MRSA in pets - a closer look

From the research team at the University of Guelph Ontario Veterinary College — who have probably done more than any other group to elucidate MRSA in companion animals — comes a look at MRSA infections in dogs.

In order to get better data, the team used a study model that is much-employed in human epidemiology — and has often been used for MRSA — but under-employed in veterinary medicine: a case-control study matching MRSA infections against MSSA, or drug-sensitive staph. Studies matching MRSA against MSSA have been able, for instance, to show that certain (human) MRSA infections have higher death rates, keep patients in the hospital longer, and cause more healthcare expense.

The Guelph team used the same method to compare the presentation and outcome for 40 MRSA-infected dogs and 80 dogs with MSSA who were seen between 2001 and 2007 in three veterinary hospitals, in Guelph, Philadelphia and Boston. Their verdict:
MRSA is an emerging problem in dogs, and the risk factors for MRSA infections are similar to those in humans, particularly the use of IV catheters and both beta-lactam and fluoroquinolone antibiotics.

The researchers were not able to say whether MRSA in dogs causes more deaths than MSSA, because the infections that were recorded by the hospitals were mostly superficial ones in skin and ears:

Infection types for which death would be a more realistic possible outcome were limited... Comparison of mortality rates between patients with MRSA or MSSA infections would be best performed among on ly those with invasive infections and should be considered for future studies. Here, mortality rate information was obtained retrospectively and only recorded up to the time of discharge. Therefore, whether dogs died from their infections after discharge from the referral hospital, causing an underestimate of deaths, is unknown.

Dr. Scott Weese, senior author of this paper and chief of the Guelph group, has an excellent blog on infections in companion animals, called Worms and Germs. (It's in the blogroll.) And if you are looking for further information on MRSA in pets, the best resource I know of is the UK-based, but international, Bella Moss Foundation, named for a dog that died of a MRSA infection.

Antibiotics in chickens and links to human infections

From the January issue of Emerging Infectious Diseases, published by the CDC (and therefore free. Must I keep urging you to read it? Go, already), here's a roundup of bad news about bad bugs.

In Canada, researchers from that country's Public Health Agency have found a "strong correlation" between the use of ceftiofur, a third-generation cephalosporin, in chickens; the rates of a resistant strain of Salmonella in chickens; and the appearance of that same strain in humans. The strain is Salmonella enterica serovar Heidelberg, one of the most common salmonella strains in North America, and one which can be nasty: It may cause mild illness, but also causes septicemia and myocarditis and can kill. Quebec created an unplanned natural experiment: Hatcheries there were broadly using ceftiofur until 2004, backed off from its use in 2005 and 2006, and then began using it again in 2007 in response to a growing problem with a particular infection. When the drug was withdrawn, resistant infections in birds and humans plunged; when it was reintroduced, they rose again. (Look at the black and red lines in the graph above left.)

Meanwhile, broiler chickens in Iceland are passing fluoroquinolone-resistant E. coli to humans there. Researchers at the University of Iceland were puzzled by an earlier finding that bacteria resistant to fluoroquinolones (a family that includes the human drug Cipro) were increasing among chickens raised in Iceland, despite strict controls on antibiotic use in food animals and stringent disinfection in chicken batteries after cohorts of birds were sold for slaughter and removed. They have two findings: The source of the resistant bacteria in the birds appears to be feed contaminated with resistant E. coli; and resistant bacteria in Iceland residents are microbiologically indistinguishable from those in the birds. Because E. coli is a very diverse organism, the very close resemblance between the isolates from chickens and the isolates from humans pins chickens as the likely source.

And just to make clear we're not blaming every microbiological evil on farming: Seagulls in Portugal have been found carrying multi-drug resistant E. coli in their feces. The public health concern here is obvious: Just think back to the last time you were at a beach, or anywhere else seagulls frequent, and envision a seagull perch — and the masses of seagull droppings streaking it. Now imagine those droppings transmitting antibiotic-resistant E. coli into the surrounding environment: the boardwalk, the beach, the towels... Additional problem: Seagulls are migratory birds, so the resistant bacteria easily cross borders and oceans.

Another resistant bug rising: Acinetobacter

From the excellent and forward-thinking research team at Extending the Cure comes a dismaying report: over 7 years, a more than 3-fold increase in resistance in the Gram-negative bacterium Acinetobacter baumanii to its drug of last resort, imipenem.

Because MRSA is a Gram-positive, we don't talk much here about the Gram-negatives — the two categories of bacteria have different cell-wall structures and thus are treated using different categories of drugs. (That structural difference causes them to react in different ways to a stain invented by a scientist named Gram in the 19th century.) But the resistance situation with Gram-negatives is at least as dire as with MRSA, possible more so, because there are fewer new drugs for Gram-negatives in the pharmacology pipeline (as discussed in a New Yorker article by Dr. Jerome Groopman last year.)

And Acinetobacter is one nasty bug, as science journalist Steve Silberman ably documented in Wired in 2007 when he traced the spread of the organism through the military medical-evacuation chain from Iraq, demonstrating that the vast increase in resistant Acinetobacter among US forces was due to our own poor infection control.

The Extending the Cure paper (which will be published in February in Infection Control and Hospital Epidemiology) puts hard numbers to the Acinetobacter problem. Drawing on data from the private Surveillance Network, which gathers real-time electronic results from 300 US hospitals, they find:

• full resistance to imipenem rose from 4.5% of isolates in 1999 to 18.2% in 2006 — a 300% increase
• intermediate resistance rose from 1.3% of isolates to 9.4 — a 623% increase
• susceptible isolates declined from 94.1% to 72.4% — a 23% decrease.

The authors write:
Our results demonstrate substantial national and regional increases in carbapenem resistance among clinical isolates of Acinetobacter species over the period 1999–2006. Increasing carbapenem resistance among Acinetobacter species is particularly troubling, because it is very often associated with multidrug resistance and because it is occurring in the context of increases in the incidence of Acinetobacter infection.

There's a further point to be made that is not explicit in the paper that I can see (though it is often made by Extending the Cure researchers). Acinetobacter needs attention, just as MRSA does — but if we focus just on the individual organisms, we are not going far enough. Antibiotic resistance is a system problem: It is an issue of infection control, of drug development, of agricultural organization, of federal priorities. It needs sustained attention and comprehensive, thoughtful, wide-ranging response. Now would not be too soon.

One surgical infection with MRSA: $61,000

From a multi-state, public-private research team — Duke University, Wayne State University, and the Durham, NC VA — comes a precise and alarming calculation of MRSA's costs in hospitals: For one post-surgery infection, $61,681.

The group compared the course, costs and final outcome of three matched groups of patients from one tertiary-care center and six community hospitals in one infection-control network run by Duke. The three groups were: patients with a MRSA surgical-site infection; patients with a surgical-site infection (SSI) due to MSSA, drug-sensitive staph; and surgery patients who did not experience infections, matched to the other two groups by hospital, type of procedure, and year when the procedure took place. (This same cohort has been described in an earlier prospective study that looked at risks for MRSA SSIs.) Altogether, there were 150 patients with MRSA SSIs, 128 with MSSA SSIs, and 231 uninfected surgery patients to serve as controls.

Here's what they found. Patients with post-surgical MRSA infections:

• stayed in the hospital 23 days longer
• incurred an average extra cost of $61,681
• were more likely to be readmitted to the hospital within 90 days
• were more likely to die before 90 days had passed.

