Sunday, October 21, 2007

MRSA: A Plague for the 21st Century?

Recent reports of methicillin-resistant staphylococcus aureus (MRSA) spreading in schools have no doubt been panicking hypochondriacs everywhere, especially since these infections can look like an ordinary boil (or even a nasty zit). This is bad if you’re a teenager and don’t know whether you have it or not.

Before you hole up in your house and refuse to mingle with the general population, perhaps it would make sense to learn more about this “superbug” that is casting fear into the hearts of Americans everywhere.

First of all, you may ask, what is staphylococcus aureus?

Usually fondly referred to by its nickname, “Staph,” it is a bacterium that can cause a number of different illnesses, from superficial skin infections to systemic illness that can be fatal. The germ is found almost anywhere on the skin and is usually harmless. However, once in your body it can cause havoc.

I had a friend when I was young who got a staph infection from stepping on a tent stake, point-up (even now the mere idea of stepping on a tent stake gives me the horrors). She was hospitalized for over a week receiving intravenous antibiotics to quell the infection from staph germs that had gotten into her bloodstream. Luckily, being a strong, healthy 12-year-old, she recovered.

So, what is Methicillin?

Methicillin is a synthetic type of penicillin that was developed in 1959, when many drugs had already developed resistance to the original penicillin. By 1961, staph germs resistant to the drug had already been discovered, and subsequently additional drugs were introduced to fight the resistant strains. As time went on, the wily staph germ became resistant to a number of drugs, not just Methicillin, although these resistant bugs are still generically known as “Methicillin Resistant Staphylococcus Aureus.”

Currently the most resistant types of MRSA can only be attacked by what some call “the drug of last resort”: Vancomycin. When my father was hospitalized for depression in our local hospital a few years ago at age 88, he caught pneumonia while he was in the psychiatric ward. (It’s bad enough being depressed without getting pneumonia!). Because he caught it in the hospital, they immediately assumed the cause was a resistant bug and put him on I.V. Vancomycin. Thankfully, he recovered.

(By the way, here is a great term for you: A disease or condition that occurs as a result of hospitalization is called a “nosocomial” disease. It is kind of concerning to me that this happens so often that they have an official word for it. Just something to think about next time you’re hospitalized…)

MRSA is actually very common, and while it is concerning, there is something much scarier out there: Vancomycin Resistant Staphyloccocus Areus, or VRSA, which was first noted in the United States in a Michigan man in 2002. While still rare, and so far confined to people with chronic medical conditions (e.g., kidney failure) requiring catheterization or other invasive procedures, it is very concerning to know that MRSA is starting to become immune to Vancomycin. There are still a couple of other drugs that have been able to treat these very resistant bacteria, but unless science continues to develop new antibiotics, eventually these too will become ineffective.

MRSA can be acquired in two ways: through exposure through the healthcare system, or through the community without direct contact with the healthcare system. I’ll address both types here:

Healthcare-Associated MRSA:

According to the CDC:

“MRSA occurs most frequently among patients who undergo invasive medical procedures or who have weakened immune systems and are being treated in hospitals and healthcare facilities such as nursing homes and dialysis centers. MRSA in healthcare settings commonly causes serious and potentially life threatening infections, such as bloodstream infections, surgical site infections, or pneumonia.

In addition to healthcare associated infections, MRSA can also infect people in the community at large, generally as skin infections that may look like pimples or boils and can be swollen, painful and have draining pus. These skin infections often occur in otherwise healthy people.”

Hospitals have always been reservoirs of infection, even though healthcare providers have known for over a century that hand washing will cut down drastically on the spread of infection. However, CDC data show that the proportion of infections that are antimicrobial resistant has been growing. In 1974, MRSA infections accounted for two percent of the total number of staph infections; in 1995 it was 22%; in 2004 it was 63%.

The good news is that disinfection and stringent attention to hygiene can cut back on the spread of these infections in the hospital or at clinics and other medical settings. See the CDC website for more information on the precautions recommended to prevent the spread of drug-resistant staph in the medical community.

What about the Community-Associated MRSA?

This is the type that is getting all the bad press right now. The CDC definition of Community-Associated MRSA is:

“MRSA infections that are acquired by persons who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, catheters) are known as CA-MRSA infections. Staph or MRSA infections in the community are usually manifested as skin infections, such as pimples and boils, and occur in otherwise healthy people.”

What are the symptoms of MRSA?

