Maryn McKenna

Journalist and Author

Prevention v. treatment (1st Global Health Blog Carnival!)

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Constant readers, about a dozen of us who are interested in global health are co-blogging today in a Global Health Blog Carnival. If you are on Twitter, search the hashtag #ghnews. If you’re not, we will try to get them all linked somewhere. This was organized (to the degree that blogger organize, which as you can guess is like herding small felines) by reporter and blogger Christine Gorman, formerly of TIME Magazine.

Our theme for today is prevention v. treatment. Fortuitously, the New England Journal of Medicine today is publishing an editorial (for which they have posted the free full text) that reminds us of the full burden and cost of MRSA. Drs. Cesar A. Arias and Barbara E. Murray say:

Faced with this gloomy picture, 21st-century clinicians must turn to compounds developed decades ago and previously abandoned because of toxicity — or test everything they can think of and use whatever looks active. …
It is more difficult than ever to eradicate infections caused by antibiotic-resistant “superbugs,” and the problem is exacerbated by a dry pipeline for new antimicrobials with bactericidal activity against gram-negative bacteria and enterococci. A concerted effort on the part of academic researchers and their institutions, industry, and government is crucial if humans are to maintain the upper hand in this battle against bacteria — a fight with global consequences. (NEJM 360(5):439-443)

As we’ve discussed time and time again, MRSA is increasingly common worldwide and increasingly costly to treat. Moreover, what has been presented by some as the first line of prevention for hospital-acquired MRSA — active surveillance and testing programs, also called “search and destroy” — is deeply controversial.

So what’s the next step? Well, in the past, when medicine has wanted to nullify an infectious disease threat, it did not rely only on surveillance or asepsis; it developed a vaccine. And there have been a few efforts to develop a MRSA vaccine, which are recapped in a new article in Infectious Disease Clinics of North America (yes, that’s a journal):

The most extensively tested vaccine against S aureus, which is a capsular polysaccharide-based vaccine known as StaphVAX, showed promise in an initial phase 3 trial, but was found to be ineffective in a confirmatory trial, leading to its development being halted. Likewise, a human IgG preparation known as INH-A21 (Veronate) with elevated levels of antibodies to the staphylococcal surface adhesins ClfA and SdrG made it into phase 3 testing, where it failed to show a clinical benefit. … Given the multiple and sometimes redundant virulence factors of S aureus that enable it to be such a crafty pathogen, if a vaccine is to prove effective, it will have to be multicomponent, incorporating several surface proteins, toxoids, and surface polysaccharides. (23 (1): 153-171)

Several longtime MRSA researchers, including Dr. Robert S. Daum of the University of Chicago, who wrote the first paper calling attention to community-associated MRSA in 1998, have called for a vaccine to be made a research priority.

Any thoughts, constant readers? In the public mind, right now, vaccines are at a low point: People are turning away from them, manufacturing problems have led to shortages, and pharma no longer finds vaccine manufacturing a lucrative business sector. If a MRSA vaccine were developed, would you take it yourself before surgery, or give one to your children?

Well, this is bad news.

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Hi again, constant readers – yes, eye-deep again in a chapter, and sinking. About which: Is there anyone there who remembers staph 80/81 and would like to talk about it? Email me, address in the right-hand bar.

And now to the bad news. I am coming to this story late, but truthfully I am not even sure how late, as it seems to have trickled out without fanfare, and different media have covered it at different times over the past month. At any rate: The FDA has quietly reversed a decision it took last summer, and will allow cephalosporins, a human medicine, to be used without restriction in food animals.

What’s a cephalosporin? The best-known one is the very commonly used drug Keflex (cephalexin), which you might take for tonsillitis or bronchitis – not a drug that you want to stop working because bacteria have developed resistance to it. (Yes, MRSA already has.)

Supporting material, tracking backward: A notice from the National Academies of Science news office from two days ago is here. An NPR story from Dec. 29 is here. A lengthy essay hosted by food-safety expert/attorney Bill Marler is here. A statement from the Pew Charitable Trusts’ Campaign on Human Health and Industrial Farming, dated Dec. 12, is here. A short story from the Wall Street Journal, dated Dec. 9, is here.

