Is re-emerging superbug the next MRSA?

Loyola physicians warn little-known bacteria Clostridium difficile next emerging disease threat, killing 1,000s in the United States

MAYWOOD, Ill, 16 sept 2008 – Dr. Ed Corboy had no idea what was afflicting his 80-year-old mother, Joan Corboy.
All he knew for certain was that since being treated for what was a routine diarrheal infection, she seemed to be wasting away and none of her doctors or other health specialists could explain why.
"She lost almost 55 pounds between July Fourth and Christmas in 2006," said Corboy, a resident of Wilmette. "She was so sick, so weak and despite the best care of her doctors, she was getting weaker. It was clear she was in big trouble."
Afraid that his mother was running out of time, Corboy called the Centers for Disease Control in Atlanta for advice. Dr. Clifford McDonald told him the infection his mother probably had was of the NAP1 type of the bacteria Clostridium difficile, a virulent strain of a common intestinal bacteria currently plaguing hospitals that now rivals the superbug Methicillin-resistant staphylococcus aureus (MRSA) as one of the top emerging disease threats to humans.
"Disease caused by Clostridium difficile can range from nuisance diarrhea to life-threatening colitis that could lead to the surgical removal of the colon, and even death," said Dr. Stuart Johnson, associate professor of medicine, division of infectious diseases, Loyola University Chicago Stritch School of Medicine. "It's a very hardy strain and it seems to persist."
C-diff, as it is better known, is a bacterium that was discovered in 1978 to be the cause of antibiotic-associated diarrhea and colitis, said Johnson, one of the world's top C-diff researchers and physicians, and who successfully treated Joan Corboy's infection. Although C-diff sickens about 500,000 Americans a year and has reached epidemic proportions in 38 states including Illinois, most people have not yet heard of it.
"I don't think that people appreciate the urgency and severity of this disease," said Dr. Dale Gerding, professor of medicine, division of infectious diseases, Stritch School of Medicine, and associate chief of staff for Research, Hines VA Hospital. "In the past, it was thought to be a nuisance illness. Now it is a fatal illness and a lot of physicians have not figured that out as yet."
Hospitals in Quebec have been particularly hard hit by C-diff. In the 12 hospitals affected, about 2,000 deaths were directly attributable to the antibiotic resistant strain between the 2003 and 2004. In the United Kingdom, deaths from C-diff leaped by 28% in 2007 to more than 8,000, according to the nation's Department of Health.
"What was surprising was not just the rates, but the number of severe cases," said Johnson, who helped treat Joan Corboy's illness.
Similar to MRSA, C-diff is an infection that is mainly acquired in a hospital or nursing home, although like MRSA there is some evidence that a community-acquired strain may be developing, according to the CDC.
"When a patient is in the hospital getting antibiotics for some type of infection, one of the potential complications is that the normal bacterium that lives in the colon is disturbed with that antibiotic. That makes you susceptible to an infection with Clostrium difficile," Johnson said. "The great majority of cases occur in people who have recently used antibiotics."
When C-diff is not actively dividing, it forms very tough spores that can exist on surfaces for months and years, making it very difficult to kill, Johnson said.
"Antibiotics are very effective against the growing form of the bacteria but it doesn't do anything to the spores," Johnson said. "If there are spores they can sit around like stealth bombs. Once the antibiotic is gone, these spores can germinate again and spread their toxins."
Since its discovery, C-diff has grown increasingly resistant to antibiotics, according to Johnson and Gerding, who has been studying the bacteria since 1980. Though it is appearing more often in younger people, those 65 years and older face a greater risk of developing infection from C-diff and has more severe outcomes and higher death rates. Relapse is common with about 25 percent of patient experiencing a second bout of disease within two months after their first. Patients who have had two or more episodes of disease have a 30 percent to 65 percent risk of another bout.
Symptoms of C-diff include profuse diarrhea and abdominal pain and distention of the abdomen. An infection is also frequently accompanied by fever, nausea and dehydration. In some rare cases blood may be present in the stool. The infection is spread by spores that contaminate the hospital environment and hands of healthcare workers who can transmit the spores to patients. The resistance of the spores to hospital cleaning agents and to alcohol hand disinfectants makes it extremely difficult to eradicate.

Dangerous MRSA Strain Evolved Recently from Common Ancestor

By Michael Smith
HAMILTON, Mont., Jan. 22 -- It may be no exaggeration to call the highly pathogenic community-acquired methicillin-resistant Staphylococcus aureus a superbug, researchers here found.
The recently identified USA300 strain, now widespread in the U.S., evolved from a single ancestor, according to Frank DeLeo, Ph.D., of the National Institute of Allergy and Infectious Diseases' Rocky Mountain Laboratories, and colleagues.
The USA300 strain of community-acquired MRSA, unknown until 2000, has become a leading cause of skin and soft-tissue disease in otherwise healthy people. But researchers had been puzzled about the origin of the USA300 strain.
Now, whole genomic sequencing shows that the USA300 isolates found across the country share a recent common ancestor, Dr. DeLeo and colleagues reported online in the Proceedings of the National Academy of Sciences.
The data rule out the competing hypothesis that various isolates derived from different ancestors had converged on the virulent USA300 strain, the researchers said.
The findings "add an evolutionary dimension to the epidemiology and emergence of USA300," Dr. DeLeo and colleagues said.
The mechanism appears to be similar to what happened in the 1950s, when a penicillin-resistant form of S. aureus (known as phage-type 80/81 S. aureus) caused a pandemic in U.S. hospitals and the community.
Currently, community-acquired MRSA is responsible for the majority of skin and soft-tissue infections in patients coming to U.S. emergency departments and the USA300 strain has been blamed for 67% of the invasive infections, the researchers noted.
Dr. DeLeo and colleagues used genetic mapping techniques to compare 10 USA300 isolates from around the U.S. with a reference strain that was sequenced in 2006.
They looked for single nucleotide polymorphisms (SNPs) -- single-letter changes in the DNA of the organism -- as well as other so-called regions of difference (RDs), such as insertions or deletions of genetic material.
The key finding was that eight of the 10 isolates were nearly identical, with an average difference from the reference strain of only 32 SNPs and from each other of just 50 SNPs, Dr. DeLeo and colleagues said.
An indication of relatively recent divergence is the ratio of non-synonymous to synonymous SNPs -- those that lead to a change in the derived polypeptide sequence versus those that make no change.
In this case, Dr. DeLeo and colleagues said, the ratio was a "relatively high" 1.9:1 and when only the eight most closely related isolates were considered, the ratio was 2.6:1.
The only reasonable interpretation "is that there has been very recent clonal expansion and geographic dissemination" of USA300, ruling out the possibility of convergent evolution, they said.
Interestingly, not all of the isolates were equally virulent in mice.
Animals infected with two of the isolates lived significantly longer (P=0.0002) than those infected with the reference strain -- even though all were genetically similar.
The inference is that even small changes in DNA can make large changes in the virulence of the organism, Dr. DeLeo and colleagues said.
"It is reasonable to conclude that within a short period there will be an increasing pool of derivative USA300 isolates that differ in virulence potential and/or pathogenicity," the researchers said.
The research was supported by NIAID.
The researchers reported no conflicts.
Primary source: Proceedings of the National Academy of SciencesSource reference:Kennedy AD, et al "Epidemic community-associated methicillin-resistant Staphylococcus aureus: recent clonal expansion and diversification" PNAS 2008; DOI: 10.1073/pnas.0710217105.

FDA Okays Rapid Blood Test for MRSA

By Todd Neale
ROCKVILLE, Md., Jan. 2 -- The FDA today approved the first rapid blood test for methicillin-resistant Staphylococcus aureus (MRSA).
The BD GeneOhm StaphSR Assay can determine within two hours whether genetic material in a blood sample belongs to MRSA or a more treatable staph bacterium, according to the FDA. Tests currently used can take more than two days.
In October, the CDC announced a revised estimate of 94,360 invasive MRSA infections in 2005, up from 31,440 in 2000. (See: Invasive MRSA More Pervasive Than Suspected)
This was preceded by public concerns about the apparent rise of community-acquired MRSA.
The new test was cleared on the basis of a clinical trial that showed that the assay identified 100% of the MRSA specimens and 98% of the less dangerous staph bacteria.

