H5N1

Picard: Rita MacNeil’s death should make us angry

Via The Globe and Mail, André Picard writes a remarkable column about the death of Rita MacNeil, a singer whose death last week saddened Canada. Instead, he says, Rita MacNeil’s death should make us angry.

The death of Ms. MacNeil, a remarkable woman who overcame poverty, sexual and physical abuse, depression, addiction and obesity to become a star, should not only make us sad – it should make us angry. 

Angry because it underscores the scourge of hospital-acquired infections; angrier still because we have missed a glorious opportunity to take a larger lesson from her death, one that is a fitting tribute to a singer who was a social activist. 

Hospital-acquired infections sicken 250,000 patients annually and kill between 8,000 and 12,000 Canadians. The bugs patients catch while in care are one of the leading causes of death in this country; they kill twice as many people as breast cancer. 

Many, but not all, of the deaths are preventable. After all, people who are in hospital are often gravely ill; they are susceptible to infections. Sometimes, an infection can even bring about a merciful death: For a long time, physicians called pneumonia the “old man’s friend” because it is a relatively painless death. 

But people dying of hospital-acquired infections are not all frail seniors and not all are dying painlessly. They are suffering – and suffering horribly – from increasingly difficult-to-treat bugs like Clostridium difficile (where you essentially defecate to death) and methicillin-resistant Staphylococcus aureus (MRSA), which causes painful boils and can lead to the shutdown of your organs. These pathogens are increasingly resistant to treatment. 

We need to be careful not to point fingers of blame but, at the same time, we cannot simply ignore some damning facts. 

One of the greatest dangers after surgery is infection. The surgical wound can be a point of entry for a lot of nasty bugs. This is particularly true for patients with cellulitis. Their wounds must be cared for meticulously because, paradoxically, when you are being treated with antibiotics, you become more susceptible to infection. 

During Ms. MacNeil’s stay, part of the hospital was closed because of an outbreak of Norwalk virus. In that same period, several patients contracted MRSA. 

These are not airborne infections. There are two principal routes of spread of hospital-acquired infections: shared toilets combined with inadequate housekeeping and health professionals who don’t adequately wash their hands. 

The Cape Breton Regional Hospital, where Ms. MacNeil was treated and died, has a troubling patient safety record. 

When the Canadian Institute for Health Information published the first hospital standardized mortality rates (a comparison of expected deaths and actual deaths), the CBRH had the worst record in the country – with a mortality rate 37 per cent above average. (And let’s not forget that the average rate in Canada is pretty poor to begin with.)

Hong Kong: Man dies of MRSA infection

Via the Hong Kong government website: Man dies of drug-resistant infection.

The Centre for Health Protection is investigating a fatal case of invasive community-associated Methicillin-resistant Staphylococcus aureus involving a 35-year-old man.   

The patient, previously of good health with no recent travel history, was admitted to Prince of Wales Hospital with joint pain and fever on March 10. He was transferred to the Intensive Care Unit and after being diagnosed with necrotising faciitis in his left forearm, and had an amputation performed on March 11.    

His condition deteriorated and he died on March 12. His blood sample tested positive for CA-MRSA.   

MRSA is a type of Staphylococcus aureus that is resistant to beta-lactam antibiotics. It is a common infection worldwide.

Still another doctor's take on CRE

Via the blog Controversies in Hospital Infection Prevention, Dr. Eli Perencevich has some Further thoughts on CRE. Click through for the full post and a lot of links. Excerpt:

I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail. 

This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." 

And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. 

And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequence stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. 

Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE. 

My recommendations: 

(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics. 

(2) Invest in studies to improve compliance with hand hygiene – only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands. 

(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors? 

(4) Undertake studies to further optimize environmental source control 

(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other other messaging techniques that have a chance to be effective.

This is the most interesting online debate I've seen in ages.

...and another doctor's take on CRE

Via Scientific American Blogs, Dr. Judy Stone has some important points to make: CDC’s “Resistance Nightmare:” A View from the Trenches. Excerpt (but read her whole post):

I want to share my perspective as an infectious disease practitioner who cares for patients with these infections regularly. As I have mentioned more privately, there are cultural issues driving the emergence of resistance, especially in the U.S., first with MRSA, then VRE, and now with CRE. Warning: my observations may not be politically correct—but they reflect 30+ years of patient care. These include: 

— The belief  many have that people will live forever. There used to be more of an acceptance of death. But with television/movies portraying advances in medicine unrealistically, the public now often has an expectation that their loved ones will not die. Some seem to feel that any death must be a result of medical error, and there are a number of malpractice attorneys vying for their attention with aggressive advertising reinforcing that belief. 

— Pharmaceutical companies and their sales reps push doctors to use the latest wonder drugs. If a physician uses older agents, s/he is likely to be portrayed as not keeping up to date with medical advances. 

— Individual “rights” above all. Physicians and families focus on the possible benefit for one patient, with little or no concern as to public health implications of treatment. This sounds harsh, but should we reconsider treatment of nonviable patients for the good of the community. This warrants thoughtful discussion.

