Maryn McKenna

Journalist and Author

H1N1 and MRSA – first disclosed case

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Readers, once again there’s a lot of MRSA-related news piling up, and I’ll try to roll some of it out over the next few days. But first, today we have to deal with an event that many of us have been anticipating, though not with any pleasure: the first known report of a MRSA death secondary to H1N1 “swine” flu infection.

We’ve talked about this possibility for weeks, because bacterial pneumonia, especially due to MRSA, is a known and frequently deadly follow-on to flu infection. (Archive of posts here.) With swine flu so common, CDC has said several times that they have been looking for post-flu bacterial pneumonia, but had not seen it. And commenters to this blog have relayed rumors — or, to be more precise, stories with no names attached — of flu patients so ill with MRSA that they have to be put on an ECMO, what we used to call a “heart-lung machine,” and sometimes do not come off.

Today, however, the Buffalo News carries the story of a New York State teen’s death from MRSA pneumonia as a sequela of flu:

Matthew Davis was a healthy Buffalo teenager who participated in sports before complaining of headaches June 13.
Within a few days, the 15-year-old student at Harvey Austin School 97 on Sycamore Street arrived seriously ill at Women & Children’s Hospital and then died Saturday, making him the first known fatality in Erie County caused by swine flu, officially known as novel H1N1 influenza.
… By the time Matthew entered the hospital, he was seriously ill with the flu, as well as co-infected with a type of bacteria known as methicillin-resistant staphylococcus aureus, or MRSA, according to health officials. (Byline Henry L. Davis)

Under normal circumstances — as in, during the past flu season — the public health advice has been to protect against MRSA pneumonia by getting a flu shot, which by preventing flu prevents the microtrauma to the lungs that allows MRSA and other bacteria to gain a foothold. In this case, though, with no H1N1 vaccine available, ir’s not clear what protective actions could have been taken.

Still, it’s terribly sad.

H1N1 flu and swine surveillance – more relevance for MRSA

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Constant readers, you probably know that yesterday the World Health Organization declared the first flu pandemic in 41 years. I want to point out for you a side issue in the H1N1 story that has great relevance for MRSA, especially ST398.

As described in this article I wrote last night for CIDRAP, three medical journal articles have now pointed out that the virus, or its major components, could have been recognized in swine months to years ago. We missed it, though, because there is so little regular surveillance in pigs for diseases of potential importance to humans. As the authors of the most recent article, in Nature, said yesterday: “Despite widespread influenza surveillance in humans, the lack of systematic swine surveillance allowed for the undetected persistence and evolution of this potentially pandemic strain for many years.”

This is important for our purposes because we know that we are in the same situation with MRSA ST398: The strain was first spotted in France, and has been a particular research project in the Netherlands, but has been found pretty much wherever researchers have looked for it, throughout the European Union, in Canada, and most recently in the United States. All told, though, the scientists concerned with it are still a small community; there is no broad surveillance looking for this bug.

And that’s a problem, for MRSA, for influenza, and for any number of other potentially zonotic diseases: We cannot anticipate the movement of pathogens from animals to humans if we don’t know what’s in the animals to start with. That’s the argument behind the “One Health” movement, which has been arguing for several years now for including veterinary concerns in human health planning. (The human health side would probably say that the animal health side just wants more money. This is also true, which does not make it unimportant.)

To understand the need to look at animal health in order to forecast threats to human health, you can’t do better than the map I’ve inserted above (because Blogger, annoyingly, won’t let me put it below). It has appeared in various forms in various publications for about 10 years but originates I think from the IOM’s Emerging and Reemerging Diseases report in the early 90s. (This iteration comes from the One Health Initiative website.) It depicts the movement of new diseases from animals to humans over about 30 years. It’s up-to-date through SARS and through the 2003-05 movement of H5N1 avian flu around the world. I’m sure H1N1 will be added soon. How many of those outbreaks could we have shortcircuited if we had been warned of their threat in good time?

Antibiotics in water supplies

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Via the journal Environmental Health Perspectives comes an important, comprehensive review article by scientists from Environment Canada and the Universite de Montreal on the presence of antibiotics in water supplies and waste water.

The news is not good. If you are concerned about the possibility that antibiotic residues in the environment create another setting in which resistance can develop, it is worth reading. It is long (10 pages in pdf) but has a comprehensive bibliography. Also, it’s open-access.