Here’s where I think this all ends up: On Nov. 25, the FDA put a note in the Federal Register announcing that it was reversing its earlier, July 3 decision to put curbs on the “extra-label” — anything not specifically allowed by the label — use of cephalosporins in animals. (Here’s a July 16 Q and A explaining what it was prohibiting.)

The reason for the revocation of the ban/permission to use without restrictions, the FDA said in the Nov. 25 notice, was that it had gotten so many public comments on the ban — which was supposed to take effect Nov. 30 — that it decided the only appropriate action was to lift the ban until it could fully consider whether to reimpose it. And, because it was a revocation of a previous order and not a new order, it did not have to give advance notice.

As to what this means, consider this stinging op-ed from John Carling, former governor of the very agricultural state of Kansas, and chairman of the Pew Commission, which produced a mammoth report last year on industrial-scale agriculture:

The rest of the world has leapt ahead of us on this issue. In Europe, antibiotics have long been eliminated from food production. South Korea followed suit this summer. Our refusal to turn away from this practice could cost us markets for our food products overseas and, by extension, precious jobs here at home.
The Pew Commission was composed of farmers, doctors, veterinarians, economists and other talented professionals who took on the challenge of finding a model that would allow U.S. farmers and ranchers the freedom to pursue their livelihoods in a way that does not adversely impact public health, the environment and the economies of their communities.
We believe we found such a model, and it included phasing out the indiscriminate overuse of antibiotics.
Changing the way agriculture works in this country will likely prove challenging, and involve many difficult decisions.
It’s a tragedy that on this occasion the FDA took the easy — and more dangerous — way out.

A timely reminder on using antibiotics well (and badly)

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The Infectious Diseases Society of America, the professional organization for ID physicians, is criticizing large grocery store and pharmacy chains for giving antibiotics away for free. (Yes, you read that right: Not generic, not cheap, free. Here is a Wall Street Journal Health blog post explaining the practice, which has become quite common over the past two years.)

IDSA is concerned of course that these antibiotics will be used inappropriately because, being free, they will have a perceived lesser value. The Centers for Disease Control and Prevention has been campaigning for years against inappropriate antibiotic use, via its Get Smart: Keep Antibiotics Working campaign.

(Why is it important to use antibiotics only for the things they work against? All together now: Because if used inappropriately — in too-low doses, too-short courses, or against an illness where they are not useful — they will encourage the development of resistant bacteria, and also may kill your own commensal bacteria, clearing a niche that resistant ones can then occupy. Very good, class, early dismissal today.)

There’s an additional, interesting twist to these campaigns, though, which IDSA very rightly raises: They are taking place now, in flu season. One of the most common inappropriate uses of antibiotics is against viral diseases such as flu; the CDC says:

Tens of millions of antibiotics prescribed in doctors’ offices each year are for viral infections, which cannot effectively be treated with antibiotics. Doctors cite diagnostic uncertainty, time pressure on physicians, and patient demand as the primary reasons why antibiotics are over-prescribed.

IDSA is quite rightly concerned that the launch of these free-pill programs in flu season will reinforce the association between flu and antibiotics, which is precisely the association that causes antibiotics to be most overused. An excellent point.

Even more bad news on new drugs

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Via Forbes.com comes news that the Food and Drug Administration has turned back Targanta Therapeutics‘ application for its new antibiotic oritavancin, which was designed specifically to target drug-resistant staph, and has asked for additional trials. This is a follow-on to a decision by an FDA advisory panel last month that also expressed doubt about the drug.

This comes on the heels of last month‘s withdrawal of dalbavancin and delay in approval of ceftobiprole.

The long, thin pipeline of new drugs for MRSA just got longer and thinner.

