Maryn McKenna

Journalist and Author

Antibiotic resistance: international news

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Constant readers, we’ve often talked about MRSA and other resistant pathogens as a global problem (cf. these posts for resistance issues in Europe and these for resistance around the world).

But now there has been formal recognition that resistant bacteria respect no borders. On Nov. 3, the US government and the European Union signed an agreement to form a joint task force to investigate and combat antibiotic resistance. From the Joint Declaration, posted on WhiteHouse.gov:

[We therefore agree}… To establish a transatlantic task force on urgent antimicrobial resistance issues focused on appropriate therapeutic use of antimicrobial drugs in the medical and veterinary communities, prevention of both healthcare- and community-associated drug-resistant infections, and strategies for improving the pipeline of new antimicrobial drugs, which could be better addressed by intensified cooperation between us.

You may not have heard much about it here, but in Europe, this declaration was big news. Here’s a story from the Swedish newspaper Arbetarbladet (Sweden currently holds the EU Presidency) and another from the Irish Times. But while it merited barely a blink in the US mainstream media, US nonprofits were deeply involved in the declaration, notably the Infectious Diseases Society of America and the Pew Charitable Trusts:

“Antimicrobial resistance and the lack of new antimicrobial agents to effectively treat resistant infections are problems that no country can deal with alone — they threaten the very foundation of medical care,” said Richard Whitley, MD, FIDSA, president of the Infectious Diseases Society of America (IDSA). “Without effective antimicrobial drugs, modern medical treatments such as operations, transplants, intensive care, cancer treatment and care of premature babies will become very risky if not impossible.” Dr. Whitley joined with Javier Garau, MD, president of European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Shelley A. Hearne, managing director of the Pew Health Group in welcoming the multi-country initiative.
…”Antibiotic resistant bacteria respect no political borders, so we must work together to combat them,” Dr. Hearne said. “Resistance takes a terrible toll on health worldwide and is measured in lives lost, greater suffering and higher health care costs. One way that U.S. leaders can demonstrate their commitment to solving this issue is by immediately joining the EU in banning non-judicious antibiotic uses in food animal production.” (Pew press release)

This fresh focus on the problem of resistance will be sharpened in Europe this week with the celebration of European Antibiotic Awareness Day. (We should be so lucky.) More on that on Wednesday.

Antibiotic-resistant infections: millions in cost to hospitals, families, all of us

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Folks, I mentioned that I’m way behind in working down a stack of great articles. Here’s a very good one that I missed when it came out two weeks ago and is well worth your time.

A team from John H. Stroger Hospital (the new location of the iconic Cook County Hospital, public hospital for downtown Chicago) and from the Alliance for the Prudent Use of Antibiotics at Tufts University (headed by Dr. Stuart Levy, dean of antibiotic resistance scholarship in the US) has analyzed the direct and distributed costs of resistant infections, and their results are stunning. They took a random sample of patients seen at the hospital, sorted out a subgroup that suffered from resistant infections, and computed the costs that those infections imposed: in medical costs, increased length of stay, and excess deaths. Those sort of calculations have been done before at other institutions (cf. for instance the excellent work of Susan Cosgrove of Johns Hopkins), but what makes this Chicago study striking is an additional layer of analysis that computes the “social cost” to the families of those infected.

In the study’s words:

In a sample of 1391 patients, 188 (13.5%) had [antibiotic-resistant infections]. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4–12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7–$15.0 million.

(Just to underline: These are almost certainly underestimates of the current problem and its current costs — because to get very solid data, the Stroger team went back in their database to patients who were treated in 2000. That’s before the emergence and dominance of CA-MRSA USA300 nationwide, and its subsequent movement into hospitals. Since 2000, the MRSA epidemic has gotten worse.)

An accompanying editorial takes the next step in logic, stressing that if we’re not going to work to reduce ARIs because it is good medicine to do so, we should do it because it is critically cost-saving:

…[T]he findings of Roberts et al [11] are significant, making a strong case for both the medical and financial benefits of reducing antimicrobial resistance. This is an important and timely question, considering the national focus on the prevention of health care–acquired infections, a significant proportion of which are caused by antimicrobial-resistant organisms, and the call for institutions to develop antimicrobial stewardship programs. These data should help inform decisions regarding the structure and implementation of health care initiatives designed to improve patient care while controlling unnecessary costs.

The cite for the study is: Rebecca R. Roberts, Bala Hota, Ibrar Ahmad et al. Hospital and Societal Costs of Antimicrobial‐Resistant Infections in a Chicago Teaching Hospital: Implications for Antibiotic Stewardship. Clinical Infectious Diseases 2009 49:8, 1175-1184.

It's World Pneumonia Day

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Readers, we talk all the time here about the unexpected and deadly attack of MRSA pneumonia, both on its own and as a sequela of influenza infection. But we should acknowledge that MRSA pneumonia is part of an epidemic of pneumonia, an under-appreciated disease of severe lung inflammation that takes the lives of 2 million children each year around the world.