According to,

“Most MRSA infections are skin infections that produce the following signs and symptoms:

Cellulitis (infection of the skin or the fat and tissues that lie immediately beneath the skin, usually starting as small red bumps in the skin),

Boils (pus-filled infections of hair follicles),

Abscesses (collections of pus in under the skin),

Sty (infection of eyelid gland),

Carbuncles (infections larger than an abscess, usually with several openings to the skin), and

Impetigo (a skin infection with pus-filled blisters).”

However, MRSA can spread from the skin to almost any organ in the body, resulting in a severe, even life-threatening illness, particularly among those with lowered immunity.

Symptoms to watch out for are:
-Low blood pressure
-Joint pain
-Severe headaches
-Rash over much of the body

How is MRSA transmitted?

It is usually spread in one of two ways:

One way is through physical contact with someone who is infected with, or a carrier of, MRSA. The second way is “for people to physically contact MRSA on any objects such as door handles, floors, sinks, or towels that have been touched by an MRSA-infected person or carrier.

Normal skin tissue in people usually does not allow MRSA infection to develop; however, if there are cuts, abrasions, or other skin flaws such as psoriasis (chronic skin disease with dry patches, redness, and scaly skin), MRSA may proliferate. Many otherwise healthy individuals, especially children and young adults, do not notice small skin imperfections or scrapes and may be lax in taking precautions about skin contacts. This is the likely reason MRSA outbreaks occur in diverse types of people such as school team players (like football players or wrestlers), dormitory residents, and armed-services personnel in constant close contact.”

How is it diagnosed?

MRSA is easily identified through taking a sample of the skin, pus, blood or urine of an affected person and sending it to a lab to be cultured to see whether S. aureus is present. If the bacteria grow in the Petri dish in the lab, then they are exposed to antibiotics, including methicillin, to find out whether they are resistant. If so, then the patient is diagnosed as MRSA-infected. If someone is suspected as being a carrier, the same procedure is done, but by swabbing the skin or mucous membranes, not through a biopsy.

How is it treated?

MRSA can still be treated with some antibiotics, including Vancomycin and others such as Linezolid. For MRSA carriers, mupirocin antibiotic cream can eliminate MRSA from mucous membrane colonization. The best way to proceed is to determine which antibiotic can kill the MRSA and use it alone or, more often, in combination with additional antibiotics. Since resistance can change quickly, antibiotic treatments may need to change also. It is extremely important for patients infected with MRSA to take the entire course of antibiotics that are prescribed, and not stop just because they feel better. This can lead to additional resistance.

Patients infected in the community usually fare well; hospitalized patients, not so much. Since they are usually ill in the first place, being in the hospital, they are more likely to develop the serious forms of the illness. As reported by the Kaiser Foundation, “As many as 1.2 million U.S. hospital patients are infected with methicillin-resistant staphylococcus aureus each year, nearly 10 times as many as previously estimated,” and the mortality rate is estimated to be between 4%-10%.

How can you avoid getting MRSA?

Avoiding direct contact with skin, clothing, and any items that come in contact with either MRSA patients or MRSA carriers, or anyone you think might be one, is the best way to avoid MRSA infection. However, unless you want to become a germophobic recluse like Howard Hughes, this may not work very well.

However, to minimize the possible spread of infection, people can treat and cover (for example, antiseptic cream and a Band-Aid) any skin breaks and use excellent hygiene practices (for example, hand washing with soap after personal contact or toilet use, washing clothes potentially in contact with MRSA patients or carriers, using disposable items when treating MRSA patients). Also, antiseptic solutions, such as Purell, and antiseptic wipes can be used to both clean hands and surfaces that may contact MRSA.

Personally, I never go anywhere without my Purell. Maybe I’m a little paranoid, but anytime I have touched surfaces that I know many other people have touched, whether browsing in a store or using a handrail in a public place, as soon as I have an opportunity, out comes the Purell. Better safe than sorry is always my motto.

In the hospitals, the CDC has found that use of alcohol gels can be more effective and result in more compliance than handwashing. See this link for a full analysis of improvements to hygiene and sanitation that can be made in the hospital setting.

Will you get it?

Not if you’re careful. But if you get any kind of unusual skin infection or have a flulike illness in combination with a skin infection, get to a doctor and get treatment. The earlier this type of infection is caught, the better. Cellulitis in and of itself, whether caused by MRSA or just regular bacteria, can be very serious.