More bad news on new drugs

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The Infectious Diseases Society of America (IDSA) has published a new report that fills in the background on last week’s news below, and confirms: The landscape for new drugs against MRSA and other multi-drug resistant organisms is bleak. (The organisms, summarized in the acronym ESKAPE, are: E. faecium, MRSA, Klebsiella, Acinetobacter, Pseudomonas aeruginosa and Enterobacter.)

The report, published in the journal Clinical Infectious Diseases, is both an update of surveys of the new-drug landscape done in 2004 and 2006, and also a call to action that asks for broad federal effort to encourage pharma companies to produce new drugs.

Here are the highlights:

  • Since the last iteration of the survey in 2006, only one new antimicrobial, doripenem — a very broad-spectrum injectable that is most active against the Gram-negative bacterium P. aeruginosa — has been approved.
  • Only three new compounds — ceftobiprole, dalbavancin and Paratek Pharmaceutical’s PTK-0796 — are in their final rounds of trials. (The report was obviously written before the latest news about ceftobiprole and dalbavancin.)
  • Four of seven efforts to achieve a staph vaccine have been terminated.
  • Though the pharma industry, through its lobbying arm PhRMA, claims “388 infectious diseases medicines and vaccines and 83 antibacterial drugs in development“, that number is misleading:

Careful review of these data reveals that most are preclinical and phase 1 compounds. Also included are topical and nonabsorbable antimicrobials, which we do not consider here, and several compounds for which development has been terminated. Finally, … many of the listed drugs are previously approved agents that are being studied for new indications.

Just to make sure no one misses the big picture, the authors emphasize:

…The number of new antibacterials that make it through the complete development process and ultimately receive FDA approval has precipitously decreased over the past 25 years. Indeed, we found a 75% decrease in systemic antibacterials approved by the FDA from 1983 through 2007, with evidence of continued decrease in approvals, even during the most recent 5-year period.

What are the answers? IDSA is candid, as in its earlier reports, that it believes incentives for drug companies are the only way to improve the situation: financial boosts, patent extensions and changes in trial requirements. Two things are critical, the group says:

  • Novel intravenous and oral drugs to treat both hospitalized and community-based patients are needed, as opposed to “me too” drugs that provide minimal improvement over existing therapies.
  • Priority should be given to antimicrobials with the potential to treat serious infections that are resistant to current antibacterial agents.

Bad news on the new-drugs front

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Via the very robust pharma blogosphere, reports that two much-anticipated new antibiotics will be remaining in the pipeline a while longer:

Fierce Biotech says that Pfizer has withdrawn its US and European applications for dalbavancin, a much-awaited new MRSA drug, and will conduct another Phase III trial.

Pharmalot reports (via Reuters) that the Food and Drug Administration has asked for additional trials for ceftobiprole, another much-anticipated new drug for MRSA, coming from Johnson & Johnson. Shearlings Got Plowed has more detail, speculates that a “new game face” is emerging at the FDA, and notes that J&J’s partner in ceftobiprole, Basilea, acknowledged that the FDA raises “issues of data integrity” regarding the current application. J&J’s press release is here.

So it’s back to vancomycin, again, for now.

Contributing to resistance: fake drugs?

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There’s news this morning that Interpol has seized $6.65 million of counterfeit medicines in the culmination of a 5-month undercover investigation that stretched across Cambodia, China, Laos, Myanmar, Singapore, Thailand and Vietnam. The fakes included purported antiretrovirals for HIV, anti-TB drugs, antimalarials (especially artemisinin) — and, chillingly for our purposes here, fake antibiotics for pneumonia and other bacterial illnesses.

Bloomberg News says:

Under Operation Storm, which ran from April 15 to Sept. 15, police seized more than 16 million pills…
Asia is the world’s biggest producer of all counterfeit products, the Organization for Economic Cooperation and Development said in a report last year. About 40 percent of 1,047 arrests related to fake drugs worldwide last year were made in Asia, according to the Washington-based Pharmaceutical Security Institute.
Counterfeits account for as much as 30 percent of all drugs in developing nations and less than 1 percent of all medicines in developed nations such as the U.S. (Byline Simeon Bennett.)