Where do these antibiotic residues come from? From us, in some cases: We urinate out up to 90% of some drugs, wash off topical formulations, flush old prescriptions down the toilet. Sometimes from industrial residues, or from leaky hospital sewage, or from sewage treatment plants, or — of course — from industrial-scale agriculture administration and run-off.

And where do they go? According to the paper, over more than 20 years of research, 126 different antibiotics and anti-infectives have been identified in processed waste water, natural surface water and groundwater, and drinking water supplies. Among them are all the antibiotics that we are concerned about here: the drugs that MRSA is already resistant to (beta-lactams, lincosamides, macrolides) and the drugs that still work, for community MRSA at least (sulfonamides, trimethoprim, tetracycline).

Moreover, the trend is expected to get worse, the authors warn: because of increased urbanization; because many urban areas are consciously setting water-saving policies, reducing the volume of wastewater and therefore increasing the concentration of drugs in the water that remains; and because, well, CAFOs aren’t exactly going away right now, are they? As they say:

…even if our results show that high concentrations … of anti-infectives in these waters are more the exception than the rule, the existence of a few locations where these concentrations can be reached are enough to contribute to the global spreading of anti-infective resistance. Given that large populations of bacteria are being exposed to a selective pressure, environmental waters and especially wastewaters become ideal settings for the assembly and exchange of mobile genetic agents encoding for resistance in bacteria. … Anti-infectives, the miracle drugs of the 20th century, have become environmental contaminants of emerging concern in the 21st.

The cite is: Segura PA et al. Review of the Occurrence of Anti-infectives in Contaminated Wastewaters and Natural and Drinking Waters. Environmental Health Perspectives, 117 (5) May 2009.

Farm animals and antibiotics – a new campaign

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I was gobsmacked to discover today, a few days late, that the Pew Campaign on Human Health and Industrial Farming (authors of the report discussed here) have launched a marvelously in-your-face series of ads in Washington DC, aimed at bringing the issue of antibiotic use in farm animals to people who might not think about it.

The ads have been placed in the Capitol South and Union Station Metro stops, which are the stops that bracket Capitol Hill, and in Metro cars on the red and blue/orange line trains, which are the main commuter trains down to the Hill. In other words, they’ve been made to be the morning reading of the people most engaged in the health reform debate right now — and if you think those folks are not thinking about healthcare spending and the growth of antibiotic resistance, well, umm, oh never mind.

The campaign says:

The American Medical Association, the American Academy of Pediatrics and other leading medical groups agree that the growth of bacterial infections resistant to antibiotic treatment is a looming public health challenge. The groups also agree the misuse of antibiotics on industrial animal farms plays a significant role in this crisis. While antibiotics are prescribed to people for short-term disease treatment, these same critically important drugs—like tetracycline, erythromycin and ciproflaxin—are fed in low doses to large herds or flocks daily, often for the lifespan of the animal. This creates ideal conditions for the breeding of new and dangerous antibiotic-resistant bacteria.

For statistics and arguments, along with more images — cows! chickens! pills! — go to the site of the commission’s campaign, Save Antibiotics.

MRSA in pig-farm workers – very high rates

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Let’s go back for a moment to what I think of as the “third epidemic” of MRSA: ST398 and the other strains that reside in animals and cross to humans. (In my personal taxonomy, the first and second epidemics are hospital-acquired and community-associated.)

Via Emerging Infectious Diseases, the open-access journal published by the CDC (Do I have to keep telling you to read it? It’s free. It’s good. Your tax dollars pay for it.), comes a report of surveillance for MRSA colonization of pig-farm workers, conducted in Belgium by researchers from Erasmus Hospital of the Free University of Brussels, and the Veterinary and Agrochemical Research Centre of Brussels. The group persuaded 127 farm workers on 49 farms to be tested for colonization, or asymptomatic carriage, of MRSA; at the same time, they tested 30 randomly selected pigs on each farm.

They found very high rates of colonization, higher than have been found in patients in hospitals or residents of nursing homes: 38% of the farm workers carried MRSA ST398, the pig strain (plus, an additional 17% carried various strains of MSSA, drug-susceptible staph). There was a clear association between colonized farmers and colonized pigs: Out of 1500 pigs sampled, 44% carried ST398 — and half of the workers on farms with colonized pigs were colonized also, compared to only 3% of workers on farms where pigs did not carry the bug.

In a bit of good news, the researchers found only one farm worker who had suffered any MRSA disease from ST398, a man with a lesion on his hand. There was no invasive disease, though ST398 has been associated in the past with pneumonia and endocarditis.

