Wash your hands or lose your job

We've been talking the past few days about hospital infection control: Is it as simple as Sir Richard Branson suggests? Or as complex as Paul Levy's commenters make it appear?

The National Health Service of Scotland comes down on the side of simple. It is poised to enact a new, no-tolerance policy: Wash your hands or lose your job.

It is important to add that the Scottish health service (a subset of the National Health Service of the entire UK) has actually done a good job of promoting hand hygiene in its hospitals. A year ago, an audit showed that Scottish hospitals were at 79% compliance, and so the service set a 12-month goal of 90% compliance.

(All of these numbers, by the way, are better than in the United States, where even intensive attention to hand-washing gets even caring hospitals only to about 70%. And yes, it is true that hand hygiene alone does not equal infection control — but it is the basic building block. If you can't establish hand hygiene, what are your odds of accomplishing more complex interventions?)

But now they've decided to go for 100%. In Scotland the move is being applauded. The Glasgow Evening Times editorialized:

If it takes the threat of the sack to make medical staff wash their hands then it is a justified action. It is scarcely credible that up to 10% of doctors, dentists and nurses do not practice this basic hygiene measure.

Anyone want to disagree?

Reducing healthcare infections - what it really takes

Happy holidays, constant readers. Whatever you celebrate, I hope your days are full of security, calm and joy.

For those of you reading over the break, here's a pointer to a post that takes us on the other side of the curtain, into the world of hospital administrators. Those of us who are concerned about nosocomial infections are often confused about why HAIs are so intractable. I mean really, how hard could it be?

This post and especially its associated comments suggests why it's so hard. It comes from the marvelous blog Running a Hospital, which is written by Paul Levy, president and CEO of the Beth Israel-Deaconess Medical Center in Boston. As a thought experiment, he proposes getting all the hospitals in Boston (which is a LOT of hospitals: Harvard-associated, Tufts-associated, Partners, community hospitals — a huge, dense concentration) to commit to eliminating three categories of infections: central-line infections, ventilator-associated pneumonias and surgical infections, three categories for which there are well-recognized, well-tested interventions. He says:

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

It's a stirring and elegantly simple proposal — but as we all know, simple is seldom easy, and the commenters — whom I take to be health care workers and executives as well — light up how not-easy this might be. They say:

• It isn't simple enough for busy employees to put into real-world practice
• It's unreasonable to expect hospitals in competition to collaborate
• It's unthinkable that insurance companies would allow this much transparency

... and on.

The entire exchange, and Levy's blog, is worth reading. It's a consistently succinct, thoughtful, revealing look at the complexities of modern American health care, and at the unintended consequences — such as intractable infections — those complexities can provoke.

Brilliant entrepreneur asks: "So why CAN'T you fix this?"

Constant readers, you'll note that posting has slowed down a bit: I am deep into a chapter that is giving me some difficulty. (And I seem to be playing holiday host to an unexpected bout of bronchitis. I'm sure I didn't need both lungs...)

But here's something that crossed my monitor this morning, and it's worth looking at. Sir Richard Branson, founder of Virgin Air and many other extremely successful entrepreneurial efforts. has accepted a post as vice-president of the Patients Association, a nationwide nonprofit that advocates for hospital patients in the UK. Speaking up in his new position, Branson gave an interview to the BBC in which he talked about hospitals' failure to curb MRSA:

It feels like they have tinkered with the problem rather than really got to the heart of the problem. The hospitals are there to cure people. They are not there to kill people.

It's a marvelous interview — read the whole thing, it's not long — because it's such a breath of fresh air. Branson is an outsider to health care, but he knows how to make businesses work. And as the head of an airline, he's extremely familiar with what we in the US call "never events":

Sir Richard says the health service could learn a lot from the airline and rail industries on how to avoid mistakes."In the airline industry if we had that kind of track record we would have been grounded years ago," he said."In the airline industry if there is an adverse event that information is sent out to every airline in the world. And every airline makes absolutely certain that that adverse event doesn't happen twice."

So his advice is brutally practical: Health care workers carry MRSA? Screen and swab them. Workers are positive for MRSA? Treat them, and take them out of direct patient contact for two weeks. That costs money? Spend the money: It's less costly in the end than killing your patients.

Terribly sad story from Florida

Cody Shrout, a 12-year-old 6th-grader who lived in Daytona Beach, Fla., was found dead in bed a week ago today by his 8-year-old sister.

His death was initially put down to chickenpox, which was circulating in his school, but the Volusia County medical examiner determined Tuesday that his death was due to MRSA.

Two weeks ago, he scraped his knee skateboarding, subsequently spiked a 103+ degree fever, was treated at a local ER and sent home. The story describing his treatment quotes his grandfather in a way that suggests the scrape was treated as a sports injury, with ice and ibuprofen.

Cody lived with his mother, sister, 3-year-old brother and grandfather. His mother, who is single, could not afford a funeral. With extraordinary generosity, Heather and Jason Jenkins, who own a plumbing business in Apopka, Fla., have paid for the funeral. He will be buried Tuesday.

An odd tidbit in this very sad story: Ten months ago, according to the Daytona Beach News-Journal, he was treated at that same medical center for a staph infection. The story doesn't say whether he was an admitted patient or seen in the ER, and also doesn't say whether it was MRSA or drug-susceptible staph. Interesting, though.

MRSA and jails and public reaction

I have a GoogleNews Alert set to crawl for any new posts that mention MRSA. The Google crawler goes pretty deep and often finds things that I would not have known to look for; this week, it has produced a letter to the editor about conditions in a women's jail in South Florida.

The letter itself is interesting, but the public reaction to it, in the form of comments on the website where it was reproduced, is breathtaking.

Here's a quick recap: A woman named Susan M. Woods writes in the letters to the editor on TCPalm.com (which appears, after some drilling, to be a joint site for the Stuart, Fla. Treasure Coast News/Press-Tribune, the Vero Beach Press Journal, the Jupiter Courier, and the Sebastian Sun) about conditions at the Indian River County Jail, where she has been an inmate:

The absolute squalor women are forced to live in is similar to a Third World country. Backed-up toilets, black mold, roaches all around, and nothing to clean the common areas except diluted Windex — it’s frightening. It should be no surprise to hear that at least seven women have gotten MRSA — a staph infection — in as many months.

It will not surprise any of you who follow news about MRSA that jails and prisons are particularly vulnerable to outbreaks; the Los Angeles County Jail epidemic (first described in this MMWR article and further described in this one and covered in this book, which was written by, umm, me) has been going on for half a decade at this point and has affected thousands of prisoners. That there is an outbreak in a jail in Florida is exasperating and sad.

But that people in Indian River County think prisoners somehow deserve staph is just astounding. In the comments on Woods' letter, they say:

In my opinion, someone with Susan's alleged criminal record deserves far worse conditions in her cell than what she is describing in her letters.

You are supposed to not want to be there you idiot. That's why its like living in a third world county.

The conditions in jail are horrendous but people keep coming back. What should the taxpayers do then? Take money away from roads, schools, emergency services to make sure the jails are clean, bright and cheery? Or hope that the bad conditions convince just one moron to obey the law.

If I understand the trolls commenters correctly, they believe that prisoners forgo human rights to such an extent that it is an appropriate part of their punishment to subject them to infectious diseases. So, OK: If they are unmoved to care for their fellow humans, we will leave them to their karma.

But really: Don't they want to take care of themselves? It is well-established by now that MRSA in jails does not stay in jails: It moves out into the community when inmates who acquire it in jail are released and return to the outside. So unless you're going to argue that people in jail should remain there indefinitely — which seems impractical given the rate at which we put people away — to be concerned about MRSA in jails is self-protection if nothing else.