AAO: Dramatic Increase in Ocular MRSA Documented


NEW ORLEANS, Nov. 15 -- The frequency of ocular methicillin-resistant Staphylococcus aureus (MRSA) increased by almost 60% in the first six years of the decade, according to a study reported here.
Action Points
Explain to interested patients that the frequency of a drug-resistant bacteria found in ocular specimens has increased by almost 60% since 2000.
Point out that the resistant strains may not respond to antibiotics frequently used to treat eye infections.
Note that the findings were reported at a medical conference and should be considered preliminary until they appear in a peer-reviewed journal.
The proportion of MRSA isolates in ocular specimens rose from 18.3% in 2000 to 29.1% in 2005, Darlene Miller, D.H.Sc., of the Bascom Palmer Eye Institute in Miami, told attendees at the American Academy of Ophthalmology meeting.
Usually associated with hospital acquisition, ocular MRSA isolates consistent with community-acquired MRSA accounted for almost 20% of the total, she said.
"The findings suggest that the conjunctiva and lids might serve as potential reservoirs for community-acquired MRSA," Dr. Miller said. "The data also indicate that common ocular antimicrobial agents, such as erythromycin and tetracycline, might be inappropriate for treatment of MRSA."
S. aureus is the most common pathogen isolated in association with conjunctivitis, blepharitis, and adjacent soft-skin infections. S. aureus also may appear as resident flora in up to 30% of normal eyes and in up to 2% of patients undergoing cataract surgery, said Dr. Miller.
To evaluate community-associated MRSA profiles in ocular MRSA isolates, Dr. Miller and colleagues reviewed data from multiple sources to identify all MRSA isolates recovered from conjunctiva, eyelids, and orbit from 2000 through 2005. They identified a total of 484 S. aureus isolates, 141 (29%) of which were MRSA.
MRSA as a proportion of all S. aureus isolates increased by 59% from 2000 through 2005, they found. More than half of the MRSA isolates (74/141) exhibited multidrug resistance.
Dr. Miller reported that the source of the isolates was the conjunctiva in 375 cases, eyelids in 97, and orbit in 12. With respect to MRSA isolates, the site of isolation was the conjunctiva in 109 cases, eyelids in 28, and orbit in four.
The proportion of MRSA isolates did not differ significantly by site of isolation.
Hospital-acquired and community-acquired MRSA differ with respect to susceptibility profiles, chromosomal makeup, and virulence, Dr. Miller said. Of the 141 ocular MRSA isolates, 26 (18.4%) had profiles consistent with community-acquired MRSA: 12 each from the conjunctiva and eyelids and two from the orbit.
"The findings show that isolates consistent with community-acquired MRSA can be isolated from ocular sources in the absence of an outbreak," said Dr. Miller.
The study was supported by Research to Prevent Blindness. Dr. Miller had no disclosures.Primary source: American Academy of OphthalmologySource reference: Miller D, Alfonso ED, "Prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) among ocular MRSA isolates" AAO Meeting 2007; Abstract PO293.

Staph germ undermines body's defenses

By RANDOLPH E. SCHMID, AP Science WriterSun Nov 11, 2:30 PM ET
The aggressive antibiotic-resistant staph infection responsible for thousands of recent illnesses undermines the body's defenses by causing germ-fighting cells to explode, researchers reported Sunday. Experts say the findings may help lead to better treatments.
An estimated 90,000 people in the United States fall ill each year from methicillin-resistant Staphylococcus aureus, or MRSA. It is not clear how many die from the infection; one estimate put it at more than 18,000, which would be slightly higher than U.S. deaths from AIDS.
The infection long has been associated with health care facilities, where it attacks people with reduced immune systems. But many recent cases involve an aggressive strain, community-associated MRSA, or CA-MRSA. It can cause severe infections and even death in otherwise healthy people outside of health care settings.
The CA-MRSA strain secretes a kind of peptide — a compound formed by amino acids — that causes immune cells called neutrophils to burst, eliminating a main defense against infection, according to researchers.
The findings, from a team of U.S. and German researchers led by Michael Otto of the National Institute of Allergy and Infectious Diseases, appeared in Sunday's online edition of the journal Nature Medicine.
While only 14 percent of serious MRSA infections are the community associated kind, they have drawn attention in recent months with a spate of reports in schools, including the death of a 17-year-old Virginia high school student.
Both hospital-associated and community-associated MRSA contained genes for the peptides. But their production was much higher in the CA-MRSA, the researchers said.
The compounds first cause inflammation, drawing the immune cells to the site of the infection, and then destroy those cells.
The research was conducted in mice and with human blood in laboratory tests.
Within five minutes of exposure to the peptides from CA-MRSA, human neutrophils showed flattening and signs of damage to their membrane, researchers said. After 60 minutes, many cells had disintegrated completely.
"This elegant work helps reveal the complex strategy that S. aureus has developed to evade our normal immune defenses," Dr. Anthony S. Fauci, NIAID director, said in a statement. "Understanding what makes the infections caused by these new strains so severe and developing new drugs to treat them are urgent public health priorities."
Dr. George G. Zhanel, a medical microbiologist at the University of Manitoba in Canada, said the study was the first he had seen that identifies the peptides involved.
This shows at least one of the reasons CA-MRSA is able to cause serious problems, Zhanel, who was not part of the research team, said in a telephone interview.
Findings like this may help lead to better treatments, such as ways to neutralize the peptides or to activate the immune system to defeat them, he added.
Dr. Lindsey N. Shaw of the division of cell biology, microbiology and molecular biology at the University of South Florida, also was enthusiastic about the research.
"Specifically identifying a factor which seemingly makes CA-MRSA more pathogenic than HA-MRSA is a real find," Shaw, who was not part of the research group, said via e-mail. The "molecules identified in the study are indeed novel."
Zhanel noted that while hospital-based MRSA seemed to concentrate on "sick old people," the community-based strain can break out in on sports teams, prisons, cruise ships and other places where people are not necessarily sick or have weakened immune systems.
In a worrisome development, he noted that the more aggressive strains have started appearing in hospitals.
Dr. Clarence B. Creech, an assistant professor of pediatric infectious disease at Vanderbilt University, said every time scientists find a new way that staph uses to make people sick, "we open up the field of developing new vaccine targets and new drug targets."
"This is one of the papers we can look to as we develop new vaccines and drugs," Creech, who was not part of the research team, said in a telephone interview.
The research was funded by the National Institutes of Health, the German Research Council and the German Ministry of Education and Research.
___
On the Net:
Nature Medicine: http://www.nature.com/naturemedicine
NIH background on MSRA: http://tinyurl.com/2w4amj

Good hygiene can stop staph infections

By LAURAN NEERGAARD, AP Medical WriterWed Nov 7, 10:09 PM ET
Drug-resistant staph infections that have made headlines in recent weeks come from what the nation's top doctor calls "the cockroach of bacteria" — a bad germ that can lurk in lots of places, but not one that should trigger panic.
"This isn't something just floating around in the air," Dr. Julie Gerberding, head of the Centers for Disease Control and Prevention, told members of Congress on Wednesday.
It takes close contact — things like sharing towels and razors, or rolling on the wrestling mat or football field with open scrapes, or not bandaging cuts — to become infected with the staph germ called MRSA outside of a hospital, she said. But MRSA is preventable largely by common-sense hygiene, Gerberding stressed.
"Soap and water is the cheapest intervention we have, and it's one of the most effective," she told a hearing of the House Committee on Oversight and Government Reform.
At issue is methicillin-resistant Staphylococcus aureus, a form of the incredibly common staph family of germs. About one in every three people carries staph aureus in their noses. In about 1 million people, the type they carry is MRSA.
"I like to think of it as the cockroach of bacteria," Gerberding said, pointing out MRSA's ability to live on various surfaces and spread by catching a ride on an unwashed hand.
Over time, germs evolve to withstand treatment. Most staph is no longer treatable by the granddaddy of antibiotics, penicillin. By the 1960s, staph also began developing resistance to a second antibiotic, methicillin.
So MRSA is not a new problem. What is new is public anxiety about it.
MRSA mostly causes skin infections, such as boils and abscesses. But it can sometimes spread to cause life-threatening blood infections. Last month, the CDC reported the first national estimate of serious MRSA infections — 94,000 a year. It's not clear how many people die, but one estimate put the MRSA death toll at more than 18,000, slightly higher than U.S. deaths from AIDS.
There are two distinct strains of MRSA, a type spread in hospitals and other health facilities and a genetically different type spread in communities. The vast majority of victims are hospital patients; only 14 percent of serious MRSA infections are the kind spread in the community.
But the CDC's report coincided with the death of a 17-year-old Virginia high school student, prompting a spate of reports of MRSA infections in schools. That prompted lawmakers to pepper Gerberding with questions Wednesday:
_Should schools close for cleaning if a student gets MRSA? That's not medically necessary, Gerberding said. Bleach and a list of other germicides can be used in routine cleaning of areas and equipment where bacteria cluster.
"There's no need to go in and disinfect a whole school because that isn't how this organism is transmitted," she said.
_How worried should parents be? Some 200 children a year will get serious MRSA, and the vast majority will be treated successfully, Gerberding said. Community-spread MRSA is still easily treated by many other routine antibiotics. So wash and bandage cuts, and seek prompt medical care if they show signs of infection.
Most outbreaks of community-spread MRSA occur not in schools but in prisons, where inmates share toiletries and lack or don't use soap.
_Should every patient entering a hospital be tested for MRSA, and isolated if they harbor it? Some hospitals have begun that, but current guidelines call for that step only if hospitals fail to reduce MRSA infections by less drastic means, Gerberding said.
Her concern: "Patients in isolation get less care." Doctors and nurses check on them less. They get more bed sores, opening the body to other life-threatening germs.
There is a biological conundrum: Hospital-based MRSA is more common, vulnerable to fewer antibiotics than the strain spread in communities, and those already-ill patients are more likely to die from it. Yet, the community strain of MRSA may be somewhat stronger, possibly explaining why otherwise healthy people sometimes succumb.
It's a strain called USA300, and if it penetrates the skin it can cause key immune cells — white blood cells — to explode, setting off a chain reaction of inflammation, Gerberding explained. This strain, unlike most hospital MRSA, also produces a toxin known as PVL, and scientists are furiously investigating its role.
New antibiotics are important, but won't solve MRSA or the myriad other drug-resistant bacteria, she said.
Germs "will always be one step ahead of our drugstores," Gerberding said. "We have to get back to the basics" — wash your hands and cover your cuts.

