Maryn McKenna

Journalist and Author

Brand-new research: Vast increase MRSA, CA-MRSA diagnoses among kids

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I’m on the road today and have what feels like seconds between commitments, but there’s a brand new piece of research this morning that I think you folks should know about. It’s an early-online release from Pediatrics by researchers from 3 states. It uses a database called the Pediatric Health Information Systems analyze diagnosis codes and antibiotic treatment of kids treated for staph at 25 US children’s hospitals  from 1999 to 2008, and it finds:

The incidence of methicillin-resistant S aureus (MRSA) infections during this period increased 10-fold, from 2 to 21 cases per 1000 admissions, whereas the methicillin-susceptible S aureus infection rate remained stable. Among patients with S aureus infections, antibiotics that treat MRSA increased from 52% to 79% of cases, whereas those that treat only methicillin-susceptible S aureus declined from 66% to <30% of cases. Clindamycin showed the greatest increase, from 21% in 1999 to 63% in 2008. 

To translate, for those not used to reading scientific literature:

  • a 10-fold increase in MRSA diagnoses over 10 years
  • a 3-fold increase in what was not the most commonly prescribed drug, one useful for the different resistance profile of community infections 
  • clindamycin (used in mild and also invasive infections) eclipsing vancomycin (last-resort drug for invasive cases) as the most-used drug — which could be a sign of changes in prescribing patterns, changes in seriousness of the cases seen, or a warning that with so much use, clindamycin resistance could emerge more quickly, as happened when vancomycin came off the shelf in the 1990s and began to be used more.

It will take me a while to download and read the paper (hard to do in the car), but that’s the topline news. Update to come.

Community MRSA rates rising, and epidemics converging

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A study published Tuesday in Emerging Infectious Diseases makes me happy, despite its grim import, because it confirms something that I will say in SUPERBUG: Community MRSA strains are moving into hospitals, blurring the lines between the two epidemics.

The study is by researchers at the excellent Extending the Cure project of Resources for the Future, a group that focuses on applying rational economic analysis (think Freakonomics) to the problem of reducing inappropriate antibiotic use. (Here’s a post from last year about their work.)

Briefly, the researchers used a nationally representative, commercial (that is, not federal) database of isolates submitted to clinical microbiology labs, separated out MRSA isolates, divided them into whether they originated from hospitals or outpatient settings (doctors’ offices, ambulatory surgery centers, ERs), and analysed them by resistance profile, which has been a good (thogh not perfect) indicator of whether strains are hospital or community types (HA-MRSA or CA-MRSA). They cut the data several different ways and found:

  • Between 1999 and 2006, the percentage of staph isolates from outpatient settings that were MRSA almost doubled, increasing 10% every year and ending up at 52.9%. Among inpatients, the increase was 25%, from 46.7% to 58.5%.
  • Among outpatients, the proportion of MRSA isolates that were CA-MRSA increased 7-fold, going from 3.6% of all MRSA to 28.2%. Among inpatients, CA-MRSA also increased 7-fold, going from 3.3% of MRSA isolates to 19.8%.
  • Over those 7 years, HA-MRSA did not significantly decrease, indicating that CA-MRSA infections are not replacing HA-MRSA, but adding to the overall epidemic.

So what does this mean? There are a number of significant aspects — let’s say, bad news, good news, bad news.

Bad: CA-MRSA strains are entering hospitals in an undetected manner. That could simply be because patients entering the hospital are colonized by the bug and carry it with them. But it could also be because healthcare staff who move back and forth between outpatient and in-patient settings — say, an ambulatory surgical center and a med-surg ward — could be carrying the bug with them as well.

Good: If they are detected (analyzed genotypically or for drug sensitivity), CA-MRSA strains are less expensive to treat because they are resistant to fewer drugs, and some of the drugs to which they are susceptible are older generics, meaning that they are cheaper.

Very Bad: The entrance of CA-MRSA strains into hospitals risks the trading of resistance factors and genetic determinants of transmissibility and colonization aptitude in a setting where bacteria are under great selective pressure. Several research teams have already seen this: In several parts of the country, CA-MRSA strains have become resistant to multiple drug families.

Is there a response? The work of Extending the Cure focuses on developing incentives that will drive changes in behavior around antibiotic use. These results, lead author Eili Klein told me, call for developing incentives for creating rapid diagnostic tests that will identify not just that a bug is MRSA, but what strain it is, so that it can be treated appropriately and not overtreated.