File under Unintended Consequences, 2

Via the BBC comes a report, from a conference hosted by the journal Lancet Infectious Diseases, that some healthcare-infection experts in the UK are publicly questioning efforts to reduce hospital-acquired MRSA.

The argument is that, by focusing so tightly on MRSA, hospitals neglect other drug-resistant HAIs to such an extent that the overall rate of illness in the hospital remains approximately the same. They argue instead for a broader focus on all resistant and nosocomial organisms:

"It's not clear that overall things have got better," ... said [Dr Mark Millar, a medical microbiologist at St. Bartholomew's Hospital and the London NHS Trust].
"Rates of E. coli are going up and it almost compensates for MRSA.
"All you've done is replaced one problem with another one," he said. ... ""There's no evidence that overall we have fewer hospital infections or fewer people are dying." (Byline: Emma Wilkinson)

This is a highly contentious debate in the US as well, with no resolution in sight. I've covered some aspects of it here, and there is a long point-counterpoint from Infection Control and Hospital Epidemiology here and here.

File under Unintended Consequences, 1

My friend and colleague Helen Branswell of the Canadian Press reports (via the Toronto Sun) on the cruel and accidental irony behind an outbreak of healthcare-associated infections at Toronto General Hospital between Dec. 2004 and Mar. 2006. Based on a new paper in Infection Control and Hospital Epidemiology, it's a fascinating and bizarre tale of the unpredictable hurdles that a hospital can face in attempting to eradicate HAIs.

It seems the hospital, in an attempt to reduce HAIs, installed hand hygiene stations in each room in its medical-surgical intensive care unit, in between the patient's bed and a countertop that held patient-care materials. This would seem like good design: The sink was right in the middle of the "zone of action" in the room, so health care workers would be reminded to use it (unlike, for instance, retrofitted rooms I have seen where the sink is away from the bed or out of the path between the bed and the door, and where health care workers have to consciously think about using it rather than having it be automatic). And the sinks were of a particular design meant to reduce accidental contamination of health care workers' hands: When the water was turned on, it flowed from a high gooseneck faucet straight down into the sink drain, without washing around the sink's side.

But it turns out that design and location both had unanticipated flaws. Water flowing straight into the drain was more likely to splash from the drain back out of the bowl; when investigators marked the sinks with fluorescent dye, they found splashes up to a yard away. Because the sinks were so close to the patient beds, the water was able to contaminate the patients, and the countertops on the other side as well. And because the water was falling directly into the sink drains, without the reduction in velocity caused by allowing it to wash around the sides of the sink, it was able to dislodge biofilm colonies of drug-resistant Pseudomonas aeruginosa, a moisture-loving organism that was growing in the sink pipes — which then splashed out of the sinks in the water bouncing back from the drain.

When the investigators found that, they had an explanation for why 36 transplant patients in that ICU had become colonized with MDR pseudomonas over 18 months. Twenty-four of the patients developed invasive infections, and 17 died; 12 of those deaths were either caused or closely related to pseudomonas infection.

The investigators tried multiple times to decontaminate the sink drains; in a few cases, they were successful, but the drains became recolonized and grew fresh biofilms. It was not practical to relocate the sinks. Nevertheless, they shut down the outbreak: They swapped out the faucets, decreased the water pressure, put a splash barrier on the sides of the sink, and moved patient care materials on the counter next to the sink elsewhere in the ICU rooms. Once those rearrangements were complete, the outbreak stopped.

This outbreak obviously was not MRSA, and in the strictest sense it is not relevant to MRSA, which is not an organism that lives in sink drains. But in a broader sense — as an illustration of the completely unpredictable hurdles that can stand in the way of excellent infection control — it is a useful and tragic cautionary tale.

The abstract is here. The cite is: Susy Hota, MD; Zahir Hirji, MHSc; Karen Stockton, MHSc; et al. Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design. Infection Control and Hospital Epidemiology 2009 30:1, 25-3.

Even more bad news on new drugs

Via Forbes.com comes news that the Food and Drug Administration has turned back Targanta Therapeutics' application for its new antibiotic oritavancin, which was designed specifically to target drug-resistant staph, and has asked for additional trials. This is a follow-on to a decision by an FDA advisory panel last month that also expressed doubt about the drug.

This comes on the heels of last month's withdrawal of dalbavancin and delay in approval of ceftobiprole.

The long, thin pipeline of new drugs for MRSA just got longer and thinner.

More on MRSA pneumonia, flu and ER delays

Folks, yesterday I posted the very sad story of 39-year-old Robert Sweitzer of Tucson, who died of MRSA pneumonia after being triaged to an 8-hour wait, in an overcrowded emergency room, during the height of flu season.

As a follow-up, I want to emphasize that while necrotizing pneumonia may seem an unusual circumstance, there is one thing in his story that is very, very common: The ER wait.

Emergency departments all over the country are suffering extraordinary stresses thanks to a confluence of factors: The unfunded mandate of mandatory ER care or at least treatment and stabilization, through the federal legislation known as EMTALA. The closure of large numbers of in-hospital beds, which make it more difficult to get patients admitted. The lack of adequate primary care, which drives people to seek ER care because they cannot get into a regular doctor's office. The extraordinary percentage of Americans who have no health insurance — a percentage that is likely to increase as the economic meltdown continues.

How crowded are emergency departments? On average in the United States, an ambulance is diverted — denied admittance because an ER is too full to take new patients — once every minute.

To quote a bumper sticker that got a lot of use over the past few years: If you aren't outraged, you're not paying attention.

(Disclosure: I was a Henry J. Kaiser Family Foundation fellow in 2006-07, and spent an average of eight nights a month, for a year, as an ER observer. So ER overcrowding is something I both have witnessed up close, and feel passionately about.)

I mention all this in order to let you know that the American College of Emergency Physicians released today a state-by-state "report card" on the condition of ER care in the United States. Our average national grade? C-. (If you don't have time for the full report, the New York Times sums it up here. If you want to do more research, three Institute of Medicine reports on the issues, from 2006, are here.)

So, again: While Robert Sweitzer's death may seem end-of-the-curve extraordinary, the conditions that contributed to his death — a crushing overload in a community-hospital ER — are very, very common. And that should frighten all of us.

In excellent company

Constant readers, I'm pleased to report that SUPERBUG has been listed among 100 Global Health Blogs That Will Open Your Eyes by US PharmD+, an online info source for pharmacy education and the pharmacy profession.

We are in excellent company: Also listed are Effect Measure, Pump Handle, H5N1, Aetiology, Pharmalot and the indefatigable and indispensable crew at ProMED-Mail.

There are a number of intriguing-looking blogs on the list that I did not know about. I urge you to take a look. And much appreciation to Kelly Sonora and USPharmD+ for highlighting these resources and including this blog among them.

It's flu season: Watch for MRSA pneumonia.

Via the (Tucson) Arizona Daily Star, I've just caught up with the very sad story of Robert Sweitzer, a Tucson resident who died on his 39th birthday, of MRSA pneumonia.

Sweitzer died last Feb.10, but his name is in the news now because a lawsuit filed by his wife Rachel against the hospital where he died has just been scheduled for a Sept. 2009 trial.