Today, Nov. 2, has been declared World Pneumonia Day by an enormous coalition of global health organizations that includes UNICEF and Save the Children. (Mis amigos Latinos sabrán que está hoy también Dia de los Muertos. Fitting, no?) From their press release: “Pneumonia takes the lives of more children under 5 than measles, malaria and AIDS combined. The disease takes the life of one child every 15 seconds, and accounts for 20% of all deaths of children under 5 worldwide.”

World Pneumonia Day is being marked by events around the globe (here’s a clickable map) and by the release of a World Health Organization report, the Global Action Plan for Prevention and Control of Pneumonia. The plan has three main goals, aimed at the recourse-poor countries where most pneumonia deaths occur:

  • promote breastfeeding to ensure children’s nutrition and good immune status
  • protect immunity by guaranteeing the distribution in the developing world of the pneumonia vaccines we take for granted in the industrialized world, against Haemophilus influenzae and Strep pneumoniae (pneumococcus)
  • treat children when they need it by making sure that there is adequate, local primary care and — important for our purposes especially — also making sure that antibiotics are used appropriately, but not overused.

The international organization GAVI (formerly known as the Global Alliance for Vaccines and Immunization, now going just by its acronym) has announced plans to immunize 130 million children worldwide against pneumonia and other diseases by 2015.

I want to underline that pneumonia is of interest to us for several reasons: not just because we are concerned for MRSA pneumonia, but also because we are in the midst of the H1N1 pandemic, and as we have talked about before, bacterial infections appear to be playing a role in a significant percentage of the deaths. There is no MRSA vaccine, but there are Hib and pneumo vaccines, which might have prevented some of those deaths. So increasing the administration of pneumonia vaccines could affect the course of this pandemic right now, as well as the fates of children all over the world who have not contracted this flu but will be in danger of bacterial pneumonia in the future.

New reports on animals, food, MRSA ST398

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Well, constant readers, didn’t expect to be gone *that* long. Many apologies. There was a good reason — actually, several: I attended a journalism meeting, and spoke at a second meeting. But most important, I received, marked up, and returned the galleys of SUPERBUG. Yes, it’s really starting to look like a book now. There will be things to share, soon.

Meanwhile, I’ll try to roll out some of the many, many pieces of news and research related to staph that have emerged in the past few weeks. Today: News on animals, and our old opponent, MRSA ST398.

First: A team from the Universidad de La Rioja reports in the Journal of Antimicrobial Chemistry the first finding of MRSA ST398 (“pig MRSA,” archive here) in food in Spain. They tested 318 raw meat and wild-game samples (chicken, pork, veal, lamb, turkey, rabbit, game bird, wild boar, deer, hare) and found ST398 and other MRSA strains in 5 of them, an incidence of 1.6%. The authors write: “Although MRSA prevalence in raw food is low, the risk of its transmission through the food chain cannot be disregarded.”

Importantly, one of the other strains found in the meat of these animals is an uncommon variant, ST125-t067, that has already been implicated in large numbers of hospital infections in Spainand is resistant to ciprofloxacin (Cipro), erythromycin and a third antibiotic, tobramycin, in addition to the usual suspects. The other non-ST398 strain is ST217, which is a variant of a long-known hospital strain, and is also resistant to Cipro, a very valuable drug for skin and soft-tissue infections. So it appears the contamination may cross both ways, from animals, and to animals as well.

No link, but the cite is: Lozano, Carmen, et al. Detection of methicillin-resistant Staphylococcus aureus ST398 n food samples of animal origin in Spain. Journal of Antimicrobial Chemistry. e-pub Oct. 21 2009 AOP doi:10.1093/jac/dkp378

Next: If the prevalence of ST398 is so low in food, why do we care? We care because of where those organisms go next — into hospitals, among other places. A Dutch/German team that includes the original identifier of ST398 in humans are reporting that they have found an association between the density of pig-farming in parts of Germany and the probability that patients admitted to hospitals will be carrying ST398 with them, creating a possible source for nosocomial infections. R. Kock and colleagues screened 1,600 pigs on 40 German farms, and also reviewed screening results for every MRSA-positive patient admitted to the University Hospital-Munster from 2005 through 2008. They found ST398 on 70% of the farms, and also found that ST398 represented 15% of the MRSA isolates at the hospital in 2005, rising to 22.4% in 2008. The key association: The patients carrying St398 were more likely to have contact with pigs in their daily lives, and also with cattle, than patients who had other forms of MRSA or no MRSA at all.

The cite for that paper: Kock, R. et al. Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) among pigs on German farms and import of livestock-related MRSA into hospitals. European Journal of Clinical Microbiology and Infectious Diseases, e-pub Aug 25, 2009. DOI 10.1007/s10096-009-0795-4

And finally: How do you stop the evolution and spread of antibiotic-resistant organisms in livestock? One good way is to stop giving teh livestock antibiotics in the first place. In a column at the Huffington Post, Laura Rogers, project director of the Pew Campaign on Human Health and Industrial Farming, takes on the oft-repeated assertion that you can’t farm without them without risking the lives and market place of your livestock, and offers the example of Denmark, which did ban antibiotics in animals, and which has healthier, more profitable livestock as a result:

American agribusiness often has criticized Denmark’s 1998 ban on antibiotics, calling it an outright failure. But compelling new research presented by a Danish scientist earlier this year showed the opposite, revealing that antibiotic use on industrial farms has dropped by half while productivity has increased by 47 percent since 1992. Danish swine production has increased from 18.4 million in 1992 to 27.1 million in 2008. A decrease in antibiotic-resistant bacteria in food animals and meat has followed the reduced use of these vital drugs.