The results also underline the need for something that is particularly important to me: enhanced, appropriately funded surveillance that will define the true size of the MRSA epidemic and delineate the behavior of the various strains within it. Right now, surveillance is patchy and incomplete, done partially by various CDC initiatives and partially by the major MRSA research teams at academic medical centers. As we’ve discussed, there is no national requirement for surveillance of patients, and very few state requirements; there is no incentive for insurance companies to pay for surveillance, since it benefits public health, not the patient whose treatment the insurance is paying for; and there is a strong disincentive for hospitals to disclose surveillance results, because they will be tarred as dirty or problematic. Yet to know what to do about the MRSA epidemic, we first have to know the size and character of what we are dealing with, and we do not now.

The cite is: Klein E, Smith DL, Laxminarayan R. Community-associated methicillin-resistant Staphylococcus aureus in outpatients, United States, 1999–2006. Emerg Infect Dis. DOI: 10.3201/eid1512.081341

A parent’s plea and confusion

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I want to highlight a comment that was left on Labor Day by a woman named Valorie in Arkansas (thank you for reading, Valorie). She said:

I am just now learning about all of this and am very concerned about my 12 year old daughter. We were only 10 days into the school year, and she came down with the flu about a week ago. The rate at which it spread within her school as well as to me (her mother) and 2younger siblings was astonishing! We were all running high fevers within 24 hours of the onset of her first noticeable symptoms. Her junior high (which has approximately 500 students) had between 130 and 140 students absent last week due to flu like symptoms. However, the school is saying this is not H1N1 because it is too early in the season to be the actual flu. (This is absurd in my opinion.) Now, on our oldest daughter’s 5th day into the illness she has developed an MRSA infection from a small boil on her tummy. Within a day, it has swollen from a golf ball size to larger than a baseball in size. She now has 2 places of infection and is running a fever of about 101.7 on her 6th, almost 7th day of illness. Her doctor has placed her on a high powered antibiotic, but she is feeling so ill that I am scared to death for her, especially reading about the complications from having both the flu and MRSA. Do you think the oral antibiotics should take care of it, or do you think we need to have her admitted for IV antibiotics. I’ve just been surprised at how long this illness has lasted and how ill she still seems to be. No one seems to want to talk about the flu, much less any other possible complications in order to keep everyone else from panicking. I just want to get my daughter well and keep her safe. Any advice? Thanks so much for your time.

I wanted to highlight Valorie’s comment for a couple of reasons.

First, because it captures the way in which H1N1 has been ripping through schools in most places where school has returned to session. Schools in the Southeast tend to go back before the Northeast or the West; in Atlanta, where I used to live and where schools reopen long before Labor Day, H1N1 has gone through schools like a hot knife. Second, it shows how little the education about flu being pushed out by the CDC (and by others including my colleagues at CIDRAP) has penetrated: There has been H1N1 flu all over the place this summer, and it’s precisely because it is “too early in the season” that we know it is H1N1 and not the seasonal flu.

But what is most concerning and touching is Valorie’s confusion over which drugs her daughter should be taking, and whether her daughter’s physician is giving enough attention to her illness. Despite years of clinical experience, figuring out which drugs to give for MRSA is not easy. That’s first because many of them are old and now generic-only drugs for which clinical trials (in the context of this disease) were never done; and second because community MRSA’s resistance profile keeps changing as it picks up additional resistance factors.

The CDC dealt with this problem of what drugs to give in a meeting held in 2004 and a report issued in 2006. The report, going drug by drug, is here (caution, it’s 24 pages) and a flow chart summarizing the findings is here. Either is useful to have and to take to doctors if you feel uncomfortable about what is being prescribed or about a patient’s lack of progress.

Valorie, I hope your daughter does better. Keep us posted.

MRSA and pets

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It’s been a while since we’ve focused on the presence of MRSA strains in pets, and the complications that can cause for the pets’ human owners/custodians/companions (or, in the view of my own two cats, abject servants. No, I will not post their pictures. I have some shreds of pride).

The problem with MRSA and pets is not the same as the problem of MRSA ST398 in food animals. Rather, pets tend to carry human strains, passed to them by their owners. The carriage is usually asymptomatic, but not always; there are cases in the medical literature of cats and dogs suffering serious skin and soft-tissue infections from community-strain MRSA, usually USA300. But the emerging consensus seems to be that pets carry the bug transiently — not long, but long enough to reinfect the person who passed the bacterium to the pet in the first place. (This can be, but is not always, the source of recurrent infections in humans: The human takes antibiotics and recovers, but the animal holds onto the bug long enough to pass it back to the now-clear human.)

