The hunt for microbes – A day in the life of a clinical pharmacologist in Russia (9min read)
As the leading clinical pharmacologist at a hospital in Moscow, Dr. Sergey Dmitriyevich Mitrokhin has an important role to play in ensuring patients have access to effective medication. By educating staff physicians about the responsible use of antibiotics, he has brought a change in prescription behavior among his colleagues. And by introducing alternatives to commonly used antibiotics to which pathogens have become resistant, he has helped reduce infections significantly – while halving the hospital budget for anti-infective medicines.
May 16, 2018
It was a book, first published in 1926, that inspired Dr. Sergey Dmitriyevich Mitrokhin to continue an investigation that began centuries before. In Microbe Hunters, author Paul de Kruif wrote:
“Two hundred and fifty years ago, an obscure man named Leeuwenhoek looked for the first time into a mysterious new world peopled with a thousand different kinds of tiny beings, some ferocious and deadly, others friendly and useful, many of them more important to mankind than any continent or archipelago.”
Microbe Hunters explores how Dutch pioneer Antoine Philips van Leeuwenhoek began shedding light into the world of microorganisms with his early microscope. Reading about this pioneering work led Sergey Mitrokhin into the field of clinical pharmacology. His goal: to study, understand and fight dangerous microbes.
About 40 years after this book had made such an impression on him, Mitrokhin now heads the Department of Clinical Pharmacology and Center for Clinical Research at the L.A. Vorokhobov Hospital No. 67 in Moscow. And his work is deeply needed. “Hospitals are a melting pot of sick and injured people,” says Mitrokhin. And this presents a risky situation, because patients carry numerous bacteria into the clinic where others are hospitalized and already weakened due to other infections or conditions. There is a significant risk of spreading infections at any hospital, because “once the immune system is vulnerable, a person is more likely to get infected by bacteria,” he explains.
As if that wasn’t complicated enough, there is another factor that makes Mitrokhin’s work more challenging: The aggregate of microbes in a clinic, called hospital flora, is different from outpatient flora. There is a higher selection pressure, which is why bacteria populations in a hospital adapt very quickly to substances in their environment – including disinfectants and certain antibiotics. As a result, these nosocomical (hospital-acquired) germs are more likely to develop resistance than germs from outside the hospital. Adds Mitrokhin: “More than 90% of hospital bacteria are resistant to most antibiotics.”
Dr. Sergey Dmitriyevich Mitrokhin, heads the Department of Clinical Pharmacology and Center for Clinical Research at the L.A. Vorokhobov Hospital No. 67 in Moscow. His goal is to study, understand and fight dangerous microbes.
One of the most threatening examples is MRSA (Methicillin-resistant Staphylococcus aureus). What makes MRSA especially dangerous is that it can be found in many peoples’ nasal membranes and on their skin, without symptoms of disease. Although otherwise healthy people might not get sick at all, hospital patients are at a higher risk of MRSA infection. If their immune systems can’t fight the bacterium, MRSA can cause severe problems such as bloodstream infections, pneumonia and surgical site infectios1. According to WHO, between 3.5% and 12% of patients in developed countries acquire bacterial infections while in the hospital – and many of these infections are resistant to standard antibiotic treatment.
The two-fold strategy against infections There is no single solution to the problem, as Mitrokhin knows. “We try to stop infections in the first place by establishing a hospital-wide sanitizing program. But when many people with diseases are in one place, even the best disinfection routine cannot prevent all of the bacteria from spreading,” he explains. “And open wounds further increase the risk of infection with bacteria, whether through contact with other patients, nurses or just with objects in the hospital.”
This is why Mitrokhin fights the spread of dangerous bacteria with a two-fold strategy. The first aspect revolves around access to information and sharing knowledge with colleagues. “Because there is such a wide product range, physicians can’t possibly know everything about every drug that exists on the market.” For this reason, he counsels intensive care specialists on the right combination of antibiotics for each patient, every day. “If patients in our clinic do get infected, I need to find the right kind of antibiotic to help them recover. Using the wrong medicine would make their infection worse.”