The authors write:

Our study represents the largest study to date of outcomes due to SSI due to MRSA. Our findings confirm that SSIs due to MRSA lead to significant patient suffering and provide quantitative estimates of the staggering costs of these infections. SSI due to MRSA led to a 7-fold increased risk of death, a 35-fold increased risk of hospital readmission, more than 3 weeks of additional hospitalization, and more than $60,000 of additional charges compared to uninfected controls.

For just the patients in this study, the excess costs (across 7 hospitals) totalled $19 million.

This is a highly useful study on several axes. First, remarkably, there has not been agreement over whether and how much of a problem MRSA poses in post-surgical settings, particularly when compared to drug-sensitive staph. This study provides careful, thoughtful, well-documented proof that combating MRSA infection is worthwhile. (NB, MRSA infections did not increase the risk of death relative to MSSA infections, which should remind us both of the often-forgotten virulence of MSSA, and also that MRSA's perils can lie in extended illness and disability as much or more as in early death.) Second, by putting a very specific number on the cost of a post-surgical MRSA infection, it gives healthcare administrators a benchmark against which they can judge the cost of a prevention program. We've all heard complaints that prevention programs can be costly and their benefit is hard to measure in a bottom-line way. With this very specific number, that complaint should no longer be valid.

There's a final point that is implied in the paper but not called out, so let me call it out on the authors' behalf. These results are very likely an under-estimate of MRSA's costs. That's because, first, the specific procedures the patients underwent were cardiothoracic and orthopedic; those are not the surgical procedures most likely to be followed by a MRSA infection. And second, data collection for this study ceased in 2003, about a year after the first emergence of USA300 and several years before that very successful community strain began its current move into hospitals. However much MRSA was extant in 2003, there is more now.

The cite is: Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, et al. 2009 Clinical and Financial Outcomes Due to Methicillin Resistant Staphylococcus aureus Surgical Site Infection: A Multi-Center Matched Outcomes Study. PLoS ONE 4(12): e8305. doi:10.1371/journal.pone.0008305

SUPERBUG now on Kindle!

Constant readers — any of you who are Kindle users can now find SUPERBUG the blog in the Kindle store. I placed it there today; it may take 48 hours for it to propagate through the system.

SUPERBUG the book will of course be on Kindle as well, in March. Stay tuned!

Holiday gratitude, and a brief blogging break

Constant readers, my warmest greetings for Christmas or whatever winter holiday you celebrate! You are high on the list of the many gifts in my life. Thank you for gathering here and contributing to this truly international community of concern about antibiotic resistance.

I'll be back early next week with news of two fascinating new studies. Snow-dusted (12" and rising here) holiday wishes 'til then.

A plea, and not for me: Support ProMED

Constant readers, I don't often ask you for anything — OK, I did ask you to consider an advance buy of SUPERBUG, but that's a win-win for all of us, right?

But today I'm going to ask you for something, and I hope you'll trust me that it, too, is a win-win all 'round.

ProMED Mail, the disease early-warning website and listserv of the International Society of Infectious Diseases, is having its annual fundathon. If you have any cash to spare, I would like you to consider making a small donation. Here's why. Here on the net:

We value crowdsourcing. In the disease world, ProMED has been doing that longer and better than anyone. Their network of volunteer spotters — physicians, epidemiologists, animal-health experts, journalists and engaged citizens — has been running since 1994.

We value passion. ProMED has more than 30 expert editors, all significant researchers in their respective specialties, who comb through those crowdsourced reports to find them gems. They all have lives and more than full-time jobs already. And they don't do this for glory: They don't even attach their names to their pieces, just their initials. (Among ProMED aficionados, it's a moment of insider glee to spot the initials and translate them to an important name.)

We value reach. ProMED has more than 57,000 subscribers, each of them a potential contributor, in 187 countries. It runs sub-lists of news with articles relevant to particular parts of the world, volunteer-translated into Portuguese, Spanish, Russian, and French (for West Africa), and also runs sublists in English of articles relevant to the Mekong Basin and to English-speaking East Africa.

More than anything, we value effectiveness — and as a subscriber since sometime in the 1990s, I can testify that ProMED delivers. The listserv is the primary reason that the government of China fessed up to the existence of the international epidemic of SARS in spring 2003, after attempting to conceal its burgeoning outbreak for almost six months. ProMED pried loose that admission simply by posting a note from within its network: a question from a pseudonymous man in southern China that was relayed to an acquaintance in northern California and then to an epidemiologist in Annapolis who sent it to ProMED. (That story is told in my book Beating Back the Devil, and you can read it in this excerpt here.)

That is the power of a network, and that's why ProMED deserves our support.

Antibiotics in animals - a warning from the poultry world

Constant reader Pat Gardiner guided me to an enlightening post at the website of the agricultural magazine World Poultry that questions the routine use of antibiotics in food animals. It's written by Wiebe van der Sluis, a Netherlands journalist from a farming background, founder of World Poultry and also the magazines Pig Progress and Poultry Processing.

The Netherlands, let's recall, is the place where MRSA ST398 first emerged, and also the place where that livestock-MRSA strain has caused the most serious human cases and triggered the largest changes in hospital infection-control practices. In the Netherlands, swine farmers and veterinarians are considered serious infection risks because of their exposure to animals, and are pre-emptively isolated when they check into hospitals until they can be checked for MRSA colonization.

Van der Sluis takes seriously the tie between the use of antibiotics in animals and the emergence of MRSA:

Although most of the time MRSA is linked to pig production, it is also related to the veal and poultry industry. The industry, therefore, cannot shrug its shoulders and move on if nothing was wrong. In this case it would be wise to redefine the term prudent use of antibiotics. Time is up for those who use antibiotics to cover up bad management, poor housing conditions or insufficient health care. The standard rule should be: Do not use antibiotics unless there is a serious health issue and no other remedy applies. Veterinary practitioners, who usually authorise producers to use antibiotics, should also take responsibility and prevent unnecessary antibiotic use and the development of antibiotic resistance in animals and humans.

It's unusual in the US context so hear someone so immersed in agriculture speak so candidly about antibiotic use. It's refreshing.

Guest Q&A: Dr. Brad Spellberg and RISING PLAGUE

I'm thrilled today to present another guest blogger: Dr. Brad Spellberg, associate professor of medicine at the David Geffen School of Medicine at UCLA and author of the new book Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them (Prometheus Books). This new book is important reading for anyone concerned, as all of us are here, about the narrowing pipeline for new antibiotics against MRSA and other resistant pathogens. That pipeline problem is something Dr. Spellberg knows well: He is not only a practicing infectious-disease physician, but also a member of the Antimicrobial Availability Task Force of the Infectious Diseases Society of America, the specialty society that produced the "Bad Bugs" reports that I've posted on before.

Below, Dr. Spellberg thoughtfully answers some questions about the difficulties of treating resistant infections and of developing drugs to control them.


From your point of view as a practicing ID physician, why is it so difficult to prevent resistant infections?

It's difficult to prevent all infections period. Not more difficult to prevent infections caused by resistant organisms than any other organisms. However, also difficult to prevent the spread of resistance among bacteria that are causing infections.

So, why is it difficult? People have this crazy belief that hospital acquired infections are the result of sloppy medicine. Not so. They are the result of very sick people with tremendously sophisticated levels of intensive medical care being delivered in a concentrated environment (i.e., a hospital). Crowd a bunch of sick people together with plastic catheters, mechanical ventilators, and nasty bacteria, and such infections are inevitable. What we are learning is that we have to go above and beyond normal to stop these infections from happening. Research is needed on how best to do this. It's not as simple as people think.

You can't stop the spread of the resistance itself. It is inevitable.

