals need to be more prudent in their antibiotic use. C. diff thrives when healthy bacteria usually present in the intestines are wiped out by certain antibiotics patients take. In the absence of these healthy bacteria, C. diff can take over. 

The problem is exacerbated by the overuse of antibiotics, often in place of effective infection control. All health care providers – in health care facilities and in the community –  must use antibiotics prudently in order to slow the rate at which these powerful drugs become ineffective against C. diff, MRSA, and other dangerous bacteria.

We know that the evolutionary battle with microbes is, by nature, a losing one. Bacteria will continue to become resistant faster than our efforts to stop them. So as current antibiotics become ineffective, we need new drugs at the ready. However, efforts to bring new drugs to market need to be coupled with plans to conserve their use to maintain their effectiveness.

In order to get to the root of a problem like C. diff, we need comprehensive solutions that address not just antibiotic overuse but also infection prevention (such as vaccination) and infection control.

Check out new research from Extending the Cure showing how overuse of certain antibiotics correlates with C. diff deaths and hospitalization rates in the United States.

Read about the economics of drug resistance in a recent cover story featured in the Milken Institute Review by Ramanan Laxminarayan.

Follow Extending the Cure on Twitter @ExtendgtheCure.

Ramanan Laxminarayan is director of Extending the Cure, a research effort that examines policy solutions to address the growing problem of antibiotic resistance. The project is based at the Center for Disease Dynamics, Economics & Policy (CDDEP) in Washington, D.C., and is funded in part by the Pioneer Portfolio of the Robert Wood Johnson Foundation.

Happiness is Hot

BY PAUL TARINI, SENIOR PROGRAM OFFICER, PIONEER PORTFOLIO - @PaulTarini

Happiness is gaining currency today, particularly in relationship to health and medicine. That’s what we’ve been hearing ever since Harvard School of Public Health researchers Julia K. Boehm and Laura Kubzansky published their report “The Heart’s Content: The Association Between Positive Psychological Well-Being and Cardiovascular Health” in the Psychological Bulletin, under a grant from Pioneer. This is the first study of its kind to look closely at how positive psychological well-being—including happiness and optimism—plays a role in heart health.

The story was indeed hot – gaining attention from USA Today, The Huffington Post, TIME’s Healthland blog,WebMD, The New York Times’ Well Blog, ABCNews.com, MensHealth.com, ModernHealthcare.com, Oprah.com, and hundreds more – and being shared throughout social networks and on the web.

This review, which bases its conclusions on more than 200 studies, taps into a larger conversation going on in health care today about the role of wellness and prevention. So often in health and medicine, we look at what is wrong and try to fix it. But more recently, attention has turned toward what we can do to get and stay healthy before things start to go wrong.

Prior research has primarily focused on how risk factors, such as anxiety and depression, are associated with heart disease and cardiovascular events. This investigation is the first to establish that health assets—such as optimism and happiness—are also associated with heart health. This most recent study fits into a new concept called Positive Health, which seeks to demonstrate that people can use and strengthen these assets to achieve a healthier life. 

The intersection of happiness and health – where we flourish both mentally and physically – is where we all want to find ourselves. The findings of this study make intuitive sense: They tell us that happy people are healthy, active, and health-conscious. They also point us toward a new health care paradigm that focuses on making the most of our inherent advantages—not just on avoiding what’s “bad for us.” The next step in this field is to establish whether or not we can design interventions that help build these health assets to help people increase their chances of living a healthier, longer, and perhaps happier life.

Read more of Paul Tarini’s thoughts on the growing evidence for Positive Health.

New Data Reveals High Death Rates From Clostridium Difficile (C. diff)

A new Vital Signs report issued March 6 by the Centers for Disease Control and Prevention shows rates of infection with Clostridium difficile (C. diff) are at historic highs and must be curtailed. C. diff can cause cramps, severe diarrhea and, in some cases, death.

Also on March 6, Extending the Cure—a project funded by the Pioneer Portfolio that studies antibiotic resistance—released a new analysis showing high C. diff death rates in parts of New England. In fact, the Extending the Cure analysis shows that as of 2007 Rhode Island, Maine, and Connecticut had the highest death rates for C. diff in the nation.

These top three states had death rates that were more than double the national average of 2.15 deaths per 100,000 people.  The trend is visualized using the interactive mapping platform of ResistanceMap, Extending the Cure’s online tool that tracks antibiotic use and drug resistance in North America and in Europe.