For MRSA Prevention, Clean Surfaces as Well as Hands

GLASGOW, Scotland, Oct. 31 -- Focusing more attention on cleaning door handles and other frequently-touched surfaces in hospitals may reduce transmission of methicillin-resistant Staphylococcus aureus (MRSA) beyond what can be accomplished by hand washing alone.
So reported Stephanie J. Dancer, M.D., of Southern General Hospital here, in a review published online in The Lancet Infectious Diseases.
Although clean hands are important, "introduction of additional cleaning services is easier than improvements in hand-hygiene compliance," she wrote.
The review came on the heels of increasing attention to MRSA in the media after outbreaks at Connecticut high schools and the death of a student in Virginia. (See: Survey Report: MRSA Publicity Will Make a Difference and Focus on Community-Acquired MRSA Was Preceded by Cadence of Concerns)
The focus was also turned on MRSA in the field of infectious diseases following a report earlier this month from the CDC that invasive MRSA was three times more common than previously estimated. (See: Invasive MRSA More Pervasive Than Suspected)
Despite all the attention, though, the importance of hospital cleaning is still debated, Dr. Dancer said.
"There is little direct evidence for the effectiveness of cleaning because it has never been afforded scientific status," she wrote.
Cleanliness of hospitals is usually assessed visually and is defined in cleaning manuals, monitoring strategies, and infection control guidelines, but dirt does not necessarily correlate with growth of MRSA or other pathogens, Dr. Dancer said.
One study, she noted, found that 82% to 91% of hospital wards were visibly clean but only 30% to 45% were considered microbiologically clean and just 10% to 24% were free from organic soil. Another study failed to correlate British hospital hygiene performance scores to MRSA rates.
The staphylococcal transmission cycle between people and their environment show that the disease is remarkably resilient and can be found on virtually all surfaces in hospitals, Dr. Dancer said.
Staphylococci bacteria can be found in the air and environment in which colonized patients live or through which they pass. There is "overwhelming" evidence, she said, for MRSA contamination on virtually all hospital surfaces, including door handles, television sets, beds, and paper.
On average, Dr. Dancer said, MRSA is found on about one-third of hospital surfaces sampled regardless of whether sampling occurred during an outbreak situation.
"The fact that most of these items can be touched by hands is important when considering the origin of MRSA contamination," she noted.
Infected patients most frequently carry the bacteria in their nose.
"Given the propensity for people to pick, touch, or blow their noses, it is not surprising that carriers will often harbor their own strain of S. aureus on their fingers, which they will then transfer to any site accessible to their hands," Dr. Dancer wrote.
But transmission is not limited to habitual carriers, because anyone who has just touched a contaminated site can contribute to the spread of bacteria as well, the researcher said.
Even if fingertips transport only a few colony-forming units of MRSA, as few as 10 could cause an infection.
All cleaning methods -- routine vacuuming and detergent-based cleaning, disinfectant-based deep cleaning, and decontamination with gaseous hydrogen peroxide -- have been shown to reduce MRSA in the hospital environment. Cutting down on the number of microbes present should reduce the risk of infection, Dr. Dancer said.
But, liquid disinfectants and detergents would damage the many types of electronic equipment, "providing more hand-touch sites that require a greater degree of sophisticated cleaning attention," she wrote.
Furthermore, MRSA risk lingers even at hospitals that exceeded CDC and Healthcare Infection Control Practices Advisory Committee standards for room cleaning procedures at discharge. (See: MRSA Risk Lingers from ICU Room's Prior Occupant)
And, the expense of extra cleaning can be prohibitive, especially in view of the current preoccupation with hospital budgets, she said.
Concentrating already available cleaning resources on high-risk hand-touch sites may be the most cost-effective cleaning strategy other than campaigning for more cleaning hours, she concluded.
"There can be no doubt that prioritizing hand hygiene is the single most beneficial intervention in the control of MRSA and many other pathogens," she said.
However, hand-hygiene initiatives have been less successful than environmental cleaning in some studies.
"And even if everyone does wash their hands properly, the effects of exemplary hand hygiene are eroded if the environment is heavily contaminated with MRSA," Dr. Dancer added.
Dr. Dancer reported no conflicts of interest.Primary source: The Lancet Infectious DiseasesSource reference: Dancer SJ, et al "Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning" Lancet Infect Dis 2007; DOI: 10.1016/S1473-3099(07)70241-4.

Staph screening said may wipe out germ

By LINDSEY TANNER, AP Medical WriterFri Oct 26, 11:51 AM ET
Testing all new hospital patients for a dangerous staph "superbug" could help wipe out a germ that likely kills more Americans than AIDS, consumer advocates say and early evidence suggests.
Yet few U.S. hospitals do it, and many fight efforts to require it. Jeanine Thomas, who nearly died from the drug-resistant staph bug, says the reason is simple: "Doctors don't want to be told what to do."
The Chicago suburbanite's personal crusade led Illinois this year to become the first state to order testing of all high-risk hospital patients and isolation of those who carry the staph germ called MRSA.
Powerful doctor groups fought against it. The testing and isolation of patients would be too costly, they said. Many other germs plague hospitals that also require attention. Experts said a more proven approach would focus on better hand washing by hospital staff — a simple measure tough to enforce.
Yet, Thomas prevailed. Similar measures passed this year in Pennsylvania and New Jersey. And Thomas' national crusade to make hospitals test for MRSA and report their infection rates gained steam last week after a Virginia teenager's death from the germ and a government report estimated it causes dangerous infections that sicken more than 90,000 Americans each year and kill nearly 19,000.
Suddenly the little-known germ with the cumbersome name, methicillin-resistant Staphylococcus aureus, is getting lots of attention.
People in health care settings, like hospitals and nursing homes, are most at risk for MRSA infections. Doctors and nurses who treat staph-infected patients and then don't carefully wash up can spread the germ to other patients. Germ-contaminated medical devices used on people having dialysis or medical procedures also can spread staph. Older patients and blacks are most at risk, according to the recent report by government researchers.
MRSA, pronounced Muhr-suh, has been around for decades and in recent years has spread to schools, prisons and crowded public housing projects. Even healthy people can carry it on their skin. It may look like a pimple or spider bite that doesn't heal, but it can turn deadly if it enters the bloodstream or morphs into a flesh-eating wound.
Yet, many infection control experts oppose required testing for it in hospitals.
Many note that MRSA is just one of dozens of risky germs that often infect people in hospitals — particularly those with weakened immune systems or open wounds.
But Lisa McGiffert doesn't buy it. The director of the Consumers Union's campaign to stop hospital infections calls that "an argument of distraction."
"Certainly there are other superbugs and they should be tackling those, too," said McGiffert. "To eradicate hospital-acquired infections is going to take a comprehensive effort" that should include testing hospital patients, she said.
About 1.7 million Americans each year develop infections from various germs while hospitalized and almost 100,000 of them die, according to the U.S. Centers for Disease Control and Prevention.
MRSA accounts for only about 10 percent of these infections. Other worrisome bugs include C-difficile (an intestinal infection), vancomycin-resistant Enterococcus (linked with intestinal, skin and blood infections), and drug-resistant Acinetobacter (which can cause pneumonia, skin and blood infections); none of them accounts for more than 10 percent of hospital infections.
MRSA infections have hogged attention, partly because they're on the rise. And, acknowledges the CDC's Dr. John Jernigan, "MRSA likely accounts for a disproportionate amount of illness and death" because of its strength and resistance to mainline antibiotics.
CDC recommendations for fighting drug-resistant bugs list MRSA testing as an option. However, the agency says it's unclear whether that works better than other measures. Those include judicious use of antibiotics, hand washing, and wearing gloves, gowns and other protective gear.
"We don't think (testing is) a silver bullet to that problem," Jernigan said.
The Joint Commission, an independent, nonprofit group that sets standards for the nation's hospitals, doesn't have specific rules on how to prevent MRSA.
The commission's Dr. Robert Wise said the organization wants to see evidence that MRSA testing and other measures work. He said the commission hopes to have an answer early next year and then will then decide whether to adopt new standards.
Perhaps the commission will review an experiment done in Pittsburgh. There, the Veterans Affairs hospital tested new patients for staph, using a nose swab. They isolated those who had the germ, and annual infection rates fell from about 60 to 18 cases, said Dr. Rajiv Jain.
The staph bug used to cause "occasional" deaths, but no patient has died since 2005 when testing of all patients began, said Jain, who is with the VA's MRSA prevention program.
In May, the VA began putting a $28 million testing system in place for all 155 hospitals. But it costs about $32,000 to treat one hospitalized MRSA patient, so "if you reduce infections by 50 percent, you more than recuperate the cost," Jain said.
Denmark, Iceland, Norway, and the Netherlands have reduced their MRSA rates and all test high-risk patients. In the Netherlands, that means testing foreign patients.
Opponents of mandatory testing point out that these small countries all had low rates of the germ to begin with. Hospitals in larger, more diverse nations like Britain, for example, have long had problems with MRSA.
And testing may not make sense for hospitals that treat few high-risk patients or where other bugs are more prevalent, opponents say.
"The best approach is not to have state legislators dictating how hospitals go about fighting infections, said Dr. Don Goldmann, of the Institute of Healthcare Improvement, a nonprofit advocacy group.
At the University of Chicago Medical Center, doctors have been focusing on C-difficile bacteria, which can cause severe intestinal illness.
With Illinois' new law requiring MRSA testing, "We're having to shift gears and haven't been able to devote what we'd hoped on these other pressing problems," said Dr. Stephen Weber, the hospital epidemiologist.
At Chicago's Rush University Medical Center, lab supplies alone for the testing will likely cost about $80,000, said Stacy Pur, Rush's chief nurse epidemiologist for infection control.
"It's very labor-intensive and we would really much rather focus our efforts on infection control" measures proven to work, including better hand washing by hospital staff, she said.
But Thomas, the MRSA patient-turned-advocate, argues: "You're never going to control this with hand hygiene, because you're never going to get 100 percent compliance."
Thomas had never heard of MRSA until she slipped on ice seven years ago and broke her left ankle. That landed her in a Chicago hospital, where she believes she got the infection.
Two days after being sent home, she developed throbbing pain in her left leg. She went to the emergency room, where doctors removed her splint and found the ankle hugely swollen, black and draining pus. She was admitted and given antibiotics, but within a week the infection spread inside her body; her lungs, kidneys and other vital organs shut down.
Hospitalized for three weeks and bedridden for six months, she recovered but her ankle joint was destroyed. She formed a support group and began lobbying for the new law.
Now Thomas is working with advocates in several other states.
"We have a wave happening," she said.
And if Illinois hospitals don't comply, she may push to enact testing of all — not just high-risk — hospital patients.
That has been done since 2005 at three Chicago area hospitals in the Evanston Northwestern Healthcare system. There, the MRSA infection rate has dropped 60 percent, said the system's Dr. Lance Peterson.
And at the VA hospital in Pittsburgh, Jain reported an added bonus. The rates for other hospital-acquired infections also fell after MRSA testing began.
Why? The testing may have caused hospital workers to pay more attention to hand washing and other prevention efforts, he said.
___
Medical Writer Maria Cheng in London contributed to this report.
____
CDC: http://www.cdc.gov
MRSA support group: http://www.mrsa-survivors

