Drug-resistant shigella - how worried should you be?

Recent news stories have brought to our attention a report from the CDC that multiple strains of the diarrhea-causing bacteria Shigella have acquired resistance to the antibiotics most often used to treat the illness. The first case of extensively drug-resistant Shigella was discovered in the United States in 2016; by 2022, the strains accounted for 5 percent of Shigella infections. The drug-resistant bacteria have been found in 29 states so far. Even though shigellosis is commoner in children than adults, the resistant strain has been seen most often in adults, and is particularly common in men who have sex with men, the homeless and those with immune deficiency.

Is this important? Should you care?

Shigella is a bacterium that infects the wall of the intestine and causes nasty diarrhea, usually bloody, as well as nausea, cramps and fever. While mild cases exist and may improve without treatment, antibiotics are usually needed, as well as fluid replacement – by mouth if possible or by intravenous if you are very sick.

How do bacteria become resistant to antibiotics? Some bacteria randomly mutate to become resistant to one or more antibiotics. If exposed to antibiotics, the sensitive bacteria are killed off while the resistant ones thrive. We also know that antibiotic-resistant bacteria can share their resistance genes with other bacteria.

We live in an antibiotic-obsessed culture. People who go to their doctor with a cough and fever expect to get a prescription for antibiotics, whether they believe their illness be a sinus infection, bronchitis or pharyngitis. In the time-stressed doctor’s office, many doctors realize it is easier and faster to write a prescription than to explain why the illness is probably viral and will not get better any faster with an antibiotic.

In hospitals, patients are sicker, antibiotics are frequently given, and bacteria are readily transmitted from one patient to another, including resistant ones. These “super-bugs” are responsible for many hospital deaths.

If that is not bad enough, antibiotics are widely and often unnecessarily given to farm animals, in most cases to compensate for unhealthy conditions in which the animals are raised.

What can you do?

First, if your doctor tells you that an antibiotic is not needed, accept this. Most respiratory infections will do as well or better without one. Second, if you have any intestinal infection, be scrupulous with hand washing after using the toilet – the person you save from getting ill may be family or friend.

If you are unlucky enough to be hospitalized, do not be afraid or embarrassed to ask your doctors and nurses if they have washed their hands before they examine you. Finally, make your preference known at the grocery – try to purchase meat labelled as antibiotic-free, so that hopefully this practice will lessen.

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Healthcare Fraud

Healthcare fraud tends be “under the radar” for most of us, surfacing when authorities arrest those accused of such behavior or when guilty verdicts are announced, and usually in stories buried on the inside pages of the newspaper.

While it is widely acknowledged to be a serious problem, costing the government and private insurers tens of billions of dollars, it is very hard to get factual data. The numbers that reach the press are of perpetrators who are caught. The number of schemes that go undetected is impossible to quantify.

It is also a world-wide problem, not just a North American issue. The National Academies estimated in 2018 that of the $7.35 trillion spent globally on health care, some $455 billion was lost to fraud. Investigators in China estimated that 10% of healthcare spending there was wasted due to fraud.

Fraud can take many forms. The most obvious is to bill insurers for services not rendered. A New York-based cardiologist was arrested for billing Medicare and Medicaid $1.3 million for Covid testing that was never done.

More commonly, billing can be done for expensive services and equipment that are unnecessary. Companies “cold-call” people and offer braces and electric-lift chairs that will be “free” if their doctor authorizes them. One brazen scheme involved gathering homeless people who were on Medicaid and paying them small sums to go to a testing center for a panel of totally pointless but expensive tests for fabricated diagnoses.

Twelve physicians in Ohio and Michigan were sentenced to prison last year for a scheme that required narcotic addicts seeking prescriptions to undergo spinal injections, which are richly reimbursed, before getting their prescriptions.

More subtle and more widespread is “up-coding,” providing a service but billing for a more expensive one. Take the office visit. Billing for such visits can be done at one of five tiers based on the complexity of the problem and time needed to deal with it. The higher the level, the more the payment. A Massachusetts orthopedic surgeon was charged in March of 2022 for billing top-level visits for as many as 90 patients a day – meaning that in one work-day he was claiming to do over 60 hours of care! To a lesser degree, this practice is very widespread.

Technology has unfortunately made fraud easier. The typical electronic medical record allows the user to populate a note with detailed history and physical finding with a few clicks, whether or not these were done.

Telemedicine, a boon for many during Covid lock-downs, also provided a fertile field for the unscrupulous. One of “America’s Frontline Doctors,” the headline-grabbing vaccination deniers, lost her license for providing ivermectin and hydroxychloroquine after 1-2 minute on-line visits for which she billed $90. Telemedicine visits for addiction counselling are supposed to last 45 minutes. The Recovery Connection Centers of America billed insurance programs millions of dollars for visits that lasted an average of 5 minutes federal authorities alleged last month.

Why should you care? Ultimately, whether through taxes or health insurance premiums, it is your money that is being wasted. When you suspect fraudulent billing, report it.

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Can I live to 120? Do I want to?

The Fountain of Youth is a mythical spring that restores the youth of anyone who drinks from it or bathes in its waters. Tales of such a spring have been recounted for thousands of years, appearing in the writings of Herodotus in the 5th century BC. The legend became particularly prominent in the 16th century, when it became associated with the Spanish explorer Juan Ponce de León, the first Governor of Puerto Rico. Ponce de León was supposedly searching for the Fountain of Youth when he traveled to Florida in 1513.

Modern seekers after the Fountain of Youth include tech billionaires who plan to be cryo-preserved until science finds the secret of eternal youth. Peter Thiel and Jeff Bezos have both heavily funded start-ups studying how to slow the aging process. Researchers have studied “blue zones,” where people live the longest, and are healthiest: Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Ikaria, Greece, and Loma Linda, California. Not only do these places have large numbers of residents in their 90’s and older, but they remain largely free of most of the diseases associated with aging. They share common attributes of lifestyle and diet noted below.

How long can we hope to live? The best evidence is that the limit to the human lifespan is about 120 years. It is very unlikely that any intervention will dramatically change this number.

Probably more realistic, and in my mind more important, is to delay the myriad ills that we accumulate as we get older: frailty, dementia, disabling arthritis, heart and lung disease. In other words, we should hope to extend our healthy years rather than simply living longer.

How can we accomplish this? Some of this is not new: do not smoke, drink little or no alcohol, maintain a healthy weight, eat a plant-focused diet and exercise regularly. If you do all five of these, you can add 12-14 good years to your life. Being socially engaged and having a sense of purpose is also helpful.

Further study is needed, but marked calorie restriction has been shown to extend the lifespan in many species, including mice, and is now being tested in human volunteers.

The diabetes drug metformin has been touted as having anti-aging properties and is being tested in two on-going trials. It is clearly beneficial in patients with type 2 diabetes; whether that will translate to the rest of us remains to be seen.

Some 20 years ago, reports began to emerge that taking blood from young mice and giving it to old mice seemed to dial back the clock on aging for the elderly rodents. Soon after, entrepreneurs began doing this with humans without any proof that it was effective, but researchers are now testing the idea. Still in the laboratory is injecting one of several new anti-inflammatory drugs. There are some indirect markers that suggest these may work, but as yet no meaningful results have been demonstrated.

So, at this point, practice as many of the lifestyle habits listed above as you can and wait to see what science has in store. Eat well, exercise and get involved in your community.

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