At the same time, the map shows that most Southern and Western states had death rates from C. diff that were below the national average. For example, Georgia, Colorado, and Idaho reported less than one death per 100,000 people from these infections in 2007. “The geographical variation points to the need for additional research to better understand the epidemiology of C. diff infections and highlight the most effective ways of preventing their spread,” says Ramanan Laxminarayan, director of Extending the Cure, the D.C-based research project funded in part by the Robert Wood Johnson Foundation’s Pioneer Portfolio.

While C. diff has long been linked to hospitals, the CDC report finds that patients can acquire the infection in all medical settings, including nursing homes and outpatient clinics. Those most at risk are patients who take antibiotics, which can wipe out the good bacteria living in the gut, allowing C. diff to thrive.

C. diff infections can be reduced by judicious use of antibiotics, according to the CDC, which notes that about 50 percent of all antibiotics prescribed are not necessary. Reducing unnecessary antibiotic use will not only help prevent C. diff infections, but also curtail the growing problem of antibiotic resistance.

Addressing the rising rates of C. diff infections will require a multifaceted approach.  In addition to promoting antibiotic stewardship, health officials must work towards better infection control and early diagnosis at hospitals and other facilities where C. diff and other health care-associated infections can spread from patient to patient or from one facility to the next.

 In addition, policymakers, researchers, and others can use visualizations, like the map from Extending the Cure, to identify regions of the country with the most serious problems and look for targeted solutions to the rising tide of C. diff and other disease-causing bacterial pathogens.

Check out the new data and let us know what you think: Do you have a story to tell about a solution to the problem with C. diff?

Follow @ExtendgtheCure on Twitter to track coverage of this study.

The Tip of the Iceberg for Science: Massive Biobank Starts Yielding Results

What do you get when you take 100,000 genotyped biological specimens and link them to longitudinal medical, environmental, behavioral and demographic data? You get Kaiser Permanente’s Research Program on Genes, Environment and Health (RPGEH), a Pioneer-supported effort that has developed the most robust and comprehensive research resource of its kind in the world.

At an unprecedented pace, researchers from the RPGEH biobank at Kaiser Permanente, in collaboration with colleagues at the University of California, San Francisco Institute for Human Genetics, have collected 170,000 samples and genotyped over 100,000 of them in just over a year. While currently the largest biobank in the United States, the ultimate goal is even more impressive: to collect data from a half million members of the Kaiser Permanente health plan linked to their electronic health records and population surveys – creating the largest, most comprehensive biobank on the planet.

Early research findings generated from the RPGEH data were presented this month at the joint annual meeting of the American Society of Human Genetics and the International Conference on Human Genetics in Montreal and are featured in the November issue of Nature Medicine. From an investigation of prostate cancer among African American men to a multi-ethnic study on bipolar disorder to a pharmacogenetic study of response to metformin, a drug used to treat type-2 diabetes, the RPGEH biobank is already starting to deliver.

But this is just the beginning - experts say that the possibilities for studying genetic and environmental influences over time thanks to this project are endless, with enormous potential for accelerating both the pace and breadth of medical research. The implications not only for the science community, but also for public health leaders and patients, are immeasurable. Stay tuned.

Posting from TED: Bacteria May Be The World’s Best "Risk" Players

According to Dr. Bonnie Bassler’s TED presentation on Friday, bacteria operate inside your body in way that’s similar to the game of Risk.  Bassler’s a molecular biologist at Princeton and she studies the way bacteria communicate with each other.  She said they’ve found that bacteria send out a simple chemical signal that can only be read by bacteria of the same type.  When there’s enough bacteria sending enough like-minded signals, the bacteria launch an attack (technically, it exercises a specific behavior it’s genetically programmed to exercise…in some cases that could be good for the host, in others, such as with MRSA, it could be really bad).  This communication is called quorum sensing.

It’s more complicated and more elegant, though.  Bacteria have a second simple chemical signal they send out.  This one can be read by all bacteria.  It tells a particular type of bacteria what other types of bacteria are in the host and how much of it is there.  Too much of bacteria Y, and bacteria X won’t launch its attack/exercise its behavior.

In Risk, it was always one thing to get control of Australia and another to gain enough reinforcements to successfully attack another piece of territory.  And the question of whether to attack was always informed by the size of your opponent’s army.

Bassler’s work is more than just a game.  It suggests a new approach to dealing with bacterial infections, one that involves interfering with the communication mechanism of the bacteria.  This may open up whole new avenues for pharma companies working to fight infections in this age of intensified antibiotic resistance.  In a related vein, policy changes that could facilitate the development of new antibiotics were outlined in the report "Extending the Cure: Policy research to extend antibiotic effectiveness," produced under a grant led by Ramanan Laxminaryan.