Get Smart About Antibiotics Week, Oct. 5-11 (now!)

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Every year, the CDC sponsors a week-long observance called Get Smart About Antibiotics Week, intended to bring attention to this issue of antibiotic misuse that all of us here are so concerned about, and to link the efforts of federal and state agencies, nonprofit groups, and anyone else with an interest.

Today marks the start of the 2009 week, and of course it comes as a crucial time: With the H1N1 flu pandemic causing so many people to seek care for upper respiratory illnesses, the possibility of antibiotics being misprescribed for a viral illness is greater than usual.

The homepage for the CDC campaign is here. There is an abundant list of materials, images, campaign strategies and suggestions for framing the conversation, along with graphics (I’ve lifted the one at left from a poster aimed at parents of young children), PSA sound files, and cute little web widgets such as the image at right above (sorry for the poor layout skills, it’s a busy morning).

Since this comes from the CDC and is therefore taxpayer-funded, all of it is open-access. So go, already.

Guest Q&A: Jeanine Thomas and World MRSA Day

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I want to introduce you all to a MRSA campaigner, Jeanine Thomas of Chicago. Jeanine — whose story will be told in SUPERBUG — is the founder of World MRSA Day, a worldwide event of activism and grieving that will take place Friday, Oct. 2. There will be simultaneous observances in the UK, and a candlelight vigil in Salt Lake City that evening.

Tomorrow, Oct. 1, Jeanine will be at Loyola University in Chicago to lead a press conference, commemoration for MRSA victims, and award ceremony for notable MRSA campaigners, and to urge those harmed by MRSA to observe October as MRSA Awareness Month.

In advance of the observances, I asked Jeanine to talk to SUPERBUG about her experience and her activism.

Tell us about your personal experience with MRSA.
I was infected with MRSA after ankle surgery in 2000. I came back to the ER — my incisions were black and oozing a large amount of pus and I was in teribble pain — and was admitted. Three days later my culture came back positive for MRSA. I was not put on the right antibiotic; the infection went into my bloodstream and bone marrow and I went into septic shock and multiple organ failure in the middle of the night. The night nurses were able to pull me back and save me. I had seven more surgeries to save my leg from amputation, spent a month in the hospital, and then was confined to bed on a cocktail of antibiotics for 5 more months. I also contracted C. difficile. I now have a destroyed ankle joint and a severely compromised immune system.

You started a MRSA patients’ group. Tell us about the group and why you did that.
I started MRSA Survivors Network in 2003 to give support, raise awareness and educate others. There was so little out there about this disease. I never wanted anyone else to go through what I had.

You used your experience with MRSA to help pass patients-rights legislation in Illinois. Please talk a little about the bill.
In 2003, I helped push the “Hospital Report Card Act” that then-state senator Obama introduced, to have infection rates reported. As the consumer representative on the state board for the HRCA, I saw that state health officials and doctors did not even want to have MRSA reported as a disease. So I decided I must take action and in 2006 we introduced the “MRSA Screening and Reporting Act.” It passed in 2007, the first in the country, and mandated that all ICU and other at-risk patients be screened for MRSA and infection rates reported. Since then, the Illinois Hospital Association has reported that inpatient infection rates have dropped, but they see many more CA-MRSA cases because of the screening.

How and why did you come up with the idea for World MRSA Day?
In January of 2009 I was thinking of ways to raise awareness and the idea of launching World MRSA Day and a MRSA Awareness Month popped into my head. There are awareness days for every other diisease and as MRSA is pandemic, we need global awareness. I did not know how successful I could be the first year during a recession, but the response was surprising, and I was able to launch the campaigns.

Tell us what you hope will change in the aftermath of having had this worldwide event.
I hope that awareness of MRSA as an epidemic in the US and a pandemic sweeping the globe will be revealed, and that action from the World Health Organization, Department of Health and Human Services, the CDC, governments and health departments will happen. I want all of them to declare MRSA an epidemic. This should have happened years ago, but let’s move forward now. Their inaction has caused this disease to proliferate. I also want the public to be aware of MRSA as we are all in this together and every single person on this planet is at risk. Prevention is key to saving lives.

More evidence of MRSA involvement in H1N1 flu

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When the H1N1 pandemic started at the end of last April, few of the case-patients seemed to have any secondary bacterial infections. This was unusual: In the 3 20th-c pandemics, the only ones for which there are good records, bacterial pneumonias seem to have accounted for a high percentage of illness and death. But H1N1 was unusual in a number of ways, and so health authorities wrote down the lack of bacterial infections as one more quirk of this novel strain.

