East Tennessee’s pneumococcus is the most drug-resistant in the nation

by Stephanie Piper

Quick. What's East Tennessee famous for?

The Great Smoky Mountains. The Tennessee Vols. Bacteria. Whaaat?

As dubious distinctions go, this one is a doozie. According to the Centers for Disease Control in Atlanta, East Tennessee has the highest rate in the country of serious illness caused by a drug-resistant germ called pneumococcus. Not one of the highest rates—The highest rate.

It's the bug that causes meningitis, some blood infections, and bacterial pneumonia. Nationwide, approximately 10 percent of the pneumococcus bacteria tested don't respond to standard antibiotic treatment like penicillin. In East Tennessee, it's more like 50 percent.

The Centers for Disease Control started tracking bacterial causes of disease in children in 1989. They established 13 surveillance areas across the United States and Canada, including major urban centers like Toronto and less densely populated places like Tennessee and Oregon. CDC asked hospital labs to record and report every instance of serious antibiotic-resistant infection they encountered. Of the area surveyed, East Tennessee came up with the highest score.

So how did we get to be the germ capital of the nation?

"The primary reason for antibiotic-resistant infections is the overuse and misuse of antibiotics," says Dr. Daniel Jorgenson, director of communicable diseases for the Knox County Health Department. "It's not just physicians overprescribing, it's the whole healthcare system, and that includes the patients who demand antibiotics whether they're indicated or not."

The problem, epidemiologists say, is that the drugs kill off sensitive bacteria, leaving the resistant organisms to grow and multiply.

"It's Darwin's law in a Petri dish," says Dr. Lori Patterson, pediatric infectious disease specialist at East Tennessee Children's Hospital. "You kill off the weak bacteria, and the strong survive. When the strong bacteria cause disease, it's harder to treat."

Knoxville's statistics sent up a red flag at the CDC, which sent Dr. Ben Schwartz, chief of childhood and respiratory diseases, to help the Knox County Health Department launch a community-wide education campaign last fall. Speaking to 150 healthcare providers, Schwartz said that three-quarters of all antibiotic prescription are written for respiratory illnesses, most of which are caused by viruses. He urged "judicious use of antibiotics" and stressed the importance of informing the public about the real risks involved in overprescription of these medications.

"Most people have an understanding of the differences between viruses and bacteria, but they don't remember that viruses are not treatable with antibiotics," says Patterson.

"What we're most concerned about is that the bugs may eventually become resistant to all antibiotics. We've seen that with pneumococcus—the leading cause of ear infections, sinus infections, now the leading cause of meningitis and the leading bacterial cause of pneumonia in children. Pneumococcus used to be entirely sensitive to penicillin. Now we are at the point where 75 to 80 percent of our pediatric cases show some resistance to penicillin and other drugs as well. We've had children who have had to be admitted to the hospital for IV treatment of an ear infection because IV drugs were the only ones left to us to get rid of that particular bug.

"The fear is that we may eventually have no more antibiotics to treat these things. We've been spoiled. We have no idea what it's like to be told by a doctor: I have nothing to treat your infection."

During the winter months, five respiratory illnesses account for more than 75 percent of visits to doctors: colds, sore throat, sinus infections, bronchitis, ear infections. Almost all are caused by viruses and would not require an antibiotic, Jorgenson says. The exceptions are ear infections, strep throat, and some long-lasting sinus infections.

So why do doctors continue to prescribe medicine people don't need?

"A lot of patients, especially parents of young children, don't want to leave the office without an antibiotic," says Jorgenson.

"It's been found that if the doctor spends time talking through the illness with the patient and explains why antibiotics aren't indicated, the patient is usually satisfied. But in this day and age of managed care, doctors don't have that kind of time. It's easier to go ahead and write a prescription," Jorgenson added.

"Antibiotics have become a very easy answer," says Patterson. "Whether they are the right answer is the difficult question.

"It's not always simple to tell what's a bacterial infection and what is a viral one. If a child comes to us sick, we all have a need to do something. I think a lot of doctors are afraid that if they don't write a prescription for an antibiotic, the patient will just go to the doctor down the street. That's not good for continuity and it's not good for economics. In a busy practice, it's often easier to just write a prescription than to take time to explain why you're not treating."