For anyone who needs to go deeper on this, the current issue of Lancet Infectious Diseases has a good overview of the problem that community MRSA strains pose to pets and their humans. There’s a thorough review of the major papers:

  • Cefai, 1994: hospital outbreaks traced to two nurses and through them to their dog
  • Simoons-Smit, 2000: household epidemic of three humans, one cat, one dog
  • Manian, 2003; dog is source for owner’s recurrences
  • Vitale, 2006: owner is (apparently) source of cat’s MRSA.

(This is a good place to say that this entire history, including personal stories of human and animal infection, is covered in a chapter of SUPERBUG. Publication date coming soon!)

The Lancet paper incorporates reminders of some powerful and troubling trends. As with MRSA ST398, one thing can distinguish MRSA that has been in an animal is a resistance pattern that is slightly different from what we expect but that has arisen because the animals receive different drugs. In the case of pigs and ST398, the intriguing marker is tetracycline resistance; humans don’t usually get tetracycline for MRSA, but pigs do. In the case of companion animals, it tends to be fluoroquinolone resistance; pets are more likely to get that class of drugs for a skin/soft-tissue infection. But, the authors caution, that may mean that pets serve as a breeding ground for multi-drug resistant MRSA, with their fluoroquinolone treatment adding another resistance factor into the bug’s already potent arsenal.

The authors also remind us that MRSA can come from animals much more directly than through silent carriage: that is, in a bite. Both dog and cat bites have been found infected with MRSA, due to bacterial contamination of the wound either from the pet or from colonization on the human’s skin.

The cite is: Oehler RL et al. Bite-related and septic syndromes caused by cats and dogs. The Lancet Infectious Diseases, 9(7):439 – 447, July 2009. doi:10.1016/S1473-3099(09)70110-0.

While taking a flu break, a MRSA round-up

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Constant readers, the H1N1 (Virus Formerly Known as Swine) Flu story remains a bit intense. I’ve missed a few MRSA stories over the past few days, so here is a round-up.

First, though, if you’re curious about what the swine flu reaction says about our ability to handle a pandemic, you might take a look at this story I wrote Friday at CIDRAP. Quick version: Over-reaction on the part of the “worried well” — and people seeking testing and not knowing where to get it — put ERs into meltdown nationwide. If we were facing a virus that was not only fast-spreading but virulent, we could be in serious trouble.

On to MRSA:

  • Therapy animals as a vector: In a letter to the Journal of Hospital Infection, Drs. J. Scott Weese and Sandra L. Lefebvre of the Ontario Veterinary College at the University of Guelph report on two therapy dogs that became transiently colonized with C. difficile (on its paw pads) and MRSA (on its coat; found on the hands of its handler) after visiting health care facilities, demonstrating how easily bacteria can move in and out of hospitals. Constant readers will recognize Weese’s name: He is one of the most important investigators of MRSA in food animals and pets, and among other things has written infection-control guidelines for therapy animals.
  • In the Canadan Medical Association Journal, Drs. Anne G. Matlow and Shaun K. Morris of the University of Toronto and the Hospital for Sick Children caution that while hospitals may be getting better at infection control, there is not yet as much attention to it as there should be in ambulatory-care settings: urgent care centers, surgery centers and doctors’ offices. They offer a checklist of the minimal things that a physician practice should do.
  • And in the UK, Baroness Masham of Ilton, a member of the House of Lords, offers her online notes on serious infections with community MRSA, which the Brits are calling PVL-MRSA in recognition of the toxin that the strain produces. The notes are in advance of a series of questions that she intends to pose to government ministers during a Question Time on Wednesday.

More soon.

MRSA strains crossing borders: US CA-MRSA to Italy

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Swine flu continues to dominate the headlines, but other pathogens don’t read the papers. Case in point: New news about a US community strain being found and treated in a woman in Italy — better treated, as it turns out, than she was in California, where she was infected.

In a new letter in Emerging Infectious Diseases (a free journal published online and in print by the CDC — it’s your tax dollars at work, just read it, already), Carla Vignaroli, Pietro E. Varaldo, and Alessandro Camporese of the Polytechnic University of Marche in Ancona amd the Santa Maria degli Angeli Regional Hospital, Pordenone report the case of

a 36-year-old Italian woman (who) was seen at Pordenone Hospital (northeastern Italy) for spider-bite–like skin lesions on the face, characterized by rapid evolution to furuncles and small abscesses. The infection had started ≈1 month earlier in California, where she had spent several months on business (wine import-export), and where she had been treated empirically with amoxicillin/clavulanate for 10 days (1 g, 3×/day), with no clinical improvement.