Comes now the CDC to say that while that may have been the case in the spring, it is not now. In a conference call conducted Monday for doctors, which I covered for CIDRAP, the agency said that out of 77 deaths for which it had excellent autopsy data (a small subset of the deaths so far), 22, or 29%, had some bacterial co-involvement. Among the 22, the leading bacterium was S. pneumoniae (or Pneumococcus), but S. aureus was the second leading cause, with 7 cases, and 5 of those cases were MRSA.

(There is not yet anything online from that call to link to. A transcript is promised, and the CDC reps conducting the call said the data will be out soon in the MMWR. I’ll update when possible.)

In fact, there is an emerging literature on the role of bacterial infections in illness and deaths in this flu, and an emerging consensus that bacterial infections are playing a bigger and more serious role than was thought at first. At the ICAAC meeting two weeks ago (more on that soon), KK Johnson et al of the Women’s and Children’s Hospital of Buffalo, N.Y., along with researchers from two other institutions, described two severe and ultimately fatal infections with H1N1 complicated by community-strain MRSA. The victims were children, a 9-year-old girl and a 15-year-old boy, who arrived at the emergency room several days after being seen for mild flu symptoms. Both children died of necrotizing pneumonia, one 11 days after being hospitalized and one 3 days. Cite (no link available): K.K. Johnson, H. Faden, P. Joshi, J. F. Fasanello, L. J. Hernan, B.P.Fuhrman, R.C.Welliver, J.K. Sharp and J. J. Schentag, “Two Fatal Pediatric Cases of Pandemic H1N1/09 Influenza Complicated by Community-Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA),” poster G1-1558a.

Finally, there is one recent paper that is online, and it describes MRSA necrotizing pneumonia plus flu in an adult, not a child. It comes from Hong Kong, from a group that were the first to describe SARS pneumonia and thus have a lot of experience in surfing the early wave sof a pandemic. In this new paper in the Journal of Infection, they describe the death from necrotizing pneumonia of a healthy 42-year-old man who was in the hospital only 48 hours. They believe this is the first H1N1+MRSA death to be recorded in the medical literature, and so they use the opportunity to issue a warning to doctors: If a flu patient arrives with what appears to be secondary pneumonia, drugs that can treat MRSA must be prescribed, or the infection will flourish unchecked and death will result. The cite is: Cheng VCC, et al., Fatal co-infection with swine origin influenza virus A/H1N1 and community-acquired methicillin-resistant Staphylococcus aureus, J Infect (2009), doi:10.1016/j.jinf.2009.08.021.

We’ve been talking since the beginning of this pandemic, and before that, about the unique hazards of MRSA + flu coinfection. (Archive of posts here.) It’s important ot understand that the bacterial pneumonias now being recorded are not only due to MRSA; Pneumococcus is playing a role as well. That is important because, unlike MRSA, we have vaccines against Pneumococcus; in the United States, one vaccine is approved for children and a second related one for adults. With no MRSA vaccine anywhere, and no H1N1 vaccine yet, it is worth considering whether to take a pneumococcal vaccine for additional protection as this pandemic unfolds.

New news on MRSA and animals

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Constant readers, I’ve been behind the Great Firewall of China for two weeks, unable to post. (Apparently Blogger is not always unavailable there, but access has tightened up in advance of the National Day celebrations on Oct. 1.) I left with a file of things to post in my spare time — and so now we’re way behind, with lots to catch up on.

Latest news first, though. A few days ago, an intriguing conference was held in London: Methicillin-resistant Staphylococci in Animals: Veterinary and Public Health Implications. It was co-sponsored by the American Society for Microbiology and the European Society of Clinical Microbiology and Infectious Diseases, and it was the first conference ever convened to examine the behavior in animals of MRSA and other staph species, including our old friend, ST398.

I have the abstracts (which have not otherwise been published), and wow, there was a ton of news.

Here’s the biggest: An investigation by a team at University of Iowa (the same group that first identified ST398 in pigs and pig farmers in the United States) found significant amounts of MRSA in pigs and in human workers on 4 out of 7 conventional farms, but no MRSA on 6 organic farms. MRSA was present — as a colonizing organism, not causing illness — in 23% of the 168 pigs sampled on the conventional farms, and 58% of 45 humans who worked on those farms. “These results suggest a significant number of U.S. swine may be colonized with MRSA, adding to the concern about domestic animal species as a reservoir of this bacterium,” the abstract says. “Furthermore, occupational exposure to these colonized pigs may spread the bacteria from the farm to the community via a high number of colonized swine workers.” (Author: Abby L. Harper, MPH, University of Iowa)

A partial list of the other findings announced:

  • MRSA ST398, which emerged as an animal and human pathogen in the Netherlands, is now causing human colonization and illnesses in other countries. Denmark, which like the Netherlands has a very low background rate of MRSA, has detected 109 cases since 2003, 35 of them with actual infections. Two of the infections were very serious: one pneumonia in a newborn baby, and one septic arthritis in an adult that led to sepsis and multi-organ failure. (J. Larsen, National Centre for Antimicrobials and Infection Control, Denmark)
  • Meanwhile, the Netherlands — which conducts routine screening for MRSA carriage on hospital admission — has seen its annual count of MRSA detections rise from 16 per year between 2002 ad 2006 to 148 per year between 2006 and 2008, with 81% of the current cases due to ST398. (M. Wulf, PAMM Laboratory, the Netherlands) UPDATE: Coilin Nunan of the Soil Association in the UK corrects me (thanks, Coilin!): This study covers only the southeastern pig-farming areas, or about 40% of the MRSA cases in the country.
  • MRSA ST398 spreads from infected to uninfected pigs during transport to slaughterhouses and while being held at slaughterhouses. (E. M. Broens, Wageningen University, the Netherlands)
  • More than 15% of slaughterhouse workers who handle live pigs — but none of those who handled pig carcasses after slaughter — were carrying MRSA 398, and 25% of environmental samples such as dust taken from different parts of slaughterhouses were carrying the organism as well. (B. A. van Cleef, RIVM [National Institute for Public Health and the Environment], the Netherlands)
  • Along with the pig-origin ST398, recognized human strains of MRSA can also colonize pigs, according to a study on one Norwegian farm, but human strains are less successful at persisting in pigs and tend to die out after months. (M. Sunde, National Veterinary Institute, Norway)
  • Animal-origin MRSA is rising in China, the world’s largest producer of pork, but the problematic strain there is ST9, not ST398. That MRSA strain was found on 5 out of 9 farms in Sichuan province in mainland China, and in 33.5% of 260 pigs slaughtered in Hong Kong, where more than 90% of pork comes from the mainland. (J. A. Wagenaar, Central Veterinary Institute, the Netherlands; and M. V. Boost, Hong Kong Polytechnic University)
  • And an intriguing finding for those concerned about humane slaughter methods: Broiler chickens were significantly more likely to carry MRSA, and transmit it to slaughterhouse workers, if they were killed by the traditional method of electrical shock followed by throat-slitting, and less likely to carry or transmit the bug if they were killed by carbon dioxide asphyxiation, which has been held out as a more humane method of killing. (M. N. Mulders, RIVM [National Institute for Public Health and the Environment], the Netherlands)

UPDATE: I’m still a bit jet-lagged and forgot to mention that, of course, we have a long archive of coverage of ST398 and other strains in animals. Find them here.

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.

Child deaths from flu + MRSA: CDC confirmation

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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.

Non-medical use of antibiotics: A whole new problem with ethanol

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Constant readers, we’ve talked frequently about the emerging recognition that the enormous use of antibiotics in agriculture is fueling the development of resistance, both directly in the case of specific organisms such as MRSA ST-398, and indirectly in that it pushes the evolution of resistance factors that bacteria then trade amongst themselves. (For a superb overview of the antibiotics/agriculture problem, see this article in the June issue of the Johns Hopkins (University) Magazine. Hopkins is the home of the Center for a Livable Future, which is doing excellent research on this issue.)

And we’ve also talked about the related issue of antibiotic residues elsewhere in the environment, in sewage and wastewater supplies.

But here’s a whole new peril: Antibiotic resistance generated by ethanol production, that vast corn-based industry that has been pitched as a homegrown biofuel alternative to foreign oil.

Food-policy blogger (and farmer and chef) Tom Philpott has been doggedly following this story for more than a year at Grist. And in a study published last month the Institute for Agriculture and Trade Policy brings some important numbers-based analysis. The gist of the problem is this:

  • Ethanol production uses yeast to convert corn starches into alcohol
  • Bacterial contamination, usually by lactobacilli, can hijack the process and covert the starches to unusable lactic acid instead
  • To prevent that from happening, ethanol producers dose their corn mash with antibiotics
  • Because contamination is frequent and persistent, producers use increasing amounts of antibiotics to overcome bacteria that have become resistant
  • After ethanol is extracted, the mash residue remains tainted with those resistant bacteria and with antibiotics — including penicillin, erythromycin and streptogramin (an analog of the human antibiotic Synercid)
  • The dried mash residue is sold to farmers as livestock feed, exposing livestock to resistant bacteria and dosing them with unsuspected additional antibiotics as well.

If there is any good news in this, it is that (according to the IATP), some of the faltering ethanol industry is aware of the problem and working on it, with about 45% of plants now working on non-antibiotic alternatives. The bad news is that 55% — more than 90 of the 170 ethanol facilities in the United States — are not.

Another death from H1N1 flu + MRSA

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Thanks to a commenter who alerted me to this sad story: A teenager in Austin died of a combination of H1N1 flu and MRSA pneumonia. Constant readers will know that we have been watching for this for a while; MRSA pneumonia is a known and dangerous complication of any flu infection.

For stories for CIDRAP and the Annals of Emergency Medicine, I’ve been talking to ER physicians about their expectations for the fall, when the regular flu season begins and H1N1 is expected to intensify. (A friend’s school already has cases circulating.) It’s fair to say that emergency departments are unsettled about the possibility of severe complications from this flu.