Counterfeiting medicines is both a huge business — the World Health Organization estimates that “counterfeit drug sales will reach US$ 75 billion globally in 2010, an increase of more than 90% from 2005” — and an appalling crime that attacks the most vulnerable people at their most vulnerable moments. In a recent issue brief, the WHO recounts a number of instances of counterfeiting that led to deaths in a number of countries.

Why should we care here? Because some counterfeits are not complete fakes; they contain a small amount of the active ingredient of the drug they purport to be. That means that, if someone takes a faked version of an antibiotic, they may not be going untreated. Instead, they may be undertreated, the exact situation that can lead to the emergence of resistance. Just last year, according to the Pharmaceutical Security Institute, known counterfeiting episodes involving anti-infective drugs rose 26%.

Now, NB: Activism against counterfeit drugs is politically complicated; it is supported by the pharma industry (PSI is a coalition of 26 manufacturers) and is tangled up with opposition to online pharmaceutical sales and to decisions by developing-world countries to abrogate Western drug patents. But that turf-defending by the pharma industry does not alter the reality that counterfeit drugs are an enormous international problem that imperil not only people unfortunate enough to take them, but anyone who contracts a resistant strain that those drugs helped foster.

And anyone concerned about MRSA will already know that resistant strains do not stay where they are generated. They have already demonstrated their ability to move rapidly around the world.

Despite stewardship efforts, antibiotic use increasing

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Well, this is bad news.

I hope we can all agree that antibiotic use creates antibiotic resistance. (Proof, if any were needed, that the universe has a captious sense of humor; but then it has had millennia to practice. OK, sorry for the anthropomorphizing.) The more pressure bacteria are placed under, the more resistant mutants emerge and survive. So the challenge in using antibiotics is to use them sufficiently and not too much: enough to quell infection and save lives, but not so much that the benefit of successful treatment is outweighed by the cost of increased resistance.

That’s the theory, anyway. In practice, according to a paper published today in the Archives of Internal Medicine, we’re not living up to the plan.

Amy L. Pakyz, Pharm.D. and colleagues at Virginia Commonwealth University surveyed antibiotic use at 22 academic medical centers — tertiary care teaching hospitals, ones that would be most likely to have high awareness of the dangers of resistance and good antibiotic stewardship programs — between 2002 and 2006. And found: Despite all that awareness, antibiotic use is going up, and the use of broad-spectrum agents and vancomycin, MRSA’s drug of last resort, is going up most of all.

The third significant observation is the marked increase in vancomycin use during the 5-year period such that it became the single most commonly used antibacterial in this sample of hospitals from 2004 to 2006. …
The reasons for the continued increase in vancomycin use are likely multifactorial, including the increasing numbers of hospital-acquired infections caused by MRSA and the emergence of community-associated MRSA, all of which encourage greater empirical use of vancomycin.

With only a few new drugs of comparative effectiveness on the market, and none that are significantly better, this is bad news, the authors underline:

Vancomycin use is a risk factor for emergence of vancomycin-intermediate S aureus and vancomycin-resistant S aureus, although these strains are rare in the United States. Of greater concern may be the emergence of low-level resistance in MRSA to vancomycin, referred to as minimum inhibitory concentration (MIC) “creep,” and this is far more common. Strains of MRSA having vancomycin MICs of 2.0 μg/mL are associated with longer median times to clearance of bacteremia compared with strains having MICs of 1.0 μg/mL or less, as well as frank treatment failures.

The cite is: Pakyz, AL et al. Trends in Antibacterial Use in US Academic Health Centers 2002 to 2006. Arch Intern Med. 2008;168(20):2254-2260.