You say in Rising Plague that physician misuse and overuse of antibiotics is not the cause of antibiotic resistance. What do you consider the primary driver?

This is by far the biggest misperception among the public. Let's start from first principles. Who invented antibiotics? Who invented antibiotic resistance? When were both invented?

Humans did NOT invent antibiotics. Bacteria did...about 2 billion years ago. And they invented antibiotic resistance at the same time. So, bacteria have been creating and defeating antibiotics for 20 million times longer than humans have even known that antibiotics exist (about 78 years, as the original sulfa compound was developed in late 1931 by Gerhard Domagk). Over the past 2 billion years, bacteria warring among themselves have learned to target virtually every targetable biochemical pathway with antibiotics, and have learned to create defense mechanisms to defeat virtually all such antibiotics. They are already resistant to drugs we haven't even developed yet. It is bacteria that cause antibiotic resistance, not humans.

What humans do, is we apply natural selection when we use antibiotics. We kill off susceptible bacteria, leaving behind already resistant bacteria to replicate and spread their resistance genes.

This may seem like a subtle distinction: We don't create antibiotic resistance, we just increase its rate of spread. But, from the perspective of effective response planning, this is a critical distinction. If inappropriate antibiotic use caused antibiotic resistance, all we would have to do to defeat resistance is never prescribe drugs inappropriately. Unfortunately, that won't work. All antibiotic prescription, even appropriate antibiotic prescription, increases selective pressure, which increases the rate of spread of resistance.

Eliminating inappropriate antibiotic use, and always using antibiotics appropriately is indeed critical, because it will slow the spread of resistance, buying us time to develop new antibiotics. But if 100% of our efforts are focused on antibiotic conservation, all we will achieve is a slowing of the inevitable exhaustion of the antibiotic resource. What is needed is to marry antibiotic conservation with antibiotic restoration. That is, we need new drugs to be developed. Just conserving what we have is not enough.

Why are "antibiotic stewardship" policies not a sufficient remedy for controlling resistance?

See above. Stewardship leads to conservation. That is half the battle, but by itself it will only lead to a slowing of the inevitable exhaustion of the resource.

Furthermore, the initial calls for stewardship were made by people like Max Finland in the late 1940s and early 1950s. This is not a new call. It's more than a half century old. It just doesn't work very well. An analogy is the temptation to say that we don't need condoms to stop the spread of STDs, we just need abstinence. It is true that abstinence will stop the spread of STDs. But, an abstinence-only policy just doesn't work. You've got to have the condoms too. Well, stewardship, by itself, just hasn't worked after more than 60 years of calls for it. It is too hard to change behavior, and the pressures on physicians not to be wrong about their patients' illnesses is too great.

What do you consider the chief impediments to developing newer/better antibiotics?

The two major impediments are: 1) economic, and 2) regulatory.

The primary economic impediment is that antibiotics have a lower rate of return on investment than other classes of drugs. You make a lot more money back on your R&D investment if the drug is taken every day for the rest of the patient's life (e.g. cholesterol, hypertension, dementia, arthritis) than if it is taken for 7 days and then the patient stops because he/she is cured.

The regulatory problem is a startling degree of confusion at the FDA regarding what types of clinical trials should be conducted ot lead to approval of new antibiotics. There has been a total rethinking of antibiotic clinical trials at the FDA over the past 5 years. Right now, companies don't know what trials they are supposed to do to get drugs done, and increasingly the standards are calling for infeasible study designs that simply can't be conducted. This revisionist thinking is being driven by statisticians who know nothing about clinical medicine or patient care. They are asking for things to be done that can't be done to human beings. The balance of clinical and statistical concerns is totally out of whack, and must be restored if this problem is to be solved.

What types of policies are needed to kick-start development of new antibiotics?

Simple. Solutions follow the problems above.

For the economic problem, we need Congress to pass legislation that creates special economic incentives for companies to re-enter the antibiotic R&D market. The return on investment calculation must be changed. Antibiotics are a unique, critical public health need. Congress should recognize this. Examples of programs that would work include increase in funding to scientists (e.g. via NIH) who study bacterial resistance and antibiotic development. Increased small business grants to help translate basic science discoveries to lead compound antibiotics. Tax credits, guaranteed markets, patent extensions, and prizes to serve as pull strategies to help companies improve the return on investment for antibiotics.

For the regulatory problem, Congress needs to stop hammering the FDA into a state of paralysis, where fear permeates every decision to approve a drug. We should be encouraging a balance between statistical concerns and clinical concerns, and we need to restore a sense that the agency is regulating drugs used by physicians for patients, and that trials showing those drugs are safe and effective must be feasible to conduct and relevant to how the drugs will be used in clinical medicine after they are approved.

Book news: SUPERBUG available for pre-order!

Constant readers: To my complete surprise, SUPERBUG is up on Amazon!

Mind you, the page is almost blank. The cover image has not been added; the flap copy hasn't even been finalized; and my bio is out of date. (For an up-to-date bio, visit my Amazon author page, where posts from here will soon be mirrored.)

Nevertheless, there it is — and at a lovely pre-release deep discount (34%!) too.

I had plans to roll out news about the book over the next two months, but this has scooped me, a bit. So here's the first bit of news, which you'll see confirmed on the Amazon page: We finally decided on a subtitle. So the full title of the book now is:

SUPERBUG: The Fatal Menace of MRSA

Has a nice ring to it, no?

Here's something else this scoops me on: the release date. SUPERBUG will be published on March 23, 2010.

And here's an important detail: My own experience with Amazon orders has been that pre-orders are not only discounted — they also move out from Amazon very quickly as release date approaches. So if you'd like to get a copy of SUPERBUG into your hand as soon as can be, a pre-order is one sure way to do it. (Plus, it makes my publisher happy.)

$17.16, folks. 34% off! How can you go wrong?

Bad news from California: MRSA quadrupled

Via the Fresno Business Journal and the Torrance Daily Breeze come reports of a new study by California's Office of Statewide Health Planning and Development: Known MRSA cases in the state's hospitals increased four-fold between 1999 and 2007, from 13,000 to 52,000 cases per year.

From the Torrance paper:

The good news is that the percentage of people who die of MRSA has decreased, from about 35 percent in 1999 to 24 percent in 2007. The raw number of deaths, however, more than doubled to about 12,500. (Byline: Melissa Evans)

From the Fresno paper (no byline):

Fresno, Kings, Madera and Tulare counties were among 38 counties in California that had 61 to 80% of patients with staph infections.
Only one county, Sierra, fared worse. Eight-one to 100% of patients ended up with staph infections in that county’s hospitals.
In 1999, Kings and Madera counties were in the 0 to 20% range and Fresno and Tulare counties were in the 21 to 40% range.

100%??

My guest-post elsewhere: Bad news on hospital error rates

It's been 10 years since the publication of the pathbreaking Institute of Medicine report, "To Err is Human," which for the first time focused policy attention on medical errors. The Interdisciplinary Nursing Quality Research Initiative has been running a two-week special series of posts to mark the occasion, and they very kindly asked me to contribute.

Here's a link to my guest-post, "Hospital Error Rates — Still a Long Way To Go," looking at a recent paper and editorial in the Journal of the American Medical Association that reported very discouraging results in rates of infections in ICUs worldwide. (And, umm, yes, that is what I look like.)

While you're there, please take a look also at another guest post by my good friend Nancy Shute, former staff writer and now blogger for US News & World Report, who discusses the difficulty of speaking up as a patient, based on her own experience in the hospital last summer. It's very worth a read.

