SUPERBUG's first web page!

Folks, as with my first book, I'm having a website professionally built for SUPERBUG (by the awesome Book Report Network). But while we work on that, I've put up a proto-page on my own. Please come check it out!

You'll see the gorgeous, scary cover, the hair-raising jacket copy, and links to pages about me and about the book. You'll also see links for buying the book:  at a deeply discounted pre-publication price at Amazon, and also at IndieBound.com, the site for independent book-sellers.

There's also a link through which you can check out BookTour.com, where I'll be listing appearances and speeches, and where you can request I come speak. And finally — important for academics and teachers! — there's a link through which you can order a free copy for academic evaluation.

Until we get the full site built, the page will be on my website. The URL is http://www.MarynMcKenna.com/SUPERBUG.html. Please come look.

MRSA in the journal Science - spread, outbreaks and an argument for active surveillance

I have a story tonight at CIDRAP about a paper published this evening in the journal Science. To respect fair use and make sure my colleagues get clicks, I just quote the story here — but then I want to talk about why I think it's such an important study.

   A multi-national team of researchers has applied a new genomic tool to a 50-year-old bacterial foe, using minute mutations to track the spread of drug-resistant staph both across continents and within a single hospital.
   On a global scale, their sleuthing tracked the movement of one clone of methicillin-resistant Staphylococcus aureus (MRSA) back and forth across the planet, pinpointing when individual cases transported infections across national borders to spark new outbreaks. Separately, their method demonstrated that what appeared to be a hospital epidemic of MRSA was not a single outbreak, but rather a mixed event of patient-to-patient transmission of one strain that was accompanied by multiple importations from outside the hospital of similar but unrelated strains. ...
   In a briefing yesterday for the press, the authors emphasized the latter finding, pointing out that the traditional infection control measures usually applied to hospital outbreaks would not curb the spread of infections that were carried in undetected from outside. Their method, they said, provides a proof of concept for using cutting-edge genomics to uncover the precise pathways by which MRSA spreads within hospitals—not only tracing its path from patient to patient, but also identifying the bug in patients whose undetected bacterial carriage could spark outbreaks but have not yet.

 If you'd like more, here's a very good story at Scientific American, one at BBC Health and one by the Associated Press; and Science Daily's version.

Now, the details. This team (which has 15 members from almost as many institutions) secured two collections of MRSA isolates: 43 collected from all over the globe between 1982 and 2003, and 20 from a single hospital in Thailand, collected between October 2006 and November 2007. All of the isolates were ST239, which is a hospital-acquired strain that is particularly prevalent in Asia. They analyzed them using high-throughput sequencing, with a particular analyzer (Illumina) that could produce whole genomes of up to 96 isolates very quickly (an extraordinary advance from the weeks and months it used to take to achieve a single whole genome). Then they compared the genomes, looking for single-letter changes in the genetic code (single-nucleotide polymorphisms, SNPs or "snips," and also insertions and deletions of nucleotides). They used those findings to construct a "family tree" of 239 that tracks very nicely with the known history of MRSA's emergence and initial spread, and that pinpoints rare but intriguing importations of clones from certain areas into other parts of the world.

But it's what they found in the Thai hospital isolates that is especially interesting. (Most of this is not explicit in the paper, but was related in the press briefing that Science conducted on Wednesday). The differences that can be seen in the whole-genome analysis can't be discerned by earlier identification methods, so the isolates collected at the hospital appeared to be the same. However, they weren't the same. Some of them were very closely related, and formed what seems to have been a chain of person-to-person transmission — a true hospital-acquired outbreak. But others of them were not so closely related, either to the outbreak or to each other. What they were, instead, were individual importations into the hospital of a hospital strain that had been acquired outside the hospital, and were carried in by staff, patients, visitors.