Staph screening said may wipe out germ

By LINDSEY TANNER, AP Medical WriterWed Oct 24, 8:52 PM ET
Testing all new hospital patients for a dangerous staph "superbug" could help wipe out a germ that likely kills more Americans than AIDS, consumer advocates say and early evidence suggests.
Yet few U.S. hospitals do it, and many fight efforts to require it. Jeanine Thomas, who nearly died from the drug-resistant staph bug, says the reason is simple: "Doctors don't want to be told what to do."
The Chicago suburbanite's personal crusade led Illinois this year to become the first state to order testing of all high-risk hospital patients and isolation of those who carry the staph germ called MRSA.
Powerful doctor groups fought against it. The testing and isolation of patients would be too costly, they said. Many other germs plague hospitals that also require attention. Experts said a more proven approach would focus on better hand washing by hospital staff — a simple measure tough to enforce.
Yet, Thomas prevailed. Similar measures passed this year in Pennsylvania and New Jersey. And Thomas' national crusade to make hospitals test for MRSA and report their infection rates gained steam last week after a Virginia teenager's death from the germ and a government report estimated it causes dangerous infections that sicken more than 90,000 Americans each year and kill nearly 19,000.
Suddenly the little-known germ with the cumbersome name, methicillin-resistant Staphylococcus aureus, is getting lots of attention.
People in health care settings, like hospitals and nursing homes, are most at risk for MRSA infections. Doctors and nurses who treat staph-infected patients and then don't carefully wash up can spread the germ to other patients. Germ-contaminated medical devices used on people having dialysis or medical procedures also can spread staph. Older patients and blacks are most at risk, according to the recent report by government researchers.
MRSA, pronounced Muhr-suh, has been around for decades and in recent years has spread to schools, prisons and crowded public housing projects. Even healthy people can carry it on their skin. It may look like a pimple or spider bite that doesn't heal, but it can turn deadly if it enters the bloodstream or morphs into a flesh-eating wound.
Yet, many infection control experts oppose required testing for it in hospitals.
Many note that MRSA is just one of dozens of risky germs that often infect people in hospitals — particularly those with weakened immune systems or open wounds.
But Lisa McGiffert doesn't buy it. The director of the Consumers Union's campaign to stop hospital infections calls that "an argument of distraction."
"Certainly there are other superbugs and they should be tackling those, too," said McGiffert. "To eradicate hospital-acquired infections is going to take a comprehensive effort" that should include testing hospital patients, she said.
About 1.7 million Americans each year develop infections from various germs while hospitalized and almost 100,000 of them die, according to the U.S. Centers for Disease Control and Prevention.
MRSA accounts for only about 10 percent of these infections. Other worrisome bugs include C-difficile (an intestinal infection), vancomycin-resistant Enterococcus (linked with intestinal, skin and blood infections), and drug-resistant Acinetobacter (which can cause pneumonia, skin and blood infections); none of them accounts for more than 10 percent of hospital infections.
MRSA infections have hogged attention, partly because they're on the rise. And, acknowledges the CDC's Dr. John Jernigan, "MRSA likely accounts for a disproportionate amount of illness and death" because of its strength and resistance to mainline antibiotics.
CDC recommendations for fighting drug-resistant bugs list MRSA testing as an option. However, the agency says it's unclear whether that works better than other measures. Those include judicious use of antibiotics, hand washing, and wearing gloves, gowns and other protective gear.
"We don't think (testing is) a silver bullet to that problem," Jernigan said.
The Joint Commission, an independent, nonprofit group that sets standards for the nation's hospitals, doesn't have specific rules on how to prevent MRSA.
The commission's Dr. Robert Wise said the organization wants to see evidence that MRSA testing and other measures work. He said the commission hopes to have an answer early next year and then will then decide whether to adopt new standards.
Perhaps the commission will review an experiment done in Pittsburgh. There, the Veterans Affairs hospital tested new patients for staph, using a nose swab. They isolated those who had the germ, and annual infection rates fell from about 60 to 18 cases, said Dr. Rajiv Jain.
The staph bug used to cause "occasional" deaths, but no patient has died since 2005 when testing of all patients began, said Jain, who is with the VA's MRSA prevention program.
In May, the VA began putting a $28 million testing system in place for all 155 hospitals. But it costs about $32,000 to treat one hospitalized MRSA patient, so "if you reduce infections by 50 percent, you more than recuperate the cost," Jain said.
Denmark, Iceland, Norway, and the Netherlands have reduced their MRSA rates and all test high-risk patients. In the Netherlands, that means testing foreign patients.
Opponents of mandatory testing point out that these small countries all had low rates of the germ to begin with. Hospitals in larger, more diverse nations like Britain, for example, have long had problems with MRSA.
And testing may not make sense for hospitals that treat few high-risk patients or where other bugs are more prevalent, opponents say.
"The best approach is not to have state legislators dictating how hospitals go about fighting infections, said Dr. Don Goldmann, of the Institute of Healthcare Improvement, a nonprofit advocacy group.
At the University of Chicago Medical Center, doctors have been focusing on C-difficile bacteria, which can cause severe intestinal illness.
With Illinois' new law requiring MRSA testing, "We're having to shift gears and haven't been able to devote what we'd hoped on these other pressing problems," said Dr. Stephen Weber, the hospital epidemiologist.
At Chicago's Rush University Medical Center, lab supplies alone for the testing will likely cost about $80,000, said Stacy Pur, Rush's chief nurse epidemiologist for infection control.
"It's very labor-intensive and we would really much rather focus our efforts on infection control" measures proven to work, including better hand washing by hospital staff, she said.
But Thomas, the MRSA patient-turned-advocate, argues: "You're never going to control this with hand hygiene, because you're never going to get 100 percent compliance."
Thomas had never heard of MRSA until she slipped on ice seven years ago and broke her left ankle. That landed her in a Chicago hospital, where she believes she got the infection.
Two days after being sent home, she developed throbbing pain in her left leg. She went to the emergency room, where doctors removed her splint and found the ankle hugely swollen, black and draining pus. She was admitted and given antibiotics, but within a week the infection spread inside her body; her lungs, kidneys and other vital organs shut down.
Hospitalized for three weeks and bedridden for six months, she recovered but her ankle joint was destroyed. She formed a support group and began lobbying for the new law.
Now Thomas is working with advocates in several other states.
"We have a wave happening," she said.
And if Illinois hospitals don't comply, she may push to enact testing of all — not just high-risk — hospital patients.
That has been done since 2005 at three Chicago area hospitals in the Evanston Northwestern Healthcare system. There, the MRSA infection rate has dropped 60 percent, said the system's Dr. Lance Peterson.
And at the VA hospital in Pittsburgh, Jain reported an added bonus. The rates for other hospital-acquired infections also fell after MRSA testing began.
Why? The testing may have caused hospital workers to pay more attention to hand washing and other prevention efforts, he said.

