Maryn McKenna

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Child deaths from flu + MRSA: CDC confirmation

September 9, 2009 By Maryn Leave a Comment

Hello again, constant readers. It’s been an exciting few weeks at Casa Superbug. I’ll spare you the details — most of them are both grueling and trivial — but out of the murk, here is a piece of excellent news: SUPERBUG has been edited, revised and sent back to the publisher, who has sent it into production. Yes, it’s actually beginning to become a book. There are many more steps to go, but it it is finally, really on its way.

Meanwhile, there is a ton of MRSA news to catch up on, which I will roll out over the next week or so. First: For those of you who don’t read the CDC’s weekly bulletin (called the MMWR, for Morbidity and Mortality Weekly Report. It’s the best-read magazine you’ve never heard of. It’s free. Go already), there was an important and disturbing report last Friday, reporting the case details of children who have died from H1N1 flu.

As of August 8, the CDC said, 477 people had died in the US from H1N1, and 36 of them were children and teenagers. Out of those 36:

  • 7 were younger than 5
  • 24 had at least one high-risk medical condition, many of them neurological (developmental delay, cerebral palsy) or pulmonary; 12, or one-third, did not
  • 23 had some pathologic analysis done during their illness or after their deaths
  • 10 had bacterial co-infections
  • of those 10, 5 had staph infections
  • 3 of the staph infections were MRSA.

Let’s bring the first and last terms of that equation together: 36 children; 3 known MRSA infections. Though it could be an underestimate (because 13 children had no pathology done), that is a non-trivial 8%.

The report splits the data on the child deaths a number of different ways, and reveals details that are important to note. Six of the bacterial infections (four staph) were in children older than 5 who did not have any underlying conditions; they were healthy, normal kids before developing flu. Of the 7 kids younger than 5, 2 had a bacterial infection; again, neither child had a high-risk condition.

How worrisome are these numbers? It’s hard to say with precision, but they are certainly not good news. The CDC has only been counting child deaths from flu for a few years, and the totals they have come up with are very variable: 153 in 2003-04, 47 in 2004-05, 46 in 2005-06 and 73 in 2006-07. But, important point: Those deaths were during the regular flu season, which goes from roughly October to March. These new deaths occurred between late April and early August, when there is not supposed to be any flu. What this will mean for this fall and winter, when H1N1 will still be around, and may co-circulate with seasonal flu, no one yet can say.

For our purposes, the most important point is that lethal MRSA co-infections are now confirmed to be happening in the setting of H1N1 flu. And, as the CDC paper notes, these infections happened in children who would not have been expected to have a tough course, because they had no underlying high-risk conditions:

This report also highlights the prominence of laboratory-confirmed bacterial coinfections, which were identified in 10 (43%) of the 23 children who had culture or pathology results reported. All six children who were aged ≥5 years, did not have a high-risk medical condition, and had culture or pathology results reported had an invasive bacterial coinfection, suggesting that bacterial infection, in combination with 2009 pandemic influenza A (H1N1) virus infection, can result in severe disease in children who might be otherwise healthy. Clinicians should be aware of the potential for severe bacterial coinfections among children diagnosed with influenza and treat accordingly.

Obviously those of us who are concerned about MRSA and the potential for MRSA pneumonia alongside flu have been worried about this (long archive of posts here). If there is any good news in the sad saga of these deaths, it is that the CDC has confirmed that MRSA pneumonia in H1N1 flu is a real and dangerous possibility.

So if you are concerned about this, first, bookmark the MMWR report, because it will be something to show to a physician if necessary. And second, keep in mind the potential for pneumonia if you have a young child who contracts H1N1. I am not suggesting being alarmist; if H1N1 circulates widely, doctors and ERs will be overwhelmed, and we should try not to add to their case load unless really necessary.

But on the other hand, if a child has chest pain or breathing difficulty, don’t hold back. There are online tools such as this one by Children’s Healthcare of Atlanta that can help a worried parent assess whether and when a child with flu should be taken to the ER. If you click through its steps, you’ll see that breathing difficulties and the possibility of pneumonia are things that it takes seriously, and so should we.

