I was recently at a conference (pdf file) where one speaker (Dr. Thomas O’Brien) suggested ‘VRSA hospital insurance’ to prevent the spread of vancomycin resistant Staphylococcus aureus outbreaks (‘VRSA’). Before I get into the plan, let’s talk about VRSA.
VRSA are staphylococci which are not only resistant to vancomycin, which is one of the last effective drugs against methicillin resistant Staphylococcus aureus (‘MRSA’), but are also resistant to most (or usually) all other available antibiotics. While tigecycline can be used to treat some infections (skin and abdomindal), it is not used to treat bloodstream infections; it also must be administered intravenously, requiring a hospital stay during the course of therapy (usually several days).
Linezolid can also be used against VRSA, but it is not approved for use in children under 18, and can have serious side effects; linezolid resistance, while rare, is still observed at frequencies ‘higher than anecdote.’ Keeping MRSA from evolving into VRSA must be a major public health priority.
There have been seven identified cases of VRSA which fortunately have been contained. In every case, VRSA appears to have evolved within that individual patient (i.e., it is not community-acquired VRSA). However, every epidemic starts with one bacterial isolate that ‘gets loose.’ If VRSA were to spread to other hospitals, the cost in lives lost as well as the economic burden would be tremendous.
The most important factors in preventing a VRSA outbreak are rapid identification of VRSA followed by appropriate isolation of the patient, decontamination, and screening of hospitals. At larger hospitals, this is not particularly hard to envision: most large hospitals have adequate infectious departments and facilities. However, smaller hospitals and long-term care facilities such as nursing homes, rehabilitation centers, and so on, will not have these facilities. In other words, they would be unable to contain a VRSA outbreak at their facility. Economically, all hospitals, but particularly small ones, will find the costs of VRSA containment very expensive. There would be a strong financial incentive to scrimp on containment measures.
What O’Brien suggested is that all hospitals enter an insurance pool. When a VRSA outbreak is identified by a hospital, the funds are used to provide adequate containment of the VRSA outbreak. In a perfect world, the CDC would have the informatics infrastructure to identify the outbreak and the resources to then contain the outbreak, but in the real world, it does not. To me, this seems a pretty good solution.
Of course, it would be nice if some of the money spent to prevent a bioterrorist attack were used to prevent something I think is far more likely, and far more dangerous.