Maryn McKenna

Journalist and Author

“Pig MRSA” in New York City – via the Dominican Republic?

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Folks: Back in October, I broke the news for you of an intriguing poster presentation at the ICAAC meeting. It revealed the discovery of ST 398, the anomalous staph strain found in pigs, pig farmers and health care workers in Europe, in residents of a Dominican-immigrant neighborhood in northern Manhattan, and also in the Dominican Republic.

Because there is so much traffic back and forth between those neighborhoods, the authors theorized that people are providing an “air bridge” for the bacterium — though they were unable to say whether the bug is moving from the Dominican Republic to the United States, or vice versa.

I was unable to link to that presentation at the time, because it was a meeting poster – yes, literally a poster, the authors stand by it to discuss it with anyone who wanders by. However, now it has been published as a paper, in the CDC journal Emerging Infectious Diseases; and because it is a CDC journal, the full text is available free online here.

Just to underline, despite my headline above, the strain found in NYC was not MRSA: It actually is MSSA, drug-sensitive staph. The ST 398 found in Europe, Canada and the American Midwest is MRSA. The authors hypothesize that the NYC strain is at risk of becoming MRSA also.

To see the multiple posts in this blog about MRSA ST 398 and other strains in the food chain, food animals, and pets, go to the labels under the time stamp on this post, and click “animals” or “food.”

The cite for the paper is: Bhat M, Dumortier C, Taylor B, Miller M, Vasquez G, Yunen J, et al. Staphylococcus aureus ST398, New York City and Dominican Republic. Emerg Infect Dis. 2009 Feb; [Epub ahead of print]

GlobalPost launches and SUPERBUG is there

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Constant readers, I am thrilled to let you know that SUPERBUG is among a select list of blogs invited to be featured on GlobalPost, a gutsy and innovative new online news site that launches today.

GlobalPost is the creation of Charles M. Sennott, formerly an award-winning foreign correspondent and bureau chief for the Boston Globe, and Philip Balboni, founder and former president of New England Cable News. The service links 65 foreign correspondents living in 46 countries. The founders say in their introductory note that they are:

…acutely aware of the fact that quality journalism in America is threatened more profoundly today than at any time in our history from an unprecedented combination of forces: the transformational power of technology and the internet, the dramatic erosion in the economic underpinnings of the traditional media, and a steady migration of the most devoted consumers of news as well as younger people to new content platforms, most importantly the web.
GlobalPost is a direct response to these forces. Our mission is to provide Americans, and all English-language readers around the world, with a depth, breadth and quality of original international reporting that has been steadily diminished in too many American newspapers and television networks. GlobalPost is at the leading edge of what we hope and believe will become a new flowering of journalism in the digital age, built around new models of financial support.

The site has a number of pages and options, and a notable commitment to transparency in its reporting. Sennott takes new visitors through the details in his editor’s blog. For an outside take on why GlobalPost is worth reading and supporting, read editor and digital consultant Ken Doctor’s thoughtful take.

I know that all of you who gather here regularly already understand the irrelevance of borders to infectious disease control. (For just a few recent examples, see the MRSA outbreak in a Prince Edward Island hospital, the astonishing lack of hand-washing in British health care, and the movement of the pig strain of MRSA from the Dominican Republic to New York City.)

And therefore I know you understand the crucial importance of reliable journalism from abroad. So please welcome this intriguing effort and visit the new site. I’ve placed a GlobalPost button in the right-hand column.

(And just to add, because it’s important to say such things: No money is changing hands here. I don’t get paid for being featured there, and there are no revenues accruing anywhere else. Also, nothing about being featured on GlobalPost changes anything we do or say here: The site remains on Blogger, and your comments stay within this community and continue to be moderated by me.)

Brilliant entrepreneur asks: “So why CAN’T you fix this?”