Filed Under: CDC, children, H1N1, MRSA, pneumonia

Child deaths from flu + MRSA, an update

February 27, 2009 By Maryn Leave a Comment

As predicted earlier this week: The Centers for Disease Control and Prevention (CDC) has announced more deaths of children from flu, and from flu followed by MRSA pneumonia.

My colleagues at the Center for Infectious Disease Research and Policy are tracking the case count, and here’s what they said this evening:

The CDC received eight reports of influenza-related deaths in children during the week ending Feb 21, bringing the seasonal total to 17. Four of the deaths occurred in Texas, 2 in Colorado, and 1 each in Arizona and Massachusetts.
Bacterial coinfections have been confirmed in 10 (59%) of the 17 children. Staphylococcus aureus was identified in 8 of the 10 children—3 of the isolates were sensitive to methicillin, 4 were not, and results were not reported for 1. Eight of the 10 children who had coinfections were age 12 or older. (Byline: Lisa Schnirring)

Just to recap, that’s four deaths so far this flu season from flu+MRSA, twice the number we knew of last week.

And just to remind: The CDC and its Advisory Committee on Immunization Practices now recommends flu shots for all children and adolescents, up through the age of 18. A flu shot is one defense against MRSA pneumonia. It is worth considering.

Filed Under: CDC, children, death, influenza, MRSA

Child deaths from flu + MRSA, again

February 23, 2009 By Maryn Leave a Comment

Folks, I am close to manuscript deadline and so keep disappearing down the rabbit hole; forgive me if I don’t post as regularly as usual, I’ll be back as soon as I can.

I wanted to point out the announcement by the Centers for Disease Control late Friday that we are starting to see children dying from MRSA this flu season. (The architecture of the linked page is unfortunately way clumsy; at the link, scroll down to the subhead “Influenza-Associated Pediatric Mortality.”)

Since September 28, 2008, CDC has received nine reports of influenza-associated pediatric deaths that occurred during the current season.
Bacterial coinfections were confirmed in six (66.7%) of the nine children; Staphylococcus aureus was identified in four (66.7%) of the six children. Two of the S. aureus isolates were sensitive to methicillin and two were methicillin resistant. All six children with bacterial coinfections were five years of age or older.

We’ve talked before (here, here and here, among other posts) among the emerging understanding of the particular danger that MRSA poses during flu season, when (it is hypothesized) inflammation from flu infection makes the lungs more vulnerable to secondary bacterial infection.

(For those paying attention to the hospital v. community MRSA debate, this is a community-associated infection, not a hospital one.)

This current CDC bulletin underlines, just in case we have forgotten, that drug-sensitive S. aureus (MSSA) can be a serious foe as well. Let’s remember, resistance makes MRSA less treatable than MSSA, but it does not change its virulence; MSSA by itself can be a very serious foe. Yes, there are other changes in some strains, especially the community ones, that do appear to increase virulence, but the original MSSA strain is nothing to trifle with.

Also, here’s an important addition to this unfolding story: My colleagues at the Center for Infectious Disease Research and Policy are keeping track of kid deaths around the country. According to them, these CDC numbers are already out of date; they have uncovered more that the CDC has not yet posted, but may take note of in future weekly updates.

Filed Under: CDC, children, flu, influenza, MRSA, MSSA, pneumonia

“Alarming” increase in MRSA infections in children

February 3, 2009 By Maryn Leave a Comment

I’ve been waiting to post on this paper from last week because there was something odd about the math in it. It’s an important and troubling finding, though, so even though I haven’t heard back from the authors, I’m going to describe it for you and explain where I think the error is. (NB, When corrected the error makes their findings more significant, not less.)