Invasive MRSA More Pervasive Than Suspected

ATLANTA, Oct. 16 -- Invasive infections of methicillin-resistant Staphylococcus aureus (MRSA) may be more common than suspected, according to the first nationwide surveillance estimates.The incidence of invasive MRSA infections in 2005 was 31.8 per 100,000 people, reported R. Monina Klevens, D.D.S., M.P.H., of the CDC here, and colleagues, in the Oct. 17 issue of the Journal of the American Medical Association.
Their estimate of 94,360 invasive infections was three times as high as the CDC's previous estimate of 31,440 hospitalizations for MRSA bacteremias in 2000, which was derived from discharge coded data rather than surveillance.
The findings were astounding, commented Elizabeth A. Bancroft, M.D., S.M., of the Los Angeles County Department of Public Health in Los Angeles, in an accompanying editorial.
"To put this number into context, the estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000)," she noted.
And, if the projection by the CDC investigators of 18,650 MRSA-related deaths in 2005 was accurate, "these deaths would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States," Dr. Bancroft said.
Because the vast majority of MRSA cases are noninvasive, such as skin abscesses, these estimates are likely "only the tip of the drug-resistance iceberg" with respect to disease burden, she added.
The researchers analyzed invasive MRSA infections detected in the CDC's Active Bacterial Core laboratory surveillance system from July 2004 through December 2005.
The active, population-based surveillance was done at nine laboratories covering 16.5 million patients, about 5.6% of the U.S. population. Reports of MRSA were investigated and classified as health care-associated or community-associated.
The analysis included only invasive MRSA, which was defined as infections in normally sterile sites, such as blood, cerebrospinal fluid, and internal organs.
Most of the 8,987 observed invasive MRSA infection cases were among patients whose medical records showed they had risk factors for exposure in a health care setting. The most common of these risk factors were history of hospitalization, surgery, long-term care residence, or prior MRSA infection or colonization.
Overall, 58.4% of cases were health care-associated infections with a community onset and 26.6% were health care-associated cases with onset in the hospital.
Another 13.7% were community-associated infections, which included only patients without any established health care risk factors for MRSA infection. The origin of 1.3% could not be classified.
For 2005, the standardized incidence rate of invasive MRSA was 31.8 per 100,000 after adjusting for age, race and sex. It ranged from an average of 24.4 at the three sites with the lowest incidence to 35.2 at the three with the highest incidence, excluding an outlier where incidence was 116.7 per 100,000 per year.
The standardized annual mortality rate was 6.3 per 100,000 with a similarly calculated interval from 3.3 to 7.5 to 100,000.
Factors associated with increased incidence and mortality rates, respectively, included:
Age 65 and older (127.7 and 35.3 per 100,000).
Black race (66.5 and 10.0 per 100,000).
Male gender (37.5 and 7.4 per 100,000).
A convenience sample of isolates sent to the laboratories showed that the USA 300 strain typically associated with community-origin infections showed up in some hospital-onset MRSA cases (15.7%).
However, the majority of invasive infections overall -- including 23.0% of community-associated isolates tested -- were still associated with the USA 100 MRSA strain typically found in health care settings.
"It appears that what happens in the hospital does not stay in the hospital," Dr. Bancroft commented. "Working vigorously to decrease transmission of MRSA in health care facilities may decrease both nosocomial and community-onset MRSA that occurs in persons with prior health care exposure."
She cautioned, though, that the incidence and mortality estimates might have been subject to misclassification error in determining the origin of MRSA cases because the presence of a health care risk factor does not preclude patients from acquiring the infection in the community and not all risk factors may have been recorded in hospital charts.
Furthermore, the MRSA rates in the surveillance areas may not have been representative of the nationwide distribution since incidence is known to vary geographically.
The study was funded through the Emerging Infections Program of the CDC. The researchers and Dr. Bancroft reported no financial conflicts of interest. Additional source: Journal of the American Medical AssociationSource reference: Klevens RM, et al "Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States" JAMA 2007; 298: 1763-1771. Additional source: Journal of the American Medical AssociationSource reference: Bancroft EA "Antimicrobial Resistance: It's Not Just for Hospitals" JAMA 2007; 298: 1803-1804.

Staph fatalities may exceed AIDS deaths

By LINDSEY TANNER, AP Medical WriterWed Oct 17, 7:48 AM ET
More than 90,000 Americans get potentially deadly infections each year from a drug-resistant staph "superbug," the government reported in its first overall estimate of invasive disease caused by the germ.
Deaths tied to these infections may exceed those caused by AIDS, said one public health expert commenting on the new study. Tuesdays report shows just how far one form of the staph germ has spread beyond its traditional hospital setting.
The overall incidence rate was about 32 invasive infections per 100,000 people. That's an "astounding" figure, said an editorial in Wednesday's Journal of the American Medical Association, which published the study.
Most drug-resistant staph cases are mild skin infections. But this study focused on invasive infections — those that enter the bloodstream or destroy flesh and can turn deadly.
Researchers found that only about one-quarter involved hospitalized patients. However, more than half were in the health care system — people who had recently had surgery or were on kidney dialysis, for example. Open wounds and exposure to medical equipment are major ways the bug spreads.
In recent years, the resistant germ has become more common in hospitals and it has been spreading through prisons, gyms and locker rooms, and in poor urban neighborhoods.
The new study offers the broadest look yet at the pervasiveness of the most severe infections caused by the bug, called methicillin-resistant Staphylococcus aureus, or MRSA. These bacteria can be carried by healthy people, living on their skin or in their noses.
An invasive form of the disease is being blamed for the death Monday of a 17-year-old Virginia high school senior. Doctors said the germ had spread to his kidneys, liver, lungs and muscles around his heart.
The researchers' estimates are extrapolated from 2005 surveillance data from nine mostly urban regions considered representative of the country. There were 5,287 invasive infections reported that year in people living in those regions, which would translate to an estimated 94,360 cases nationally, the researchers said.
Most cases were life-threatening bloodstream infections. However, about 10 percent involved so-called flesh-eating disease, according to the study led by researchers at the federal Centers for Disease Control and Prevention.
There were 988 reported deaths among infected people in the study, for a rate of 6.3 per 100,000. That would translate to 18,650 deaths annually, although the researchers don't know if MRSA was the cause in all cases.
If these deaths all were related to staph infections, the total would exceed other better-known causes of death including AIDS — which killed an estimated 17,011 Americans in 2005 — said Dr. Elizabeth Bancroft of the Los Angeles County Health Department, the editorial author.
The results underscore the need for better prevention measures. That includes curbing the overuse of antibiotics and improving hand-washing and other hygiene procedures among hospital workers, said the CDC's Dr. Scott Fridkin, a study co-author.
Some hospitals have drastically cut infections by first isolating new patients until they are screened for MRSA.
The bacteria don't respond to penicillin-related antibiotics once commonly used to treat them, partly because of overuse. They can be treated with other drugs but health officials worry that their overuse could cause the germ to become resistant to those, too.
A survey earlier this year suggested that MRSA infections, including noninvasive mild forms, affect 46 out of every 1,000 U.S. hospital and nursing home patients — or as many as 5 percent. These patients are vulnerable because of open wounds and invasive medical equipment that can help the germ spread.
Dr. Buddy Creech, an infectious disease specialist at Vanderbilt University, said the JAMA study emphasizes the broad scope of the drug-resistant staph "epidemic," and highlights the need for a vaccine, which he called "the holy grail of staphylococcal research."
The regions studied were: the Atlanta metropolitan area; Baltimore, Connecticut; Davidson County, Tenn.; the Denver metropolitan area; Monroe County, NY; the Portland, Ore. metropolitan area; Ramsey County, Minn.; and the San Francisco metropolitan area.
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On the Net:
JAMA: http://jama.ama-assn.org

