H5N1

‘Our greatest fear’: Highly drug-resistant gonorrhea confirmed by health officials

Via The Washington Post: ‘Our greatest fear’: Highly drug-resistant gonorrhea confirmed by health officials. Excerpt and then a comment:

A super-resistant strain of gonorrhea has been reported in the United Kingdom following warnings from global public health officials that the common sexually transmitted disease is becoming more difficult to treat.  

Health officials in England said it is the first time that a case of gonorrhea could not be treated successfully with antibiotics that are commonly used to cure it. 

Earlier this year, a man, who was not named, sought treatment there for symptoms that he developed about a month after he had sexual contact with a woman in Southeast Asia, according to a case report from Public Health England. The bacterial infection was treated with two antibiotics, azithromycin and ceftriaxone, but subsequent tests still came back positive for the disease, the officials said.

“This is the first time a case has displayed such high-level resistance to both of these drugs and to most other commonly used antibiotics,” Gwenda Hughes, who leads the sexually transmitted infection section at Public Health England, said Wednesday in a statement. 

Gonorrhea, which is caused by the bacterium, Neisseria gonorrhoeae, is one of the most common sexually transmitted diseases around the world.  

Each year, there are an estimated 78 million cases across the globe — about 820,000 of which are reported in the United States, according to data from the Centers for Disease Control and Prevention and the World Health Organization. 

But public health officials said it is becoming more and more resistant to drugs. 

Teodora Wi, medical officer of human reproduction at WHO, said in a news release last year that the bacteria that cause gonorrhea are highly intelligent, explaining that “every time we use a new class of antibiotics to treat the infection, the bacteria evolve to resist them.” 

It's not certain how the patient in England contracted the super-resistant strain. Although he had contact with a woman in Asia, he also had one female partner in the United Kingdom, according to the recent report from Public Health England. She avoided infection. 

Following treatment, a throat swab revealed that the man's infection was still present.  

The patient was then treated intravenously with another antibiotic called ertapenem, and preliminary tests show that the medication may be working. 

He will be tested again next month.

As Maryn McKenna pointed out in a recent tweet, all the attention has been paid to this man—not to the woman he had sex with in Asia, or to her other possible contacts. But I hope that Public Health England, ECDC, and WHO are working hard to trace that woman and her contacts.

Branswell: Nevada woman dies of superbug resistant to all available US antibiotics

Via STAT, Helen Branswell has a big story: Nevada woman dies of superbug resistant to all available US antibiotics. If you read it and shiver as if someone just walked on your grave, you're probably right. Excerpt:

If it sometimes seems like the idea of antibiotic resistance, though unsettling, is more theoretical than real, please read on.  

Public health officials from Nevada are reporting on a case of a woman who died in Reno in September from an incurable infection. Testing showed the superbug that had spread throughout her system could fend off 26 different antibiotics.  

“It was tested against everything that’s available in the United States … and was not effective,” said Dr. Alexander Kallen, a medical officer in the Centers for Disease Control and Prevention’s division of health care quality promotion.  

Although this isn’t the first time someone in the US has been infected with pan-resistant bacteria, at this point, it is not common. It is, however, alarming.  

“I think this is the harbinger of future badness to come,” said Dr. James Johnson, a professor of infectious diseases medicine at the University of Minnesota and a specialist at the Minnesota VA Medical Center.  

Other scientists are saying this case is yet another sign that researchers and governments need to take antibiotic resistance seriously. It was reported Thursday in Morbidity and Mortality Weekly Report, a journal published by the CDC. 

The authors of the report note this case underscores the need for hospitals to ask incoming patients about foreign travel and also about whether they had recently been hospitalized elsewhere. 

The case involved a woman who had spent considerable time in India, where multi-drug-resistant bacteria are more common than they are in the US. She had broken her right femur — the big bone in the thigh — while in India a couple of years back. She later developed a bone infection in her femur and her hip and was hospitalized a number of times in India in the two years that followed. Her last admission to a hospital in India was in June of last year. 

The unnamed woman — described as a resident of Washoe County who was in her 70s — went into hospital in Reno for care in mid-August, where it was discovered she was infected with what is called a CRE — carbapenem-resistant enterobacteriaceae. That’s a general name to describe bacteria that commonly live in the gut that have developed resistance to the class of antibiotics called carbapenems — an important last-line of defense used when other antibiotics fail. CDC Director Dr. Tom Frieden has called CREs “nightmare bacteria” because of the danger they pose for spreading antibiotic resistance. 

