Rapidly growing levels of antibiotic resistance one of biggest current medical problems

[philb]

Nosocomial Infections and Antibiotic Resistance: Prophylaxis and Treatment in the Surgical Setting Release Date: January 31, 2007

Nosocomial infection is a serious threat to millions of US inpatients yearly and carries a high rate of mortality (approximately 5%).

http://www.docmeonline.com/ce-bin/owa/pkg_disclaimer_html.display?ip_cookie=24257639&ip_mode=secure&ip_test_id=10917&ip_company_code=AOAM
JAMA -- Antibiotic-Resistant "Superbugs" May Be Transmitted From Animals to Humans, November 14, 2007, Kuehn 298 (18): 2125.
2 recent epidemiological studies in distinct human populations suggest that bacteria are developing resistance to antibiotics on poultry farms and that these resistant bacteria are colonizing humans.
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Floroquinolones making resistance more likely
Link: HighWire Press -- Medline Abstract.
Our study underlines the need for infection control teams to focus efforts on preventing both MRSA- and MSSA-BSI. As recently demonstrated in vitro, fluoroquinolones may enhance horizontal transfer of virulent and antibiotic resistance genes. These antibiotics are widely used in France, so our findings raise the issue of whether their use has contributed to acquisition of mecA and tst genes by S. aureus strains.
Children becoming resistant to drugs they've never taken
Link: Journal Watch Infectious Diseases.
Worldwide, quinolone-resistance rates among gram-negative bacilli are rising rapidly. Widespread use of this class of antibiotics can cause selection of resistant organisms in the gut flora. Because these agents are rarely administered before age 18, children provide an opportunity to investigate the prevalence of quinolone-resistant gram-negative bacilli in individuals not exposed to quinolones. Investigators recently reported the results of stool screening among children without diarrhea who attended a general ambulatory pediatric office in Seattle between September 2001 and June 2002. Information on antibiotic use by the child and by other household members during the preceding 4 weeks was collected by questionnaire. Stools from 13 of 455 children (2.9%) grew gram-negative bacteria with high-level quinolone resistance (Escherichia coli, 7 children; Stenotrophomonas maltophilia, 4 children; Enterobacter aerogenes and Achromobacter xylosoxidans, 1 child each). Six of the 7 E. coli isolates were found to have additional extraintestinal virulence factors. Besides quinolone resistance, the 13 isolates showed varying resistance rates to other classes of antibiotics. None of the 13 children with resistant isolates had used a quinolone during the preceding 4 weeks, nor had members of their households. Use of other antibiotics by the children or their household members was not associated with detection of quinolone-resistant bacteria.

WHO | Antimicrobial resistance
http://www.who.int/mediacentre/factsheets/fs194/en/

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Florida Antibiotic Resistance Trends (One hospital) (2001-2005) (Gainesville)
METHODS: Antibiogram/sensitivity reports from a single medical center were incorporated into the database between 2001 and 2005. Data were reviewed for resistance trends for Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, Streptococcus pneumoniae, Stapylococcal aureus, methicillin-resistant Staphyloccal aureus (MRSA), Enterococcus faecium, and Enterococcus sp.
RESULTS: For E.coli, increasing resistance was found for ampicillin, levofloxacin, ciprofloxacin, and piperacillin. All were consistent with national averages, except ampicillin which was slightly higher. For K. pneumoniae, ciprofloxacin and levofloxacin resistance trended higher, along with most cephalosporins; however, all rates were below national averages. For P. aeruginosa, an increasing trend was identified for ceftazidime and imipenem, but both rates were lower than national averages. For P. mirabilis, increased resistance was found for ampicillin, ciprofloxacin, and imipenem. Resistance rates for ciprofloxacin were higher than national averages. For S. aureus, increased resistance was seen with erythromycin, ciprofloxacin, levofloxacin, and oxacillin. Methicillin-resistant S. aureus (MRSA) rates were higher than national averages. http://meeting.chestjournal.org/cgi/content/abstract/132/4/562
***************************************************************************************************
U.S. Antibiotic Resistance Trends - children (2002-2004)
The overall resistance rates for females and males, respectively, were as follows:
ampicillin 44.3% and 44.6%; sulphamethoxazole/trimethoprim 24.5% and 36.7%; cefazolin 10.9% and 27.1%;
amoxicillin/clavulanic acid 12.4% and 27.5%; ciprofloxacin 0.9% and 2.4%; and nitrofurantoin 4.4% and 11.0%. Uropathogen resistance to commonly used antibiotics in the paediatric population was high.
************************************************************************************
Table 1. Methicillin resistance - Staph. Aureus bacteraemias, East of England 2001 – 2005 44% http://www.hpa.org.uk/eastofengland/pdf/Antibiotic_Trends_bacteraemia.pdf
*************************************************************
Wisconsin Antibiotic Resistance Campylobacter jejuni 2005
Tetracycline 53.7% ciprofloxacin 11% erythromycin 4.24% www.slh.wisc.edu/wps/wcm/connect/extranet/publications/campylobacter_jejuni_2005.php
*********
Children’s Urinary Tract Infection 2003
Resistance to cefotaxime sodium was 3% in the patients not receiving antibiotic prophylaxis, but was 27% in the children receiving prophylactic antibiotics. Resistance to aminoglycoside antibiotics was 1% in the children not receiving prophylaxis and 5% in the children receiving prophylactic antibiotics.
***********
Louisiana 2004 Table 1: Trend analysis of resistance for S. pneumoniae, S. aureus, Enterococcus species Louisiana, 2000-2004
DRSP, MRSA, VRE
2000 2001 2002 2003 2004 Z (C-A trend test) p-value
S Pneumoniae
% Resistant 42.87% 47.08% 44.05% 41.70% 43.34% -0.9648 0.3346
S. aureus
% Resistant 38.20% 44.46% 53.79% 56.67% 60.62% 42.4123 <.0001
Enterococcus
%Resistant 5.00% 4.95% 6.49% 6.08% 6.71% 6.3074 <.0001
******************
Texas Group B Streptococcus 2001 2004 whites twice as high as non-whites
Erythromycin 0 9%
Clindamycin 0 13%
E or C 0 19%
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1581469