One more set of recommendations

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… and then next week I’ll be back to analyzing the medical literature: A stack of interesting new journal articles is threatening to topple and bury my computer.

For the moment, though:

First, the Hearst newspapers chain has conducted a nationwide investigation into medical errors that should be required reading for anyone who wonders why hospitals can’t do a better job controlling hospital-acquired infections. It is a 7-part series focusing on the 5 states (New York, Texas, California, Connecticut, Washington) where there are Hearst papers, and hosted on the site of the San Francisco Chronicle. The introductory article says:

Ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years.
Instead, federal analysts believe the rate of medical error is actually increasing.
A national investigation by Hearst Newspapers found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.
… in five states served by Hearst newspapers — New York, California, Texas, Washington and Connecticut — only 20 percent of some 1,434 hospitals surveyed are participating in two national safety campaigns begun in recent years.
Also, a detailed safety analysis prepared for Hearst Newspapers examined discharge records from 1,832 medical facilities in four of those states. It found major deficiencies in patient data states collect from hospitals, yet still found that a minimum of 16 percent of hospitals had at least one death from common procedures gone awry — and some had more than a dozen. (Byline: Cathleen F. Crowley and Eric Nalder)

From that opening statement, the investigation goes on to explore many patient stories that individually are tragedies and collectively — as we here know all to well — are a scandal.

There is just one notable MRSA story in the mix, the death of a retired hospital president who contracted the bug in his own hospital. But they are all worth reading.

Second, an executive and apparently new writer named David Goldhill has written for The Atlantic a passionate and well-thought out piece on his father’s death from a hospital-acquired infection and on what needs to change for such deaths to never happen again. “My survivor’s grief has taken the form of an obsession with our health-care system,” he writes:

My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

You may not agree with his conclusions, but it is worth reading through to the end to experience how one intelligent citizen from outside health care understands and attempts to re-think our broken system.

Catching up on some reading: health care reform, food bugs, vaccine, MRSA+flu

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Folks, while I was caught in travel hell, some excellent stories and blogposts were released. Here’s a quick round-up of recommendations for a rainy weekend:

  • At Roll Call (covers Congress like a blanket), Ramanan Laxminarayan, PhD MPH, of the rational-use-of-antibiotics project Extending the Cure and infection-control physician Ed Septimus, MD make a strong argument for including control of hospital infections in health care reform. Hard to argue against when you realize that HAIs cost the United States more than $33 billion each year.
  • At Meat Wagon, a blog of the online magazine Grist, the always-excellent Tom Philpott digs into the ongoing outbreak of antibiotic-resistant Salmonella in hamburger meat. Key quote: “Outbreaks of [antibiotic-resistant foodborne illnesses] are really ecological markers — feedback that our way of producing meat is deeply unsustainable and really quite dangerous.”
  • The Associated Press reports that the long-in-development staph vaccine made by Nabi Pharmaceuticals may have received a second life: It’s been purchased by international pharma giant GlaxoSmithKline in a $46-million deal.
  • And finally and sadly, the Sacramento Bee reports that a California nurse who died of H1N1/swine flu also had MRSA pneumonia. Karen Ann Hays, 51, died despite being extremely healthy: she was a triathlete, skydiver and marathon runner. No one yet has been able to say whether she caught the flu — or MRSA — at work (though her partner believes that to be true), but her death has fueled disquiet among members of the California Nurses Association, who are protesting a lack of protective equipment for nurses.

For those of us concerned about MRSA pneumonia — and we have been talking here since the start of the H1N1 pandemic about the danger of MRSA co-infection — that last item about Hays’ very sad death should underline a vital point. Public health authorities have been stressing that H1N1 is most deadly when the infected person has a pre-existing condition: pregnancy, heart disease, obesity, diabetes, cystic fibrosis. It is possible that MRSA infection is also a pre-existing condition that will put anyone infected with flu at risk of deadly complications.

If you have had MRSA, even a minor skin infection — and especially if you have experienced recurrent infections — you should probably discuss with your personal physician whether you should take the H1N1 vaccine when or if it becomes available. It could be the step that prevents a minor case of flu from tipping over into something much more serious.

Federal plan to reduce HAIs: public meetings

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Let’s switch back for a moment to MRSA and other infections in hospitals. An estimated 1.7 million healthcare-associated infections (HAIs) occur in the US each year. Approximately 99,000 of the infected die. Care for the infected costs the health care system $33 billion (yes, with a B) each year.

The US Department of Health and Human Services (parent agency of the CDC, USDA, Center for Medicare and Medicaid Services, etc.) in late June issued a draft of a National Action Plan to Prevent Healthcare-Associated Infections. The plan is here (.pdf, 116 pages). It calls for more research, changes in regulation of health care, more disclosure and significant simplification of the more than 1,200 actions for reducing HAIs that are currently recommended in government documents (yes, 1,200.)

HHS is taking the plan on the road: Before Labor Day, there will be public meetings to air the plan in Denver (tomorrow, July 25), Chicago (July 30) and Seattle (Aug. 27). If you are concerned at all about HAIs and government and health care industry response to them, these meetings would be a good place to be.