(At this point, I know every clinician reader and everyone who has had a MRSA skin infection is shaking his or her head. Surely by now the knowledge that “spider bite” is practically diagnostic for CA-MRSA has penetrated? But apparently not, since she was given amoxicillin/clavanulate, AKA Augmentin, which is partially penicillin-based.)

When the woman’s lesions were cultured, they turned out to be caused by USA400, the original community strain, which back in the 1990s was known as MW2. That’s interesting, especially in California, since USA300 has become such a dominant strain. Nevertheless, the key point is that USA400, as with USA300, has barely been recorded in Italy:

All 3 previously reported cases of CA-MRSA infection in Italy were caused by type IV SCCmec, PVL-positive strains, none of which, however, belonged to the ST80 clonal lineage that predominates in Europe (7). The first case (in 2005) was a necrotizing pneumonia caused by an ST30 isolate; the 2 other cases (2006) were severe invasive sepsis and a neck abscess, both caused by ST8 (USA300) isolates.

The concern, of course, is that once imported, they will not remain rare:

The case we note here documents the importation of a US pathogen into a country in Europe, from an area where the pathogen is widespread and has been highly virulent since the late 1990s, to an area where its penetration in the past has been poor.

The cite is: Vignaroli C, Varaldo PE, Camporese A. Methicillin-resistant Staphylococcus aureus USA400 clone, Italy [letter]. Emerg Infect Dis. 2009 Jun; [Epub ahead of print]. DOI: 10.3201/eid1506.081632

New York Times takes up “pig MRSA” ST398

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Constant readers, I know that many of you are very interested in ST 398, the “pig strain” of MSRA that has caused both mild and life-threatening human infections in Europe and has been found in retail meat in Canada and on farms and in farmers here in the Midwest. So I just want to bring to your attention that New York Times columnist Nicholas Kristof takes up the topic today, in the first of two promised columns: Our Pigs, Our Food, Our Health.

In today’s piece, he describes an apparent epidemic of skin and soft-tissue infections in a pig-farming area of Indiana that caught the attention of a local family physician, who subsequently died.

What we’d need to know, of course — and may never know, given that the investigation may have ended with the doctor’s death — is what strain of MRSA those local folks had. They may have ST 398, picked up if they worked on farms, or if it migrated out of the farms via groundwater or dust or flies. Or they may have USA300, the human community-associated strain, which in some areas is astonishingly common — a fact that most people don’t appreciate if they have heard only about the invasive child-death cases or the outbreaks in sports teams.

The full archive of posts on MRSA in animals is here and stories only about ST398 are here.

Seriously, a global problem

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Serendipitously, as I was preparing the previous post (an intro to GlobalPost.com, which will be featuring posts from SUPERBUG), an auto-push email from the National Library of Medicine‘s PubMed service landed in my inbox.

For those of you whose bedtime reading is not obscure medical journals (I know: This is what you have me for), PubMed is a search interface that allows you to pull articles for medical journals wordwide. It also offers a push option: Set a search term, fill in your email, and links to the latest articles on your term of choice are delivered. I have my search set to “MRSA” and have the results pushed once a week; there are never fewer than 25 new papers, which is a great gauge of how active an area of research — and how important a topic — MRSA is.

The latest push — 26 articles — vividly reminded me that, as NIAID Diretor Dr. Anthony Fauci said a few months ago, we are in the midst of “a global pandemic.”

Here is a sampling of those latest papers, from, again, a single week:

No question, constant readers: What we are talking about here is an international problem, a truly global bug.

Terribly sad story from Florida

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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.

MRSA and jails and public reaction

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I have a GoogleNews Alert set to crawl for any new posts that mention MRSA. The Google crawler goes pretty deep and often finds things that I would not have known to look for; this week, it has produced a letter to the editor about conditions in a women’s jail in South Florida.

The letter itself is interesting, but the public reaction to it, in the form of comments on the website where it was reproduced, is breathtaking.

Here’s a quick recap: A woman named Susan M. Woods writes in the letters to the editor on TCPalm.com (which appears, after some drilling, to be a joint site for the Stuart, Fla. Treasure Coast News/Press-Tribune, the Vero Beach Press Journal, the Jupiter Courier, and the Sebastian Sun) about conditions at the Indian River County Jail, where she has been an inmate:

The absolute squalor women are forced to live in is similar to a Third World country. Backed-up toilets, black mold, roaches all around, and nothing to clean the common areas except diluted Windex — it’s frightening. It should be no surprise to hear that at least seven women have gotten MRSA — a staph infection — in as many months.