Besides giving advice to the doctors, the second part of his job – and strategy - is about offering alternatives. For this work, he supports other authorities in the hospital. “When the hospital manager needs advice, I help decide which drugs to purchase to ensure we apply the best possible medication for patients,” he continues. By putting up and updating this list of products, he increases access to effective medicine at the Moscow’s Clinical Hospital No. 67. After handling all patient matters, Mitrokhin also spends time developing hospital formulations of pharmaceuticals. And to improve his antimicrobial tactics, he has teamed up with four other clinical pharmacologists. When describing the team’s role and expertise, he says: “We combine the diagnostic skills of a physician with the pharmaceutical knowledge of a pharmacist.” The goal is to find better treatment options for patients and to fight microbes more effectively.
We combine the diagnostic skills of a physician with the pharmaceutical knowledge of a pharmacist
Fighting resistance – and prejudice Things haven’t always been easy for Mitrokhin. While he had strong support from the hospital’s administrative head since he began his work there, other colleagues were more reserved. “At first, many doctors did not see how I could help them,” he states. In Russia, clinical pharmacology is a young field, introduced only in 1997 by an order from the Ministry of Health. For a long time, the necessity of clinical pharmacologists was misunderstood, and physicians often reached out to him as a formality. “Although we are specialists, some doctors just wanted my signature on their prescriptions,” recalls Mitrokhin.
When Dr. Mitrokhin started in this hospital, he stopped the overuse of the four antibiotics that he refers to as “The Four Horsemen of Apocalypse.” Using alternatives can avert deadly resistance.
Credit: Four Horsemen of Apocalypse by Viktor Vasnetsov (1887).
When he started at the Clinical Hospital No. 67 in Moscow five years ago, he faced another threat: The clinic’s medical staff were caught in a vicious circle. Infections in the hospital were rising daily despite physicians’ best efforts to fight them. “When I started working here, four antibiotics were most commonly used,” Mitrokhin says. “These broad-spectrum antibiotics are effective against several kinds of bacteria. But I called them the ‘Four Horsemen of the Apocalypse.’ Our doctors were prescribing them for nosocomial infections, yet these medicines often showed no effect. So doctors had to prescribe them in higher doses, but they were still without results, and they came with a huge price tag.”
Mitrokhin was aware that saving money is both essential for his hospital and for the Russian healthcare system, which Bloomberg has ranked 55th among countries with the most efficient healthcare. In Russia, employers pay up to 5.1% of their employees’ wages into a social tax, which sponsors Russia’s Obligatory Medical Insurance (OMI). This covers free emergency and medical care in state and municipal medical facilities for citizens. Still, more than one third of the Russian healthcare system is financed through out-of-pocket payments. And according to World Bank data, in 2014 the country spent 5.9%2 of its GDP on healthcare, while the global average is 9%3. Clearly, the Russian healthcare system is under pressure.
To do his part to improve medical outcomes in Russia, Mitrokhin started by fighting the ‘Four Horsemen’ – a fight which began with investigations in the laboratory. “Our lab data showed that the specific hospital flora causing these infections was resistant to these four antibiotics.” As a result, he removed all ineffective and unnecessary medicines. Instead, he purchased alternatives with the same high quality, and to which those bacteria were still sensitive. His actions resulted in more effective treatment for the patients, while saving the hospital a significant amount of money. “Before I started here in 2013, the hospital spent RUB 74-75 million per year on antibiotics – 25% of the total budget for all medicines. By 2016, we spent only RUB 36 million.”
When the doctors at the Clinical Hospital No. 67 in Moscow realized that Mitrokhin managed to improve patient outcomes while reducing the medicine budget by 50%, they began to understand his expertise – and he earned their respect. With his two-fold strategy to increase access to information and medicines, and the support of his colleagues, he carries on with his mission more effectively than ever. “I see myself as a microbe hunter,” he says. “I’m an antibiotic therapist, and I have worked with antibiotics all my life. Fighting infectious diseases is my passion.” And his passion saves lives.