In the woman’s case, the specific bacteria attacking her was called Klebsiella pneumoniae, a bug that often causes urinary tract infections. 

Testing at the hospital showed resistance to 14 drugs — all the drug options the hospital had, said Lei Chen, a senior epidemiologist with Washoe County Health District and an author of the report. “It was my first time to see a [resistance] pattern in our area,” she said. 

A sample was sent to the CDC in Atlanta for further testing, which revealed that nothing available to US doctors would have cured this infection. Kallen admitted people in this field experience a sinking feeling when they’re faced with a superbug like this one.

UN agrees to fight 'the biggest threat to modern medicine': antibiotic resistance

Via The Guardian: UN agrees to fight 'the biggest threat to modern medicine': antibiotic resistance. Excerpt:

All 193 United Nations member states are set to sign a declaration agreeing to combat “the biggest threat to modern medicine” in Wednesday’s high-level meeting on antibiotic resistance.  

The agreement was reached just before the general assembly convened to discuss the threat of antibiotic resistance, which is only the fourth health issue to trigger a general assembly meeting. 

“It’s ironic that such a small thing is causing such an enormous public threat,” said Jeffrey LeJeune, a professor and head of the food animal research program at Ohio State University. “But it is a global health threat that needs a global response.” 

The declaration routes the global response to superbugs along a similar path as the one used to combat climate change. In two years, groups including UN agencies will provide an update on the superbug fight to the UN secretary general. 

It is estimated that more than 700,000 people die each year due to drug-resistant infections, though it could be much higher because there is no global system to monitor these deaths. And there has been trouble tracking those deaths in places where they are monitored, like in the US, where tens of thousands of deaths have not been attributed to superbugs, according to a Reuters investigation.

Scientists warned about the threat of antibiotic resistance decades ago, when pharmaceutical companies began the industrial production of medicine. The inventor of penicillin, Alexander Fleming, cautioned of the impending crisis while accepting his Nobel Prize in 1945: “There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant”.

The 25-year-old Malaysian Chinese who may have just solved the superbug problem

Via the South China Morning Post: The 25-year-old Malaysian Chinese who may have just solved the superbug problem. Excerpt:

She is all of 25 and may have already made one of the most significant discoveries of our time. 

Scientists in Australia this week took a quantum leap in the war on superbugs, developing a chain of star-shaped polymer molecules that can destroy antibiotic-resistant bacteria without hurting healthy cells. And the star of the show is 25-year-old Shu Lam, a Malaysian-Chinese PhD candidate at the University of Melbourne, who has developed the polymer chain in the course of her thesis research in antimicrobials and superbugs. 

A polymer is a large molecule composed of several similar subunits bonded together. Polymers can be used to attack superbugs physically, unlike antibiotics that attempt to kill these bugs chemically and killing nearby healthy cells in the process. 

“I’ve spent the past three and a half years researching polymers and looking at how they can be used to kill antibiotic resistant bacteria,” or superbugs, she told This Week in Asia, adding the star-shaped polymers work by tearing into the surface membrane of the bacteria, triggering the cell to kill itself. 

Using the polymer, bacteria doesn’t exhibit the same resistance as it does to antibiotics and can still be killed after multiple generations of mutations, Lam’s PhD supervisor Professor Greg Qiao said. 

“The components of the polymer can also be tweaked differently depending on the application,” said Qiao, who also leads the Polymer Science Group and is a professor of macromolecular chemistry and engineering at the university’s School of Engineering. 

The World Health Organisation lists superbugs as a key threat to human health, having adapted to become resistant to all forms of antibiotics. The UN General Assembly has called a meeting this month to address the superbug explosion.  

“We think superbugs will cause around 10 million deaths per year by 2050,” Lam said. Lam’s breakthrough with Qiao on polymers has been published in the research journal Nature Microbiology. 

However, Lam’s research is still in early stages, according to Qiao, and much more work needs to be done to verify the best formula and structure, as well as to reduce the dosage and further test toxicity before the substance is completely safe for the human cell. 

“Even with all the money in the world, it would take at least five years to go to the first human test, because many resources and work are needed for its commercialisation,” he said.

I am now following Shu Lam with great interest.

India: Movie star is TB survivor

Via The Guardian: Is Amitabh Bachchan's shock revelation paying off in India's battle to control TB? Excerpt:

If there’s one voice India recognises it is that of Bollywood superstar Amitabh Bachchan, an actor whose deep baritone has placed him in the spotlight as one of the country’s greatest stars. And Bachchan hopes that Mumbai residents have listened to his own experience of suffering from tuberculosis, so helping to reduce the stigma surrounding the disease and encourage sufferers to seek treatment. 