It will not surprise any of you who follow news about MRSA that jails and prisons are particularly vulnerable to outbreaks; the Los Angeles County Jail epidemic (first described in this MMWR article and further described in this one and covered in this book, which was written by, umm, me) has been going on for half a decade at this point and has affected thousands of prisoners. That there is an outbreak in a jail in Florida is exasperating and sad.

But that people in Indian River County think prisoners somehow deserve staph is just astounding. In the comments on Woods’ letter, they say:

In my opinion, someone with Susan’s alleged criminal record deserves far worse conditions in her cell than what she is describing in her letters.

You are supposed to not want to be there you idiot. That’s why its like living in a third world county.

The conditions in jail are horrendous but people keep coming back. What should the taxpayers do then? Take money away from roads, schools, emergency services to make sure the jails are clean, bright and cheery? Or hope that the bad conditions convince just one moron to obey the law.

If I understand the trolls commenters correctly, they believe that prisoners forgo human rights to such an extent that it is an appropriate part of their punishment to subject them to infectious diseases. So, OK: If they are unmoved to care for their fellow humans, we will leave them to their karma.

But really: Don’t they want to take care of themselves? It is well-established by now that MRSA in jails does not stay in jails: It moves out into the community when inmates who acquire it in jail are released and return to the outside. So unless you’re going to argue that people in jail should remain there indefinitely — which seems impractical given the rate at which we put people away — to be concerned about MRSA in jails is self-protection if nothing else.

It’s flu season: Watch for MRSA pneumonia.

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Via the (Tucson) Arizona Daily Star, I’ve just caught up with the very sad story of Robert Sweitzer, a Tucson resident who died on his 39th birthday, of MRSA pneumonia.

Sweitzer died last Feb.10, but his name is in the news now because a lawsuit filed by his wife Rachel against the hospital where he died has just been scheduled for a Sept. 2009 trial.

The apparently undisputed facts of the case (according to news reports that I cannot usefully link to because they require registration) are:

  • Sweitzer was a healthy man, married three years, who worked a full-time job and devoted all his spare hours to animal rescue.
  • On Saturday, Feb. 9, he woke up feeling as though he were coming down with a cold, with a cough and low back pain. He and his wife went to a regular volunteer shift at a local cat shelter, but by evening, he was having trouble breathing. They arrived at St. Mary’s Hospital ER at 6:30 p.m.
  • Sweitzer was triaged within a half-hour, judged to be a low-acuity case, and sent to wait.
  • It was February, the height of a bad flu season, and the ER was slammed with 170 patients.
  • Sweitzer’s breathing and back pain got worse and his wife twice asked unsuccessfully for him to be re-evaluated.
  • When he was finally seen at 2:30 am, an X-ray showed his lungs filled up with fluid. He was put on 100% oxygen.
  • He arrested twice and was pronounced dead near 7 a.m.

Following an autopsy, the Pima County Medical Examiner and the Arizona Department of Health Services asked the Centers for Disease Control and Prevention to evaluate Sweitzer’s case; based on the extensive lung destruction, they feared he died of hantavirus. Tissue samples were sent to the CDC, which reported in August that Sweitzer actually died of necrotizing pneumonia caused by MRSA.

We have talked before (here, here, here, here and here) about the particular danger of MRSA infection during flu season, when (it is theorized) micro-trauma to the lungs by flu infection allows MRSA to gain a foothold. Once it begins, MRSA pneumonia proceeds with incredible speed — I have spoken to parents whose children went literally from apparently healthy to dead or close to it, within 24 hours — and it is commonly mistaken either for flu or for community-acquired pneumonia, the usual drugs for which have no impact on MRSA.

So, constant readers: It is flu season. Please get a flu shot. The observations and research on this are still limited, but it does appear that if you prevent flu, MRSA will have a more difficult time gaining a foothold in the lungs. (And if you nevertheless find yourself in a situation similar to Robert Sweitzer’s, and you truly believe it is life-threatening for yourself or your loved one, do whatever is necessary to direct clinical attention to you in time.)

Because I cannot link through to the Arizona Star stories, here are the dates and headlines:

  • 20 February 2008, “His pet projects: rescuing dogs, cats,” byline Kimberly Matas
  • 16 March 2008, “39-year-old’s ER death leaves a lot of unanswered questions,” byline Carla McClain
  • 27 August 2008, “Feb. death of Tucson man, 39, tied to staph,” byline Stephanie Innes
  • 1 December 2008, “Suit over death at St. Mary’s ER set for trial in September” (no byline).