The HHS statement about the plan and the meetings, including contact information to sign up to attend, is here. Go, already.

Decolonization: disappointing news

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I know that many of you who are MRSA patients, especially with recurrent infections, are especially interested in the issue of decolonization, the grueling regimen of antibiotic nasal gel (containing mupirocin; usually sold as Bactroban) combined with body washes with chlorhexidine (Hibiclens) that is believed to eradicate MRSA carriage in the nose and on the skin. Decolonization is an essential part of the “search and destroy” measures practiced by zero-tolerance hospitals who want to detect any MRSA transport in their institution, and it is a last-ditch hope in recurrent community-strain infections. (I told the story of several women’s struggles with recurrent infections in SELF and Health magazines.)

It’s disheartening, then, to realize that decolonization is not a universally agreed-upon measure, and there is relatively little research that can say in which setting (household, hospital, ICU) it works best, and why. There have been a few studies, and a few review papers summing up studies, on the role that decolonization can play in reducing the risk of infection in already hospitalized, colonized patients — ones about to undergo surgery, for instance. A meta-analysis by the Cochrane group, of 8 trials, found that decolonization in the hospital did reduce the likelihood of infections in surgical patients.

The role that decolonization can play in short-circuiting community infections is much less clear, though there are many, many people who have suffered recurrent infections and testify that it worked for them. (Please speak up in the comments if you are!) One problem is that outside hospitals, there is no one recommended regimen: One physician might tell her patient to use mupirocin and chlorhexdine only, whereas another might tell his patient to also take bleach baths, or bleach all the laundry or household surfaces. The CDC has so far declined to put its muscle behind decolonization in community-strain infections, recommending only that frustrated patients with recurrences seek the advice of an infectious-disease specialist. (See this flowchart of treatment options (.pdf) that the CDC published in 2007.)

Comes now the infectious-diseases division of Evanston Northwestern Healthcare, whom some of you will recognize as being among the most successful and evangelical practitioners of “search and destroy” in the United States. (ENW has recently been renamed NorthShore University HealthSystem and is affiliated with Northwestern University. Disclosure, in case you care: I went to grad school at Northwestern, though not in medicine.) In a paper published in Infection Control and Hospital Epidemiology, the group evaluates the use and success rate of decolonization in ENW/NorthShore’s 3 hospitals and finds, well, not such good news: a temporary reduction in patients’ being colonized with MRSA, but no success in preventing infection.

This is an important and troubling finding, because decolonization comes with costs. There is the obvious cost to hospitals (and the follow-on cost to insurance companies and consumers) of paying for mupirocin and chlorhexidine themselves. But there is also a hidden cost that we here should be particularly sensitive to: Because mupirocin is being used so lavishly, mupirocin resistance is rising.

In the same issue of ICHE (which, yes, is pronounced Itchy), a related editorial by Dutch researchers reviews the difficulty of conducting decolonization trials, but summarizes the ENW/NorthShore study as not an endorsement of decolonization regimens:

It is clear that staphylococcal carriage is an important risk factor for infection and that eradication of carriage has proven successful for patients who are undergoing elective surgery. For other groups of patients, it is still unclear what the benefits are. It is obvious that indiscriminate use of mupirocin is associated with development of resistance. Therefore, additional studies are warranted to define the optimal MRSA decolonization strategy, including what should be given, to whom, and at what moment and who should guide and supervise the regimen.

The cites are:
Robicsek A, Beaumont JL, Thomson RB Jr et al. Topical therapy for methicillin-resistant Staphylococcus aureus colonization:impact on infection risk. Infect Control Hosp Epidemiol. 2009 Jul;30(7):623-32.
Kluytmans J, Harbarth S. Methicillin-resistant Staphylococcus aureus decolonization: “Yes, we can,” butwill it help? Infect Control Hosp Epidemiol. 2009 Jul;30(7):633-5.

Media round-up: recommending MRSA stories

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By chance — or is it because interest is really picking up? — a couple of worthwhile stories on MRSA have been published almost simultaneously:

  • For when the science gets wonky: Environmental Health Perspectives has an excellent lay-language explanation of how drug resistance emerges and spreads — with gorgeous graphics!
  • For when yet another drug doesn’t work: Scientific American covers development of new antibiotics, and even more important, development of new ways of creating antibiotics.
  • For yet more depressing news about MRSA in meat: Prevention adds to the discussion of MRSA in the food supply with a “special report” review. Constant readers who have been following along as we’ve drilled into this topic over the past two years won’t find a lot new, except for an intriguing account of an outbreak of MRSA in an Arkansas chicken plant (in which the bug went disappointingly untyped, so we don’t know whether it was a human strain or ST398). The story hits on issues we have talked about here: Surveillance for MRSA in animals is non-existent, practically speaking, and when the bug is found, investigation falls between human and animal health agencies. It’s a longer than usual story for Prevention, and should bring the knotty food-policy questions around MRSA in meat to a new audience.