[Avalux]

1. In a nutshell.

Big Pharma will not fund research for innovative new antibiotics because they will not make big profits. The government will not provide grants to non-profits and academia for their research.

This is hardly a new problem; we've been talking about it for years. The bugs will get the better of us if we don't get on the ball.

[TZ]

7. FYI, this may help some....

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=222x29355
Now, if people will just be patient and listen before demanding antibiotics, and doctors not hand them out like candy...

[Heddi]

2. As a nurse, let me give my opinion

I deal with many patients who have MRSA (methacilin-resistant stap-areus---superbug in the news) and it's evil sister VRE (Vancomycin resistant enterococcus) and the other, Clostridium Difficile (C-Diff, which isn't exactly antibiotic resistant, but generally speaking, if you have one, you'll have C-diff)

. I deal mainly with the chronically ill and elderly and many of these cases are contracted in Nursing Homes and other group-home settings where the sanitation standards aren't what they are in hospitals (and not every hospital has the sanitation standards of any other hospital). These are highly contagious organisms that live on surfaces for extended periods of time. You can pass MRSA via sputum (coughing, sneezing), blood, and other body fluids like spinal, etc. VRE lives in the bowel and is transmitted via fecal matter. C-Diff is caused by many things, most often long-term or high dose antibiotic use and is VERY VERY VERY contagious and not killed with alcohol hand sanitizers (like VRE and MRSA are).

However, I have people come in as patients that have antibiotic resistance and the main reasons are:

1) People WANT antibiotics, even if Antibiotics will do NOTHING for their condition. Someone has a viral infection (Viral Pharyngitis--sore throat). There's not really anything that can be done for that other than some topical gel to gargle with and patience. But people don't want patience. They don't have the time to take off work and they want to feel better NOW. So they press and press and press for antibiotics. The MD shouldn't give in, but often they do just to get a patient to shut up and feel better through some placebo effect. THe MD's are aware of ABX (shorthand for antibiotic) resistance, but they generally are of the attitude "One antibiotic won't cause resistance". This is true, but what they tend NOT to consider is how many times a patient, in the past, may have been given an abx they didn't need for the same reasons they're getting one now.

2) PARENTS want Antibiotics for their children. I don't know why, but parents (generally speaking here) feel that Amoxicillin and Penicillin, the bubblegum flavoured pink junk that every child gets is the cure-all for everything. EVEN NURSES I WORK WITH THINK THIS. If their child is sick, has a runny nose, farts sideways, they're on the phone to the Doc to get some Amox. Doesn't matter that whatever ails their child is in no way bacterial--THEY WANT THE MAGIC PINK MEDICINE!!!!

3) People don't finish their antibiotics when they have bacterial infections. THe biggie is strep throat. People NEVER EVER EVER finish the abx schedule for strep throat. After a few doses they're feelin' good and stop taking the meds. Doctors generally do a good job of emphasizing the importance of finishing all antibiotics, even if you feel well, but many don't. Pharmacists generally do a good job of emphasizing the importanve of finishing all abx,even if you feel well, but many don't. Even for people who are told and who understand don't finish. Either they don't want to or forget or are tired of taking 3 pills a day every day for 2 weeks.