The chart below shows the breakdown of who gets MRSA (more blacks than whites, higher rates of infection for the very young, teens and young adults, followed by a higher spike over age 50. About 58% of cases are associated with medical care within the past year; 27% start in the hospital, and just 13.8% are non-healthcare related.

The biggest concern is that new antibiotics are not being developed as frequently as in the past; once staph becomes resistant to Vancomycin and the other last resort drugs, we may have no defense against the next superbug. One way to forestall the rise of resistant bacteria is for doctors not to overprescribe antibiotics for every little ailment. Often patients go to the doctor with a sore throat or some other malady and literally expect to be prescribed an antibiotic and are disappointed or annoyed if the doctor sends them away without one. Doctors need to explain to patients that not all illnesses are caused by bacteria and that antibiotics do not work on viruses. The other danger is patients who do not finish their course of antibiotics, which means that if not all of the bacteria are killed, the ones that are left are more apt to be resistant and reproduce themselves.

Please see the links throughout this article for more detailed information on MRSA.

Thursday, October 4, 2007

More on Misdiagnoses

Not to belabor this subject, but CNN had another article about misdiagnoses that I thought I would share with you. This article was about several of the most common illnesses or conditions that tend to be misdiagnosed. Here, briefly, are the five they list:

1. Aortic dissection: This is when the aorta, the main artery leading from the heart to the rest of the body, actually tears. This is obviously catastrophic, since a complete tear results in massive blood loss. But sometimes this condition is hard to diagnose, as the pain or sensation the person feels can mimic other illnesses, or even something as simple as heartburn.

I had a friend whose father died of this; the pain he felt was in his back, and he thought he had injured his spine or had a slipped disk. He went to a chiropracter for treatment. The chiropracter immediately realized something much more serious was going on, and called an ambulance, but by the time my friend's father was on the operating table, sadly it was too late.

2. Cancer: In a Harvard study of malpractice claims in the U.S., cancer was the most misdiagnosed illness.

In my previous post on oral cancer, the young chef with tongue cancer was initially misdiagnosed by his dentist. And I had a friend whose doctor kept treating her for bladder infections when all along what she had was bladder cancer. Sadly, her initial surgery did not keep the cancer at bay and she died of the disease 2-1/2 years after her diagnosis.

3. Clogged arteries: Sometimes doctors tell patients they're short of breath because they're out of shape, when it's actually coronary artery disease. Chest pain can masquerade as heartburn or a pulled muscle.

4. Heart attack: Heart attacks don't always have the "classic" symptom of severe chest pain. Sometimes the only signs of a heart attack are a feeling of pressure or fullness in the chest, nausea, tiredness or malaise. Pain can also occur in the jaw or left arm. In women, in particular, heart attacks are often misdiagnosed as women tend to have less typical symptoms of heart attack than men do.

5. Infection: In the Harvard study, infection followed cancer as the most misdiagnosed condition.

An example of this is, a friend's mother, who is a lung cancer survivor, had problems breathing after a trip to Eastern Europe. The doctor she was going to at the time thought she was having symptoms of a recurrence of cancer. As it turned out, she had an infection with Mycobacterium avium, which is an unusual type of infection.

So how can you keep yourself from becoming a victim of misdiagnosis?

1. Ask for more tests (Do your research and find out what tests are commonly prescribed for symptoms such as yours).

2. Ask, "What else could my illness be?" (And of course, do your research so that you are aware of what other illnesses it could be, and can suggest them if your doctor does not).

3. Don't assume no news is good news. This is very important; my friend with the bladder cancer had been receiving CT scans regularly as follow-ups to her cancer surgery. Apparently, she did not hear any results from the last one she had had, and somehow did not find out until 3 months later that the scan had showed enlarged lymph nodes in her abdomen. Who knows whether her outcome might have been different had she found this out sooner?

This goes for all kinds of tests, including your yearly Pap test. If you had one and don't hear from your doctor, call him or her and ask if everything was OK. And ask for copies of your lab tests, and read them carefully. If something doesn't look right, call your doctor and ask about it.

4. Assume your doctors don't talk to one another. Always tell each doctor you go to about anything going on with the other doctor: Any tests, any blood results, any scans, any symptoms. If you feel your doctors should be working together as a team, schedule a conference call.

5. Be wary when your doctors work in shifts - be sure each one passes on information to the other. And whenever possible, try to always see the same doctor even in a practice that has a number of physicians.

Sometimes you only get one chance to get your diagnosis right. Make sure you do everything that is in your own power to accomplish that.