NEJM: Antibiotics for pneumonia in H1N1

The New England Journal of Medicine has been running an open-access blog on H1N1 flu, and they've put up a post on when to give antibiotics to prevent secondary bacterial pneumonia, including MRSA pneumonia, in flu patients.

There's a table of key clinical points to consider, and these important points are made:

For the child or adult admitted to a hospital intensive care unit in respiratory distress, we believe that empirical initial therapy with broad-spectrum antibiotics to include coverage for MRSA, as well as Streptococcus pneumoniae and other common respiratory pathogens, is appropriate.
For the previously healthy child or adult with influenza who requires admission to a community hospital and has features that suggest a secondary pneumonia (Table 1), we would recommend empirical treatment with a drug such as intravenous second- or third-generation cephalosporin, after an effort has been made to prove the association with influenza and to get adequate lower respiratory tract specimens for Gram’s stain and bacterial culture.
If the Gram’s stain suggests the presence of staphylococci or if there is a rapidly progressive or necrotizing pneumonia, an additional antimicrobial agent to cover MRSA is appropriate. ...
We do not believe that initial coverage for MRSA is indicated in all patients who are thought to have secondary bacterial pneumonia.

So, to recap:

• Development of apparent pneumonia in the presence of flu should be met with antibiotics that will treat drug-sensitive bacteria, along with a test to show which bacteria are causing the illness.
• If staph is present (or the pneumonia appears very serious), then the antibiotics should be upped to one that can control MRSA.
• But if the pneumonia is serious enough to send a patient straight to the ICU, then drugs that can quell MRSA should be started right away.

For anyone concerned about pneumonia in the aftermath of H1N1, this is worth bookmarking.

Wednesday a.m.: Congressional briefing on antibiotics in livestock - live-tweeted!

Folks: On Wednesday 2 December, at 9:30 a.m. EST, Rep. Louise Slaughter (D-NY) will host a Congressional briefing about antibiotic use in food animals. As a reminder, Rep. Slaughter is an MPH and Congress's only microbiologist, and the chief sponsor of PAMTA, the Preservation of Antibiotics for Medical Treatment Act that proposes restricting antibiotic use in animals to therapeutic uses under the guidance of a veterinarian and phases out "growth promotion" with sub-therapeutic doses, which consumes millions of pounds of antibiotics every year, many of them close analogs to human drugs.

Appearing at the briefing along with Rep. Slaughter are leaders of efforts that have produced an important string of reports on antibiotic overuse — the Pew Commission on Industrial Farm Animal Production and the Extending the Cure project of Resources for the Future:

• Michael Blackwell, DVM, MPH–former Vice Chair, Pew Commission on Industrial Farm Animal Production; Assistant Surgeon General, USPHS (ret.); Former Dean, College of Veterinary Medicine, University of Tennessee, Knoxville, TN.
• Robert Lawrence, MD–Director, The Johns Hopkins Center for a Livable Future, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
• Ramanan Laxminarayan, PhD, MPH–Senior Fellow, Center for Disease Dynamics, Economics, and Policy, Resources for the Future, Washington, DC
• Robert Martin–Senior officer, Pew Environmental Group; former Executive Director, Pew Commission on Industrial Farm Animal Production, Washington, DC
• Lance Price, PhD– Director, Center for Metagenomics and Human Health, Translational Genomics Research Institute, Flagstaff, AZ

Here's a post explaining the importance of this issue from the blog of the Center for a Livable Future, a Johns Hopkins University research group that has produced some of the most mportant papers on leakage of antibiotic-resistant bacteria and antibiotic residues from CAFOs ("confined" or "concentrated" "animal-feeding operations" — very, very large-scale farms). And here's some video on the issue from last summer from Lou Dobbs Tonight.

Because the event Wednesday is an informational briefing, not a hearing, I can't find any link for a live webcast. (I'll update if I find one.) But the hearing will be live-tweeted by the staff of the Center for a Livable Future (@LivableFuture) at the hashtag #CLF09. BLOGGERS: They will take tweeted questions toward the end of the hearing, ~10:45 a.m. — use the hashtag.

Antibiotics - the EU pipeline is empty too

We've talked before about the shrinking number of drugs available to treat MRSA and about the challenges of getting new drugs to market. Well, it's not just a problem in the United States.

A new report from the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMEA) — that's the CDC and the FDA of the European Union — analyzes the bench-to-market "pipeline" of new drug development in the EU and finds... not good news. Out of 167 antibacterial agents that are somewhere in the pipeline of development, only 15 look likely to improve treatment of resistant organisms over drugs that already exist — and 10 of those 15 are in early-stage trials and will not come to market anytime soon.

That leaves 5 potential new drugs, for an epidemic of antibiotic resistance that, just in the EU, causes 25,000 deaths and $1.5 billion Euros ($2.27 billion) in extra healthcare spending each year.

(Within that epidemic of resistance, by the way, the single most common organism is MRSA.)

It's worth understanding how the agencies conducted their analysis. When we look for new drugs to treat resistant organisms, we ideally need several things:

• a formula or molecule that is new (and not just an improved version of an existing one, because if bacteria have developed resistance against the existing one, they have a head start in developing resistance against the new one)
• a new mechanism or target on the bacterial cell, and not an improved version of an existing one (ditto)
• evidence that it works in living organisms, and not just in lab dishes (in vivo, not just in vitro)
• evidence that it can be given internally, not just topically (necessary for addressing the most serious infections)
• and some indication that it is making its way through the regulatory approval process in time to achieve some practical good.

Here's what the EU pipeline looks like:

• 167 agents in process
• 90 that have shown effectiveness in vivo
• 66 that are new substances
• 27 that have a new target or mechanism
• 15 that can be administered systemically

If you're wondering whether you should be depressed, the answer is Yes.

... it is unclear if any of these identified agents will ever reach the market, and if they do, they may be indicated for use in a very limited range of infections.

The agencies call for a concerted government effort to turn this around, and ask for quick action because it takes years to get drugs through the pipeline:

...a European and global strategy to address this serious problem is urgently needed, and measures that spur new antibacterial drug development need to be put in place.

This echoes a call that has already been made in this country by the Infectious Diseases Society of America, which has asked for changes in incentives to drug-makers, and has backed what's known as the STAAR Act (STrategies to Address Antimicrobial Resistance). With this latest EU report — which comes on the heels of a US-ER agreement to work cooperatively on resistance — the IDSA is asking for an international commitment to bringing forth 10 new drugs in 10 years, what they are calling 10 x '20.

New pig strain in China

Via Emerging Infectious Diseases comes the full version of a piece of research I posted on in September that was presented at the London conference Methicillin-resistant Staphylococci in Animals: Veterinary and Public Health Implications. A new MRSA variant — not ST398 — has been spotted in pigs in China.

Luca Guardabassi and Arshnee Moodley of the University of Copenhagen and Margie O'Donoghue, Jeff Ho, and Maureen Boost of the Hong Kong Polytechnic University report that they found a pig-adapted MRSA strain in 16 of 100 pig carcasses collected at 2 wet markets in Hong Kong. By multi-locus sequence typing, the strain is ST9, previously found in pigs in France; by PFGE, they fall into categories that tend to carry the community-strain cassettes SCCmec IV and V.

Here's the bad news: This strain possesses resistance factors that resemble human hospital-associated MRSA more than they do ST398.

Twelve isolates displayed a typical multiple resistance pattern, including resistance to chloramphenicol, ciprofloxacin, clindamycin, cotrimoxazole, erythromycin, gentamicin, and tetracyline. The remaining 4 isolates were additionally resistant to fusidic acid. ... All isolates were negative for Panton-Valentine leukocidin and susceptible to vancomycin and linezolid.