The apparently undisputed facts of the case (according to news reports that I cannot usefully link to because they require registration) are:

• Sweitzer was a healthy man, married three years, who worked a full-time job and devoted all his spare hours to animal rescue.
• On Saturday, Feb. 9, he woke up feeling as though he were coming down with a cold, with a cough and low back pain. He and his wife went to a regular volunteer shift at a local cat shelter, but by evening, he was having trouble breathing. They arrived at St. Mary's Hospital ER at 6:30 p.m.
• Sweitzer was triaged within a half-hour, judged to be a low-acuity case, and sent to wait.
• It was February, the height of a bad flu season, and the ER was slammed with 170 patients.
• Sweitzer's breathing and back pain got worse and his wife twice asked unsuccessfully for him to be re-evaluated.
• When he was finally seen at 2:30 am, an X-ray showed his lungs filled up with fluid. He was put on 100% oxygen.
• He arrested twice and was pronounced dead near 7 a.m.
  

Following an autopsy, the Pima County Medical Examiner and the Arizona Department of Health Services asked the Centers for Disease Control and Prevention to evaluate Sweitzer's case; based on the extensive lung destruction, they feared he died of hantavirus. Tissue samples were sent to the CDC, which reported in August that Sweitzer actually died of necrotizing pneumonia caused by MRSA.

We have talked before (here, here, here, here and here) about the particular danger of MRSA infection during flu season, when (it is theorized) micro-trauma to the lungs by flu infection allows MRSA to gain a foothold. Once it begins, MRSA pneumonia proceeds with incredible speed — I have spoken to parents whose children went literally from apparently healthy to dead or close to it, within 24 hours — and it is commonly mistaken either for flu or for community-acquired pneumonia, the usual drugs for which have no impact on MRSA.

So, constant readers: It is flu season. Please get a flu shot. The observations and research on this are still limited, but it does appear that if you prevent flu, MRSA will have a more difficult time gaining a foothold in the lungs. (And if you nevertheless find yourself in a situation similar to Robert Sweitzer's, and you truly believe it is life-threatening for yourself or your loved one, do whatever is necessary to direct clinical attention to you in time.)

Because I cannot link through to the Arizona Star stories, here are the dates and headlines:

• 20 February 2008, "His pet projects: rescuing dogs, cats," byline Kimberly Matas
• 16 March 2008, "39-year-old's ER death leaves a lot of unanswered questions," byline Carla McClain
• 27 August 2008, "Feb. death of Tucson man, 39, tied to staph," byline Stephanie Innes
• 1 December 2008, "Suit over death at St. Mary's ER set for trial in September" (no byline).

More bad news on new drugs

The Infectious Diseases Society of America (IDSA) has published a new report that fills in the background on last week's news below, and confirms: The landscape for new drugs against MRSA and other multi-drug resistant organisms is bleak. (The organisms, summarized in the acronym ESKAPE, are: E. faecium, MRSA, Klebsiella, Acinetobacter, Pseudomonas aeruginosa and Enterobacter.)

The report, published in the journal Clinical Infectious Diseases, is both an update of surveys of the new-drug landscape done in 2004 and 2006, and also a call to action that asks for broad federal effort to encourage pharma companies to produce new drugs.

Here are the highlights:

• Since the last iteration of the survey in 2006, only one new antimicrobial, doripenem — a very broad-spectrum injectable that is most active against the Gram-negative bacterium P. aeruginosa — has been approved.
• Only three new compounds — ceftobiprole, dalbavancin and Paratek Pharmaceutical's PTK-0796 — are in their final rounds of trials. (The report was obviously written before the latest news about ceftobiprole and dalbavancin.)
• Four of seven efforts to achieve a staph vaccine have been terminated.
  
• Though the pharma industry, through its lobbying arm PhRMA, claims "388 infectious diseases medicines and vaccines and 83 antibacterial drugs in development", that number is misleading:

Careful review of these data reveals that most are preclinical and phase 1 compounds. Also included are topical and nonabsorbable antimicrobials, which we do not consider here, and several compounds for which development has been terminated. Finally, ... many of the listed drugs are previously approved agents that are being studied for new indications.

Just to make sure no one misses the big picture, the authors emphasize:

...The number of new antibacterials that make it through the complete development process and ultimately receive FDA approval has precipitously decreased over the past 25 years. Indeed, we found a 75% decrease in systemic antibacterials approved by the FDA from 1983 through 2007, with evidence of continued decrease in approvals, even during the most recent 5-year period.

What are the answers? IDSA is candid, as in its earlier reports, that it believes incentives for drug companies are the only way to improve the situation: financial boosts, patent extensions and changes in trial requirements. Two things are critical, the group says:

• Novel intravenous and oral drugs to treat both hospitalized and community-based patients are needed, as opposed to “me too” drugs that provide minimal improvement over existing therapies.
• Priority should be given to antimicrobials with the potential to treat serious infections that are resistant to current antibacterial agents.

Bad news on the new-drugs front

Via the very robust pharma blogosphere, reports that two much-anticipated new antibiotics will be remaining in the pipeline a while longer:

Fierce Biotech says that Pfizer has withdrawn its US and European applications for dalbavancin, a much-awaited new MRSA drug, and will conduct another Phase III trial.

Pharmalot reports (via Reuters) that the Food and Drug Administration has asked for additional trials for ceftobiprole, another much-anticipated new drug for MRSA, coming from Johnson & Johnson. Shearlings Got Plowed has more detail, speculates that a "new game face" is emerging at the FDA, and notes that J&J's partner in ceftobiprole, Basilea, acknowledged that the FDA raises "issues of data integrity" regarding the current application. J&J's press release is here.

So it's back to vancomycin, again, for now.

MRSA in newborns on Prince Edward Island: HA? CA? Matters?

There's been a running story for several weeks now about the Queen Elizabeth Hospital on Prince Edward Island (home to mussels and Anne of Green Gables). The hospital struggled earlier this year with an outbreak of MRSA and a second outbreak of VRE among adult patients. It got those under control, but since earlier this month has been dealing with a new outbreak of MRSA in its newborn nursery, according to the PEI Guardian:

Nine newborns and one mother have now tested positive for MRSA. Five of those nine cases can be connected to the same source. (Byline: Wayne Thibodeau)

The stories are detailed, for a small paper — they go into depth about the cleaning measures the hospital is taking — and yet they don't answer the questions that we here want to know. Does "tested positive" mean colonized or infected? Does "connected to the same source" mean they all have the same strain, or does it mean there is an epidemiologic link?

In the latest news (Tuesday's paper and online edition), the hospital reports that it is doing nasal swabs on more than 300 staff, with the intention to do a 7-day decolonization regimen on anyone who turns up positive. They won't however, disclose the source when they find it — though, again, it's not clear whether that means not identifying the staffer (appropriate) or not admitting that it is a nosocomial outbreak (inappropriate and at this stage lacking in credibility):

Rick Adams, CEO of the Queen Elizabeth Hospital, said about 290 staffers have already been screened.
“In terms of the test results, we’re not going to be making anything public,’’ Adams told The Guardian.
“We want to make sure the environment here is supportive of staff and create a climate where they can feel comfortable and open to come forward and be screened knowing that any results will be kept strictly confidential.’’
Adams said he realizes a solid argument can be made that the public should be informed if the source is found and that source is a staff member.
But he said the public should also realize the hospital is doing everything it can to prevent a further spread of the superbug.
“The staff are under enormous pressure. They feel like they are under a microscope.’’ (Byline: Wayne Thibodeau)

Some readers may know that it is outbreaks among newborns that have demonstrated that the designations "community-associated" and "hospital-acquired" are passing out of usefulness. There have been several MRSA outbreaks in newborns and their mothers in the US (in New York City, Houston, Chicago, Los Angeles and Houston again because Baylor College of Medicine has been particularly alert to this) that were clearly nosocomial, and yet when the microbiology was done, were found to be caused by community strains.