Aerosolized Hydrogen Peroxide May Counter MRSA Environmental Contamination

Bob Roehr

September 18, 2007 (Chicago) — Aerosolized hydrogen peroxide demonstrates an excellent ability to neutralize methicillin-resistant Staphylococcus aureus (MRSA) environmental contamination, according to a new study. The neutralization appears to approach 100% and to last for weeks. It holds the promise of cost-effective infection control.
The key study, presented here yesterday at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, was conducted at the Royal Hampshire County Hospital, Winchester, in the United Kingdom. In January 2007, a previously "clean" 28-bed surgical ward suffered an unexpected outbreak of MRSA in which 11 patients quickly became colonized.
Rotating sections of the ward were closed, and traditional decontamination cleaning took place. Moistened cotton swabs were used to gather samples from 29 standardized sites both before and after the hydrogen peroxide treatment and then at 1-week intervals for 4 weeks. Patients were screened at admission and discharge, and the staff was also screened; anyone found positive for MRSA was decolonized successfully.
The study found MRSA at 8 (27.6%) of 29 sites after traditional cleaning but at 1 (3.4%) of 29 sites after hydrogen peroxide treatment. The sites remained negative for MRSA on 3 successive weekly examinations, but on week 4, MRSA could be detected at 3 (10.3%) of 29 sites.
Study coauthor Jonathan Otter, PhD(c), works for Bioquell Ltd, the company that is developing commercial application of the technology, and participated in the study along with the hospital and government health agencies.
Mr. Otter believes that managing environmental contamination — in which the source of an infection has no direct physical contact with the patient who becomes infected but instead deposits the pathogen on a surface for third-party transmission — is an underappreciated part of infection control.
Mr. Otter explained that the decontamination process uses 30% hydrogen peroxide and a hot plate to create the vapor. Over the course of about 2 hours, the H2O2 settles on all exposed surfaces, and the highly reactive molecule destroys the pathogen. The reaction is not specific to MRSA, but that was the only pathogen measured in this study.
"In a previously presented study, a hospital in Connecticut instituted this technology for a period of 10 months throughout the entire facility, with a 53% reduction in colonization," Mr. Otter said.
He was not prepared to discuss cost of the decontamination process but said that a regularly provided service would be cheaper and more cost-effective than a single, small intervention. In addition, although institutional settings are the first priority, he believes that it will be a cost-effective technology for use in small medical practices where there is reason to believe there may be MRSA contamination.
Earlier research has shown that dust and organic matter can create a shield that provides some protection to the pathogen from exposure to H2O2 vapor, so prior cleaning is advised. However, Mr. Otter said that even without precleaning, the process seems to kill about 90% of MRSA.
The work in England has focused on hospital-acquired MRSA in part because community-acquired (CA)-MRSA occurs at much lower levels than have been seen recently in the United States. Molecular analysis in the Winchester study identified 5 different genetic sequences of MRSA. The process worked against all of them, and given its mechanism of action, there is no reason to believe that the procedure will not work equally well against CA-MRSA.
Although anterior nares is the most sensitive site for detecting MRSA colonization, 2 other studies presented at the conferences demonstrated that it is not the only place one should be looking.
A study of 72 residents of extended care units within the Veterans Administration Maryland Health Care System compared colonization of USA300 and non-USA300 MRSA. It found 48 (67%) of 72 residents with a history of MRSA to be colonized; 41 residents (85%) had a positive anterior nares culture.
However, the rates of colonization differed by genotype. Among residents colonized with USA300 MRSA, 14 (78%) of 18 residents were colonized in the anterior nares compared with 27 (90%) of 30 residents with non-USA300 MRSA colonized in the anterior nares. The rates of skin colonization did not differ by genotype; 56% (10 of 18) for USA300 and 57% (17 of 30) for non-USA300 MRSA.
Dominik Mertz, MD, working at the University Hospital Basel in Switzerland, found that a quarter of carriers of MRSA were colonized in the throat and not in the nares. Using multivariate analysis, he also found that young age and lack of regular interface with the healthcare system were associated with carriage in the throat. Dr. Mertz could offer no explanation as to why.
The Westminster study activities were funded jointly by Bioquell, the Royal Hospital, and the National Health Service. Dr. Otter is employed by Bioquell. Dr. Mertz reported no relevant financial relationships.
47th Interscience Conference on Antimicrobial Agents and Chemotherapy: Abstracts K-464, K-448, K-449. Presented September 17, 2007.

Vancomycin roars back as front-line therapy Hospitalists try to figure out how to make the best of a flawed antibioticby