You can see where this is going, right? If all the cases in the hospital had represented patient to patient transmission within a known outbreak, excellent infection control might have corralled them. But some of them were not part of that outbreak, so infection control measures aimed at that outbreak would not have kept those other cases from spreading. What would have stopped them from spreading, as the authors pointed out, is detecting them at some other point in their entry into the hospital:

..."That implies you have to have a different perspective on where you are going to apply your infection-control procedures and strategies," co-author Dr. Sharon Peacock of the University of Cambridge said during the briefing.

What that sounds like — and the authors acknowledged as much — is an argument for active detection and isolation/active surveillance and testing/search and destroy, the process of screening some percentage of patients coming into a hospital for MRSA carriage so that the bug can be detected and dealt with long before its presence triggers an outbreak. It is probably not a coincidence that the majority of the authors (including Peacock) are British, and search and destroy has recently become widely accepted in the UK; in fact, the National Health Service recently made it mandatory.

But search and destroy remains remarkably controversial here in the US, despite strong proof of concept demonstrations in healthcare institutions such as Evanston-Northwestern Healthcare, and adoption throughout the VA system. I'll be interested to see whether this paper makes a dent in the overall resistance to search and destroy, and if not, to hear why not.

The cite is: Harris SR, Feil EJ, Holden MTG, et al. Evolution of MRSA during hospital transmission and intercontinental spread. Science 2010 Jan 22;327(5964):469-74

News round-up!

As promised, lots to catch up on — so here's a quick round-up of some great reading that I have been stashing and that you may have missed in the past few weeks.

BBC News: Disinfectants may train bacteria to resist antibiotics
The BBC Health page (bookmark it!) translates a paper from the journal Microbiology on Pseudomonas aeruginosa's newly recognized ability to pump the active ingredient in disinfectants out of its cells — and then to apply that same ability to the antibiotic Ciprofloxacin, even when it has never been exposed to Cipro before. Money quote: "... Residue from incorrectly diluted disinfectants left on hospital surfaces could promote the growth of antibiotic-resistant bacteria."

Associated Press:  Solution to killer superbug found in Norway
In the latest installment in a 6-month series, AP writers Martha Mendoza and Margie Mason examine Norway's success in forcing down rates of hospital MRSA. chiefly by extremely strict control of antibiotics dispensed in hospitals. I have some disagreements with this story; I don't think they account for how much easier it is to do antibiotic stewardship, as it's called, in a single-payer health system such as Norway or their second example, England, compared to the extremely complex US system. But I'm very glad to see the AP (and the Nieman Foundation at Harvard, where Mason was a fellow) support public exploration of antibiotic resistance, which I obviously feel gets insufficient attention. (Stay tuned for SUPERBUG's discussion of one US stewardship program that has worked and may be replicable.)

Time: Should weight factor into antibiotic dosage?
Time.com looks at a provocative new paper in the Lancet that questions whether standard prescribed dosing of antibiotics isn't really a form of inappropriate use. Money quote: "Dosage according to body mass is standard in anesthetics, pediatrics, oncology and other fields, [but] when it comes to antibiotics and antimicrobials the dosing guidelines are too broad... and may undermine a medications efficacy. ...In the face of both widespread obesity and the increasing prevalence of antibiotic-resistance, tailoring dosage for optimal results is increasingly important."

And finally, new today:
Science Daily: Bacteria Are More Capable of Complex Decision-Making Than Thought
University of Tennessee researchers explore the ability of a bacterium (the soil bacterium Azospirillum brasilense) to sense changes in its environment, process that information and make surprisingly complex decisions in response.

SUPERBUG's cover - a sneak peek!

Constant readers, apologies for disappearing unexpectedly. It's been a challenging few weeks at Casa Superbug, with a death in the family and a sudden trip to a part of the country with, hmm, low connectivity.

But I'm back. And there's so much to talk about. Here's the first in a long list: The cover art for SUPERBUG!

(Let us pause for a moment while I jump up and down and hug myself with glee.)

My editor says it will be even more gorgeous in real life: There are glossy areas, and embossed areas, and color that will fly off the bookstore shelf, smack you in the eye and insist on being carried to the cashier.