New drugs for MRSA, at various experimental stages

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As you might guess by the name, ICAAC (the Interscience Conference on Antimicrobial Agents and Chemotherapy) features much research on the pharma side of things. There were many research reports this past week on drugs at various stages that I was intending to write up for you, but I just noticed that Reuters got there first and did quite a good job. So consider checking this story, which discusses PTK 0796, iclaprim, ceftobiprole, dalbavancin and televancin:

Two experimental antibiotics appear to work safely against an increasingly common and dangerous form of infection called methicillin-resistant Staphylococcus aureus or MRSA, researchers said on Sunday.
Doctors are clamoring for drugs that can fight the so-called superbug infection, which kills an estimated 19,000 people a year in the United States alone. (Reuters)

An important consideration that is not much discussed: It is not enough just to have new drugs; what we need are new classes of drugs. That’s because, when staph acquires protection against one drug, it is likely to be acquiring protecting against all chemically similar drugs — thus, not just methicillin but all the synthetic penicillins; not just Keflex but all the first-generation (and second- and third-generation) cephalosporins.

Breaking MRSA news from the ICAAC meeting 1

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There are 15,000+ people at the 48th Interscience Conference on Antimicrobial Agents and Chemistry (known as ICAAC – yes, “Ick-ack”) and 46th Infectious Diseases Society of America Annual Meeting, and at least half of them seem interested in MRSA. At the keynote address last night, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at NIH, referred to MRSA as a “global pandemic.”

Here are some highlights — a few of very, very many — from the first two days:

  • MRSA is truly a global phenomenon: Researchers here are reporting on local epidemics in Argentina, Australia, Botswana, Canada, Colombia, Ecuador, Greece, Japan, Nigeria, Peru, South Korea, Sweden and Taiwan.
  • In the United States, USA300 — the virulent community strain that is crowding out all other community strains — continues its dominance. It first appeared in the San Francisco jail in 2001 and now is the only cause of community MRSA infections there. (Tattevin, P. et al. “What Happened After the Introduction of USA300 in Correctional Facilities?” Poster C2-225.)
  • And MRSA continues to demonstrate its protean ability to cause unexpected forms of illness: The number of cases of sinusitis caused by MRSA seen at Georgetown University tripled between 2001-03 and 2004-06. (I. Brook and J. Hausfeld. “Increase in the Frequency of Recovery of Methicillin-Resistant Staphylococcus aureus in Acute and Chronic Maxillary Sinusitis.” Poster C2-228.)
  • Meanwhile, treatment options are shrinking. Hospitalization for vancomycin-resistant pathogens (that is, resistant to vancomycin, the drug of last resort for MRSA) doubled between 2003 and 2005 according to national healthcare utilization databases. (A.M. Ramsey et al. “The Growing Burden of Vancomycin Resistance in US Hospitals, 2000-2005.” Poster K-560.)
  • But, new drugs are beginning to emerge from the pipeline. Early results from a privately held company called Paratek Pharmaceuticals (co-founded by resistance guru Dr. Stuart Levy) showed that their new tetracycline relative PTK 0796 scored as well or slightly better than linezolid (Zyvox) in safety, tolerability and adverse events, and is advancing to a full Phase 3 trial. (R.D. Arbeit et al. “Safety and Efficacy of PTK 0796.” Poster L-1515.)

More as the meeting goes on.

Non-pharm prevention alternative for MRSA skin infections

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Longtime reader and botanical-medicine expert Robyn spotted this new story and study this morning and pointed it out in the comments to a previous post. It’s about a product, but it’s a product with science to back it, so under my rules regarding commercial products, I am moving it up to post status. (Robyn didn’t say, but given the internals of her post I assume, that she has no commercial interest in this. Right, Robyn?)

The product under investigation is an over-the-counter cream called StaphASeptic that contains the natural antimicrobials tea tree (Melaleuca alternifolia) oil and white thyme (Thymus vulgaris — the “white” refers to the preparation not the species) oil, along with the commercial antiseptic benzethonium chloride. That product’s effect on isolates of CA-MRSA was compared against two common OTC first aid creams, one containing the topical antibiotic polymyxin B and the other containing both polymyxin B and the topical antibiotic neomycin.