New England Journal editorial: MRSA, H1N1 parallels

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There’s a very interesting piece in a recent New England Journal of Medicine (unfortunately, only the abstract is online) that draws parallels between MRSA and public expectations for pandemic flu. Written by Dr. Kent Sepkowitz, chief of infection control at Memorial Sloan-Kettering Cancer Center in New York and one of the authors of the “Medical Examiner” column at Slate, it’s an exploration of microbial sleight of hand: We were looking in one direction for a problem to develop, and — like Wile E. Coyote staring after the Road Runner but missing the Acme anvil — the problem came around and socked us in the back of the head.

In the case of flu, Sepkowitz writes, we concentrated on the threat of H5N1 avian influenza — the focus, until H1N1/swine flu arrived, of billions of dollars and years of effort in pandemic preparation — but were surprised by the sudden catastrophic emergence of seasonal flu strains resistant to oseltamivir (Tamiflu), one of the few antiviral drugs that can reduce illness and death from flu if taken early enough. In the case of MRSA, medicine focused on containing the spread of hospital MRSA and its rare transformation into VRSA, vancomycin-resistant staph — and mostly discounted, until far too late, the enormous threat of community MRSA strains:

The intensity of our concern and the frequency of the doomsday dispatches were appropriate. We were simply chasing the wrong microbe. It is community-acquired MRSA, not VRSA… that now occupies the center of the public health stage. And just about everything predicted for VRSA has come true for community-acquired MRSA. It’s everywhere; it’s deadly; it has changed the day-to-day management of skin infections and pneumonia in clinics, emergency rooms and intensive care units. It’s a true public health disaster. It’s just a different disaster from the one we were exercised about.

As we wrangle the new threat of H1N1, Sepkowitz warns that it is vital to remember how many millennia of practice microbes have in foiling our expectations:

We should marvel at the raw, restless power of microbes. They have the numbers — trillions and quadrillions and more that replicate wildly, inaccurately and disinterestedly. Nothing microbes do, whether under the duress imposed by antimicrobials or from some less evident pressure, should surprise us. It’s their world; we only live in it.

(Image courtesy Sansceo Design)

Antibiotic overuse in animals: Obama administration comes out against

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For anyone who cares about the overuse of antibiotics in food animals, and the resistant bacteria that overuse has been shown to produce, this is important news.

In testimony today, new FDA Commissioner Dr. Joshua Sharfstein announced the administration’s opposition to the use of growth promoters: sub-therapeutic doses of antibiotics used not as disease treatment, but to encourage animals to put weight on rapidly. Further, he also came out against the administration of antibiotics in food animals without the involvement of a veterinarian — a common situation out here in farm country, where veterinary antibiotics are freely available over the counter. (We discussed Scott Weese’s proposal to end that practice here.)

Both of these practices have been repeatedly linked to antibiotic resistance, and for the administration to come out against them is highly significant — not just for the struggle against resistant bacteria, but also for the movement to reduce industrial-scale agriculture, which relies on antibiotics to keep food animals healthy while they are in the close confinement of CAFOs.

Sharfstein made the announcement while giving testimony on behalf of Rep. Louise Slaughter (D-NY)’s Preservation of Antibiotics for Medical Treatment Act of 2009, which has been introduced (and opposed into nonexistence) multiple times over the past decade. (Earlier post on the legislation, including its text, here.) He said:

To avoid the unnecessary development of resistance under conditions of constant exposure (growth promotion/feed efficiency) to antibiotics, the use of antimicrobials should be limited to those situations where human and animal health are protected. Purposes other than for the advancement of animal or human health should not be considered judicious use. …
Important factors in determining whether a prevention use is appropriate include evidence of effectiveness, evidence that such a preventive use is consistent with accepted veterinary practice, evidence that the use is linked to a specific etiologic agent, evidence that the use is appropriately targeted, and evidence that no reasonable alternatives for intervention exist. FDA also believes that the use of medications for preventino and control should be under the supervision of a veterinarian. …
FDA supports the treatment of ill animals according to appropriate veterinary practice within a valid veterinary-client-patient relationship.

Also on the docket at Slaughter’s hearing:

  • Margaret Mellon, PhD, of the Union of Concerned Scientists (who specifically discussed MRSA ST398): “As long as the massive use of antibiotics continues, animals … will remain a fountain of resistant pathogens, dangerous to both animals and humans. The straightforward solution to the problem is to reduce the use of antibiotics in animal production and thereby diminish the pool of resistant organisms and traits.”
  • Robert Martin of the Pew Environment Group (Pew Charitable Trusts): “The present system of producing food animals in the United States is not sustainable and presents an unacceptable level of risk to public health, damage to the environment, as well as unnecessary harm to the animals we raise for food.”
  • And statements of support from the Chipotle restaurant chain and the Bon Appetit Management Company (which operates catering services in corporations and universities).

Of note, the Pew Commission on Human Health and Industrial Farming, which supports Slaughter’s bill, said after the hearing that Sharfstein’s proposals are only necessary but not sufficient: ““The proposed FDA position does not go far enough in this regard and would allow the continuation of conditions that necessitate the improper use of antibiotics in the first place.”