There was a lot of interest in in TDR-TB Friday; both The Leonard Lopate Show on WNYC and Science Friday kindly asked me to be on to talk about it. While I was waiting for the phone link to Science Friday to become live, an alarming bulletin arrived in my e-mail. The early-warning list ProMED reported that the existence of two additional cases of TDR-TB have been disclosed, in Bangalore, 600 miles from Mumbai where the first known Indian cases were identified. The patients, a 56-year-old man and a 29-year-old woman, had been coming to a hospital for directly observed administration of their TB for more than two years; they were initially recognized as MDR-TB patients, with disease that was highly resistant but not untreatable, but were not getting better. For the past two weeks, though, the man has not shown up, and no one appears to know where he is.
Totally Resistant TB: Earliest Cases in Italy
A follow-up to Monday’s post on the recognition in India of totally drug-resistant tuberculosis, TDR-TB: The fantastic early-warning list ProMED points out that the earliest recorded cases of TDR were not the current 12 known cases in Mumbai or the 15 cases in Iran in 2009, but rather two women from Italy who died in 2003 after being sick for several years.
It’s a sad story that was briefly recounted in 2007 in the journal EuroSurveillance, published by the European Centre for Disease Prevention and Control (ECDC).
India Reports Completely Drug-Resistant TB
Well, this is a bad way to start the year.
Over the past 48 hours, news has broken in India of the existence of at least 12 patients infected with tuberculosis that has become resistant to all the drugs used against the disease. Physicians in Mumbai are calling the strain TDR, for Totally Drug-Resistant. In other words, it is untreatable as far as they know.
News of some of the cases was published Dec. 21 in an ahead-of-print letter to the journal Clinical Infectious Diseases, which just about everyone missed, including me. (But not, thankfully, the hyper-alert global-health blogger Crawford Kilian, to whom I hat-tip.) That letter describes the discovery and treatment of four cases of TDR-TB since last October. On Saturday, the Times of India disclosed that there are actually 12 known cases just in one hospital, the P. D. Hinduja National Hospital and Medical Research Centre; in the article, Hinduja’s Dr. Amita Athawale admits, “The cases we clinically isolate are just the tip of the iceberg.” And as a followup, the Hindustan Times reported yesterday that most hospitals in the city — by extension, most Indian cities — don’t have the facilities to identify the TDR strain, making it more likely that unrecognized cases can go on to infect others.
More News: FDA Curbs One Class of Farm Drugs
Here’s a bookend to the Food and Drug Administration’s disappointing Christmas Eve notice that it will cease trying to regulate the largest classes of growth-promoter antibiotics. Today, the agency announced that it is forbidding certain uses of a different class of drugs, cephalosporins.
To those who are concerned about antibiotic overuse in agriculture, though, this is good news — though it may be more good news-bad news-bad news-good news.
The dialectic looks like this:
News: FDA Won't Act Against Ag Antibiotic Use
With no notice other than a holiday-eve posting in the Federal Register, the US Food and Drug Administration has reneged on its long-stated intention to compel large-scale agriculture to curb over-use of agricultural antibiotics, which it had planned to do by reversing its approval for putting penicillin and tetracyclines in feed.
How long-stated? The FDA first announced its intention to withdraw those approvals in 1977.
From the official posting:
The Food and Drug Administration (FDA or the Agency) is withdrawing two 1977 notices of opportunity for a hearing (NOOH), which proposed to withdraw certain approved uses of penicillin and tetracyclines intended for use in feeds for food-producing animals based in part on microbial food safety concerns.1 … (1FDA’s approval to withdraw the approved uses of the drugs was based on three statutory grounds: (1) The drugs are not shown to be safe (21 U.S.C. 360b(e)(1)(B)); (2) lack of substantial evidence of effectiveness (21 U.S.C. 360b(e)(1)(C)); and (3) failure to submit required reports (21 U.S.C. 360b(e)(2)(A)).)
There is a lot of background to this, but here is the takeaway: For 34 years, the FDA has been contending that administering small doses of antibiotics to healthy animals is an inappropriate use of increasingly scarce drugs — a position in which it is supported by organizations as mainstream as the American Medical Association. With this withdrawal, it backs away from the actions it took to support that assertion — which may indicate there will be no further government action on the issue until after the 2012 election.
Antibiotics: Connected to Obesity, Diabetes and Stroke?
In consideration of your glaze-eyed tryptophan coma — at least among those who weren’t frightened off by the MRSA-in-turkey news — today’s post is mostly composed of brightly colored pictures. (Also, speculation. You’ve been warned.)