The authors found that the botanical-containing cream did a better job of killing CA-MRSA in a time-kill analysis, finding specifically that it went on killing longer — up to 24 hours — than the other two creams. The assumption obviously is that this non-antibiotic cream would do a better job of protecting superficial wounds and scrapes from MRSA infection than the antibiotic-containing ones, while presumably not promoting resistance.

But the important question, which Robyn raises, is whether the essential oils are not in fact acting as natural antibiotics, possibly synergistically. Let’s remember that the majority of antibiotics — including, for instance MRSA drug-of-last-resort vancomycin, and its replacement daptomycin — were initially isolated from natural substances (fungi, in both those cases). Overall, however, botanical products receive much less research attention that pharmaceuticals, so their action and their therapeutic potential remain unexplored.

The cite is: Bearden, DT, Allen GP and Christensen JM. Comparative in vitro activities of topical wound care products against community-associated methicillin-resistant Staphylococcus aureus. Journal of Antimicrobial Chemotherapy (2008) 62, 769–772. NB: The research was supported by an unrestricted grant from StaphASeptic ‘s manufacturers, Tec Laboratories Inc., and JM Christensen, of the Oregon State University College of Pharmacy, disclosed a consultant relationship with Tec.

CDC educational campaign on antimicrobial resistance

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The Centers for Disease Control and Prevention has a long-running educational campaign called “Get Smart: Know When Antibiotics Work.”

But with flu season starting, the agency has decided to make an extra push, hoping to prevent parents from asking pediatricians to prescribe antibiotics for colds and flu. (Which are, all together now: Viruses! And are not affected by: Antibiotics! Gold stars all ’round.) So it has named next week, Oct. 6-10, as “Get Smart About Antibiotics Week.”

There’s a website page specifically for the campaign, which seems to be aimed mostly at health-care institutions and public agencies — places that would mount campaigns and plan activities to reinforce the stewardship message. (The campaign has 14 health-agency and professional-association partners.) If you’re in any of those roles, there are scripts, ads, PSAs, pre-written “articles” and web graphics and widgets. Find them here.

If you’re looking for more general information that you can, for instance, share with friends, this page has explanations in everyday language.

Here’s a question: Are there any readers who are health-care professionals (doctors, nurses, NPs, PAs etc.) who feel you are pressured to prescribe antibiotics? If so, please get in touch via the comments or the email address in the right-hand bio box. I would love to hear from you.

The importance of MRSA in a flu pandemic

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Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I’ve been following since writing the first story in the American media about avian influenza H5N1 (in August 1997; find it on this page.)

And people concerned about MRSA realize that flu and MRSA have an important overlap: For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we’ve been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA (blogged here and here). Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place. Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Gram-negatives need love too

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Britain’s Health Protection Agency warns today that the supply of new drugs for resistant Gram-negative infections — Acinetobacter, Pseudomonas, Burkholderia — is in even worse shape that the drug pipeline for MRSA and other Gram-positives.

“Over the last ten years the pharmaceutical industry has significantly invested in antibiotic treatments for bacteria such as Staphylococcus aureus (including MRSA). There is however a big public health threat posed today by multi-resistant gram-negative bacteria and therefore there is an urgent need for the pharmaceutical industry to work towards developing new treatment options to tackle infections caused by these bacteria, in the same way as they did for bacteria like MRSA.” (Dr. David Livermore, HPA press release)

The announcement comes between two important events: the release of the HPA’s annual survey of antibiotic prescribing patterns in England, Wales and Northern Ireland (report .pdf here, 2mb); and the start next week of the HPA’s annual scientific conference, which will have a full-day symposium on resistant infections (agenda here).

Interesting: The meme “MRSA’s taken care of, let’s get on to the gnarly Gram-negatives” has picked up traction in the past few months. While I’d certainly agree with the second proposition — pharmaceuticals for resistant Gram-negatives are the next big task — I reject the first, that the MRSA problem is solved and all we have to do is wait for the drugs to roll down the pipeline. Doesn’t exactly square with all those posters at the last ICAAC and IDSA exploring emerging resistance to daptomycin and other new compounds.