The fear of TB and its association with death was arguably inflated by the Bollywood movies of the 60s and 70s, which regularly featured characters coughing up blood and dying shortly afterwards. As a result many TB sufferers still hide their illnesses from friends, neighbours and employers for fear of being ostracised or losing their jobs, further increasing the risk of spreading the disease. 

Speaking publicly for the first time about his battle against the disease at the launch of an anti-TB campaign in December, Bachchan revealed that he worked on Kaun Banega Crorepati, India’s version of the Who Wants To Be A Millionaire game show, throughout his treatment in 2000. 

“After complete treatment, I am standing here healthy before you,” Bachchan told a stunned audience. “You don’t have to stop working because you have TB. You have to eat those 10 or 12 pills a day – then you get better.” 

India has an estimated 2 million cases of TB annually – the highest in the world – with 300,000 people dying each year, according to the World Health Organisation. Of the 31,789 people diagnosed with the disease in Mumbai 2013, nearly 2,400 were children, including cases of multi-drug resistant TB (MDR-TB) and the extensively drug-resistant form (XDR-TB).  

“We needed a figure like Bachchan for the control programme” said Dr Minnie Khetarpal of Mumbai’s TB programme. “We saw that during India’s HIV epidemic, a lot of film stars spoke publicly, which helped with advocacy. When a person of the stature of Bachchan endorses a campaign, it is easier for us.”  

Mumbai’s problem is compounded by the high number of drug-resistant cases, which became apparent when doctors at the private P D Hinduja hospital described 12 cases of “totally drug-resistant TB” in a letter to the Journal for Clinical Infectious Diseases in 2012.

South Africa risks spreading totally drug-resistant TB: study

Thanks to Andrew M. Seaman for tweeting the link to this Reuters report: South Africa risks spreading totally drug-resistant TB: study. Excerpt:

Patients with contagious and highly drug-resistant tuberculosis (TB) are being routinely discharged from hospitals across South Africa, exposing others in their communities to potentially deadly infections, researchers said on Friday. 

In a study in the medical journal The Lancet, they said the patients, with strains of TB known as extensively-drug resistant (XDR) and totally drug resistant (TDR) TB, have exhausted all available treatment options and are sent home. 

"These patients can survive for months or even years and are contributing to the community-based spread of XDR-TB," said Keertan Dheda, who led the study at the University of Cape Town's department of medicine. 

Tuberculosis infects the lungs and can spread through coughing and sneezing. In recent years, drug-resistant strains have spread around the world, batting off standard antibiotics and posing an increasingly urgent public health threat. 

The World Health Organization (WHO) estimates that in Eastern Europe, Asia and South Africa, 450,000 people have MDR-TB, and around half of these will fail to respond to existing treatments.

McKenna: What we lose when we lose antibiotics

Via her blog Superbug, Maryn McKenna writes: When We Lose Antibiotics, Here's Everything Else We'll Lose Too. Excerpt (but read the whole post):

If we really lost antibiotics to advancing drug resistance — and trust me, we’re not far off — here’s what we would lose. Not just the ability to treat infectious disease; that’s obvious. 

But also: The ability to treat cancer, and to transplant organs, because doing those successfully relies on suppressing the immune system and willingly making ourselves vulnerable to infection. Any treatment that relies on a permanent port into the bloodstream — for instance, kidney dialysis. Any major open-cavity surgery, on the heart, the lungs, the abdomen. Any surgery on a part of the body that already harbors a population of bacteria: the guts, the bladder, the genitals. Implantable devices: new hips, new knees, new heart valves. Cosmetic plastic surgery. Liposuction. Tattoos. 

We’d lose the ability to treat people after traumatic accidents, as major as crashing your car and as minor as your kid falling out of a tree. We’d lose the safety of modern childbirth: Before the antibiotic era, 5 women died out of every 1,000 who gave birth. One out of every nine skin infections killed. Three out of every 10 people who got pneumonia died from it. 

And we’d lose, as well, a good portion of our cheap modern food supply. Most of the meat we eat in the industrialized world is raised with the routine use of antibiotics, to fatten livestock and protect them from the conditions in which the animals are raised. Without the drugs that keep livestock healthy in concentrated agriculture, we’d lose the ability to raise them that way. Either animals would sicken, or farmers would have to change their raising practices, spending more money when their margins are thin. Either way, meat — and fish and seafood, also raised with abundant antibiotics in the fish farms of Asia — would become much more expensive. 