Deborah Gesensway

In a packed room at a recent meeting of the Infectious Diseases Society of America (IDSA), a leading infectious diseases expert took a hard-line position on vancomycin during a debate on the drug."Current antibiotics have vanquished vancomycin," he told the audience. He went so far as to say that the 50-year-old antibiotic compound "is a weak stick for all of us."The problem is that not only does vancomycin kill bacteria slowly and penetrate tissues poorly, but resistance to it is growing. That resistance can be widespread, as in the case of vancomycin-resistant enterococci (VRE), or it can be rare, as in the new strains of methicillin-resistant Staphylococcus aureus (MRSA) that are either less sensitive or entirely resistant to the drug.Despite those problems, however, reliance on the drug is clearly on the rise among front-line physicians. Far from being vanquished, vancomycin is more
"Compared to 10 or even five years ago, I use vancomycin much more as first-line therapy."–Lakshmi Halasyamani, MD St. Joseph Mercy Hospital
firmly entrenched in physicians' antibiotic arsenals than ever. In part, that's because many hospitalists find themselves turning to the drug more frequently when confronted with very sick patients whose skin and soft tissue infections, pneumonia, endocarditis, epidural abscesses or bacterimia may be caused by MRSA.First-line therapy"No one now would fault you for starting vancomycin first-line for a sick enough patient," says Lakshmi Halasyamani, MD, a hospitalist and vice chair of the department of internal medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich. "Compared to 10 or even five years ago, I use vancomycin much more as first-line therapy."Although Dr. Halasyamani says she worries that making vancomycin her go-to drug could lead to "problems for the future," she is quick to add that she doesn't see any alternative. It's the classic dilemma: Is your responsibility to the patient in front of you, or to the community at large and a potential future patient for whom treatment may not work?"We talk about that a lot," notes Scott Flanders, MD, associate professor of medicine at the University of Michigan in Ann Arbor and director of its hospitalist program. "Regardless of resistance, I have to treat the patient in front of me, so the pendulum seems to be shifting toward a lower threshold for using vancomycin."Infectious diseases experts warn, however, that the way vancomycin is now being used may contribute to new resistance that could make MRSA even harder to treat. They also question whether doctors are using the drug against organisms without susceptibility and ordering it at dosage levels too low to work. Those problems could ensure the drug's legacy as a "weak stick" that prolongs patient suffering.MRSA's reachAlthough community-associated MRSA was nearly unheard of before the late 1990s, the organism is now widespread. Contrary to initial opinion, community-associated MRSA is now known to be a completely different strain of MRSA than the much older health care-acquired strain.Although community-associated MRSA was first believed to infect only specific populations, including prisoners and others in close proximity, the organism is now found among all population groups, including healthy young people and children. A study in the Aug. 17, 2006, New England Journal of Medicine found that MRSA was a common, identifiable cause of skin and soft tissue infections among patients presenting to emergency departments in 11 U.S. cities, accounting for about 60% of all isolates.So far, at least, data on the intersection between MRSA and vancomycin have been relatively good. According to the Centers for Disease Control and Prevention (CDC), only 16 cases of infection caused by vancomycin-intermediate S. aureus (VISA and heteroVISA) and six cases of vancomycin-resistant S. aureus (VRSA) had been reported in the U.S. as of April 2006.But despite those data, the future is grim. "There is no question that vancomycin is losing its effectiveness because of the development of resistance among MRSA strains," says Robert C. Moellering Jr., MD, a Harvard Medical School professor and infectious diseases specialist at Beth Israel Deaconess Medical Center in Boston. The handful of lethal VRSA cases seen already could portend a future dominated by incurable deadly bacteria.The comeback kidFor physicians who have been around, the growing concern over vancomycin may seem like a flashback of sorts. It wasn't all that long ago, after all, that the drug appeared to be headed toward the pharmaceutical dustbin.When vancomycin was first approved, the drug's high expectations were quickly dashed because of concerns about potential toxicities."There was always the impression that this was the big gun," said Donald P. Levine, MD, professor of medicine and infectious diseases at Wayne State University in Detroit. The reality, however, was that vancomycin was physicians' only gun—and a "puny" one at that, he says.That's because while vancomycin has long been considered the gold standard for treating many MRSA infections, it's far from perfect. In addition to low cure rates and many failures, it is burdensome to use because it is an IV-only drug.Only a decade ago, in fact, few wanted to extend the drug's useful life. At that time, the CDC and others were promulgating guidelines aimed at reducing vancomycin use. Experts were rightly concerned that VRE had the potential to spread its resistance from enterococci to other pathogens, in particular to S. aureus.Several CDC reports in the mid-1990s contained recommendations for controlling the spread of vancomycin resistance. But then came the rapid spread of community-associated MRSA."With that being such a moving target, many institutions that had been aggressive about restricting vancomycin use have had to relax a little bit," says James Pile, MD, a hospitalist and infectious diseases specialist at MetroHealth Medical Center in Cleveland.Less-than-perfect alternativesAlthough several alternatives to vancomycin have emerged in the last decade, there's little proof that most work better against various MRSA-related illnesses.The handful of head-to-head comparison studies of linezolid (Zyvox) and daptomycin (Cubicin) for several different MRSA infections have not shown clear superiority. Some suspect linezolid may penetrate lung tissues better than vancomycin and therefore should be used in MRSA pneumonia cases.Meanwhile, daptomycin may be better for patients with bacterimia or endocarditis. Another New England Journal of Medicine study in the Aug. 17, 2006, issue concluded that daptomycin was "not inferior to standard therapy for S. aureus bacteremia and right-sided endocarditis."However, each alternative has downsides, whether it's IV-only dosing (daptomycin) or toxicities and severe side effects such as low platelet counts and bone marrow suppression (linezolid). A third alternative—quinupristin/dalfopristin (Synercid)—is even more difficult to use because it is best infused through a central line and can cause debilitating myalgias and arthralgias."All these other drugs are quite expensive," adds Daniel Kaul, MD, assistant professor in the infectious diseases division at the University of Michigan. "They may turn out to be better than vancomycin, but at this point, for the average case, they have not been proven to be superior. And overuse of some of the newer drugs is already leading to significant rates of resistance."With the absence of evidence showing a better alternative, "there is the argument that vancomycin doesn't work all that well, but at least it doesn't break the budget," adds Dr. Levine. "That's the reality." Several other drugs that, in testing, seem to work against vancomycin-resistant staph are in the development pipeline, says Harvard's Dr. Moellering, including other glycopeptides—such as televancin and oritavancin—and cephalosporins, including ceftobiprole and ceftaroline. They may be approved by the FDA for clinical use within the next two years, he says.How to make doUntil a better alternative appears or the bacteria evolve further, clinicians need to make the best of the flawed antibiotic, and experts are now scrambling to figure out how to do just that.A Jan. 1, 2006, supplement of the IDSA's journal Clinical Infectious Diseases was devoted to the topic of vancomycin, and several consensus panels are now working on papers to advise clinicians on how to use vancomycin and how to best treat community-associated MRSA.But Dr. Levine, who sits on one of these panels, says experts still have a long way to go before they can offer clinicians concrete help. The only consensus so far, he claims, is that "we really need to stop using vancomycin the way we have been using it."Cleveland's Dr. Pile suggests that "we compound the problem when we don't use the drug at the correct dosage." "In the past, we tended to underdose vancomycin, and we used a one-size-fits-all dose in patients with more or less normal renal function," he points out. Over the last several years, "we have gained a better sense that it needs to be dosed based on weight, and we need to be shooting for more aggressive levels."Evidence for this is mixed, however, with at least one article in Chest in October 2006 concluding that "aggressive dosing strategies for vancomycin may not offer any advantage" for patients with MRSA health care-acquired pneumonia. And very little data exist to help physicians understand the relationship between vancomycin serum levels and treatment outcome."What to measure, when to measure and what is the relevance of those measurements?" Dr. Levine says are all areas that need investigation. "What predicts outcomes better: trough levels, peaks, under the curve?" The various consensus panels convening on this topic, he adds, "are trying to sort that out."Testing for susceptibilityAnother reason vancomycin may not help cure patients with MRSA infections as quickly or as effectively as needed, says Beth Israel's Dr. Moellering, is because clinicians may not understand that some of the organisms infecting the patient may be somewhat—or totally—resistant to vancomycin.Although VRSA is extremely rare, heteroVISA and VISA are less so. The way most clinical laboratories test for susceptibility is not sensitive enough to show that type of resistance, many experts now believe, because tests do not regularly report minimum inhibitory concentrations (MICs). Nor do labs do the more sophisticated testing needed to demonstrate heteroresistance."Knowledge of the therapeutic concentration and MIC of the pathogen might overcome the intrinsic deficiencies of the drug and improve its utility," Dr. Levine wrote in an article in the 2006 Clinical Infectious Diseases supplement on vancomycin. "A return to monitoring serum levels, a practice almost abandoned long ago … might extend the useful life of this antibiotic."Meanwhile, clinicians on the front lines are struggling with how to reduce use of a worrisome antibiotic, while still providing the best care for sick patients.Michigan's Dr. Flanders says that hospitalists often find themselves treating patients who received oral levofloxacin or cephazolin from their doctor two days ago and are now in the ER because their skin infection is getting worse.With cellulitis hard to culture, "we often are left wondering, 'Are they not getting better because they need an IV drug instead of an oraldrug? Do they need to have their foot elevated? Or is this community-associated MRSA and we have the wrong drug?' " Dr. Flanders explains. "Often we are stuck with giving them vancomycin, and we don't know if we are giving them unnecessarily broad and potent IV antibiotics."Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.Getting the most mileage out of vancomycinIf vancomycin is here to stay—at least until the next chapter of its long history is written—then infectious disease experts recommend using it as judiciously as possible.The biggest problem, they say, is that vancomycin is still used when it is not needed. While patients hospitalized for serious infections that may be caused by methicillin-resistant S. aureus (MRSA) may need vancomycin, experts stress the need to determine susceptibilities as quickly as possible and to change drugs accordingly.To do so, experts recommend the following strategies:● Culture all you can. Hospitalists need to become adept at taking tissue cultures, experts say. And while skin abscesses were rarely cultured in the past, "it has become important to do that now," says James Pile, MD, a hospitalist and infectious diseases specialist at MetroHealth Medical Center in Cleveland.● Speed is of the essence. Treating a patient with a severe pneumonia with the wrong antibiotic for 48 hours is bad for the patient as well as for the community.To that end, the VA Medical Center in Pittsburgh, Pa., as part of a project to identify all cases of MRSA that come into its facility, has invested in technology that can analyze swabs from the nose or from any open wound by fast PCR testing, rather than slower culturing. "We run that twice a day, so that usually we get same-day results, as opposed to 48 hours later," said Robert Muder, MD, the center's chief of infectious diseases. The results are used to isolate patients with MRSA and, if findings show that the bug causing the infection is not methicillin-resistant, "then we can change the patient over quickly from vancomycin to a beta-lactam."
● Treat as briefly as possible. "We have a tendency to treat for too long," says Daniel Kaul, MD, assistant professor of infectious diseases at the University of Michigan in Ann Arbor. For example, he points out, most cases of hospital-acquired pneumonia can be treated for eight days, and "we used to treat for as long as three weeks."
● Get your lab to make changes. Experts say that labs need to lower the breakpoint for routinely reporting minimum inhibitory concentrations (MICs). Although "strains with an MIC of 4 often are heteroresistant and fail vancomycin therapy," says Robert C. Moellering Jr., MD, an infectious diseases specialist at Boston's Beth Israel Deaconess Medical Center, new information indicates that even lower MICs will contain resistant subpopulations as well. That may explain why some patients, whose organisms are thought to be susceptible, don't do as well as expected.
● Pay attention to proper dosage. "The standard dosing regimen worked perfectly well" in the past, but "as the MICs have edged up, you probably need higher doses of vancomycin to achieve the same ends," Dr. Moellering says. Debate continues, however, over whether higher doses will achieve better results and not be too toxic to patient's kidneys.
● Change to a more narrow spectrum drug as quickly as possible. In culturing all infections, you need to quickly determine whether the S. aureus causing the illness is methicillin-resistant or methicillin sensitive (MSSA). "Vancomycin clearly is inferior to the beta-lactams for treating serious MSSA infection," Dr. Pile says. "You need to switch the patient to a more appropriate choice if the isolate proves to be methicillin-sensitive."

VA Hospital Dramatically Lowers Its MRSA Rate

A Veterans Affairs hospital that screens all new patients for methicillin-resistant S. aureus (MRSA) cut infections to 17 cases from an average of 60 in previous years, according to the New York Times.
The paper quotes the hospital's chief of staff as saying that the entire program — added personnel, screening, using disposable blood pressure cuffs, isolating MRSA carriers, leaving a stethoscope in each room — costs about $500,000 while saving some $900,000 annually in treatment costs. Estimated U.S. costs for treating these infections run up to $30 billion annually.
The article quotes an infection-control advocate who criticizes the CDC's 2006 guidelines for infection control as "lax" and giving hospitals "an excuse to do too little."