For a full and thoughtful exploration of the Gram-negatives problem, see this recent New Yorker article, written by the inestimable Dr. Jerome Groopman. (True story: When Groopman’s first book came out, I interviewed him by phone – I was working in Atlanta – and wrote a complimentary piece about it. Fast-forward several years, he has at least one more book out, has become a writing rockstar – in addition to being a hugely respected Harvard clinician and professor — and I am doing a journalism fellowship on genomics at Harvard Medical School. I’m standing in line at the Longwood area Starbucks, and I spy Groopman about four people ahead of me. And I’m too shy to say anything. So much for reportorial moxie.)

New CDC educational campaign on CA-MRSA, aimed at parents

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This morning, the CDC is launching a “National MRSA Education Initiative” aimed at raising awareness among parents and average health-care professionals — not academic center researchers so much as front-line nurses, NPs, PAs and others who are likely to be the first set of eyes on a community MRSA infection.

The campaign’s front door is a newly constructed page on the CDC’s website that looks well-stocked with fact sheets for parents and for health-care workers; lots of informative photos, most of them taken by physicians, of what a MRSA skin infection looks like; specific information about MRSA infections in schools and in sports; and a free-of-charge radio PSA.

Especially useful, for those who might need it, is a copy of the CDC’s recommended “treatment algorithm” for suspected MRSA — a flowchart or decision-tree for choosing antibiotics when MRSA is suspected. The algorithm was the result of a number of meetings of experts convened by the CDC and represents the best advice on what to take when. It’s a useful thing to consult if you suspect you may be dealing with MRSA and wonder whether you have been given the appropriate drug. All of these materials are downloadable and printable; open-access/no copyright because they are government-produced.

From the agency’s press release (not posted yetposted here):

The National MRSA Education Initiative is aimed at highlighting specific
actions parents can take to protect themselves and their families. CDC
estimates that Americans visit doctors more than 12 million times per
year for skin infections typical of those caused by staph bacteria. In
some areas of the country, more than half of the skin infections are
MRSA. …
“Well-informed parents are a child’s best defense against MRSA and other
skin infections,” said Dr. Rachel Gorwitz, a pediatrician and medical
epidemiologist with CDC’s Division of Healthcare Quality Promotion.
“Recognizing the signs and receiving treatment in the early stages of a
skin infection reduces the chances of the infection becoming severe or
spreading.”

If you don’t believe in evolution…

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…is taking new antibiotics an act of bad faith?

Given, you know, that they’re designed to counter the evolution of disease organisms into more resistant forms?

Just asking. Prompted, probably, by the news that our governor here in Minnesota, Tim Pawlenty, has endorsed teaching creationism in schools here.

Perhaps we’ll see him wearing these T-shirts? (I like the Atlantis one myself): Teach The Controversy.

(Actually, I would like an answer to my question. If anyone can explain the argument, post it in the comments please?)

We pause in our goggle-eyed convention watching to bring you…

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[I’m sorry, faithful readers. It’s the most compelling election of my voting lifetime. I’m riveted. Also, I spent hours in the ER Sunday getting stitched up from a bike crash. A very clean ER … I hope.]

… an intriguing paper on controlling antibiotic prescribing within health care institutions.

Limiting inappropriate use of antibiotics is one of the central goals of the movement to control MRSA. Often, that’s interpreted as getting primary-care docs and pediatricians to resist pressure from consumers, especially parents with busy lives who need to limit their sick child’s illness so they can get back to work (or put the child back in day care) and stubbornly insist that antibiotics will help even when the illness is viral. But it’s just as important, possibly more important, to control inappropriate use in hospitals, where sick patients with depleted immune systems who are getting lots of drugs provide a fertile breeding ground for resistant strains.

So how to do that? If possible, you want the intervention to be systematized, not exceptional; you want it to be a routine occurrence, so clinicians don’t feel singled out for their prescribing choices, and you want it to be not face-to-face, so that the encounter remains about the patient and the drug, not about a clash of personalities.