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Constant readers, you’ll note that posting has slowed down a bit: I am deep into a chapter that is giving me some difficulty. (And I seem to be playing holiday host to an unexpected bout of bronchitis. I’m sure I didn’t need both lungs…)

But here’s something that crossed my monitor this morning, and it’s worth looking at. Sir Richard Branson, founder of Virgin Air and many other extremely successful entrepreneurial efforts. has accepted a post as vice-president of the Patients Association, a nationwide nonprofit that advocates for hospital patients in the UK. Speaking up in his new position, Branson gave an interview to the BBC in which he talked about hospitals’ failure to curb MRSA:

It feels like they have tinkered with the problem rather than really got to the heart of the problem. The hospitals are there to cure people. They are not there to kill people.

It’s a marvelous interview — read the whole thing, it’s not long — because it’s such a breath of fresh air. Branson is an outsider to health care, but he knows how to make businesses work. And as the head of an airline, he’s extremely familiar with what we in the US call “never events”:

Sir Richard says the health service could learn a lot from the airline and rail industries on how to avoid mistakes.”In the airline industry if we had that kind of track record we would have been grounded years ago,” he said.”In the airline industry if there is an adverse event that information is sent out to every airline in the world. And every airline makes absolutely certain that that adverse event doesn’t happen twice.”

So his advice is brutally practical: Health care workers carry MRSA? Screen and swab them. Workers are positive for MRSA? Treat them, and take them out of direct patient contact for two weeks. That costs money? Spend the money: It’s less costly in the end than killing your patients.

British infection control: Epic fail

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Via the Guardian comes news that British hospitals are failing miserably at hygiene and infection-control targets set by the Healthcare Commission, a government-funded but independent watchdog agency somewhat analogous to the United States’ Joint Commission (formerly called JCAHO).

While community-associated MRSA is still a somewhat new story in the the UK, hospital or nosocomial MRSA is a major epidemic, with resistant Clostridium difficile (“C.diff”) coming close behind. So there has been significant attention paid in the UK to improving infection control programs in hospitals, through the vehicle of benchmarks set for the National Health Service trusts (essentially, regional organizational groupings of hospitals).

And the results, according to unannounced spot-checks made by the UK commission, are appalling. Only 5 of 51 trusts ( 51 = 30% of all acute-care hospitals in the UK) that were checked hit the mark. For those slow at math, that means 3% of UK hospitals are doing what they should to protect patients from infections they cause. (UPDATE: To be fair, if we assume the “5 out of 51” holds true across the NHS, then 10% are doing what they should. That’s still appalling.)

“At nearly all trusts we have found gaps that need closing,” said Anna Walker, the commission’s chief executive. “It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems.” (Byline: Sarah Boseley)

How weak? This weak, according to the commission’s own report:

  • 27 of the 51 trusts inspected were failing to keep all areas of their premises clean and well maintained. These lapses covered issues ranging from basic cleanliness, to clutter which makes cleaning difficult, to poorly maintained hospital interiors.
  • One in five trusts in this sample did not comply with all requirements for the decontamination of instruments and other equipment used in the care of patients. Trusts that breached this duty tended to have no clear strategy for decontamination or to lack an effective process to assure compliance.
  • In one in eight trusts, the provision of isolation facilities was not adequate. The containment of infections is extremely important to managing outbreaks. Hospitals without adequate facilities must ensure they have contingency plans so that the risk of infections spreading between patients is minimised.
  • For over one in five trusts there were issues related to staff training, information and supervision. While training on preventing and controlling infection was often in place, boards could not always ensure that training days were well attended or that staff used their knowledge in practice.

UK hospitals have until next April to learn to hit these benchmarks or be held accountable under a new Care Quality Commission.

For infection-control geeks, the full text of the “hygiene code” which the hospitals must abide by is here. Details of inspections at individual trusts are here.

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.

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.

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.)

Antibiotic resistance in food animals all across Europe

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Via a journal that’s new to me — the Acta Veterinaria Scandinavica, the open-access journal of the Veterinary Associations of the Nordic Countries — comes an amazing review of the prevalence of antibiotic resistance in cattle in 13 European countries. Based on 25,241 isolates collected over three years, Denmark, Britain, the Netherlands, Norway, Sweden and Switzerland do well, but “many isolates from Belgium, France, Italy, Latvia and Spain were resistant to most antimicrobials tested.“

Most resistant pathogen: E. coli. MRSA is present as well:

Of major concern is the level of resistance to oxacillin and 3rd generation cephalosporins (i.e. ceftiofur) in S. aureus. The prevalence of oxacillin resistance in Spain (3.7%) and France (8.3%) and the resistance towards cephalosporins in Spain (0.9% in 2004) and France (4.2% in 2002; 1% in 2003) indicate the presence of methicillin resistant S. aureus (MRSA) in these two countries.