Why does this matter? Well, for the PEI hospital, it may not: They have an outbreak, it appears to be nosocomial in nature, and whether it is HA left over from their earlier outbreak, or CA that came in via a health care worker or a pregnant woman, mostly affects what drugs they give the children and mothers if those patients do in fact have infections. And for those of us who are primarily concerned with nosocomial infections, the distinction may also feel not-relevant: Failures of infection control are failures of infection control and should not happen period full stop.

But for those of us who are are also interested in the natural history of this perplexing bug, the answer to what is going on at the Queen Elizabeth will be an important piece of information, because it could underline that the distinction between HA and CA is becoming increasingly artificial. The epidemics are converging.

British infection control: Epic fail

Via the Guardian comes news that British hospitals are failing miserably at hygiene and infection-control targets set by the Healthcare Commission, a government-funded but independent watchdog agency somewhat analogous to the United States' Joint Commission (formerly called JCAHO).

While community-associated MRSA is still a somewhat new story in the the UK, hospital or nosocomial MRSA is a major epidemic, with resistant Clostridium difficile ("C.diff") coming close behind. So there has been significant attention paid in the UK to improving infection control programs in hospitals, through the vehicle of benchmarks set for the National Health Service trusts (essentially, regional organizational groupings of hospitals).

And the results, according to unannounced spot-checks made by the UK commission, are appalling. Only 5 of 51 trusts ( 51 = 30% of all acute-care hospitals in the UK) that were checked hit the mark. For those slow at math, that means 3% of UK hospitals are doing what they should to protect patients from infections they cause. (UPDATE: To be fair, if we assume the "5 out of 51" holds true across the NHS, then 10% are doing what they should. That's still appalling.)

"At nearly all trusts we have found gaps that need closing," said Anna Walker, the commission's chief executive. "It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems." (Byline: Sarah Boseley)

How weak? This weak, according to the commission's own report:

• 27 of the 51 trusts inspected were failing to keep all areas of their premises clean and well maintained. These lapses covered issues ranging from basic cleanliness, to clutter which makes cleaning difficult, to poorly maintained hospital interiors.
• One in five trusts in this sample did not comply with all requirements for the decontamination of instruments and other equipment used in the care of patients. Trusts that breached this duty tended to have no clear strategy for decontamination or to lack an effective process to assure compliance.
• In one in eight trusts, the provision of isolation facilities was not adequate. The containment of infections is extremely important to managing outbreaks. Hospitals without adequate facilities must ensure they have contingency plans so that the risk of infections spreading between patients is minimised.
• For over one in five trusts there were issues related to staff training, information and supervision. While training on preventing and controlling infection was often in place, boards could not always ensure that training days were well attended or that staff used their knowledge in practice.

UK hospitals have until next April to learn to hit these benchmarks or be held accountable under a new Care Quality Commission.

For infection-control geeks, the full text of the "hygiene code" which the hospitals must abide by is here. Details of inspections at individual trusts are here.

A moment of silence

Constant readers, I am very sad to tell you that Lori Hall Steele, the writer and single mother afflicted with amyotrophic lateral sclerosis, died Wednesday. As I told you back in September, she could no longer work, could not pay her mortgage or her medical bills, and was about to lose her house to foreclosure, leaving her 7-year-old son homeless at the same time that she was about to be hospitalized with what is inevitably a fatal disease. The news prompted a blogathon on her behalf by fellow freelancers around the country that raised almost $20,000 more than $30,000, enough to ensure that her house was safe for as long as necessary.

A heartbreaking essay that she wrote about her son, before she knew she was sick, is here.

Many of you told me privately how much this story touched you. (And readers outside the US expressed shock that the cost of healthcare could turf a dying young mother out of her home.)

I send sincere thanks to all of you who sent Lori (whom I never met) money, or prayers, or warm thoughts for her and for her son. I am confident that none of it was in vain.

UPDATE: Lori's obituary is here.

Contributing to resistance: fake drugs?

There's news this morning that Interpol has seized $6.65 million of counterfeit medicines in the culmination of a 5-month undercover investigation that stretched across Cambodia, China, Laos, Myanmar, Singapore, Thailand and Vietnam. The fakes included purported antiretrovirals for HIV, anti-TB drugs, antimalarials (especially artemisinin) — and, chillingly for our purposes here, fake antibiotics for pneumonia and other bacterial illnesses.

Bloomberg News says:

Under Operation Storm, which ran from April 15 to Sept. 15, police seized more than 16 million pills...
Asia is the world's biggest producer of all counterfeit products, the Organization for Economic Cooperation and Development said in a report last year. About 40 percent of 1,047 arrests related to fake drugs worldwide last year were made in Asia, according to the Washington-based Pharmaceutical Security Institute.
Counterfeits account for as much as 30 percent of all drugs in developing nations and less than 1 percent of all medicines in developed nations such as the U.S. (Byline Simeon Bennett.)

Counterfeiting medicines is both a huge business — the World Health Organization estimates that "counterfeit drug sales will reach US$ 75 billion globally in 2010, an increase of more than 90% from 2005" — and an appalling crime that attacks the most vulnerable people at their most vulnerable moments. In a recent issue brief, the WHO recounts a number of instances of counterfeiting that led to deaths in a number of countries.

Why should we care here? Because some counterfeits are not complete fakes; they contain a small amount of the active ingredient of the drug they purport to be. That means that, if someone takes a faked version of an antibiotic, they may not be going untreated. Instead, they may be undertreated, the exact situation that can lead to the emergence of resistance. Just last year, according to the Pharmaceutical Security Institute, known counterfeiting episodes involving anti-infective drugs rose 26%.

Now, NB: Activism against counterfeit drugs is politically complicated; it is supported by the pharma industry (PSI is a coalition of 26 manufacturers) and is tangled up with opposition to online pharmaceutical sales and to decisions by developing-world countries to abrogate Western drug patents. But that turf-defending by the pharma industry does not alter the reality that counterfeit drugs are an enormous international problem that imperil not only people unfortunate enough to take them, but anyone who contracts a resistant strain that those drugs helped foster.

And anyone concerned about MRSA will already know that resistant strains do not stay where they are generated. They have already demonstrated their ability to move rapidly around the world.

New newspaper series on HA-MRSA

The Seattle Times this morning launched an three-day investigative project on incidence of HA-MRSA in Washington State that is worth reading.

As readers here already know, MRSA is not a reportable disease, and there are no diagnosis codes that directly correspond to MSRA that make infection or death easily trackable through hospital records or death certificates. The Times' team came up with some innovative data-drilling techniques and apparently did a massive amount of number-crunching to come up with the incidence estimates that underpin their reporting. They use those to challenge hospitals' reluctance to undertake surveillance and treatment that would wipe out MRSA on colonized patients and thus reduce the likelihood of MRSA infecting those patients or spreading to others via healthcare workers who neglect infection control. (NB, Michael Berens, the series' co-author, did a huge project on nosocomial infections when he was at the Chicago Tribune a number of years ago.)

I am puzzled by one thing I am seeing on the story's web page — one of the items in the break-out box that sums the story up very quickly to attract eyeballs to it. It says: "About 85 percent of people infected with MRSA get the germ at a hospital or other health-care facility. " That figure doesn't make sense to me; it sounds as though it is a mis-translation of the CDC finding a year ago (in the Klevens JAMA paper) that approximately 85% of invasive cases of MRSA have hospital-associated risk factors. Constant readers will remember that estimate has been challenged by researchers on community MRSA, who believe that CA-MRSA accounts for a much larger proportion of the current epidemic than has been acknowledged, and think that the wide spread of the community strain is the actual driver of the overall epidemic. I can't see where in the text the Times team has done the math to support that assertion, so if anyone else spots it, or knows the reference it comes from, please let me know.