3) People don't finish their antibiotics because of the side effects. I had bacterial vaginosis---a common malady among those of us with vaginas :) and had to take Flagyl, an antibiotic. WHen you take flagyl, you can't have alcohol in any way---it prohibits alcohol metabolism and you can end up with ETOH poisioning. You can't even take it for 72 hours AFTER you finish the meds because of the systemic effects. This isn't just beer and whiskey---Nyquil, Mouthwash---ANYTHING with alcohol that can be ingested evne in the smallest amounts can be potentially dangerous.

So I take the Flagyl for 7 days and it killed the bacterial vaginosis, and every other flora in my body. I got a horrible yeast infection, my stomach was shot to hell, and I developed oral thrush. SO after I was done with the Flagyl I had to go to an anti-fungal medicine for another week just to deal with the side effects.

People who are on chronic or long-term abx therapy for legitimate reasons sometimes CAN_NOT take the side effects, so they stop taking the meds.

4) Antibacterial EVERYTHING!!! Sheesh! Soap and warm water will do the trick for EVERYTHING. C-diff. MRSA. VRE. Wash your hands for the amount of time it takes you to sing the alphabet twice and you're good to go. If you can't do that, then use an alcohol-based hand sanitizer. That kills everything but C-Diff (which most people outside of healthcare don't have to worry about anyways).

THe other day I was at the store and saw antibacterial SHAMPOO!!! What??? How crazy! They have Antibacterial kleenex (considering most causes of runny noses and colds are viral.....) Antibacterial dish soap...the list goes on and on. It's ridiculous. We don't need everything to be antibacterial. Not only that, but the wash-off down drains and toilets kills helpful bacterial growths in water supplies and causes overgrowths of harmful bacteria.

----
I apologize for my most likely rampant misspellings and gramatical errors---Really, I have a degree and I'm a good RN with a stellar GPA. I just got off of a 12 hour night shift (number four in a row---2 more to go, woohoo!) and haven't slept. I checked in on DU when I got home and had to share my thoughts before I went to bed this morning :)

REMEMBER--WASH YOUR HANDS!!! CARRY ALCOHOL BASED HAND SANITIZER!!! THAT"S ALL YOU NEED (oh and cover your nose when you sneeze and cough). Simple 10% bleach solution (10% bleach to 90% water) in a spray bottle will kill everything in your kitchen that needs to be killed. Microwave your kitchen sponges every day for 30 seconds to kill the bacteria. WASH HANDS WASH HANDS WASH HAND

that is all :D

[lizerdbits]

3. Awesome rant!

Antibacterial Shampoo?! That's pretty sad. I have to search high and low to find non antibacterial soap. I had to resort to some flowery smelling stuff at whole foods just to get plain old soap.

[trotsky]

4. Thank you, Heddi.

I am always glad to see you chime in with real-world experience.

[chicagomd]

5. Oh, and lets not forget this one:

"I had some of that pink stuff left over from last time and he was just feeling miserable, so I gave him a few doses and he got better. But now he is sick again, can you call me in some more?"

I get that call about once a week. Not only did they not finish their abx the first time, but they now have either:
1) Partially treated a bacterial infection so now they need a antibiotic with broader coverage ("stronger").
2) Gave their child drugs without direction from a physician or pharmacist.

Drives me nuts, especially given the amount of time I spend trying to educate the parents in my practice about antibiotics.

[Heddi]

9. oh yeah! I had forgot that one

It's amazing to me the things that people do---especially nurses. I work with a group of highly trained (in school and on the job) professionals who are on top of patient issues and get shit done, to be so crude. We ROCK with our patients and we take care of sickies (ICU/ACU).

But these ladies keep a bottle(s) of whatever meds they had 3 years ago in their closet and when they get a sniffle they take a few Amox here, a few whatever there for a day or two......how ridiculous.

They do the same thing with their children. I think because they are all 30s or older, and they were brought up like I was---anything that causes you to be brought to the MD calls for Happy Pink Refrigerated Liquid.

I'm 32, and I swear I can't think of a time when I was young and went to the MD that I *DIDN"T* get Amox/PCN when I got home. I had frequent ear infections---I don't know if they were bacterial or viral.....but I always got amoxicillin/PCN when I went to the doctor with an ear-ache. And my mom, like most moms, always kept that little bit that was left over (because you always get too much) in the fridge "just in case".