Workers were more likely to acquire the bug if they had regular contact with pigs, dogs or horses, which makes intuitive sense. But in an odd finding, their odds of acquiring ST398 did not go down if they wore protective clothing — which is to say, aprons, gloves and masks did not protect them from picking up the bug, leading the researchers to wonder whether airborne spread or contaminated surfaces are playing a role in transmission.

So what does this mean? The lack of invasive disease in this population must be good news; and it’s consistent with a number of papers that have reported low rates of disease from ST398 even when colonization is present. But to me, the high rate of colonization must be bad news. The more of this bug there is (and every researcher who looks for it seems to find it), the more chance there is of the bug adapting in an unpredictable — potentialy more resistant, potentially more virulent — way. If that did happen, it could well go undetected for a while — because as swine flu has been teaching us, disease surveillance in animals is patchy at best, and new pathogens can and do arise and ciruclate for years before being detected.

For more on the paucity of surveillance in animals, see my CIDRAP colleague Lisa Schnirring’s story here. For a complete archive of posts on “pig MRSA” ST398, go here.

The cite is: Denis O, Suetens C, Hallin M, Catry B, Ramboer I, Dispas M, et al. Methicillin-resistant Staphylococcus aureus ST398 in swine farm personnel, Belgium. Emerg Infect Dis. 2009 Jul; [Epub ahead of print] DOI: 10.3201/eid1507.080652.

Infections rise, but hospital budgets – and infection control – shrink

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Bad news from the Association of Professionals in Infection Control and Epidemiology (APIC): In a survey of almost 2,000 of their 12,000 members, 41% say that their hospitals’ infection-prevention budgets have been cut due to the down economy.

According to the survey, conducted March 2009 and released Tuesday morning:

Three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile.
Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources.
Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

As we know here, there are (by CDC estimate) 1.7 million hospital-acquired infections and 99,000 deaths as a result of them, each year. These are numbers we are supposed to be trying to reduce. That is going to be less likely if less money flows toward what may already be an underfunded goal:

A third of survey respondents say that cuts in staffing and resources have reduced their capacity to focus on infection prevention activities.
A quarter of respondents have had to reduce surveillance activities to detect, track and monitor HAIs.

Disturbingly, at a time when electronic health records are such an important part of the health-reform debate, “Only one in five respondents have data-mining programs – electronic surveillance systems that allow infection preventionists to identify and investigate potential infections in real time.”(APIC press release)

The full report is here.

10 years but little progress on patient safety

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Constant readers, I’ve been away for a week — trying to get my breath back now that the chaos of the novel H1N1/swine flu is diminishing — and so I’ve missed a lot of news. Over this week, I’ll try to catch you up on it.

First up: Some of you know that, 10 years ago, the nonpartisan, Congressionally-chartered Institute of Medicine (IOM) published a groundbreaking report called To Err is Human (html here, pdf here) that jump-started examination of medical quality in the United States. That report said:

Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…
Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. …
Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (To Err is Human, executive summary)

The report prompted a huge groundswell of legislative interest and patient advocacy that led, years later, to the successful passage of state laws insisting on public reporting of hospital infections and more recently on disclosure of hospital-acquired MRSA.

And yet: Despite all that scrutiny and activism, we are nowhere near as far as we should be in reducing medical errors. Just in the area of hospital infections, which is our greatest interest here, there is not mandatory reporting in all states, and there is no nationwide reporting.

So says the Safe Patient Project of Consumers Union, which has produced an update to the IOM report called To Err is Human — To Delay is Deadly. They conclude:

Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.
Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year — a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year.

The project finds that many of the reforms recommended by the IOM in 1999 have not been created:

  • Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes.While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.
  • A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.
  • No national entity has been empowered to coordinate and track patient safety improvements.Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.
  • Doctors and other health professionals are not expected to demonstrate competency.There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The entire report is well worth reading. Its lamentable but well-supported conclusion:

We give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.


MRSA and H1N1 "swine" flu – still not a lot of evidence

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Hello again, constant readers. It’s busy out there.

The CDC said Wednesday that new infections with the novel H1N1 virus (Formerly Known As Swine Flu) may be trending down. Nevertheless, there is still a lot of rumor and speculation out there regarding what role MRSA pneumonia may have played in serious cases.