Despite stewardship efforts, antibiotic use increasing

Well, this is bad news.

I hope we can all agree that antibiotic use creates antibiotic resistance. (Proof, if any were needed, that the universe has a captious sense of humor; but then it has had millennia to practice. OK, sorry for the anthropomorphizing.) The more pressure bacteria are placed under, the more resistant mutants emerge and survive. So the challenge in using antibiotics is to use them sufficiently and not too much: enough to quell infection and save lives, but not so much that the benefit of successful treatment is outweighed by the cost of increased resistance.

That's the theory, anyway. In practice, according to a paper published today in the Archives of Internal Medicine, we're not living up to the plan.

Amy L. Pakyz, Pharm.D. and colleagues at Virginia Commonwealth University surveyed antibiotic use at 22 academic medical centers — tertiary care teaching hospitals, ones that would be most likely to have high awareness of the dangers of resistance and good antibiotic stewardship programs — between 2002 and 2006. And found: Despite all that awareness, antibiotic use is going up, and the use of broad-spectrum agents and vancomycin, MRSA's drug of last resort, is going up most of all.

The third significant observation is the marked increase in vancomycin use during the 5-year period such that it became the single most commonly used antibacterial in this sample of hospitals from 2004 to 2006. ...
The reasons for the continued increase in vancomycin use are likely multifactorial, including the increasing numbers of hospital-acquired infections caused by MRSA and the emergence of community-associated MRSA, all of which encourage greater empirical use of vancomycin.

With only a few new drugs of comparative effectiveness on the market, and none that are significantly better, this is bad news, the authors underline:

Vancomycin use is a risk factor for emergence of vancomycin-intermediate S aureus and vancomycin-resistant S aureus, although these strains are rare in the United States. Of greater concern may be the emergence of low-level resistance in MRSA to vancomycin, referred to as minimum inhibitory concentration (MIC) “creep,” and this is far more common. Strains of MRSA having vancomycin MICs of 2.0 μg/mL are associated with longer median times to clearance of bacteremia compared with strains having MICs of 1.0 μg/mL or less, as well as frank treatment failures.

The cite is: Pakyz, AL et al. Trends in Antibacterial Use in US Academic Health Centers 2002 to 2006. Arch Intern Med. 2008;168(20):2254-2260.

MRSA in meat in Louisiana: pig meat, human strain

On Nov. 3, I posted on an enterprising group of TV stations in the Pacific Northwest who had retail meat in four states tested for MRSA. I said at the time that it was the first finding of MRSA in meat in the US that I knew of.

Turns out that I was wrong by three days. On Oct. 31, the journal Applied and Environmental Microbiology published an electronic version of a study that they will be printing in the paper journal on some future date. Journals do this when a finding is so important or timely that it should see the light immediately, rather than wait through the additional weeks or months of print production.

And this finding is certainly timely. Shuaihua Pu, Feifei Han, and Beilei Ge of the Louisiana State University Agricultural Center have made what appears to be the first scientifically valid identification of MRSA in retail meat in the United States. But — and this is an important point — it is not the swine strain, ST 398, that has been found in meat in Canada and Europe, and in hospital patients in Scotland and the Netherlands, and in pigs in Iowa; and in humans in New York, though that strain was drug-sensitive.

Instead, what the researchers found (in 5 pork and 1 beef samples, out of 120 bought in 30 grocery stores in Baton Rouge, La. over 6 weeks in February-March 2008) was USA300, the dominant community MRSA strain, and USA100, the main hospital-infection strain. In other words, they found meat that had been contaminated during production by an infected or colonized human, not by a pig. As they say:

...the presence of MRSA in meats may pose a potential threat of infection to individuals who handle the food. ... (G)reat attention needs to be taken to prevent the introduction of MRSA from human carriers onto the meats they handle and thereby spreading the pathogen.

As we've discussed before, the primary danger from MRSA in meat is not that people will take the bug in by mouth (though that is a danger, since S. aureus because of its toxin production can cause severe foodborne illness — and these researchers found, overall, an S. aureus contamination rate of 46% of their pork samples and 20% of their beef samples). Rather, the danger is that people handling the raw meat will be careless in preparing it, and will colonize themselves by touching the meat and then touching their own noses or mucous membranes, leading to a possible future infection. As reader Rhoda pointed out in a comment last week, people could also infect themselves directly, by getting MRSA-laden juice or blood into an abrasion or cut.

So: Be careful in the kitchen, keep meat separate from other foods, wash cutting boards and knives, and (say it with me, now) wash your hands, wash your hands, wash your hands.

The cite for the new paper: Pu, S. et al. Isolation and Characterization of Methicillin-Resistant Staphylococcus aureus from Louisiana Retail Meats. Appl. Environ. Microbiol. doi:10.1128/AEM.01110-08. Epub ahead of print 31 Oct 08.

Housekeeping note: This is the 16th post I've written on MRSA in food animals and/or meat. Providing all the links to the previous posts is starting to obstruct the new news. So if you are looking for all those past posts, go to the labels at the end of this post, below the time-stamp, and click on "food." You should get something that looks like this.

New report and recommendations, "Why Infectious Diseases Are a Threat to America"

I'm still catching up post-ICAAC - and in addition am on the road reporting, again. But I'm trying to keep all y'all informed. (That's a clue to my destination. Where in the US is "y'all" a single noun and "all y'all" the plural? Hint: It's the same place where "barbecue" is only made of beef... Oh, OK, I'm in Texas, enough with the quiz already.)

While the ICAAC-IDSA meeting was happening, the very good nonprofit organization Trust for America's Health released a report that, just in time for the election, proposed a policy framework for emerging infections and infectious diseases generally. "Germs Go Global: Why Emerging Infectious Diseases Are a Threat to America" lists five major, ongoing, under-appreciated threats:

• Emerging infectious diseases that appear without warning (SARS, H5N1)
• Re-emerging infectious diseases (measles, pertussis/whooping cough)
• "Neglected” infectious diseases (dengue)
• Diseases used as agents of bioterrorism (smallpox, anthrax)
• Rising/spreading antibiotic resistance.

The report makes a number of important, well-argued recommendations for the next administration to consider. Several concern us particularly:

The U.S. government, professional health organizations, academia, health care delivery systems, and industry should expand efforts to decrease the inappropriate use of antimicrobials in human medicine, agriculture and aquaculture.
The U.S. Congress should amend the Orphan Drug Act to explicitly address infectious diseases like MRSA, or create a parallel incentive system to address the unique concerns in this area.

The entire report is worth reading. (If you're short on time, there is an executive summary that covers the main points.) I recommend it.

Final report from ICAAC-IDSA 08 (news from ICAAC, 3)

The ICAAC-IDSA (48th Interscience Conference on Antimicrobial Agents and Chemotherapy and 46th annual meeting of the Infectious Diseases Society of America) meeting ended a week ago, and I'm still thrashing my way through the thousands of abstracts.