The further bad news, of course, is that this is being found in Hong Kong, adjacent to China, which is the world's single largest producer of pork, raising tens of millions of tons of pig meat per year. Most of the pigs sold in Hong Kong come from the Chinese mainland, not from the SAR. Pig surveillance for MRSA in China is practically non-existent (which is not much of a criticism since it does not exist in the United States, either). A human infection with ST9 has already been recorded in Guangzhou, the province adjacent to Hong Kong.

The question, for this strain as for all MRSA strains in pigs, is what is its zoonotic potential? Here again, the news is not good. According to Maureen Boost, who presented this research at the London conference, the isolates were obtained by the researchers from intact heads from butchered pigs; the researchers took the snouts to the lab and and swabbed them there. Pig snout happens to be a desirable meat in China; it is bought in markets, taken home and made into soup. Boiling in broth would probably kill MRSA bacteria — but home butchering of a pig snout could pass the bug on to the human cutting it up, or to that human's kitchen environment, long before the snout ever got into the pot.

The cite is: Guardabassi L, O'Donoghue M, Moodley A, Ho J, Boost M. Novel lineage methicillin-resistant Staphylococcus aureus, Hong Kong. Emerg Infect Dis. 2009 Dec. DOI: 10.3201/eid1512.090378

"Pig MRSA" in the EU - long-awaited survey

It's not very likely that people will be eating much pork today — OK, maybe some pancetta in the Brussels sprouts — and that's good, because there's lots of news today about MRSA in pigs.

(In fact, there's a ton of news just this week. Make it stop.)

The European Food Safety Authority has published a long-awaited, European Union-wide survey looking for the presence of MRSA in pigs. Here's the key points: Investigators found MRSA on 1 out of 4 farms where pigs were being raised and in 17 of the 24 EU states. (Two non-member states were included in the analysis.)

Strictly speaking, this is not a survey of MRSA in pigs; the study samples not the pigs themselves, but the dust in pig-raising sheds. The sites were 1,421 breeding farms and 3,176 farms where pig are raised to slaughter age. By far the most common strain was MRSA ST398, though other strains were detected, including some known human strains. The prevalence in various countries went from a low of 0 to as high as 46% of farms. (Highest, in descending order: Spain, Germany, Belgium, Italy, Portugal. The Netherlands, where St398 was first identified, had a prevalence of 12.8%. Countries reporting no MRSA: Bulgaria, Cyprus, Denmark, Estonia, Finland, Hungary, Ireland, Latvia. Lithuania, Luxembourg, Sweden, the United Kingdom, Norway and Switzerland.)

The report closes by recommending comprehensive monitoring of pigs for MRSA, as well as monitoring of poultry and cattle.

About the potential of ST398 crossing to humans, it has this to say:

In humans, colonisation with MRSA ST398 originating from pigs has been identified as an occupational health risk for farmers and veterinarians and their families. Although MRSA ST398 represents only a small proportion of the total number of reports of human MRSA infections in the EU... in some countries with a low prevalence of human MRSA infection, CC398 is a major contributor to the overall MRSA burden.
In most cases, colonisation with MRSA ST398 in humans is not associated with disease, although clinical cases associated with MRSA ST398 have been reported. MRSA ST398 can be introduced into hospitals via colonised farmers and other persons in a region with intensive pig farming. Therefore, MRSA ST398 may add substantially to the MRSA introduced in health care settings. However, it seems that the capacity for dissemination in humans (patient-to-patient transmission) of livestock-origin MRSA, in particular ST398, is lower as compared to hospital-associated MRSA).
... Food may be contaminated by MRSA (including ST398), however there is currently no evidence for increased risk of human colonisation or infection following contact or consumption of food contaminated by ST398 both in the community and in hospital.

Britain's Soil Association, which pressed for the study to be done, has released a statement quoting the food safety agency warning that the testing method may have underestimated MRSA's presence on farms, and warning that if ST398 is not yet in England, it is certainly soon to arrive. Germany's Federal Institute for Risk Assessment also released a statement, admitting that ST398 in German pig stocks is "widespread."

The report is here, executive summary here, and press release here. All well worth reading.

CDC warns of deaths from H1N1 flu + bacterial infections

Over at CIDRAP, my colleague Lisa Schnirring writes tonight about the CDC's concern over increasing numbers of deaths from bacterial pneumonia in people who have come down with H1N1 flu.

We've talked about this before here. Our concern of course has been MRSA, and there is good evidence that there have been fatal MRSA infections in flu victims. But the primary culprit now is not MRSA but pneumococcus (S. pneumoniae):

Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, told reporters at a press briefing that the CDC is seeing an increasing number of invasive pneumococcal disease cases around the country, but the numbers were particularly high in Denver at a time when pandemic H1N1 activity was peaking in the area.
Over the past 5 years the Denver area averaged 20 pneumococcal disease cases in October, but this year the area recorded 58, and most were in adults between the ages of 20 and 59, many of whom had underlying medical conditions.
Health officials expect to see more pneumococcal disease when seasonal flu circulates, but the infections typically strike people who are older than 65. In past pandemics secondary bacterial pneumonia infections, particularly those involving Streptococcus pneumoniae, frequently contributed to illnesses and deaths.

This is particularly troubling and sad because we have good vaccines for pneumococcus, one for adults and a different one for children. Only, people are not taking them: Uptake is only about 25% in high-risk groups and much lower in the general population, despite urgings from CDC and other health advisory boards.

Perhaps it's not surprising that people have not heeded advice to get the pneumococcus vaccine as a protection against flu's worst effects, given that uptake of the flu vaccine itself has been so low. But if you or someone you love is in a high-risk group, it would be a really good idea to rethink that.

Two good reports published elsewhere

Some holiday reading:

• Mike the Mad Biologist, who often blogs about MRSA, has an analysis up about the varying degrees of attention that the Senate and House healthcare reform bills give antibiotic resistance and healthcare infections
• And Jacob Goldstein at the Wall Street Journal's WSJHealth blog describes and links to a program at UCLA Medical Center that uses volunteer undergraduate observers to make sure healthcare staff wash their hands. (h/t @ePatientDave)
  

Community MRSA rates rising, and epidemics converging

A study published Tuesday in Emerging Infectious Diseases makes me happy, despite its grim import, because it confirms something that I will say in SUPERBUG: Community MRSA strains are moving into hospitals, blurring the lines between the two epidemics.

The study is by researchers at the excellent Extending the Cure project of Resources for the Future, a group that focuses on applying rational economic analysis (think Freakonomics) to the problem of reducing inappropriate antibiotic use. (Here's a post from last year about their work.)

Briefly, the researchers used a nationally representative, commercial (that is, not federal) database of isolates submitted to clinical microbiology labs, separated out MRSA isolates, divided them into whether they originated from hospitals or outpatient settings (doctors' offices, ambulatory surgery centers, ERs), and analysed them by resistance profile, which has been a good (thogh not perfect) indicator of whether strains are hospital or community types (HA-MRSA or CA-MRSA). They cut the data several different ways and found:

• Between 1999 and 2006, the percentage of staph isolates from outpatient settings that were MRSA almost doubled, increasing 10% every year and ending up at 52.9%. Among inpatients, the increase was 25%, from 46.7% to 58.5%.
• Among outpatients, the proportion of MRSA isolates that were CA-MRSA increased 7-fold, going from 3.6% of all MRSA to 28.2%. Among inpatients, CA-MRSA also increased 7-fold, going from 3.3% of MRSA isolates to 19.8%.
• Over those 7 years, HA-MRSA did not significantly decrease, indicating that CA-MRSA infections are not replacing HA-MRSA, but adding to the overall epidemic.