And it wouldn’t be just meat. Antibiotics are used in plant agriculture as well, especially on fruit. Right now, a drug-resistant version of the bacterial disease fire blight is attacking American apple crops. There’s currently one drug left to fight it. And when major crops are lost, the local farm economy goes too.

The Lancet on World Tuberculosis Day

The Lancet has published a special issue today. The executive summary:

To commemorate World TB Day 2013, The Lancet Infectious Diseases publishes a Series of papers on tuberculosis, a disease that has long plagued human beings and was declared a global emergency in 1993 by WHO. 

Without concerted action from political leaders, health policy makers, funders, and others, health systems worldwide are at risk of being overwhelmed by increasing numbers of patients with treatment-resistant tuberculosis. 

As new diagnostic tests, drugs, and drug regimens become available that have the potential to radically improve the detection and management of tuberculosis, the papers in the Series explore the challenges for successful implementation of these interventions.

South Africa: New totally resistant TB identified

Just in time to ruin World Tuberculosis Day on Sunday, a report via allAfrica.com from Health-e: South Africa: Further Resistance to TB Drugs Identified in SA. Excerpt:

Researchers have identified a new strain of tuberculosis in 17 patients in the Eastern Cape which is totally resistant to the all current drug regimens. 

When an earlier study of extensively drug resistant (XDR) TB in the Eastern Cape showed that patients weren't responding to treatment - 58 percent of patients died within a year and only 8.4 percent became un-infectious after more than four months of treatment – epidemiologists at Stellenbosch University (SU) decided to investigate the bacteria that seemed to be more resistant against the available drugs. The Eastern Cape cases are the first to be identified in South Africa, and the fourth country in the world to report totally drug resistant (TDR) TB – it was discovered in India last year, and in Italy (2003) and Iran (2009). 

What they found was an emerging strain of TB even more resistant to drugs than XDR, which is already resistant to all first line drugs and some second line drugs. This new strain has shown resistance to at least 10 anti-TB drugs currently in use in the health sector. 

According to Prof Tommy Victor, from SU's Division of Molecular Biology and Human Genetics, the World Health Organisation and many experts in the field, including him, think the name "totally drug-resistant" (TDR), which is currently used in scientific literature, is not appropriate. They believe there may be a cure for TDR among some of the new drugs currently being developed, or old medication not in use anymore. 

"We really are facing bacteria that has become increasingly resistant, and there are now some bacteria that are hyper resistant, irrespective of the definition," said Victor who was one of the authors of the study. 

In the scientific paper, which was published in the Emerging Infectious Disease Journal in March this year, they used molecular techniques to study cultures of the tuberculosis bacterium of just under 400 Multi-drug resistant (MDR) TB patients in the Eastern Cape. Among these a large number were pre-XDR and XDR's, and 17 cases of TDR. 

There are approximately 18 000 new MDR cases diagnosed each year and "there may be be more TDR cases in South Africa ," says Victor, explaining that 17 cases emerged from only 400 MDR samples tested. 

A shortcoming of the study, which was acknowledged by the authors, is that they only studied the cultures from the infected patients, and don't have any data on patient outcomes – so they don't know how long they may have survived, or if any have been cured. Although a related study on the Eastern Cape cohort showed that patients responded quite badly to even the fiercest treatment.

South Africa: XDR-TB and totally resistant TB emerging

Via Emerging Infectious Diseases, the least welcome news of the day: Emergence and Spread of Extensively and Totally Drug-Resistant Tuberculosis, South Africa. The abstract:

Factors driving the increase in drug-resistant tuberculosis (TB) in the Eastern Cape Province, South Africa, are not understood. Using a convenience sample of 309 drug-susceptible and 342 multidrug-resistant (MDR) TB isolates, collected July 2008–July 2009, we characterized them by spoligotyping, DNA fingerprinting, insertion site mapping, and targeted DNA sequencing. 

Analysis of molecular-based data showed diverse genetic backgrounds among drug-sensitive and MDR TB sensu stricto isolates in contrast to restricted genetic backgrounds among pre–extensively drug-resistant (pre-XDR) TB and XDR TB isolates. Second-line drug resistance was significantly associated with the atypical Beijing genotype. 

DNA fingerprinting and sequencing demonstrated that the pre-XDR and XDR atypical Beijing isolates evolved from a common progenitor; 85% and 92%, respectively, were clustered, indicating transmission. 

Ninety-three percent of atypical XDR Beijing isolates had mutations that confer resistance to 10 anti-TB drugs, and some isolates also were resistant to para-aminosalicylic acid. 

These findings suggest the emergence of totally drug-resistant TB.