The CDC commented on this in its May 19th press briefing:

Q: Is anybody looking for, and is anybody finding any evidence of, coinfection with MRSA?
A: We′re very interested in that question. As you know, the seasonal influenza in children we′ve been tracking pediatric deaths, and we have seen MRSA among seasonal flu cases in children at a higher rate than we had expected. MRSA is a big problem in the United States right now in terms of the community associated resistant staff or its infections. So far as we′ve been looking at the patients with the H1N1 virus, we don′t have evidence of coinfection. Not everybody has been tested for bacterial infections. But among the ones that have been tested, we aren′t seeing an important role for bacterial coinfection, including MRSA. I think this is an important issue for us to continue to follow, whether bacterial co-infections or bacterial pneumonias following the illness are featured. It′s a feature we′re interested in but haven′t seen this turn up yet.

We’ve talked a number of times before here about MRSA necrotizing pneumonia, and about the apparent importance of secondary bacterial infections to the death rates in prior flu pandemics.

But for anyone who needs a refresher, I recommend an excellent new paper by researchers at Emory University, published last week in the journal Lancet Infectious Diseases. It recounts the clinical course of two people who were treated at Atlanta’s Grady Memorial Hospital for MRSA pneumonia. Both were adults, and both survived, but their courses were complicated; the clinicians note that they did not improve until they were given additional antibiotics aimed at shutting down MRSA’s toxinproduction, a step that is not universally considered by doctors treating a MRSA patient.

The cite is: Hidron, AI et al. Emergence of community-acquired methicillin-resistant Staphylococcus aureus strain USA300 as a cause of necrotising community-acquired pneumonia. Lancet Infect Dis. 2009 Jun;9(6):384-92. The abstract is here.

MRSA in space

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No, really — but not quite the way you think. The weekly geekfest that is Aviation Week and Space Technology reports that the payload of the space shuttle Atlantis includes a MRSA experiment. The goal is to investigate whether bacteria held in the microgravity of space become more virulent — this was done earlier with salmonella — and then to determine whether any new virulence markers suggest targets for a potential staph vaccine.

A vaccine of course, is the Holy Grail of MRSA research — and it has remained frustratingly out of reach. For a great review of past research and future challenges, see this review article from March.

MRSA in the House of Lords — the silly, the serious

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Thanks to constant reader Pat Gardiner, we have the transcript of the UK House of Lords discussion on community MRSA, called there PVL-MRSA after the toxin. (Go to the linked page, and click down to the time-mark 3.16 pm.) It’s encouraging to see some members of a government taking MRSA seriously. The members are asking for

  • better surveillance
  • better infection control
  • consideration of MRSA as a notifiable disease
  • and promotion of both vaccine research and point-of-care diagnostics.

Hear, hear to Baroness Masham of Ilton for bringing it up.

To get to that discussion, though, you’ll have to click down through some silliness (the ghost of Monty Python is never far from the British government, is it?): a discussion at time-stamp 3.07 p.m. of whether a House of Lords restaurant can afford to serve British bacon, rather than Dutch bacon, given that British bacon is almost twice as expensive and Dutch pigs are associated with MRSA ST398:

Lord Hoyle: My Lords, I thank the noble Lord for that reply, although there is more than a whiff of hypocrisy about it. After all, I and many others on all sides of the House have argued that it should not be a matter of price. We have urged the British consumer to buy British bacon because of the higher welfare standards that are applied in this country. Will the noble Lord also take into account the presence in Dutch bacon of a deadly form of MRSA, ST398, which can cause skin infection, heart trouble and pneumonia? Is he not putting people in this country at risk, particularly as the strain has passed from animals to humans? Indeed, when Dutch farmers go into hospital, they go into isolation. Why is he putting the British consumer and those who buy bacon in this House at risk in this way?

The discussion quickly devolves into foolishness about British Tomato Week — but if you read carefully, you’ll see that behind the silliness, there are serious issues at stake: animal welfare, farming standards, truth in labeling (the Lord Bishop of Exeter advances the very newsworthy claim that pork imported from other countries is subsequently labeled “British” only because it is packaged in the UK) and movement of zoonotic pathogens across national borders thanks to globalized trade.

Sadly, the leader of the discussion — the Chairman of Committees, AKA Lord Brabazon of Tara (no, really) — appears not to have been keeping up with the news, since he notes of ST398:

As far as MRSA is concerned, I read the article in, I think, the Daily Express a couple of weeks ago. I do not think that it has been followed up by anybody else.

Apparently the Lord’s staff have not been keeping up, since MRSA in pigs in the EU has been covered by the Daily Mail, the Independent, comprehensively by the Soil Association, and by, ahem, us.