So what does this mean? There are a number of significant aspects — let's say, bad news, good news, bad news.

Bad: CA-MRSA strains are entering hospitals in an undetected manner. That could simply be because patients entering the hospital are colonized by the bug and carry it with them. But it could also be because healthcare staff who move back and forth between outpatient and in-patient settings — say, an ambulatory surgical center and a med-surg ward — could be carrying the bug with them as well.

Good: If they are detected (analyzed genotypically or for drug sensitivity), CA-MRSA strains are less expensive to treat because they are resistant to fewer drugs, and some of the drugs to which they are susceptible are older generics, meaning that they are cheaper.

Very Bad: The entrance of CA-MRSA strains into hospitals risks the trading of resistance factors and genetic determinants of transmissibility and colonization aptitude in a setting where bacteria are under great selective pressure. Several research teams have already seen this: In several parts of the country, CA-MRSA strains have become resistant to multiple drug families.

Is there a response? The work of Extending the Cure focuses on developing incentives that will drive changes in behavior around antibiotic use. These results, lead author Eili Klein told me, call for developing incentives for creating rapid diagnostic tests that will identify not just that a bug is MRSA, but what strain it is, so that it can be treated appropriately and not overtreated.

The results also underline the need for something that is particularly important to me: enhanced, appropriately funded surveillance that will define the true size of the MRSA epidemic and delineate the behavior of the various strains within it. Right now, surveillance is patchy and incomplete, done partially by various CDC initiatives and partially by the major MRSA research teams at academic medical centers. As we've discussed, there is no national requirement for surveillance of patients, and very few state requirements; there is no incentive for insurance companies to pay for surveillance, since it benefits public health, not the patient whose treatment the insurance is paying for; and there is a strong disincentive for hospitals to disclose surveillance results, because they will be tarred as dirty or problematic. Yet to know what to do about the MRSA epidemic, we first have to know the size and character of what we are dealing with, and we do not now.

The cite is: Klein E, Smith DL, Laxminarayan R. Community-associated methicillin-resistant Staphylococcus aureus in outpatients, United States, 1999–2006. Emerg Infect Dis. DOI: 10.3201/eid1512.081341

Antibiotic misuse in animals - one example

Via the Minneapolis Star Tribune and the excellent blog Fair Food Fight comes the story of two cows, from two Minnesota farms, that have been reprimanded by the US Food and Drug Administration for bringing cows to slaughter that turned out to have been massively overdosed with antibiotics.

From the Strib:

In a rare move, federal officials sent stern warning letters to two central Minnesota dairy farms, which were among only 30 farms nationwide reprimanded so far this year for violating the rules governing how animal drugs can be used.
J&L Dairy, in Clarissa, Minn., sent a dairy cow to slaughter in March, even though it was drugged with 129 times the amount of penicillin allowed under federal regulations.
Another farm, Evergreen Acres Dairy, LLC, in Paynesville, Minn., was warned by the FDA last month, after one of its cows was found to have more than four times the allowed amount for a certain type of antibiotic. Further inspection found that the farm had misused 10 other drugs. (Byline Lora Pabst)

From one of the FDA's reprimand letters, to J&L Dairy of Clarissa, Minn.:

Our investigation ... found that you hold animals under conditions that are so inadequate that medicated animals bearing potentially harmful drug residues are likely to enter the food supply. ... Our investigation found that you routinely administered penicillin G procaine to dairy cows without following the daily dosage amount or dosage amount per injection site as stated in the approved labeling. Your extralabel use of penicillin G procaine was not under the supervision of a licensed veterinarian, in violation of 21 CFR 530.11 (a), and your extralabel use of penicillin G procaine resulted in illegal drug residue, in violation of 21 CFR 530.11(d).

From the other reprimand letter, to Evergreen Acres Dairy of Paynesville, Minn.:

Our investigation ... found that you hold animals under conditions that are so inadequate that medicated animals bearing potentially harmful drug residues are likely to enter the food supply.
...The investigation ... found that you adulterated the new animal drugs neomycin sulfate, sulfadimethoxine oral solution, oxytetracycline injection, oxytetracycline hydrochloride injection, ceftiofur hydrochloride, ceftiofur crystalline free acid, ceftiofur sodium, penicillin G procaine aqueous suspension, florfenicol, tetracycline hydrochloride soluble powder, and tylosin. Specifically, the investigation revealed that you did not use these drugs as directed by their approved labeling. Use of these drugs contrary to their approved labeling is an extralabel use.

There are some important points to make here.

As we've talked about before, many of the antibiotics used in food animals are effectively over-the-counter drugs; farmers can buy them in feed stores and administer them without a veterinarian's supervision. (Putting an end to OTC animal antibiotics is the goal of Rep. Louise Slaughter's legislation, the Preservation of Antibiotics for Medical Treatment Act (PAMTA), supported by the Obama Administration supports; post here.) Without such supervision, it is easier for a farmer to make a mistake in dosing, or to give the drugs too close to animal's slaughter time, so that the drug's don't wash out of the animal's system but remain in its meat after death.

A second important point is that we talk a lot here about the dangers of industrial-scale farming, in which antibiotics are given to animals that are not sick, either in small doses as growth promoters or in treatment-size doses to prevent illness spreading through a flock or herd. Antibiotic misuse has become linked in the public mind with the enormous animal-raising operations known as CAFOs. But both these reprimanded farms were family farms, not CAFOs. These reprimands underline that inappropriate antibiotic use is not a function of farm size — it's a by-product of market pressure.

It's (European) Antibiotic Awareness Day

UK and EU readers can hug themselves with self-congratulation this morning (OK, admittedly, for you it's afternoon already): It's Antibiotic Awareness Day across the European Union, featuring a slate of public-awareness activities, public-service announcements, educational efforts, and random appearances by the charming little hedgehog above (kicking antibiotics, don't you see). It's all meant to convince people that antibiotics are a precious resource and that misusing them encourages antibiotic resistance.

The campaign is organized by the European Centre for Disease Prevention and Control (the EU equivalent of the US CDC) and is being carried out by an enviably long list of national agencies within the EU. It's accompanied by the publication in the journal Eurosurveillance of an article setting out the challenges of controlling antibiotic resistance across such diverse nationalities and geographies.

There are materials on the site that would be useful for anyone attempting to get the message of antibiotic stewardship across to physicians, family members or friends: There's a fact sheet for the general public, one for physicians and other experts, and one that specifically addresses the temptation to take antibiotics in cases of H1N1 flu.

There's also a short film explaining the genesis of Antibiotic Awareness Day and the basics of antibiotic resistance, and a marvelous set of pull-no-punches short video spots. This one — comparing antibiotics to a lightbulb slowly burning out — is my favorite.

Antibiotic resistance: international news

Constant readers, we've often talked about MRSA and other resistant pathogens as a global problem (cf. these posts for resistance issues in Europe and these for resistance around the world).

But now there has been formal recognition that resistant bacteria respect no borders. On Nov. 3, the US government and the European Union signed an agreement to form a joint task force to investigate and combat antibiotic resistance. From the Joint Declaration, posted on WhiteHouse.gov:

[We therefore agree}... To establish a transatlantic task force on urgent antimicrobial resistance issues focused on appropriate therapeutic use of antimicrobial drugs in the medical and veterinary communities, prevention of both healthcare- and community-associated drug-resistant infections, and strategies for improving the pipeline of new antimicrobial drugs, which could be better addressed by intensified cooperation between us.

