Tuesday, August 28, 2012

The Rise of the MIC: Microbiological Industrial Complex

Mike "Alexander" Edmond
Note: This is the post I wanted to write regarding the NIH Clinical Center KPC outbreak last week until I noticed the posts and comments blaming the front line infection prevention staff.

"...we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex (MIC). The potential for the disastrous rise of misplaced power exists and will persist....As we peer into society's future, we-you and I, and our government-must avoid the impulse to live only for today, plundering, for our own ease and convenience, the precious resources of tomorrow. We cannot mortgage the material assets of our grandchildren without risking the loss also of their political and spiritual heritage." - President Eisenhower's Farewell Address January 17, 1961

In microbiology and clinical medicine, the MIC is the "lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after overnight incubation."  I think it's time to recognize a new definition for MIC: the Microbiological Industrial Complex. The MIC encompasses the industry, associated lobbying efforts and government agencies that most benefit from the adoption of expensive and unproven testing and treatment. The MIC has had a tremendous impact on infection prevention practice through economic forces pushing for MRSA active surveillance mandates and perhaps mandatory flu vaccinations of health care workers. This MIC leads to the utilization of expensive (and largely unproven) interventions at great cost both economically and to the well-being of patients.  The more we spend on expensive sequencing, the less we can spend on actual prevention. Hand hygiene might not be sexy, but it does more to prevent the spread of resistant infections than any PCR test.

The latest evidence of the insidious rise of the MIC is the initial discussion surrounding the NIH Clinical Center KPC outbreak. So far, the only paper describing the outbreak covered the miracle of whole-genome sequencing and how it helped halt the outbreak, which it most certainly did not. The outbreak was halted using a grab bag of unproven and expensive interventions including the hiring of 9 hand hygiene "police" that monitored infection control practice 24-7.  Even NIH's Henry Masur speaking today on the Diane Rehm show said that sequencing "didn't conclusively prove" (what caused the outbreak).  Both he and Jule Segre suggested they only stepped up their infection control efforts because of the whole genome sequencing evidence, which is almost certainly not true. They would have used infection control escalation even without expensive testing. (listen to the Diane Rehm show segment here)

To understand the power of the MIC, you don't have to look further than a recent MSNBC report, which noted that the NIH sequencing cost $40,000 and suggested that this technique could spawn a $1 billion industry in the US alone. In discussing the whole genome technique, Dr. Segre was noted to say "When you have patients in your ICU who just paid $100,000 for an organ transplant,"...spending a few thousand dollars to protect them from an outbreak of deadly bacterial infections "doesn't seem like too much to ask."

It seems to me that since there is no evidence that whole genome identified the source of transmission here or elsewhere and even if it did it wouldn't have altered the course of the outbreak, we might better spend our infection control research and clinical dollars elsewhere.  Unfortunately, the MIC has more money and more NIH backing. The NIH has a National Human Genome Research Institute but it doesn't have a "National Infection Prevention Institute", for example.

Almost a year ago, Mike peered through his crystal ball and accurately predicted the future of KPC prevention in the US.  The NIH outbreak and report starts the countdown, and much like MRSA before it, the prevention efforts will be focused on expensive DNA surveillance efforts backed by large industry lobbying efforts and not investments in the research and expansion of basic and simple infection control efforts. It is easy to blame the healthcare worker for not washing their hands and look for a quick scientific panacea (DNA). Sadly, given that there have been only four high-quality hand hygiene improvement studies since 1980, we haven't provided clinicians with the proven tools to improve hand hygiene. If we continue to bow to the pressure of the MIC and avoid the harder tasks of infection prevention, we will be squandering our precious resources of tomorrow (antibiotics), as Eisenhower warned 50 years ago.

Further Reading:
(1) Maryn McKenna: The ‘NIH Superbug’: This Is Happening Every Day
(2) Ed Yong:  Genome detectives unravel spread of stealthy bacteria in a hospital
(3) Dr. Judy Stone: The NIH Superbug Story-A Missing Piece
(4) Mike the Mad Biologist: Some thoughts on the CRE Superbugs

Image source: wikimedia commons

4 comments:

  1. Good points, Eli.

    As someone who has spent many years providing molecular typing information for outbreak investigation and response, I am often frustrated by how little the information adds to on-the-ground prevention efforts. The data we provide regarding genetic relatedness usually confirms what we already suspect (that there is patient-to-patient transmission or a common-source outbreak), and leads to interventions that we would apply regardless of the typing results (improved hand hygiene, contact precautions, enhanced environmental disinfection, etc.). The results are most helpful when they lead to a specific environmental source or mode of transmission that is amenable to intervention (e.g. finding the same strain of Legionella in a patient and in the hospital water supply). It is more often the case that we take our gel pictures to a patient care unit and let them know that patients A, B and C were all infected or colonized with the same strain of pathogen X, and when they ask how to respond, we tell them the same things: wash your hands, adhere to appropriate barrier precautions, focus your environmental disinfection efforts, etc.

    I think the reason that WGS is receiving so much attention relates to how much additional information it can provide--if it indeed becomes as inexpensive as other routine laboratory tests, and if it were linked to a robust data analysis/interpretation software system, it could provide useful data not only about genetic relatedness of isolates, but also antimicrobial resistance profiles, virulence determinants, and propensity for emerging resistances if specific therapies are chosen. The clinical microbiologist in me looks forward to the day when we have a "black box" WGS system that provides rapid turnaround and information-rich reports to help guide clinicians, infection preventionists, and antimicrobial stewardship programs, and at an affordable price. I think we are a long way from that.

    It's also important to note that not all new technologies increase costs--one example of an emerging technology that is likely to reduce laboratory costs is MALDI-TOF (mass spec for identification of bacteria), a technology that increases the accuracy of organism ID at a lower cost per organism than conventional ID methods.

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  2. I forgot to add...if you wish to read prior posts about WGS not contributing as much as advertised to an outbreak or case investigation, you can find them here:

    http://haicontroversies.blogspot.com/2012/06/whole-genome-sequencing-and-infection.html

    http://haicontroversies.blogspot.com/2011/08/you-cant-b-cereus.html

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  3. Thanks for adding the links Dan and your comments. The focus of my post was on the evolution of infection prevention standards to include mandated and expensive surveillance techniques to the detriment of actual infection prevention. In this case the NIH built walls, tore out plumbing and hired 9 hand hygiene police with no effect and no guidance from WGS from what I can tell (they never identified the transmitting source). Thus, why are most of the posts and articles focusing on WGS?

    I do agree that advanced micro methods for clinical diagnosis and as research tools have a very important role and will hopefully will bring down costs as they provide increased accuracy and additional benefits. True that MALDI has great potential in species identification. However, I was focusing solely on infection prevention, specifically mandates for these technologies that will lead them to their $1 billion annual market. You don't get a $1 billion market based on the data from the NIH outbreak nor the studies whose links you provided.

    I don't think the WGS benefits inform prevention in hospital outbreaks - i.e. I don't see virulence determinants informing infection prevention when we don't know how to get hand hygiene near 100% (or whatever level is needed) and we don't know how to keep the room environment clean. Thus, I think the WGS $1 billion market will be achieved through mandates as Mike suggests.

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  4. I guess the easiest way to explain my concern is that the weakest link in the infection prevention chain is evidence identifying optimal methods to prevent transmission, be it hand hygiene, cleaning, gloves/gowns etc, and focusing efforts on WGS will do nothing to improve the chain and will likely make it far worse.

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