(Or, alternatively, wing off the page. Such as this Amazon page, where SUPERBUG is available at a pre-release price that is 34% off.)

More to come soon, on the many stories that occurred last week, and an exciting paper in a medical journal later this week.

Warning on ST398: Monitor this now

Drawing your attention: I have a story up tonight at CIDRAP on a new paper by Dr. Jan Kluytmans, a Dutch physician and microbiologist and one of the lead researchers tracking "pig MRSA," ST398. (All past stories on ST398 here.) It's a review paper, which is to say that it summarizes key existing findings rather than presenting original research.

Still, it's important reading because Kluytmans is one of the few scientists who have some history with this bug and understand how quickly and unpredictably it has spread across borders and oceans, from pigs to other livestock, to pig farmers and veterinarians, into health care workers and hospital patients who have no known livestock contact, and now into retail meat in Europe, Canada and the United States.

Take-away: A plea and warning for better surveillance, so that we can track not only the bug's vast range, but also its evolution as it moves into new ecological niches — including humans who are buying that retail meat and possibly becoming colonized with it as they prep it for cooking in their home kitchens.

To honor fair use (and in hopes you'll kindly click over to CIDRAP), I won't quote much, but here's the walk-off:

Because the novel strain has spread so widely and has already been identified as a cause of hospital outbreaks, it should not be allowed to spread further without surveillance, Kluytmans argues."It is unlikely that this reservoir will be eradicated easily," he writes. "Considering the potential implications of the reservoir in food production animals and the widespread presence in meat, the epidemiology of [MRSA] ST398 in humans needs to be monitored carefully."

The cite is: Kluytmans JAJW. Methicillin-resistant Staphylococcus aureus in food products: cause for concern or case for complacency? Clin Microbiol Infect 2010 Jan;16(1):11-5. The abstract is here.

SUPERBUG website coming - what would you like to see?

Constant readers, with publication of SUPERBUG the book coming closer, I'm starting to put together the pieces for a website. It will have stuff about the book, of course: details, excerpts, behind-the-scenes goodies, news on the key characters, and more. But my hope would be for the site to go beyond that, and to be a resource for people who want information about MRSA, or who want to network with other patient and family members, or find like-minded activists to talk with about the dangers of antibiotic resistance in agriculture.

But any site is not just going to be about me: We've become a community here over the past few years. So please tell me in the comments or by email: What would be most useful to you? Let me know what your wish-list is for SUPERBUG, and I'll take it to the designers when we plan the new site.

I'd really like to know.

Questioning meat-raising and meat-eating — in eat-everything France

Happy New Year, constant readers. I'm honored and flattered to have had the chance to spend the past few years with you here. 2010 is going to be a big year — not just because SUPERBUG will be published, but because the issue of antibiotic resistance really, really is gathering force in the public mind. I not only believe that, I see it in the news that flows through my computer everyday. The wind is shifting.

Here's one excellent example. In France of all places, a culture that embraces meat-eating and finds the idea of animal rights quixotic. a book has been published that questions the environmental and moral effects of modern factory farming. It's called Bidoche, L'industrie de la viande menace le monde ("Bidoche" is a slangy, dismissive term for meat), and it has made enough of a splash that the newspaper Le Monde ran both an article on the book and a readers' Q&A with the author, journalist Fabrice Nicolino. (The article ran two days before Christmas but was called out on Twitter today by Paula Crossfield of CivilEats.com, who spotted it while on holiday, and to whom hat/tip.)

Sadly, the article is behind a paywall; you can see the first 100 words or so here. The Q&A is open though. It's titled, "To save the planet, should we eat less meat?"and makes fascinating reading (GoogleTranslate into English here), as do the comments, some of which raise the issue of the use of antibiotics in agriculture. But what's most striking to me is that the conversation is taking place at all, actively and in a public forum, in a place where only a few years ago the local culture would not have been open to the debate. Things are changing indeed.