You may not have heard much about it here, but in Europe, this declaration was big news. Here's a story from the Swedish newspaper Arbetarbladet (Sweden currently holds the EU Presidency) and another from the Irish Times. But while it merited barely a blink in the US mainstream media, US nonprofits were deeply involved in the declaration, notably the Infectious Diseases Society of America and the Pew Charitable Trusts:

"Antimicrobial resistance and the lack of new antimicrobial agents to effectively treat resistant infections are problems that no country can deal with alone -- they threaten the very foundation of medical care," said Richard Whitley, MD, FIDSA, president of the Infectious Diseases Society of America (IDSA). "Without effective antimicrobial drugs, modern medical treatments such as operations, transplants, intensive care, cancer treatment and care of premature babies will become very risky if not impossible." Dr. Whitley joined with Javier Garau, MD, president of European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Shelley A. Hearne, managing director of the Pew Health Group in welcoming the multi-country initiative.
..."Antibiotic resistant bacteria respect no political borders, so we must work together to combat them," Dr. Hearne said. "Resistance takes a terrible toll on health worldwide and is measured in lives lost, greater suffering and higher health care costs. One way that U.S. leaders can demonstrate their commitment to solving this issue is by immediately joining the EU in banning non-judicious antibiotic uses in food animal production." (Pew press release)

This fresh focus on the problem of resistance will be sharpened in Europe this week with the celebration of European Antibiotic Awareness Day. (We should be so lucky.) More on that on Wednesday.

Antibiotic-resistant infections: millions in cost to hospitals, families, all of us

Folks, I mentioned that I'm way behind in working down a stack of great articles. Here's a very good one that I missed when it came out two weeks ago and is well worth your time.

A team from John H. Stroger Hospital (the new location of the iconic Cook County Hospital, public hospital for downtown Chicago) and from the Alliance for the Prudent Use of Antibiotics at Tufts University (headed by Dr. Stuart Levy, dean of antibiotic resistance scholarship in the US) has analyzed the direct and distributed costs of resistant infections, and their results are stunning. They took a random sample of patients seen at the hospital, sorted out a subgroup that suffered from resistant infections, and computed the costs that those infections imposed: in medical costs, increased length of stay, and excess deaths. Those sort of calculations have been done before at other institutions (cf. for instance the excellent work of Susan Cosgrove of Johns Hopkins), but what makes this Chicago study striking is an additional layer of analysis that computes the "social cost" to the families of those infected.

In the study's words:

In a sample of 1391 patients, 188 (13.5%) had [antibiotic-resistant infections]. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4–12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7–$15.0 million.

(Just to underline: These are almost certainly underestimates of the current problem and its current costs — because to get very solid data, the Stroger team went back in their database to patients who were treated in 2000. That's before the emergence and dominance of CA-MRSA USA300 nationwide, and its subsequent movement into hospitals. Since 2000, the MRSA epidemic has gotten worse.)

An accompanying editorial takes the next step in logic, stressing that if we're not going to work to reduce ARIs because it is good medicine to do so, we should do it because it is critically cost-saving:

...[T]he findings of Roberts et al [11] are significant, making a strong case for both the medical and financial benefits of reducing antimicrobial resistance. This is an important and timely question, considering the national focus on the prevention of health care–acquired infections, a significant proportion of which are caused by antimicrobial-resistant organisms, and the call for institutions to develop antimicrobial stewardship programs. These data should help inform decisions regarding the structure and implementation of health care initiatives designed to improve patient care while controlling unnecessary costs.

The cite for the study is: Rebecca R. Roberts, Bala Hota, Ibrar Ahmad et al. Hospital and Societal Costs of Antimicrobial‐Resistant Infections in a Chicago Teaching Hospital: Implications for Antibiotic Stewardship. Clinical Infectious Diseases 2009 49:8, 1175-1184.

It's World Pneumonia Day

Readers, we talk all the time here about the unexpected and deadly attack of MRSA pneumonia, both on its own and as a sequela of influenza infection. But we should acknowledge that MRSA pneumonia is part of an epidemic of pneumonia, an under-appreciated disease of severe lung inflammation that takes the lives of 2 million children each year around the world.

Today, Nov. 2, has been declared World Pneumonia Day by an enormous coalition of global health organizations that includes UNICEF and Save the Children. (Mis amigos Latinos sabrán que está hoy también Dia de los Muertos. Fitting, no?) From their press release: "Pneumonia takes the lives of more children under 5 than measles, malaria and AIDS combined. The disease takes the life of one child every 15 seconds, and accounts for 20% of all deaths of children under 5 worldwide."

World Pneumonia Day is being marked by events around the globe (here's a clickable map) and by the release of a World Health Organization report, the Global Action Plan for Prevention and Control of Pneumonia. The plan has three main goals, aimed at the recourse-poor countries where most pneumonia deaths occur:

• promote breastfeeding to ensure children's nutrition and good immune status
• protect immunity by guaranteeing the distribution in the developing world of the pneumonia vaccines we take for granted in the industrialized world, against Haemophilus influenzae and Strep pneumoniae (pneumococcus)
• treat children when they need it by making sure that there is adequate, local primary care and — important for our purposes especially — also making sure that antibiotics are used appropriately, but not overused.

The international organization GAVI (formerly known as the Global Alliance for Vaccines and Immunization, now going just by its acronym) has announced plans to immunize 130 million children worldwide against pneumonia and other diseases by 2015.

I want to underline that pneumonia is of interest to us for several reasons: not just because we are concerned for MRSA pneumonia, but also because we are in the midst of the H1N1 pandemic, and as we have talked about before, bacterial infections appear to be playing a role in a significant percentage of the deaths. There is no MRSA vaccine, but there are Hib and pneumo vaccines, which might have prevented some of those deaths. So increasing the administration of pneumonia vaccines could affect the course of this pandemic right now, as well as the fates of children all over the world who have not contracted this flu but will be in danger of bacterial pneumonia in the future.

New reports on animals, food, MRSA ST398

Well, constant readers, didn't expect to be gone *that* long. Many apologies. There was a good reason — actually, several: I attended a journalism meeting, and spoke at a second meeting. But most important, I received, marked up, and returned the galleys of SUPERBUG. Yes, it's really starting to look like a book now. There will be things to share, soon.

Meanwhile, I'll try to roll out some of the many, many pieces of news and research related to staph that have emerged in the past few weeks. Today: News on animals, and our old opponent, MRSA ST398.

First: A team from the Universidad de La Rioja reports in the Journal of Antimicrobial Chemistry the first finding of MRSA ST398 ("pig MRSA," archive here) in food in Spain. They tested 318 raw meat and wild-game samples (chicken, pork, veal, lamb, turkey, rabbit, game bird, wild boar, deer, hare) and found ST398 and other MRSA strains in 5 of them, an incidence of 1.6%. The authors write: "Although MRSA prevalence in raw food is low, the risk of its transmission through the food chain cannot be disregarded."

Importantly, one of the other strains found in the meat of these animals is an uncommon variant, ST125-t067, that has already been implicated in large numbers of hospital infections in Spain and is resistant to ciprofloxacin (Cipro), erythromycin and a third antibiotic, tobramycin, in addition to the usual suspects. The other non-ST398 strain is ST217, which is a variant of a long-known hospital strain, and is also resistant to Cipro, a very valuable drug for skin and soft-tissue infections. So it appears the contamination may cross both ways, from animals, and to animals as well.