Here's my final, highly unscientific selection of papers that caught my eye:

* Evidence that the community-strain clone USA300 is a formidable pathogen: It first appeared in the San Francisco jail in 2001. By last year, it had become the sole MRSA strain found in the jail — it crowded out all others. (P. Tattevin, abstract C2-225)
* Another paper from the same UCSF research group finds that the emergence of USA300 has caused a dramatic increase in bloodstream infections, most of which are diagnosed in the ER, not after patients are admitted to the hospital. (B. Diep, abstract C2-226)
* And the CDC finds that USA300 is picking up additional resistance factors, to clindamycin, tetracycline and mupirocin, the active ingredient in the decolonization ointment Bactroban. (L. McDougal, abstract C1-166)
* An example of the complexity of "search and destroy," the active surveillance and testing program that seeks to identify colonized patients before they transmit the bug to others in a health care institution: Patients spread the bug within hours, often before test results judging them positive have been returned from the lab. (S. Chang, abstract K-3379b)
* In addition to the report from Spain I posted on during the meeting, there is a report of emerging linezolid resistance in France. (F. Doucet-Populaire, abstract C1-188)
* And in addition to the abundant new news about MRSA in pork, and "pork-MRSA" or ST 398, in humans, over the past few days, there were reports of MRSA in milk in Brazil (W. Gebreyes, abstract C2-1829) and Turkey (S. Turkyilmaz, abstract C2-1832), and beef and chicken in Korea (YJ Kim, abstract C2-1831), as well as ST 398 itself acquiring resistance to additional drugs. (Kehrenberg, abstract C1-171)
* Echoing many earlier findings that MRSA seems most common among the poor, the poorly housed and the incarcerated, BR Makos of the University of Texas found that children are more likely to be diagnosed with the bug if they are indigent, or from the South (which I imagine is a proxy for lower socio-economic status, since the South is a more rural, more poor region). (abstract G2-1314)
* And finally, to the long list of objects (ER curtains, stethoscopes) that harbor MRSA, here are more: The ultrasound probes in emergency rooms (B. Wessman, abstract K-3377). Also: Dentures. (Ick.) (D. Ready, abstract K-3354)

Everyone, everyone, everyone: Vote.

I hope my constant readers outside the US will forgive me for a moment if I speak just to my countrymen.

Folks: This is the most extraordinary election of my lifetime, and I suspect of yours too.
Please vote.
The strength of our democracy depends on the participation of all of us.

And non-US readers, hold a thought in your hearts for us today.
The past eight years have displayed so much that is not good about America.
We profoundly hope for change — and we hope equally to be brave, and civil to each other, in creating it.

Thank you all.

TV stations find MRSA in retail pork in Pacific Northwest

In the comments, Coilin Nunan of the UK's Soil Association (which published the wonderful 2007 report MRSA in Farm Animals and Meat report) calls attention to a report that I also spotted over the weekend.

A network of TV stations in Washington, Idaho, Oregon and California did a joint report in which they bought 97 packages of ground pork or pork cutlets and sent them to a laboratory for testing. The lab found that three of the packages, all ground pork, contained MRSA.

I believe this is the first time anyone has found (or, perhaps, looked for) MRSA in retail pork in the US. You'll remember that MRSA ST 398 has been found in meat in Canada and Europe, and in hospital patients in Scotland and the Netherlands, and in pigs in Iowa; and MSSA ST 398 in humans in New York City.

There are some important unanswered questions about this report:

• We aren't told the strain. If it's ST 398, that would be information on the spread of ST 398 in the US. If it's USA300, on the other hand, it could be contamination from an infected or colonized human, perhaps someone in the preparation chain.
• We aren't told the provenance of the pork. Was it bought from a variety of markets, or one chain of supermarkets that might have one regional supplier? Was it organic v. conventional? Small-farm versus feedlot?
• We can't draw any broad conclusions from this. I am a poor biostatistician, but to me, this is purely a convenience sample. (If anyone disagrees with me, please weigh in.) In other words, it's one data point. It says: There is MRSA in these packages of pork — which is an important piece of information — but it doesn't say: 3% of all US pork contains MRSA.

Also, while the written version of the report that I linked above isn't bad, overall, it contains one significant error. It says:

This drug-resistant bacteria is already responsible for more deaths in the US than AIDS. What makes MRSA so potentially dangerous is the bacteria can cause sickness just by touching it.

Well, not exactly. The concern with MRSA in meat is that, if you handle it without strict cleanliness, you might become colonized with the bacteria. That is not at all the same as developing a MRSA infection, much less the invasive MRSA the first sentence of that quote refers to. And yes, colonization can lead to infection. But to say that touching MRSA-contaminated meat will inevitably cause an invasive MRSA infection is alarmist.

I'm assuming the stations undertook this because it is sweeps month. (For those who have so far been spared the internals of TV news, "sweeps" are months — usually February, May, July and November — when stations' audiences are measured to determine market rank and advertising rates. Because it is in the stations' interest to attract as much audience as possible during those months, sweeps is usually when news stations run big investigative projects.) Interesting that they chose this topic. I think we can take this as an indicator — again, just one data point, but an interesting one — of emerging US concern over MRSA in meat.

New drugs for MRSA, at various experimental stages

As you might guess by the name, ICAAC (the Interscience Conference on Antimicrobial Agents and Chemotherapy) features much research on the pharma side of things. There were many research reports this past week on drugs at various stages that I was intending to write up for you, but I just noticed that Reuters got there first and did quite a good job. So consider checking this story, which discusses PTK 0796, iclaprim, ceftobiprole, dalbavancin and televancin:

Two experimental antibiotics appear to work safely against an increasingly common and dangerous form of infection called methicillin-resistant Staphylococcus aureus or MRSA, researchers said on Sunday.
Doctors are clamoring for drugs that can fight the so-called superbug infection, which kills an estimated 19,000 people a year in the United States alone. (Reuters)

An important consideration that is not much discussed: It is not enough just to have new drugs; what we need are new classes of drugs. That's because, when staph acquires protection against one drug, it is likely to be acquiring protecting against all chemically similar drugs — thus, not just methicillin but all the synthetic penicillins; not just Keflex but all the first-generation (and second- and third-generation) cephalosporins.

Microbes in US meat, but no MRSA

The ICAAC-IDSA meeting has ended, but there are still many abstracts that I have not been through. While I pore over them, though, an interesting paper has just been published that somewhat contradicts earlier research on the presence of MRSA in meat. (Earlier posts are here, here, here, here, here, here, here and here.)

The researchers, from the Warren Alpert Medical School of Brown University and Rhode Island Hospital, bought ground beef, boneless chicken breasts and pork chops from 10 stores in and around Providence. Two stores offered both conventional and "natural" choices, so they bought both, giving them 36 (=[10+2]x3) samples all told. They cultured for MRSA, vancomycin-resistant Enterococcus, extended-spectrum beta-lactamase producing Gram-negative bacteria and E. coli 0157:H7.

And they found... almost nothing. Only one samples grew a resistant microbe, the ESBL Gram-negative Serratia fonticola. A secnd level of testing, however, uncovered four samples carrying S. aureus — but all methicillin-sensitive, not MRSA.

So are we in the clear? Not necessarily. It is, as they say themselves, as small study, in which only a third of the samples were pork, though pigs are the animals most associated with MRSA via the strain ST398. And the presence of S. fonticola is troubling, because it not only causes disease directly (in animals and in humans), but also harbors a plasmid that can transfer resistance to other bacterial strains.

Nevertheless, it is a comforting reminder that, though MRSA has been found in meat, it has not been found everywhere. (Or at least, not in Providence.) Still, we shouldn't let our personal vigilance lapse. The hypothetical danger from MRSA in meat is not that we'll swallow it, but rather that we'll be colonized if we handle the raw meat without being careful enough about kitchen hygiene. So keep raw meat away from other food, wash your cutting boards and counters, and (say it with me, now), wash your hands, wash your hands, wash your hands.

The cite is: Philip A. Chan, Sarah E. Wakeman, Adele Angelone and Leonard A. Mermel, Investigation of multi-drug resistant microbes in retail meats. Journal of Food, Agriculture & Environment, Vol.6 (3&4), July-October 2008.

Outbreak of Zyvox-resistant staph (breaking news from ICAAC 2)

Physicians from Madrid reported today on what's believed to be the first outbreak of MRSA caused by a strain that was resistant to linezolid, usually known as Zyvox, a relatively new and costly drug that is used for complicated MRSA infections and when older drugs fail.