The authors ascribe the differences among countries to different patterns of antimicrobial use by veterinarians and stress that it is time for veterinarians to begin using measurements of local resistance patterns (in human medicine, an “antibiogram”) before prescribing. Cite coming when the Acta site is updated. UPDATE: The paper is here; cite is: Hendriksen, RS et al. Prevalence of antimicrobial resistance among bacterial pathogens isolated from cattle in different European countries: 2002-2004. Acta Veterinaria Scandinavica 2008, 50:28doi:10.1186/1751-0147-50-28.

I wasn’t aware that this same set of authors (Hendriksen, RS et al.) just a few weeks ago published a similar review of antimicrobial resistance in pigs in Europe. It looks at several bacterial species in pigs, but unfortunately for our purposes, no S. aureus.

Closing the loop: meat, meat-eaters, health-care workers

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A posting on the international disease-alert mailing list ProMED led me to a scientific abstract presented at a European meeting this spring on the ST 398 MRSA strain. It adds another, quite unnerving piece to the emerging interplay of MRSA in pigs, humans who have close contact with pigs, humans who have contact only with pig meat, and health-care workers who treat those humans.

Brief precis: About a year ago, Dutch health authorities discovered that a patient who had come in for surgical debridement of a diabetic foot ulcer had an unrecognized MRSA strain in that ulcer. Subsequently, they discovered that four other patients and five health-care workers in the same institution were carrying the same strain. None of the patients reported any contacts with pigs (or calves, which have also been found to carry the strain). One of the health-care workers lived on a farm that raised pigs, but said that she had no contact with the animals in her daily life; nor did her partner.

The authors conclude:

While the source is not fully established it could be the HCW living on a pig farm. This outbreak makes clear that transmission on a larger scale can occur, even with NT-MRSA.

(Hat-tip to Helen Branswell of the Canadian Press for telling me about the ProMED report. And a note to loyal readers: The “MRSA in meat” story is being picked up by some US newspapers. Doesn’t it feel good to know you’ve been reading about the issue here for months? And if you’re a reader of Helen’s work, months more? Of course it does.)

One more on MRSA in meat

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It turns out that European governments — in contrast to the United States — are taking very seriously the emergence of MRSA in food animals and its potential for transfer to humans. (For background, posts here, here, here and here.)

How seriously? They’re doing a sampling survey of pigs on farms across the European Union, at a cost of about $3 million in EC funds, with matching funds expected from each government.

The MRSA survey piggybacks (sorry) on a year-long survey of Salmonella incidence that the EC called for in September 2007. But in December, following publication of several significant papers about the ST 398 MRSA strain in pigs and pig farmers, the EC Directorate-General for Health and Consumer Protection pushed for an addition to the Salmonella study: a same-time sampling for the presence of MRSA strains in pig operations across 29 countries.

The sampling is taking place from January to December of this year, with results mandated by mid-2009, though individual country authorities may release data earlier if they choose. (In the wake of the finding of three ST 398 cases apparently caused by retail meat in the UK, the Soil Association has called on the British government to release whatever data it has ASAP. Before the EC decision, the UK government had refused to test its pigs; cf. these House of Lords minutes.)

Of note: The Soil Association is pressing the argument that ST 398 has developed in the setting of widespread use of antibiotics in food animals, and contends the strain’s arising in the Netherlands is especially alarming because they have some of the lowest animal-antibiotic use rates in the EC it illustrates the difficulties that even a society conscientious about antibiotic overuse can have keeping track of veterinary applications. The Netherlands has been successful limiting overuse in humans, but has found controlling veterinary use much more of a struggle. (Thanks to the Soil Association for correcting my misunderstanding!)