A team at Johns Hopkins’ children’s hospital seems to have hit it whang in the gold. In the Sept. 15 issue of Clinical Infectious Diseases, Allison Agwu, Christoph Lehmann and colleagues describe a Web-based system that they instituted that significantly reduced inappropriate dosing and saved more than $370,000 in a year while making clinicians and pharmacists happier than they were with the previous system (which involved pagers and was face-to-face).

By chance, the Wall Street Journal ran a story this morning looking at such intervention programs, though not the Hopkins one — a story I missed because, in my normal reading time, I was interviewing Agwu and Lehmann. (H/t Joanne Kenen for alerting me to it though.)

Oh no they *didn’t*…

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The Environmental Protection Agency will allow apple growers in Michigan to spray the human antibiotic gentamicin on apples to control an apple-tree disease, fire blight.

This because the disease had already become resistant to a previously used, different human antibiotic, streptomycin.

The Infectious Diseases Society of America tries to get them to see reason:

“At a time when bacteria are becoming increasingly resistant to many of our best antibiotics, it is an extremely bad idea to risk undermining gentamicin’s effectiveness for treating human disease by using it to treat a disease in apples.” (IDSA President Donald Poretz, MD in a press release.)

Gentamicin is used against staph and against a range of Gram-negative bacteria, and is an important drug for bloodstream infections in newborns. In a bizarre irony, the EPA bans its use on imported fruits/vegetables — because of fears of fostering resistance.

The decision in the Federal Register here. The original EPA proposal here. A Clinical Infectious Diseases article about human antibiotic use in plant agriculture here. And somewhere in the immediate vicinity, me clutching my head and wandering away muttering.

Please route to the Dept. of Unintended Consequences.

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Via the open-access Journal PLoS One, an unnerving report of Canadian researchers finding fluoroquinolone resistance in E. coli in a group who are vanishingly unlikely to have ever taken a quinolone: indigenous Indians in isolated villages in the Guyanese rainforest.

For most people the most familiar quinolone is likely to be ciprofloxacin (Cipro), a very valuable antibiotic in the arsenal because it works against a broad array of Gram-positive and Gram-negative organisms and is off-patent and therefore relatively inexpensive. (Cipro became a household word in the US during the anthrax attacks — it is given prophylactically on suspicion of exposure to inhalational anthrax — and was recently given a “black box” warning by the FDA because of an association with tendon ruptures.)

Quinolone resistance has certainly been recorded: In 2003, a team found 4.0 percent of E. coli in US intensive care units were resistant to cipro. The Canadians — 20 volunteer medical personnel from Ontario — found 5.4 percent among the Guyanese. That’s in a setting where there is no selective antibiotic pressure, because no one is taking antibiotics.

Aha: But they are taking malaria prophylaxis, including the extremely common and cheap antimalarial chloroquine. The team theorizes that chloroquine is sufficiently chemically similar to the quinolones to provoke the development of resistance. If correct, this is very bad news: Malaria is a major killer especially of children, so no one is about to stop prescribing a cheap, effective antimalarial in a highly malarious area. In fact, the WHO and other agencies are preparing a new antimalarial program called ACT (for “artemisin combination therapy”; artemisin is a botanical) that includes a drug family called quinolines that are chemically similar to chloroquine.

Controlling malaria is an important public health goal, but so is controlling antibiotic resistance, especially resistance to effective drugs that poor countries can afford. As one of the authors, Michael Silverman of Oshawa, Ont. warned as the study was releasing:”Chloroquine use for malaria may make the fluoroquinolones less effective for many common tropical diseases such as typhoid fever, diarrheal illnesses, and possibly also tuberculosis and pneumonia in the developing world.”

The cite is: Davidson RJ, Davis I, Willey BM, Rizg K, Bolotin S, et al. (2008) Antimalarial Therapy Selection for Quinolone Resistance among Escherichia coli in the Absence of Quinolone Exposure, in Tropical South America. PLoS ONE 3(7): e2727. doi:10.1371/journal.pone.0002727