October 29, 2007

Antibiotic Resistant Infections No Longer Confined To Hospitals

By  Michael D. Shaw

Readers of this column will recall that I have discussed the severe problem of hospital-acquired infections in the past. One of the worst is methicillin-resistant Staphylococcus aureus (MRSA), that appeared only a few years after this antibiotic was introduced in 1959. In 2005, in the US, more than 18,000 people died of hospital-acquired MRSA, within the group of over 94,000 who developed a serious Staphylococcus aureus infection while in the hospital.

It was the 18,000 figure—exceeding the number of fatalities from AIDS—widely publicized in a recent edition of the Journal of the American Medical Association that has brought the issue to the forefront. In the wake of the Journal piece, newspaper articles appeared all over the country, adding local color such as the Seattle Times did with one-year-old Anna DeBord, who spent a tense weekend at the city’s Children’s Hospital & Regional Medical Center being treated for an MRSA infection of apparently unknown etiology.

Although MRSA was first identified in Europe in the 1960s, it made its way into the US by the next decade, and through the 1990s seemed to be confined to hospitals and long-term care facilities. During this period, perhaps 60% of the cases were diagnosed in intensive care units, and the good news about MRSA was that it stayed out of the “community” (meaning the normal environment outside of hospitals).

At least, that was the working hypothesis. Some feel that the problem was never taken seriously enough in the hospitals. Betsy McCaughey, chairwoman of the New York-based Committee to Reduce Infection Deaths, and a former lieutenant governor of the state thinks she knows why:

“It’s inertia. For many years, it was assumed that infection was the inevitable risk you faced when you went into the hospital. Now, the evidence is compelling that as many as 90 percent of these infections are preventable through cleaning and screening.”

By 2000, though, the picture had changed. At this point, 73% of MRSA cases were being diagnosed in communities (community-acquired MRSA or CA-MRSA), and by 2004, 89% of MRSA cases were community-acquired.

Community outbreaks have occurred in athletes in close-contact sports, IV drug users, inmates, group-home residents, in health clubs/gyms, tattoo parlors, and emphatically—schools. The bug is usually transmitted via skin contact, either from person to person or from surface to person.

The infection presents initially as small red bumps, which then become deep, painful abscesses, or cellulitis. Diagnosis is made by culturing the drainage from the area. Treatment includes several antibiotics, such as vancomycin, Synercid, and Tygacil. It is noted in the medical literature that the natural remedy oil of oregano can be quite effective against MRSA, as well.

The CDC identifies five important factors that promote MRSA transmission. They call them the five C’s:  Crowding, frequent skin-to-skin Contact, Compromised skin (i.e., cuts or abrasions), Contaminated items and surfaces, and lack of Cleanliness.

The CDC goes on to suggest:

• Practicing good hygiene (e.g., keeping your hands clean by washing with soap and water or using an alcohol-based hand sanitizer and showering immediately after participating in exercise)
• Covering skin trauma such as abrasions or cuts with a clean dry bandage until healed
• Avoiding sharing personal items (e.g., towels, razors) that come into contact with your bare skin; and using a barrier (e.g., clothing or a towel) between your skin and shared equipment such as weight-training benches
• Maintaining a clean environment by establishing cleaning procedures for frequently touched surfaces and surfaces that come into direct contact with people’s skin

Currently, tracking of MRSA infections is spotty at best. Betsy McCaughey minces no words:

“[T]he CDC’s lax guidelines and failure to adequately count the number of hospital infections are largely to blame for this problem. They have given hospitals an excuse to do too little.”

Lisa McGiffert, director of Consumers Union’s Stop Hospital Infections campaign, argues that MRSA can’t be stopped unless it’s tracked:

“Some people say, ‘We know it’s a problem; we don’t have to count.’ But we’ve been kind of denying it is a problem. Denial is a dangerous thing when it comes to antibiotic resistance. You cannot solve a problem until you’re aware of the extent of the problem.”

Ideally, tracking would include both hospital-acquired and community-acquired MRSA, and a number of politicians are finally jumping on the bandwagon. It’s about time.