About a week ago, a nonprofit research group called Extending the Cure published the latest in a fantastic series of maps they have been producing for several years, based on public and privately collected data. Earlier iterations have looked at the incidence of various resistant organisms over time. This time, they decided to look instead at the major drivers of resistance, and focused on national data about antibiotic prescriptions, broken down by drug type and by state between 1999 and 2007.
The graphics they produced document both a troubling growth in the use of some precious (because still effective) antibiotic classes, and also a surprising differential in the amounts of antibiotics prescribed in different parts of the country. The rate of use of antibiotics, measured by outpatient prescriptions per 1,000 inhabitants, varied from a low of 533 in Alaska to a high of 1,214 in West Virginia. [Read more…]
More MRSA Found In U.S. Retail Meat (Turkey, Too)
There are two new studies out that confirm, once again, that drug-resistant staph or MRSA — normally thought of as a problem in hospitals and out in everyday life, in schoolkids, sports teams, jails and gyms — is showing up in animals and in the meat those animals become.
The strain of staph that shows up in farm animals, known as “livestock-associated” MRSA or MRSA ST398, first emerged in pigs in the Netherlands, and has been widely identified in retail meat in Europe. (You can find a long archive of posts on ST398 here, and more here.) But that same strain has been difficult to identify in the United States. That may be due in part to the U.S. having a uniquely massive epidemic of community-associated MRSA, far larger than in any other country, which likely both obscures any animal epidemic from detection, and possibly also fills the ecological niche that livestock-associated staph might otherwise occupy. But, it must be said, there’s also remarkably little political will to look for livestock-associated MRSA (though the U.S. Department of Agriculture has now funded a study).
Nevertheless, individual investigators keep trying, and when they look for the pathogen, they find it, such as in these studies from May and this one from April. Now, two other teams have as well.
Running Out of Antibiotics: Europe Gets It
In the United States, it’s been “Get Smart About Antibiotics” Week this past week, an annual observance in which the Centers for Disease Control and Prevention and its medical and public health partners try to raise awareness of antibiotic resistance. The real action this week though was in Europe, where individual researchers and the EU’s version of a CDC — the European Centre for Disease Prevention and Control — are speaking out about the problem with unusual candor.
Here’s the short version: In Europe, according to the ECDC, 25,000 people each year die as a result of multi-drug resistant infections, causing an additional cost to society of 1.5 billion Euros ($2.02 billion): 938 million Euros ($1.27 billion) in hospital and outpatient medical costs, and an additional 596.3 million Euros ($806 million) in lost productivity.
Dr. Marc Sprenger, director of the ECDC, said Friday:
This certainly is an underestimate of the true economic impact of antimicrobial resistance. In particular, the figures were based on data for just five multidrug-resistant bacteria.The estimate was also based on a conservative figure for the cost of a day in hospital… We think the real cost of treating a patient with a multidrug-resistant infection would be higher than this. My take home message is that antimicrobial resistance is one of the most serious public health challenges that we face.
EU Parliament Votes To Oppose Most Farm Antibiotic Use
A quick post, because I’m on a ferocious deadline, but still can’t let this news go by. In a vote that’s non-binding but high profile and influential, the European Parliament has resolved to end “prophylactic use” of antibiotics in farming, and to prevent any “last resort” antibiotics from being used in animals, in order to keep resistance from developing so that the drugs will still be effective in human medicine.
This is a significant development. The European Union has already banned “growth promotion,” the use of micro-doses of antibiotics that cause meat animals to fatten more quickly. What the Parliament is doing here is asking the European Commission, the EU’s law-making body, to add “disease prevention” use to the ban. That’s the delivery of treatment-strength doses of antibiotics to all animals on a farm in order to prevent their becoming ill as a result of the confinement conditions in which they are held. It accounts for a substantial portion of the antibiotics used in agriculture, and is a major driver of the emergence of antibiotic-resistant organisms.
Government Health Agency Agrees Mega-Farms Are A Health Risk (In The UK)
It’s very odd sometimes watching how the same issues play out in different parts of the world. The French environment ministry confidently ascribes the growth of seaweed choking its beaches to farm runoff. The European Parliament denounces the establishment of very large-scale “meat factories.” China (China!) enacts a ban on growth-promoting uses of antibiotics in agriculture.
Here in the United States, on the other hand, the government gropes unsuccessfully for a way to put controls on confinement agriculture, despite evidence of its environmental harm, while at the same time those farms grow by an estimated 4,600 hogs and 5,800 broiler chickens per day.
For more of that difference between Europe and the US, look this week to England, where the Health Protection Agency has just rejected the zoning application for a hog farm that was small by US standards, with a plan for only 2,500 sows producing about 20,000 piglets. The HPA said:
… those living up to 150 meters downwind of an intensive swine farming installation could be at risk of adverse human health effects associated with exposure to multi-drug resistant organisms. (this .pdf, p.30 of 44)
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