No link, but the cite is: Lozano, Carmen, et al. Detection of methicillin-resistant Staphylococcus aureus ST398 n food samples of animal origin in Spain. Journal of Antimicrobial Chemistry. e-pub Oct. 21 2009 AOP doi:10.1093/jac/dkp378

Next: If the prevalence of ST398 is so low in food, why do we care? We care because of where those organisms go next — into hospitals, among other places. A Dutch/German team that includes the original identifier of ST398 in humans are reporting that they have found an association between the density of pig-farming in parts of Germany and the probability that patients admitted to hospitals will be carrying ST398 with them, creating a possible source for nosocomial infections. R. Kock and colleagues screened 1,600 pigs on 40 German farms, and also reviewed screening results for every MRSA-positive patient admitted to the University Hospital-Munster from 2005 through 2008. They found ST398 on 70% of the farms, and also found that ST398 represented 15% of the MRSA isolates at the hospital in 2005, rising to 22.4% in 2008. The key association: The patients carrying St398 were more likely to have contact with pigs in their daily lives, and also with cattle, than patients who had other forms of MRSA or no MRSA at all.

The cite for that paper: Kock, R. et al. Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) among pigs on German farms and import of livestock-related MRSA into hospitals. European Journal of Clinical Microbiology and Infectious Diseases, e-pub Aug 25, 2009. DOI 10.1007/s10096-009-0795-4

And finally: How do you stop the evolution and spread of antibiotic-resistant organisms in livestock? One good way is to stop giving teh livestock antibiotics in the first place. In a column at the Huffington Post, Laura Rogers, project director of the Pew Campaign on Human Health and Industrial Farming, takes on the oft-repeated assertion that you can't farm without them without risking the lives and market place of your livestock, and offers the example of Denmark, which did ban antibiotics in animals, and which has healthier, more profitable livestock as a result:

American agribusiness often has criticized Denmark's 1998 ban on antibiotics, calling it an outright failure. But compelling new research presented by a Danish scientist earlier this year showed the opposite, revealing that antibiotic use on industrial farms has dropped by half while productivity has increased by 47 percent since 1992. Danish swine production has increased from 18.4 million in 1992 to 27.1 million in 2008. A decrease in antibiotic-resistant bacteria in food animals and meat has followed the reduced use of these vital drugs.

Read more at: http://www.huffingtonpost.com/laura-rogers/what-can-danish-hogs-teac_b_318478.html

Get Smart About Antibiotics Week, Oct. 5-11 (now!)

Every year, the CDC sponsors a week-long observance called Get Smart About Antibiotics Week, intended to bring attention to this issue of antibiotic misuse that all of us here are so concerned about, and to link the efforts of federal and state agencies, nonprofit groups, and anyone else with an interest.

Today marks the start of the 2009 week, and of course it comes as a crucial time: With the H1N1 flu pandemic causing so many people to seek care for upper respiratory illnesses, the possibility of antibiotics being misprescribed for a viral illness is greater than usual.

The homepage for the CDC campaign is here. There is an abundant list of materials, images, campaign strategies and suggestions for framing the conversation, along with graphics (I've lifted the one at left from a poster aimed at parents of young children), PSA sound files, and cute little web widgets such as the image at right above (sorry for the poor layout skills, it's a busy morning).

Since this comes from the CDC and is therefore taxpayer-funded, all of it is open-access. So go, already.

A reminder: It's World MRSA Day

SUPERBUG listed among "50 Excellent Public Health Blogs"

Constant readers, I'm thrilled to let you know that SUPERBUG has been chosen one of "50 Excellent Public Health Blogs" by the nursing website RNCentral.com.

We are in extremely flattering company. Also among their choices are:

• Effect Measure, the premier public-health blog, now the go-to place for analyses of public responses to pandemic flu
• the Pump Handle, on public and occupational health
• the New Health Dialogue, on health-care reform, whose writers include my friend and former Kaiser Foundation co-fellow Joanne Kenen,
• Covering Health, the blog of the Association of Health Care Journalists, where I am a board member
• Schwitzer Health News, the journalism-quality blog of Gary Schwitzer, University of Minnesota professor and founder of Health News Review
• Barf Blog, written by food-safety experts at Kansas State University and North Carolina State University

along with many others that are new to me and that I look forward to checking out. I urge you to do the same.

MRSA involvement in H1N1 flu: UPDATE

The CDC's MMWR report on their analysis of bacterial co-infections in H1N1 flu deaths has been placed online here.

And there are two excellent analyses of it by the marvelous blogs Effect Measure and Mike the Mad Biologist.

Guest Q&A: Jeanine Thomas and World MRSA Day

I want to introduce you all to a MRSA campaigner, Jeanine Thomas of Chicago. Jeanine — whose story will be told in SUPERBUG — is the founder of World MRSA Day, a worldwide event of activism and grieving that will take place Friday, Oct. 2. There will be simultaneous observances in the UK, and a candlelight vigil in Salt Lake City that evening.

Tomorrow, Oct. 1, Jeanine will be at Loyola University in Chicago to lead a press conference, commemoration for MRSA victims, and award ceremony for notable MRSA campaigners, and to urge those harmed by MRSA to observe October as MRSA Awareness Month.

In advance of the observances, I asked Jeanine to talk to SUPERBUG about her experience and her activism.

Tell us about your personal experience with MRSA.
I was infected with MRSA after ankle surgery in 2000. I came back to the ER — my incisions were black and oozing a large amount of pus and I was in teribble pain — and was admitted. Three days later my culture came back positive for MRSA. I was not put on the right antibiotic; the infection went into my bloodstream and bone marrow and I went into septic shock and multiple organ failure in the middle of the night. The night nurses were able to pull me back and save me. I had seven more surgeries to save my leg from amputation, spent a month in the hospital, and then was confined to bed on a cocktail of antibiotics for 5 more months. I also contracted C. difficile. I now have a destroyed ankle joint and a severely compromised immune system.

You started a MRSA patients' group. Tell us about the group and why you did that.
I started MRSA Survivors Network in 2003 to give support, raise awareness and educate others. There was so little out there about this disease. I never wanted anyone else to go through what I had.

You used your experience with MRSA to help pass patients-rights legislation in Illinois. Please talk a little about the bill.
In 2003, I helped push the "Hospital Report Card Act" that then-state senator Obama introduced, to have infection rates reported. As the consumer representative on the state board for the HRCA, I saw that state health officials and doctors did not even want to have MRSA reported as a disease. So I decided I must take action and in 2006 we introduced the "MRSA Screening and Reporting Act." It passed in 2007, the first in the country, and mandated that all ICU and other at-risk patients be screened for MRSA and infection rates reported. Since then, the Illinois Hospital Association has reported that inpatient infection rates have dropped, but they see many more CA-MRSA cases because of the screening.

How and why did you come up with the idea for World MRSA Day?
In January of 2009 I was thinking of ways to raise awareness and the idea of launching World MRSA Day and a MRSA Awareness Month popped into my head. There are awareness days for every other diisease and as MRSA is pandemic, we need global awareness. I did not know how successful I could be the first year during a recession, but the response was surprising, and I was able to launch the campaigns.

Tell us what you hope will change in the aftermath of having had this worldwide event.
I hope that awareness of MRSA as an epidemic in the US and a pandemic sweeping the globe will be revealed, and that action from the World Health Organization, Department of Health and Human Services, the CDC, governments and health departments will happen. I want all of them to declare MRSA an epidemic. This should have happened years ago, but let's move forward now. Their inaction has caused this disease to proliferate. I also want the public to be aware of MRSA as we are all in this together and every single person on this planet is at risk. Prevention is key to saving lives.