I really appreciate her observations about the cultural attitudes and corporate values that drive health care, especially here in North America. Until we can look at ourselves with some detachment, we will experience more unintended consequences of our own actions.

US: A doctor's take on CRE

Via The Daily Beast, an article by Dr. Kent Sepowitz: Why I’m Not Worried About Dying From a Superbug, and You Shouldn’t Be, Either. Click through for the full article with links. After discussing the current discussion of CRE as the new superbug, Dr. Sepkowitz writes:

We have been here before of course: methicillin-resistant Staphylococcus aureus (MRSA) played through the hospitals and the headlines (and even the National Football League) last decade, alarming the public and spurring new regulations to contain it as well as the application of money, sort of, to develop new weapons. 

Perhaps because of all the hubbub, MRSA now seems almost quaint and surely not a headline-screaming scourge: mostly contained, a nuisance, a problem, but being dealt with at the right place by the right people. In other words, it has assumed its proper proportion in the world of threats and dangers. 

The same likely will happen with CRE. More cases will occur, hospitals will make the necessary adjustments suggested by the CDC, specialists will learn their way around the diseases, and eventually the threat and the excitement around it will flatten out. And then the next red-hot development on some other front will emerge rendering the acronym to oblivion. 

The problem though is this: the mix of steady CDC concern about a real issue that requires attention, a world with infinite capacity for both news and “news,” and a perverse public enjoyment of being frightened has succeeded in little other than scaring the crap out of people who might need medical care. 

Indeed, hospitals seem to occupy the same imagined place as the Overlook Hotel, the cavernous inn Jack Nicholson prowled in The Shining—the last place on earth a sane person would go. Health care in general and hospitals specifically are viewed these days by just about everyone as a veritable killing field, the place where the two inevitabilities—death and taxes—meet daily as people are fleeced then killed. 

Such is not the case. Honest. Yes, I know I am tainted goods because of my conflict of interest: I work in a hospital and I believe in medical care. But please remember that people in ICUs, where CRE and so many other deadly infections lurk, are not denizens of executive suites. They are already quite ill, usually with multiorgan failure from the heart attack or stroke or high-speed automobile crash that brought them to emergency medical care. They then are exposed to the high-tech ballet of life-sustaining futuristic machines, venous and urinary catheters, potent and often toxic medications, and all the rest. 

They also are exposed to the bacteria in their own intestines, mouth, and skin, as well those in the environment, much less the imperfectly cleaned hands of hospital staff. Horrible, heartbreaking, and fully preventable things happen in ICUs, but so too are many lives saved. 

The demonization of health care has occurred simultaneously with our deepening fascination of the promise of tomorrow, an almost religious belief that medicine is just inches away from conquering just about everything. 

These two fantastic extremes pervert reality with equal force and fully obscure the truth about medical care in 2013: we are neither in a hell of ineptitude and willful neglect nor just inches from the next great golden age of health. And though hospitals are complicated, difficult places to spend time, the view that, to preserve health, it is safer to avoid care than to seek it is a dangerous and troubling delusion.

Drug resistance in MRSA is finely tuned

Via Public Health Perspectives at PLOS Blogs, a very interesting account of a dishwashing accident and its consequences: Drug Resistance in MRSA is Finely-tuned.

MRSA infections have long been associated with health care settings such as hospitals and nursing homes. These settings, characterized by a sick general population coupled with high antibiotic usage which selects for drug-resistance, are a perfect environment for MRSA strains to gain a foothold. Given that I had my stitches done at an urgent care center I just assumed that’s where I came into contact with MRSA. 

In recent years, however, community-acquired MRSA (CA-MRSA) infections have been on the rise. These are infections contracted from settings like schools, childcare centers, gyms, and prisons. Infections caused by CA-MRSA strains are a particular concern because they are more virulent, spread more rapidly, and can cause more severe infections than its healthcare-acquired MRSA (HA-MRSA) counterparts. 

What’s worse is the line between the two are blurring as HA-MRSA strains move out into the community and CA-MRSA moves into the hospitals. Because of the increased virulence of CA-MRSA strains there are fears that these strains will eventually replace HA-MRSA strains in healthcare settings–although a recent model published in PLOS Pathogens suggests otherwise. 

How MRSA developed β-lactam resistance is still unclear. While there are quite a few different strains of MRSA (some of which have also developed resistance to other classes of drugs) they all carry the mecA gene. The mecA gene, in turn, is part of a larger piece of foreign DNA known as the SCCmec element, which is not normally found in S. aureus. 

Since bacteria are quite adept at exchanging DNA with each other, scientists speculate that the SCCmec element found its way into a normal staph strain from an as-of-yet identified trading partner. This process of swapping and transferring DNA is known as horizontal gene transfer. 

Interestingly, MRSA has a finely-tuned, “on-demand system” that turns mecA expression on in the presence of β-lactam drugs, while keeping expression turned off in the absence of these drugs. This regulation is carried out by proteins whose genes are also found on the SCCmec element. 