MRSA in newborns on Prince Edward Island: HA? CA? Matters?

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There’s been a running story for several weeks now about the Queen Elizabeth Hospital on Prince Edward Island (home to mussels and Anne of Green Gables). The hospital struggled earlier this year with an outbreak of MRSA and a second outbreak of VRE among adult patients. It got those under control, but since earlier this month has been dealing with a new outbreak of MRSA in its newborn nursery, according to the PEI Guardian:

Nine newborns and one mother have now tested positive for MRSA. Five of those nine cases can be connected to the same source. (Byline: Wayne Thibodeau)

The stories are detailed, for a small paper — they go into depth about the cleaning measures the hospital is taking — and yet they don’t answer the questions that we here want to know. Does “tested positive” mean colonized or infected? Does “connected to the same source” mean they all have the same strain, or does it mean there is an epidemiologic link?

In the latest news (Tuesday’s paper and online edition), the hospital reports that it is doing nasal swabs on more than 300 staff, with the intention to do a 7-day decolonization regimen on anyone who turns up positive. They won’t however, disclose the source when they find it — though, again, it’s not clear whether that means not identifying the staffer (appropriate) or not admitting that it is a nosocomial outbreak (inappropriate and at this stage lacking in credibility):

Rick Adams, CEO of the Queen Elizabeth Hospital, said about 290 staffers have already been screened.
“In terms of the test results, we’re not going to be making anything public,’’ Adams told The Guardian.
“We want to make sure the environment here is supportive of staff and create a climate where they can feel comfortable and open to come forward and be screened knowing that any results will be kept strictly confidential.’’
Adams said he realizes a solid argument can be made that the public should be informed if the source is found and that source is a staff member.
But he said the public should also realize the hospital is doing everything it can to prevent a further spread of the superbug.
“The staff are under enormous pressure. They feel like they are under a microscope.’’ (Byline: Wayne Thibodeau)

Some readers may know that it is outbreaks among newborns that have demonstrated that the designations “community-associated” and “hospital-acquired” are passing out of usefulness. There have been several MRSA outbreaks in newborns and their mothers in the US (in New York City, Houston, Chicago, Los Angeles and Houston again because Baylor College of Medicine has been particularly alert to this) that were clearly nosocomial, and yet when the microbiology was done, were found to be caused by community strains.

Why does this matter? Well, for the PEI hospital, it may not: They have an outbreak, it appears to be nosocomial in nature, and whether it is HA left over from their earlier outbreak, or CA that came in via a health care worker or a pregnant woman, mostly affects what drugs they give the children and mothers if those patients do in fact have infections. And for those of us who are primarily concerned with nosocomial infections, the distinction may also feel not-relevant: Failures of infection control are failures of infection control and should not happen period full stop.

But for those of us who are are also interested in the natural history of this perplexing bug, the answer to what is going on at the Queen Elizabeth will be an important piece of information, because it could underline that the distinction between HA and CA is becoming increasingly artificial. The epidemics are converging.

MRSA in meat in Louisiana: pig meat, human strain

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On Nov. 3, I posted on an enterprising group of TV stations in the Pacific Northwest who had retail meat in four states tested for MRSA. I said at the time that it was the first finding of MRSA in meat in the US that I knew of.

Turns out that I was wrong by three days. On Oct. 31, the journal Applied and Environmental Microbiology published an electronic version of a study that they will be printing in the paper journal on some future date. Journals do this when a finding is so important or timely that it should see the light immediately, rather than wait through the additional weeks or months of print production.

And this finding is certainly timely. Shuaihua Pu, Feifei Han, and Beilei Ge of the Louisiana State University Agricultural Center have made what appears to be the first scientifically valid identification of MRSA in retail meat in the United States. But — and this is an important point — it is not the swine strain, ST 398, that has been found in meat in Canada and Europe, and in hospital patients in Scotland and the Netherlands, and in pigs in Iowa; and in humans in New York, though that strain was drug-sensitive.

Instead, what the researchers found (in 5 pork and 1 beef samples, out of 120 bought in 30 grocery stores in Baton Rouge, La. over 6 weeks in February-March 2008) was USA300, the dominant community MRSA strain, and USA100, the main hospital-infection strain. In other words, they found meat that had been contaminated during production by an infected or colonized human, not by a pig. As they say:

…the presence of MRSA in meats may pose a potential threat of infection to individuals who handle the food. … (G)reat attention needs to be taken to prevent the introduction of MRSA from human carriers onto the meats they handle and thereby spreading the pathogen.