Dr. George Larsen of Baptist Hospital's Senior Health Center in Alcoa says he had always associated drug-resistant bacteria with large medical centers where high doses of powerful antibiotics are used regularly.

"As someone practicing in small towns, first in Minnesota and then here, I almost never saw typical resistance to the penicillins and commonly used medicines. We are now starting to perceive some resistance to common antibiotics. I can't say it's epidemic, but I have had more treatment failures with commonly used antibiotics than I had before."

But he stresses that these are the exception rather than the rule.

"In the case of sinusitis, for example, treated with amoxicillin, the success rate is somewhere between 80 and 90 percent. I have seen a few more cases where the amoxicillin hasn't cleared it up, making the success rate more like 75 percent."

In his geriatric practice, Larsen says, "I'm quicker to pull the trigger on antibiotics. If I suspect that pneumonia may be coming on in a frail, elderly person, that person gets antibiotics. I think that's the safest thing to do."

"Overprescription of antibiotics does occur, " he says. "There is a trend for people taking care of patients day by day to assume that the disease is more severe than it may possibly be. I think that's been true for years and is true today, away from academic circle. We're healers, we want to do the best for our patients. You're never sure without extensive studies what is actually going on with a patient."

Jorgenson and Patterson both stress that there's an urgent need for education at every level: healthcare providers, HMO administrators, pharmacists, day care operators, parents, and the community at large.

The day care system is an important target, since large day care centers have been linked to the increase of resistant bacteria.

"If one child gets a resistant bug, he shares it with all his friends," Patterson says.

And parents of children in day care may feel pressured to give unnecessary antibiotics because of a center's rules about illness—or the appearance of illness.

"Take a runny nose, for instance," Patterson says. "There's this horrendous myth out there that green or yellow drainage means a bacterial infection. That is just not true. Unfortunately, there are a lot of day cares that perpetuate the myth. And there are a lot of doctors and nurses who still believe it, too.

"Realistically, the things that can be treated with antibiotics are much less common in day care centers and much less likely to be transmitted to other children than viruses. You don't catch an ear infection from someone. You may catch the virus that may set you up for an ear infection, but an antibiotic is not going to do anything for that virus."

The Knox County Health Department, in cooperation with the CDC, is working to build awareness of the problems posed by resistant bacteria. They've distributed more than 72,000 pamphlets to schools, clinics, pharmacies, and day care centers and hosted informational events for healthcare providers. Information on antibiotics, viruses, and infections goes into every informational packet the Health Department provides to new mothers and was also distributed to anyone who received a flu shot through their services. Revco and Walgreen's pharmacies in the area are also distributing brochures. Jorgenson has made local TV appearances to explain the problem. And the relentless monitoring of bacteria continues.

"We've set up a surveillance system which requires hospital labs and providers to report to us at the Health Department when they isolate this resistant bacteria," Jorgenson says.

"We're also getting detailed information about who's getting the diseases, identifying people by age and race and whether they've been in day care, since we think that's a risk factor. We're trying to find out if they've had a lot of previous exposure to antibiotics.

"And we want to know where they live in Knox County, so we can map them. We think there may be geographic clusters of illness caused by drug-resistant bacteria. Besides New York City, we're the only place in the U.S. with this kind of tracking system."

"Like all patient data gathered by the Health Department, this information is strictly confidential," Jorgenson says. Overall trends and the geographic analysis will be reported in the Epi Update, the Health Department's newsletter, later this spring.

Initial reaction to the information campaign has been positive, Jorgenson says.

"Judging from the response to our Epi Update newsletter and to Dr. Schwarz's presentation, we feel that a lot of doctors are now on board with this. There is also some evidence that antibiotic prescription rates have gone down during the winter season, a time when most respiratory illnesses are caused by viruses."

But there is still plenty of work to be done, says Patterson.

"If you need an antibiotic, that's one thing. But we need to be much more circumspect about when they're actually needed. We need to get away from the 'let's give an antibiotic just in case' mindset. And we need to emphasize the non pharmacological things we can do to help children feel better, like fluids, TLC, Tylenol for fever.

"Families need to become more savvy about what will and won't work. Every month I see something in the paper where someone is talking about the antibiotic I took for my flu virus. It's like fingernails on a chalk board to me."