Swabs in Hand, Hospital Cuts Deadly Infections

By KEVIN SACK
PITTSBURGH — At a veterans’ hospital here, nurses swab the nasal passages of every arriving patient to test them for drug-resistant bacteria. Those found positive are housed in isolation rooms behind red painted lines that warn workers not to approach without wearing gowns and gloves.
Every room and corridor is equipped with dispensers of foamy hand sanitizer. Blood pressure cuffs are discarded after use, and each room is assigned its own stethoscope to prevent the transfer of microorganisms. Using these and other relatively inexpensive measures, the hospital has significantly reduced the number of patients who develop deadly drug-resistant infections, long an unaddressed problem in American hospitals.
The federal Centers for Disease Control and Prevention projected this year that one of every 22 patients would get an infection while hospitalized — 1.7 million cases a year — and that 99,000 would die, often from what began as a routine procedure. The cost of treating the infections amounts to tens of billions of dollars, experts say.
But in the past two years, a few hospitals have demonstrated that simple screening and isolation of patients, along with a relentless focus on hygiene, can reduce the number of dangerous infections. By doing so, they have fueled a national debate about whether hospitals are doing all they can to protect patients from infections, which are now linked to more deaths than diabetes or Alzheimer’s disease.
At the Veterans Affairs hospital in Pittsburgh, officials say the number of infections with a virulent bacterium known as methicillin-resistant Staphylococcus aureus, or MRSA, dropped to 17 cases last year from an average of 60 before the program started. The 40-bed surgical unit that began the experiment in 2001 has cut its infection rate by 78 percent.
Such results are not unprecedented. Several European countries, including the Netherlands and Finland, have all but eliminated MRSA through similarly aggressive campaigns. But at many American hospitals, experts say, high infection rates have been accepted as a cost of doing business. Barely a quarter of American hospitals screen patients for bacterial colonies in any methodical way, a recent survey found.
“People don’t believe it’s in their institution, and, if it is, that it’s too big to do anything about, that you just have to accept it,” said Terri Gerigk Wolf, director of VA Pittsburgh Healthcare Systems. “But we have shown you can do something about it.”
Three state legislatures, including Pennsylvania’s, broke ground this year by passing bills to require that hospitals routinely test high-risk patients, like those in intensive care units. But some infection-control experts warn that such regulations may have unintended consequences, including lesser care for patients who linger in isolation. Studies have found that patients in isolation are seen by hospital staff members half as frequently and tend to suffer more from falls, bed sores and stress.
Dr. John A. Jernigan, a MRSA expert at the disease control agency, said there was “a legitimate scientific debate” about whether hospitals should devote precious resources to screening every patient.
“It is a daunting problem, and it has been a recalcitrant problem,” Dr. Jernigan said. “We’re starting to see encouraging results. But I think we’ve been so stuck in this argument about what works and what doesn’t that people have not put programs in place.”
The problem of infections in hospitals is growing. MRSA has been a particularly troublesome pathogen since its emergence in the United States in 1968. Resistant to a number of antibiotics, it can cause infections of surgical sites, the urinary tract, the bloodstream and the lungs, leading to extended hospital stays.
MRSA can be brought into hospitals by patients who show no symptoms, and it then thrives in settings where immune systems are weakened and where incisions provide inviting ports of entry. It now accounts for 63 percent of hospital staphylococcus infections, up from 22 percent in 1995.
Johanna Sullivan Daly, a 63-year-old Brooklyn woman, developed MRSA and other infections after surgery to repair a broken shoulder in 2004, said one of her daughters, Maureen J. Daly. Ms. Daly said that just before her mother’s discharge from a Manhattan hospital, she watched a doctor remove her dressings with bare, unwashed hands.
Five days later, her mother developed intense pain and they went to have her wound examined. “When the dressing came off,” Ms. Daly said, “I saw this — I can’t describe the smell, it was the foulest thing — just this greenish fluid coming out of her arm, oozing and oozing.”
Soon after, her mother developed a high fever and then lost the ability to move her limbs, Ms. Daly said. She spent several months on a ventilator before dying in a nursing home. The hospital bill came to $600,000 for what was to have been a $40,000 procedure.
“I have lost friends to breast cancer, to AIDS, to car accidents, to things we don’t have answers to,” she said. “That I lost my mother to someone not washing their hands or cleaning a hospital room properly is disgusting to me.”
The disease control agency projected seven years ago that the added annual cost of treating infected hospital patients was nearly $5 billion. Now officials there believe it may approach $20 billion, or 1 percent of the nation’s $2 trillion health care bill. Other experts put the number above $30 billion.
As at other hospitals experimenting with rigorous controls, the Pittsburgh veterans hospital has found that preventing infection is cost-effective.
Dr. Rajiv Jain, the hospital’s chief of staff, said its infection control program cost about $500,000 a year, including test kits, salaries for three workers and the $175-per-patient expense of gloves, gowns and hand sanitizer. But the hospital, which has a $431 million budget, realized a net savings of nearly $900,000 when the number of infected patients fell, Dr. Jain said.
The V.A. began phasing in the program at each of its 140 acute-care centers in March.
Dr. Richard P. Shannon, who championed a program to reduce catheter infections at Allegheny General Hospital in Pittsburgh, was able to show administrators that the average infection cost the hospital $27,000. He demonstrated that reimbursement payments for weeks of extended treatment were not keeping pace with actual costs. “I think it was assumed that hospitals didn’t mind treating these infections because they were getting paid for it,” Dr. Shannon said.
A major emphasis at the Pittsburgh hospitals has been hand hygiene. Studies have consistently shown that busy hospital workers disregard basic standards more than half the time. At the veterans hospital, where nurses have taken to pushing elevator buttons with their knuckles, annual spending on hand cleaner has doubled.
State governments, which reimburse hospitals for infection-related costs through Medicaid and other insurance programs, have taken notice and are beginning to impose new mandates.
Eighteen states now require hospitals to publish their infection rates. Last month, legislatures in New Jersey and Illinois approved bills that would make those states the first to require hospitals to screen all intensive-care patients for MRSA.
Here in Pennsylvania, Gov. Edward G. Rendell recently signed a bill requiring MRSA screening of certain high-risk patients. Mr. Rendell did not, however, win legislative approval to end state reimbursements to hospitals for the treatment of infections and to test all hospital patients for drug-resistant bacteria.
It is the screening and isolation of patients that draws the most debate. Screening presents an upfront cost for hospitals, and administrators worry that keeping patients in isolation will further clog emergency rooms and reduce the quality of care. Some researchers believe that improving hygiene and surgical practices alone may be equally effective.
In guidelines released last year, the centers recommended that other precautions be taken first and that hospitals resort to screening high-risk patients if they cannot otherwise reduce their infection rates. The guidelines are endorsed by the American Hospital Association, which believes that hospitals must be able to tailor plans to varying needs.
Others do not see the issue that way. Betsy McCaughey, who became a hospital infection crusader after serving as the New York lieutenant governor, said it was paradoxical that the centers encourage hospital screening for H.I.V. but not for bacterial infections, which are associated with seven times as many deaths. Ms. McCaughey said the agency “is largely to blame” for the failure to contain drug-resistant organisms.
“Their lax guidelines,” she said, “have given hospitals an excuse to do too little.”

Inpatients With MRSA Much More Common Than Suspected

SAN FRANCISCO, June 28 -- The rate of methicillin-resistant Staphylococcus aureus in U.S. hospital patients is now nearly 5% -- dramatically higher than previously thought, according to a nationwide survey of healthcare facilities.
In a one-day snapshot of infection rates conducted late last year, 46 of every 1,000 patients harbored MRSA, according to the Association for Professionals in Infection and Epidemiology (APIC). This is eight to 11 times higher than earlier estimates.
Of those MRSA patients, the survey found, 34 of every 1,000 were infected while 12 of every 1,000 were simply colonized and -- while they did not yet have active disease -- could potentially have transmitted the organism.
The survey "presents a grim picture," according to principal investigator William Jarvis, M.D., of Jason and Jarvis Associates, a private consulting firm in healthcare epidemiology.
"The findings argue for immediate, aggressive efforts to detect and prevent transmission of MRSA," Dr. Jarvis said.
The survey results, released here at APIC's annual meeting, includes data from 1,237 healthcare facilities in 50 states, each of which was asked to provide a "snapshot" of all MRSA cases in the hospital during a single day.
The survey included almost all types of healthcare facilities, including acute, cancer, cardiac, pediatric, rehabilitation, and long-term care. County, public, and private facilities were included and sizes ranged from fewer than 100 beds to more than 300.
The snapshots found 8,654 MRSA cases, including both community-acquired MRSA and healthcare-associated MRSA, in a total of 187,058 inpatients.
The survey also found:
54% of MRSA cases were in men.
67% were on the medical service of their respective hospitals.
81% of cases were detected by clinical cultures and the remainder by active surveillance cultures.
77% were detected less than 48 hours after admission.
37% only had skin and soft tissue infections, which are most commonly seen with community-acquired MRSA, and the rest had infections of the lungs, bloodstream, and urinary tract.
Fewer than 30% of isolates were susceptible to clindamycin (Cleocin) and fewer than 20% were susceptible to levofloxacin (Levaquin).
Because 81% of cases were detected only after clinical manifestations of disease, the association said, it is likely that a "significant number" of patients have the potential to transmit MRSA to healthcare workers or other patients.
"This survey is a wake up-call for healthcare facilities," APIC president Denise Murphy, R.N., said, "because the transmission of MRSA is preventable."
"The scope of this public health threat demands commitment and participation from every hospital, at all levels of the facility," said Murphy, who is a senior safety officer at Barnes-Jewish Hospital in St. Louis.
According to the CDC, MRSA infections accounted for 2% of the total number of staph infections in 1974, but by 1995 it was 22% and in 2004 it was 63%.
The agency last year issued new recommendations for managing MRSA and other drug-pathogens in hospitals that urged "judicious use" of antibiotics, frequent hand washing, and active surveillance.
The survey was financed by APIC.Additional source: Association for Professionals in Infection Control & EpidemiologySource reference: "National Prevalence Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Healthcare Facilities"