As we’ve discussed before, the primary danger from MRSA in meat is not that people will take the bug in by mouth (though that is a danger, since S. aureus because of its toxin production can cause severe foodborne illness — and these researchers found, overall, an S. aureus contamination rate of 46% of their pork samples and 20% of their beef samples). Rather, the danger is that people handling the raw meat will be careless in preparing it, and will colonize themselves by touching the meat and then touching their own noses or mucous membranes, leading to a possible future infection. As reader Rhoda pointed out in a comment last week, people could also infect themselves directly, by getting MRSA-laden juice or blood into an abrasion or cut.

So: Be careful in the kitchen, keep meat separate from other foods, wash cutting boards and knives, and (say it with me, now) wash your hands, wash your hands, wash your hands.

The cite for the new paper: Pu, S. et al. Isolation and Characterization of Methicillin-Resistant Staphylococcus aureus from Louisiana Retail Meats. Appl. Environ. Microbiol. doi:10.1128/AEM.01110-08. Epub ahead of print 31 Oct 08.

Housekeeping note: This is the 16th post I’ve written on MRSA in food animals and/or meat. Providing all the links to the previous posts is starting to obstruct the new news. So if you are looking for all those past posts, go to the labels at the end of this post, below the time-stamp, and click on “food.” You should get something that looks like this.

ST 398 in New York City – via the Dominican Republic?

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Here’s a piece of MRSA news from the ICAAC meeting (see the post just below) that is intriguing enough to deserve its own post.

US and Caribbean researchers have found preliminary evidence of the staph strain ST 398, the animal-origin strain that has caused human illness in the Netherlands and has recently been found in Ontario and Iowa, in Manhattan. How it may have arrived: Via the Dominican Republic.

Th researchers (from Columbia University and Montefiore Medical Center in New York, three institutions in the Dominican Republic and one in Martinique) examine the influence of an “air bridge” — very frequent household travel — that is bringing MRSA and methicillin-sensitive staph back and forth between the Dominican Republic and the immigrant Dominican community at the north end of Manhattan. They compared 81 staph isolates from Dominican Republic residents and 636 from Manhattan residents and, among other findings, say that 6 Dominican strains and 13 Manhattan strains were ST398.

It is the first time ST398 has been found in Manhattan or in the Dominican Republic. (Most likely also the first time anyone has looked.)

The authors observe with some understatement:

Given the history of ST398’s rapid dissemination in the Netherlands, its history of methicillin-resistance and its ability to cause infections in both hospital and community, it will be important to monitor its prevalence in these new regions.

It is important to note that these ST398s were not MRSA — they were MSSA, methicillin-sensitive. However: Earlier this year, the Dutch researchers who have delineated the emergence of ST398 in Holland commented on the diversity of ST398 they have found on different pig farms and hypothesized that the resistance element has been acquired several different times by methicillin-sensitive staph. (van Duijkeren, E. et al. Vet Microbiol 2008 Jan 25; 126(4): 383-9.)

So it is possible to hypothesize that this strain arrived in Manhattan from the more rural Dominican Republic, though with the growth of hobby urban farming in NYC, one could also make the case that transmission went the other way. And it is also possible — I emphasize possible — that this could be a precursor to ST398 MRSA emerging in Manhattan. An interesting thought.

(This research is not online, because it is a poster presented at a medical meeting. For reference, the cite is: C. DuMortier, B. Taylor, J. E. Sanchez et al. “Evidence of S. aureus Transmission Between the USA and the Dominican Republic.” Poster C2-224. 48th ICAAC-46th IDSA, Washington DC, 24-28 Oct 2008.)

MRSA in sports

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I am possibly the most sports-impaired person on the planet (a consequence of growing up with the lovely but impenetrable game of cricket), but even I noticed these stories recently.

  • University of North Carolina-Asheville basketball center Kenny George has lost part of his right foot to amputation as the result of a staph infection.
  • Cleveland Browns tight end Kellen Winslow has emotionally gone public — to the displeasure of his coaches — with the news that he was hospitalized for three days for a staph infection. Winslow has been struggling with MRSA since 2005, when he had a motorbike accident, had surgery, and developed a post-surgical infection. Four other Browns players — Braylon Edwards, Joe Jurevicius, LeCharles Bentley and Brian Russell — have had MRSA as well.