Linezolid resistance in single cases has been recorded before — the first isolate I can see in a quick scan of the literature dates to 2002 — but this appears to be the first outbreak.

Dr. Miguel Sanchez of the Hospital Clinico San Carlos said the outbreak was discovered April 13, 2008 in an ICU patient and subsequently spread to 11 other patients in the ICU and two elsewhere in the hospital. The patients, 8 men and 4 women, had been in the unit for at least three weeks for a variety of reasons; they were intubated, had central venous catheters, and had been receiving broad-spectrum antibiotics. None of them were colonized with MRSA on admission. The outbreak went on for 12 weeks, until June 27.

It was eventually shut down by a combination of strategies: taking the patients off linezolid in favor of other anti-staph drugs (vancomycin and tigecycline); drastically restricting linezolid use, a policy that is already followed by many US hospitals; checking the patients very frequently for colonization; and cohorting them, which means grouping them together physically, away from uninfected patients, and putting them under isolation.

In a quick briefing with reporters, Sanchez seemed to suggest that the hospital does not believe its infection control failed. The hospital swabbed 91 environmental surfaces (such as bed rails and room furniture) and the hands of 47 health-care personnel and found only one sample that grew the linezolid-resistant strain on a culture. A case-control study to find the cause is being conducted, he said.

Half of the patients died, he said, but not as a result of the linezolid-resistant strain.

Sanchez' data slides were not available to reporters this evening. (More precisely, they were delivered to the press room, but in a format that wasn't readable). I'll update with more details if/when we get access to them. Meanwhile, the cite is: M. De la Torre, M. Sanchez, G. Morales et al. "Outbreak of Linezolid-Resistant Staphylococcus aureus in Intensive Care." Abstract C2-1835a.

ST 398 in New York City - via the Dominican Republic?

Here's a piece of MRSA news from the ICAAC meeting (see the post just below) that is intriguing enough to deserve its own post.

US and Caribbean researchers have found preliminary evidence of the staph strain ST 398, the animal-origin strain that has caused human illness in the Netherlands and has recently been found in Ontario and Iowa, in Manhattan. How it may have arrived: Via the Dominican Republic.

Th researchers (from Columbia University and Montefiore Medical Center in New York, three institutions in the Dominican Republic and one in Martinique) examine the influence of an "air bridge" — very frequent household travel — that is bringing MRSA and methicillin-sensitive staph back and forth between the Dominican Republic and the immigrant Dominican community at the north end of Manhattan. They compared 81 staph isolates from Dominican Republic residents and 636 from Manhattan residents and, among other findings, say that 6 Dominican strains and 13 Manhattan strains were ST398.

It is the first time ST398 has been found in Manhattan or in the Dominican Republic. (Most likely also the first time anyone has looked.)

The authors observe with some understatement:

Given the history of ST398's rapid dissemination in the Netherlands, its history of methicillin-resistance and its ability to cause infections in both hospital and community, it will be important to monitor its prevalence in these new regions.

It is important to note that these ST398s were not MRSA — they were MSSA, methicillin-sensitive. However: Earlier this year, the Dutch researchers who have delineated the emergence of ST398 in Holland commented on the diversity of ST398 they have found on different pig farms and hypothesized that the resistance element has been acquired several different times by methicillin-sensitive staph. (van Duijkeren, E. et al. Vet Microbiol 2008 Jan 25; 126(4): 383-9.)

So it is possible to hypothesize that this strain arrived in Manhattan from the more rural Dominican Republic, though with the growth of hobby urban farming in NYC, one could also make the case that transmission went the other way. And it is also possible — I emphasize possible — that this could be a precursor to ST398 MRSA emerging in Manhattan. An interesting thought.

(This research is not online, because it is a poster presented at a medical meeting. For reference, the cite is: C. DuMortier, B. Taylor, J. E. Sanchez et al. "Evidence of S. aureus Transmission Between the USA and the Dominican Republic." Poster C2-224. 48th ICAAC-46th IDSA, Washington DC, 24-28 Oct 2008.)

Breaking MRSA news from the ICAAC meeting 1

There are 15,000+ people at the 48th Interscience Conference on Antimicrobial Agents and Chemistry (known as ICAAC - yes, "Ick-ack") and 46th Infectious Diseases Society of America Annual Meeting, and at least half of them seem interested in MRSA. At the keynote address last night, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at NIH, referred to MRSA as a "global pandemic."

Here are some highlights — a few of very, very many — from the first two days:

• MRSA is truly a global phenomenon: Researchers here are reporting on local epidemics in Argentina, Australia, Botswana, Canada, Colombia, Ecuador, Greece, Japan, Nigeria, Peru, South Korea, Sweden and Taiwan.
• In the United States, USA300 — the virulent community strain that is crowding out all other community strains — continues its dominance. It first appeared in the San Francisco jail in 2001 and now is the only cause of community MRSA infections there. (Tattevin, P. et al. "What Happened After the Introduction of USA300 in Correctional Facilities?" Poster C2-225.)
• And MRSA continues to demonstrate its protean ability to cause unexpected forms of illness: The number of cases of sinusitis caused by MRSA seen at Georgetown University tripled between 2001-03 and 2004-06. (I. Brook and J. Hausfeld. "Increase in the Frequency of Recovery of Methicillin-Resistant Staphylococcus aureus in Acute and Chronic Maxillary Sinusitis." Poster C2-228.)
• Meanwhile, treatment options are shrinking. Hospitalization for vancomycin-resistant pathogens (that is, resistant to vancomycin, the drug of last resort for MRSA) doubled between 2003 and 2005 according to national healthcare utilization databases. (A.M. Ramsey et al. "The Growing Burden of Vancomycin Resistance in US Hospitals, 2000-2005." Poster K-560.)
• But, new drugs are beginning to emerge from the pipeline. Early results from a privately held company called Paratek Pharmaceuticals (co-founded by resistance guru Dr. Stuart Levy) showed that their new tetracycline relative PTK 0796 scored as well or slightly better than linezolid (Zyvox) in safety, tolerability and adverse events, and is advancing to a full Phase 3 trial. (R.D. Arbeit et al. "Safety and Efficacy of PTK 0796." Poster L-1515.)
  

More as the meeting goes on.

MRSA and pets - any experience?

Constant readers, I'm working on a chapter on MRSA in animals and would be curious to hear from anyone who has had experience with MRSA in a pet, whether as an owner/companion or on the veterinary side.

If this is you, please get in touch! Your options are: via the email address in the right-hand column; or via comments here. (I moderate all comments, which means that I see them before they post; so I can read a comment and remove it without its going public, if you prefer.)

Erratic posting ahead

Constant readers: I am headed to the ICAAC/IDSA meeting. (For those not into medical acronyms, that's the Interscience Conference on Antimicrobial Agents and Chemotherapy, which is the biggest infectious-disease conference of the year that isn't exclusively about HIV, and which this year is combined with the annual meeting of the Infectious Diseases Society of America, the second biggest. Yes, it's an infectious-disease geekgasm.)

Posting is likely to be erratic: I expect there to be a ton of MRSA news, but no time to write about it. However, I'll be throwing things up here as I can, and will also be filing flu news to CIDRAP — though, since CIDRAP doesn't publish on weekends, don't expect anything there til Monday or Tuesday.

See you on the far side.