In the absence of β-lactams–when the bacteria doesn’t need the drug-resistant PBP2a protein around– the expression of mecA is kept in check by the protein MecI. MecI binds to the DNA promoter region of mecAand prevents gene transcription. However, in the presence of β-lactam drugs the bacteria needs PBP2a around in order to survive.

Can we control CRE?

Further to the CDC's news release today about carbapanem-resistant Enterobacteriaceae, here's a post in a blog I'm delighted to add to the Bloggers list: Controversies in Hospital Infection Prevention: KPC, CRE, MDR-GNR: Call 'em what you will, but stop pretending we know how to control them! Excerpt:

The proportion of Enterobacteriaceae that were CRE rose from 1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN facilities. In Klebsiella species, the situation is dire with 10.4% classified as CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and 17.8% of long-term acute-care hospitals reported at least one CRE in their facility. 

So things are pretty bad, at least 17.8% bad. 

What can we do about this? This is what they say in the abstract: "Interventions exist that could slow the dissemination of CRE. Health departments are well positioned to play a leading role in prevention efforts by assisting with surveillance, situational awareness, and coordinating prevention efforts." 

Which interventions? Certainly there are no evidence-based interventions, unless we call an uncontrolled quasi-experimental study evidence. The CDC authors made reference to VRE control efforts in the Siouxland, MRSA control efforts in The Netherlands and CRE control efforts in Israel. 

I think these are poor and overly optimistic comparisons for several reasons. For one, the first two efforts targeted Gram-positive bacteria and it's unclear if we can extrapolate these to control efforts targeting MDR-GNRs.  For example, we have effective antibiotics for VRE and MRSA (quinupristin/dalfopristin-approved in 1999; linezolid-approved in 2000, daptomycin-approved in 2003) but not for CRE.  Additionally, we can decolonize for MRSA but not CRE. 

However, the most important aspect of the The Netherlands and Israel examples were that they instituted NATIONAL RESPONSES aimed at MRSA and CRE. There are no such national efforts here in the US targeting CRE. This is what we have in the US per the MMWR report: "six states have made CRE reportable, and three additional states are actively pursuing this option." This is not a national response. This is a national tragedy.

Hong Kong: Man treated for MRSA

Usually I admire the health news on the Hong Kong government website as clear, prompt, and concise. But this item is a little too concise: Man treated for drug-resistant infection. The whole report:

The Centre for Health Protection today confirmed a case of invasive community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA), a drug-resistant bacterium, involving a 25-year-old man living on the Mainland.   

He fell ill and sought medical consultation on the Mainland in early January.   

He was admitted to a private hospital in Hong Kong on January 5, and was discharged the next day. His clinical diagnosis was pneumonia.   

He tested positive for CA-MRSA.

So what happened next?

McKenna: Livestock MRSA found for first time in UK milk

Via her blog Superbug, Maryn McKenna has a big story: Livestock MRSA Found For First Time In UK Milk. Excerpt:

This paper almost slipped by me. It was published quietly a few weeks ago, and it’s a little eyebrow-raising. From EuroSurveillance, the open-access peer-reviewed bulletin of the European Centre for Disease Prevention and Control (Europe’s CDC): The ST398 strain of MRSA, better know as “livestock-associated MRSA” or just “pig MRSA,” has been found for the first time in milk in England. (And therefore probably in cows, or at least on farms.) 

Apparently there has been an ongoing study looking for any evidence of MRSA in UK cows, possibly because of this news from last year (of which more in a minute). Between last January and July, the program tested 1,500 samples of milk from farms’ bulk tanks — that’s the cooler in which milk from a number of cows is collected until it can be picked up by a truck for processing — and found seven of the samples were contaminated by MRSA. 

All seven isolates were MRSA ST398, the livestock-associated strain. Three came from one farm, so five farms had MRSA in their tanks.  According to the paper, this is the first discovery of ST398 in the UK other than one finding in horses in 2009. 

Some background: ST398 represents what I think of as the “third epidemic” of MRSA, dating from 2004 and following on hospital-associated (dating from the 1960s) and community-acquired (dating from the 1990s). I told the long story of its emergence and international spread in the book Superbug, but briefly: 

This strain was discovered in 2004 thanks to the care with which the Netherlands checks for MRSA in people about to be hospitalized; it was found in a toddler whose family were pig farmers, and subsequently in their friends, also farmers, and then in their pigs and their friends’ pigs also. 

In the eight years since, it has spread into health care workers and hospitalized patients, into people with no connection to farming, and then into retail meat, in Europe, Canada and in the United States.

Hong Kong: Man ill with drug-resistant infection

Via the Hong Kong government website: Man ill with drug-resistant infection.

The Centre for Health Protection is investigating a confirmed case of invasive community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA), a drug-resistant bacterium, involving a 49-year-old man living in Wan Chai.   

He was admitted to Queen Mary Hospital on November 25, and was later diagnosed as having pneumonia. He tested positive for CA-MRSA, but is now stable.   

MRSA is a type of Staphylococcus aureus that is resistant to beta-lactam antibiotics. It is a common infection worldwide.