MRSA in sports is not new news, but the prominence of some of its victims has brought great attention to the bug: For instance, Redskins defensive tackle Brandon Noble, who was sidelined for a season, and eventually ended his career, over a MRSA infection following arthroscopic knee surgery. And it is not limited to pro players: Lycoming College senior Ricky Lanetti died in 2003 from an overwhelming MRSA infection that began as a pimple-like “spider bite” lesion.

There has been so much concern about MRSA among schools and parents that the CDC has issued specific advice for sports programs. Some of the reasons why athletes may be vulnerable are well-understood: They work in crowded conditions, they undergo a lot of skin-to-skin contact, they are likely to get scraped and injured, and they may not get clean immediately (especially high school players — does anyone shower after high school sports any more?).

But some factors, such as the role of artificial turf, are still murky. An investigation of eight MRSA infections among the St. Louis Rams in the 2003 season (first author Sophia Kazakova) found that linemen and linebackers were more likely to develop MRSA, possibly because they ended up with more turf abrasions. On the other hand, an investigation of 10 infections among players at Sacred Heart University in Connecticut (first author Elizabeth Begier) found that, while turf burns played a role, a contaminated team whirlpool — and sharing razors for shaving body hair — did too.

More teen MRSA deaths

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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:

UK grapples with community MRSA

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Regular readers in the US will have noticed that the MRSA situation here is quite different from Europe. In the UK, for instance, hospital MRSA has been an enormous scandal, but community MRSA — both skin and soft-tissue infections, and fatal invasive infections such as necrotizing pneumonia — has been much less of a concern.

That appears to be changing. Today, the BBC’s Radio 4 broadcast a documentary, “The Bug That Can Kill Within Hours,” that focuses on fears of a dramatic rise in the UK of cases of serious community MRSA. According to the UK’s Health Protection Agency, lab-confirmed cases of community MRSA strains hit 1,361 in 2007, three times what they were the year before. (Soundfile here, starts automatically.)

The documentary refers to CA-MRSA as “PVL-MRSA,” a recognition of the fact that most of the community strains produce the toxin Panton-Valentine leukocidin, or PVL. (PVL is known to destroy white blood cells, but whether it is responsible for the virulence of CA-MRSA is a hotly disputed question in MRSA research.) Aside from the difference in terminology, any of the statements from the accompanying BBC website story could have been said here any time in the past 10 years:

Professor Brian Duerdan, the Inspector of Infection Control at the Department of Health, admits however that many aspects of this virulent bug are a mystery.
“We do know that it spreads in the community amongst close contacts, families, people who share the same sporting events. But we still need to know a lot more about its exact prevalence in the community,” he said.

People who have been tracking the relentless expansion of CA-MRSA, espeially its dominant clone USA 300, are likely to find some of the statements in the documentary both troubling and poignant. The UK is beginning to deal with some of the wuestiosn that the US has struggled with: how much surveillance to do, how to spend scarce research dollars, and what the consequences may be if CA-MRSA is not focused on now.

Hugh Pennington, Emeritus Professor at the University of Aberdeen, and President of MRSA Action, told the BBC that the HPA lacks the resources to keep proper surveillance on outbreaks of infection from this strain of bugs.
“The scandal here is that we know what to do, the technology’s there to spot these things as they are appearing and we know how to react to them.
“It would be quite wrong if we allow these things to develop and of course history tells us that it we do neglect these bugs, we neglect them at our peril.”

Indeed.

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.”

New MRSA-control campaign on Web

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A new website offering personal stories of MRSA patients and survivors has launched: The Stop MRSA Now! Coalition (here and in the “MRSA communities” list on the right).

It offers materials including a downloadable handbook, an email link to ask questions of experts and a spot to submit your own MRSA story. Included among the coalition members is Phoenix Suns’ player Grant Hill, who lost 6 months of his career to a post-surgical MRSA infection while he was with the Orlando Magic.

Sharp-eyed readers will notice a familiar tiny logo on each page of the site. It’s the corporate diamond of The Clorox Company, which sponsors the coalition. Diluted bleach can be used to disinfect MRSA-contaminated syrfaces, but to give Clorox credit, the site abstains from using MRSA as a marketing opportunity. The handbook, for instance, doesn’t say “Use Clorox”; instead, it says:

All washable (hard, non-porous) surfaces
of bathrooms and living areas should be disinfected routinely,
especially in public settings like schools and workplaces.
If no disinfection instructions exist, use 1 tablespoon of
disinfecting bleach diluted in 1 quart of water (1:100 concentration),
or use another Environmental Protection Agency approved
disinfectant according to the manufacturer’s
instructions to disinfect commonly touched surfaces.