Much new news on hospital-acquired infections

There's a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on "search and destroy," the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. "Search and destroy" has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:

• the design and implementation of state HAI public reporting systems,
• the initiatives hospitals have undertaken to reduce MRSA infections, and
• the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)
  

The report is too thick to summarize here, but here are some key points:

• No two places are doing this the same way — which means that data still does not match state to state
• Experts are still divided about how much MRSA control is necessary
• Hospitals that have undertaken MRSA-reduction programs have taken different paths
• But MRSA control does work: It does reduce in-hospital infections, but at a cost.

This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don't really know how much MRSA - in hospitals or in the community - we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!

MRSA in sports

I am possibly the most sports-impaired person on the planet (a consequence of growing up with the lovely but impenetrable game of cricket), but even I noticed these stories recently.

• University of North Carolina-Asheville basketball center Kenny George has lost part of his right foot to amputation as the result of a staph infection.
• Cleveland Browns tight end Kellen Winslow has emotionally gone public — to the displeasure of his coaches — with the news that he was hospitalized for three days for a staph infection. Winslow has been struggling with MRSA since 2005, when he had a motorbike accident, had surgery, and developed a post-surgical infection. Four other Browns players — Braylon Edwards, Joe Jurevicius, LeCharles Bentley and Brian Russell — have had MRSA as well.

MRSA in sports is not new news, but the prominence of some of its victims has brought great attention to the bug: For instance, Redskins defensive tackle Brandon Noble, who was sidelined for a season, and eventually ended his career, over a MRSA infection following arthroscopic knee surgery. And it is not limited to pro players: Lycoming College senior Ricky Lanetti died in 2003 from an overwhelming MRSA infection that began as a pimple-like "spider bite" lesion.

There has been so much concern about MRSA among schools and parents that the CDC has issued specific advice for sports programs. Some of the reasons why athletes may be vulnerable are well-understood: They work in crowded conditions, they undergo a lot of skin-to-skin contact, they are likely to get scraped and injured, and they may not get clean immediately (especially high school players — does anyone shower after high school sports any more?).

But some factors, such as the role of artificial turf, are still murky. An investigation of eight MRSA infections among the St. Louis Rams in the 2003 season (first author Sophia Kazakova) found that linemen and linebackers were more likely to develop MRSA, possibly because they ended up with more turf abrasions. On the other hand, an investigation of 10 infections among players at Sacred Heart University in Connecticut (first author Elizabeth Begier) found that, while turf burns played a role, a contaminated team whirlpool — and sharing razors for shaving body hair — did too.

How to wash your hands, a tutorial

More still to come on hospital-acquired infections. (No, really. I mean it.) But first:

Somehow I sadly missed that last Wednesday, Oct. 15, was Global Handwashing Day, sponsored by the World Bank, CDC, UNICEF and a number of other organizations including several soap manufacturers. Here's a BBC story describing massive social mobilization efforts that were supposed to take place across South Asia last week. (Can any Asian readers report in whether they saw anything? Mumbai and Hyderabad readers, I'm looking at you.)

Though we missed the festivities, here's an excellent take-away: A great series of videos produced by the Grey-Bruce Health Unit, a local health department northwest of Toronto, about the right way to wash hands with soap and water and/or alcohol gel.

Sign of the times: Taking your own cleaning materials to the hospital

There are several new and important reports out on hospital-acquired infections (HAIs) that I hope to get to this week, but I spotted something today that I just had to highlight first:

Constant readers may know that I've done a lot of reporting in the developing world. In parts of Asia and Africa, it is assumed that patients or their families bring food to the hospital. People do not trust the hospitals to feed them, with good reason: Hospitals can't afford it. Provision of food in the hospital, which we take for granted, is not part of the health-care culture. (In particularly poor countries, the family may feed not only the patient, but the health care workers taking care of the patient as well.)

Here now is an industrialized-world version of that developing-world practice. A company in England (which, as we've discussed, has ferocious rates of hospital MRSA and C. difficile) has begun marketing the PatientPak, the "world's first personal anti-superbug kit." It's a $28 sample-sized collection of antimicrobial hair and body wash, hand wipes, hand sanitizer and a germ-killing spray for sheets and cubicle curtains, along with lip balm, bar soap, and a disposable nail brush and pen.

It's entirely possible that using products like this might protect a patient from some hospital-acquired infections; the company suggests that a patient use the wipes and the hand spray when going to and from the bathroom or after touching any surfaces. But the difficult reality, of course, is that most hospital-acquired infections are not the patient's fault: They are due to infection-control breaches by hospital staff, something over which a patient — with antimicrobial wipes or without — has little control.

This company will probably sell quite a few of these kits — and I don't know that I can criticize them for doing so. If one of my family members was being admitted to hospital, I might well send something like this with them. But what a sad commentary on our own health-care culture that any of us would consider this necessary.

New MRSA group discussion, caveat lector

A UK-based site called iCareCafe posted a link in the comments to the previous post, inviting readers who are MRSA patients or caregivers to visit. Per my rules I'm elevating it to post status so that you can see it and I can comment on it.

Here is their post:

...The icarecafe has been set up to provide a space for patients, carers and their supporters online.
Some of the members have set up a discussion group on the subject of MRSA. The group has asked lots of questions which are still in the process of being answered. So we thought it appropriate if we invited people from other MRSA discussion group and blogs to ask if they wished to participate.
To have a look at the discussions so far please have a look at http://www.icarecafe.com/?page_id=1107&group_id=71
Best wishes
Belinda Shale
Moderator – the icarecafe

My due diligence:

• As you'll see in the right-hand sidebar, I am a sympathetic member and promoter of authentic communities online. However, as I have warned before, I am skeptical of sites that exist mainly to sell products to patients.
• The iCareCafe appears to be an authentic discussion forum that covers numerous diseases and conditions, though a few of the members are using what appear to be "stock art" pix of models to represent themselves; make of that what you will.
• The MRSA forum currently has 6 threads running; in a few, people are sharing their stories, and in a few others, people are aggressively pushing nutritional regimens and recommending cleaning products.
• The iCareCafe is backed by a marketing company, as it discloses here:

  ...The icarecafe is a project from The Patients Voice (which is itself part of Healthcare Landscape. By way of earning our living we provide our clients with medical market research services. Or to put it another way we run surveys and focus groups and things of that nature so that we can provide patients with a voice.

FWIW.

Five-fold increase in flu+MRSA deaths in kids

I have a story up this evening at CIDRAP News about a new paper in the journal Pediatrics that analyzes the incidence of child deaths from pneumonia caused by the combination of MRSA and flu, a sad and scary development that we've talked about here, here and here.

(NB: CIDRAP News is the original-reporting and news-aggregation arm of the Center for Infectious Disease Research and Policy at the University of Minnesota, an infectious disease research center headed by noted epidemiologist Michael Osterholm, PhD. I have a part-time appointment there. CIDRAP News is the best-read infectious-disease website you have never heard of, with about 10 million visitors a year, and is a notable resource for news on seasonal and pandemic flu, select agents and bioterrorism, and foodborne disease.)

It is bad netiquette and not fair use to reproduce another publication's entire story here, even if I wrote it. Here though are the highlights:

• 166 children died of influenza in the past three seasons (2004-05, 2005-06, 2006-07) according to 39 states and 2 local health departments (86 this year in preliminary reporting)
• The proportion of deaths from bacterial co-infection rose each year, from 6% to 15% to 34%, a five-fold increase
• Almost all of the bacterial co-infections were staph; 64% of them MRSA
• The rapid rise in MRSA colonization (from 0.8% of the population in 2001 to 1.5% in 2004 — that's more than 4 million people) may be playing a role
• And, some of these deaths could have been avoided if children had had flu shots — but overall, only 21% of under-2s and 16% of 2- to 5-year-olds get the two shots they need to be fully protected against flu.
  

Please click through to CIDRAP for more.

The cite is: Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805-11.