So: Authors from Emory University in Atlanta reviewed a national database of head and neck infections in children that were reported by 300 hospitals between 2001 and 2006. In those years, there were 21,009 S. aureus infections: ear infections, sinus infections and so on. But, in 2001, the proportion of S. aureus that was MRSA was 11.8%. In 2006, it was 28.1%. That’s more than a doubling — it’s a 138% increase. (Here’s the error: The authors say it was a “16.3% increase“. I believe they mean “16.3 percentage points,” which would be correct but significantly undersells their finding.)

Because 60% of the infections were outpatient, the authors make the reasonable assumption that these are community-associated MRSA (CA-MRSA). CA-MRSA is generally resistant to fewer drug than the hospital (HA-MRSA) variety. Unfortunately, they also find that this community strain is gaining additional resistance factors: More than 48% of all MRSA stains in this study were resistant to clindamycin, which is not a traditional resistance for CA-MRSA but recently has been reported more and more. Also, head and neck infections are not traditional presentations for MRSA, suggesting the bug is expanding its range.

Their comment:

…[T]he results of this study depict an alarming increase in MRSA in the United States. There is an increasing trend of clindamycin resistance among MRSA isolates. Expeditious culture of suspected head and neck infections leading to more appropriate antimicrobial drug selection is highly recommended to avoid further resistant patterns.

The cite is: Iman Naseri; Robert C. Jerris; Steven E. Sobol. Nationwide Trends in Pediatric Staphylococcus aureus Head and Neck Infections. Arch Otolaryngol Head Neck Surg. 2009;135(1):14-16.

Filed Under: children, clindamycin, MRSA

Terribly sad story from Florida

December 19, 2008 By Maryn Leave a Comment

Cody Shrout, a 12-year-old 6th-grader who lived in Daytona Beach, Fla., was found dead in bed a week ago today by his 8-year-old sister.

His death was initially put down to chickenpox, which was circulating in his school, but the Volusia County medical examiner determined Tuesday that his death was due to MRSA.

Two weeks ago, he scraped his knee skateboarding, subsequently spiked a 103+ degree fever, was treated at a local ER and sent home. The story describing his treatment quotes his grandfather in a way that suggests the scrape was treated as a sports injury, with ice and ibuprofen.

Cody lived with his mother, sister, 3-year-old brother and grandfather. His mother, who is single, could not afford a funeral. With extraordinary generosity, Heather and Jason Jenkins, who own a plumbing business in Apopka, Fla., have paid for the funeral. He will be buried Tuesday.

An odd tidbit in this very sad story: Ten months ago, according to the Daytona Beach News-Journal, he was treated at that same medical center for a staph infection. The story doesn’t say whether he was an admitted patient or seen in the ER, and also doesn’t say whether it was MRSA or drug-susceptible staph. Interesting, though.

Filed Under: children, community, death, Florida, MRSA

More teen MRSA deaths

October 3, 2008 By Maryn Leave a Comment

I just want to note that there is a sad uptick in news of MRSA illnesses and deaths among teens:

  • 18-year-old Alonzo Smith of Kissimmee, Fla. died this past Monday, Sept. 29.
  • 17-year-old Saalen Jones of Philadelphia died on Tuesday, Sept. 23.

In addition, just in the past two weeks there have been school outbreaks in:

  • Williams, AZ
  • two Cleveland, OH schools
  • a Tucson, AZ high school
  • five Tempe, AZ schools
  • an Edmond, OK high school
  • a Knoxville, TN high school
  • Bedford County, VA
  • Uniontown, PA
  • schools in Commack and Westhampton Beach, Long Island, NY
  • Bath and Ferryhaven, MI
  • central NY state
  • Copperopolis, CA
  • and Northhampton, PA.

Filed Under: children, community, death, football, MRSA, schools

CDC educational campaign on antimicrobial resistance

October 2, 2008 By Maryn Leave a Comment

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.

Filed Under: antibiotics, CDC, children, stewardship

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

September 8, 2008 By Maryn Leave a Comment

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.”

Filed Under: antibiotics, CDC, children, community, MRSA, praise

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