Thankfully I've never been dx'ed with an ABX-resistant infection, but it scares me to think of how my resistance was tainted when I was a child and given antibiotics for no reason.

0000
Since turning 18, I have taken Antibiotics so few times that I can actually REMEMBER them:
1) strep throat when I was 20
2) preventative abx after I got a nasty injury when I fell off my bike
3) flagyl for bacterial vaginosis. Ugh. What shitty shit.

[Warpy]

6. AWESOME rant!

I would love to see a conspiracy among pediatricians and pharmacists to spell "amoxacillin" just a little differently to alert the pharmy to give the parents a bottle of inert pink glop, maybe with mild pain medicine, to give the rugrat with the viral infection, along with instructions to call in 5 days or sooner if the kid gets worse (something that can signal a bacterial superinfection has started). That alone would start us on the way to stopping the bugs from becoming resistant.

Washing your hands as the first thing you do when you return from doing anything outside your home is the best way to avoid catching nasty things out there. Another good way is to train yourself to scratch your face with the back of your wrist, not your contaminated palm or fingers.

Now if we could only get nursing homes to start testing every newly admitted patient for colonization by MRSA and/or VRE, we might start getting someplace.

[Heddi]

8. Nursing Homes and MRSA

My ICU (I work in ICU-step-down) and oncology floor do MRSA and VRE swabs on every patient that is admitted, regardless of where they are admitted from. That way, if they come back MRSA positive we know it wasn't hospital acquired (or that it was, if they were negative at admit and positive down the road).

It's a pilot program and part of some grad-level Nurse's research thesis. It was started in just ICU and was so promising and showed that nearly 40% (actually more now) of people admitted to ICU either from the "outside world" or other areas of the hospital are MRSA positive and about 15% are VRE positive that they expanded it to Oncology to see if a Med/Surg floor had the same results---theirs were even higher numbers.

We expect that by summer, every patient that is admitted to the hospital will receive MRSA/VRE swabbing upon admit, regardless of the unit they are admitted to.

WE also have a program in place where automatic C-Diff testing is done on any patient who has 2 or more wattery or yellow stools, and so far we have been able to find patients with C-Diff earlier which leads to much better treatment and less liklihood of transmission to others because we can get them into private rooms and out of doubles sooner than if we waited for them to have 3 days worth of loose stools, or until the mentally deficient MD Resident students got off their lazy asses and responded to MULTIPLE nurse calls about getting C-Diff labs for a patient (one lady went TWO WEEKS because the resident was too scared or too stupid to Okay a $20 C-Diff fecal test....fucking idiot!)

I think that MRSA/VRE swabs should be part of routine MD office visits as well. Just a little swab when you come in....it's not invasive, and I think we'd be very very amazed to see how many people are walking about our communities with these infections.

[Warpy]

10. I could diagnose C-diff when I got off the elevator

it's a stench you just never forget. Fortunately, we could originate labs like c-diff and emergency labs on my floor without a physician order, just one of the quirks of that particular hospital.

We caught them early.

[philb]

11. my 16 year old cousin died from resistant staff he got at ER for minor cut

/scratch he received at a high school football game- team captain.
Dead within a week.

My brother had a soccer teammate almost lose a foot in similar circumstances. My dad had coworker die in hospital after taken their for minor problem. Resistant Staff.

More die in U.S. each year from resistant bacteria than from AIDS.

[TZ]

12. FYI

Its a STAPH. infection, not STAFF.

[Warpy]

13. MRSA is in the community, philb

So you can't blame the hospital for contaminating the cut. He most likely got the MRSA along with the injury. All it takes is one spore, and it is a spore forming bacillus. It's now in the air and soil outside hospitals.

I've seen few people die from it if they've gotten quick treatment and appropriate follow up, even when infection has gone into the bone.

Treatment is difficult, however, and recovery is extremely slow.

Likely it would have eventually developed, but overuse of antibiotics in a population that didn't understand how antibiotics were to be taken caused it to evolve into a resistant form in record time.

[Heddi]

14. If he was a football player

chances are higher that he got MRSA from a locker-room or other shared facility than he did at the hospital. I mean, hospitals aren't the best but they certainly are cleaner than a locker-room, shower-room, etc.

We all joke at the hospital that we (nurses) are all colonized with MRSA--probably true. CHances are MOST People....or a large number of people are colonized with MRSA but it will never become a problem for them because of their immune system, or because for whatever reason it doesn't colonize in a little shaving nick or scraped knee, so no one knows. For other people, they get a hang-nail and 2 days later they're in the hospital with MRSA getting antibiotics around the clock. It depends on the person, the wound, and the MRSA, frankly. Some strains are more virulent than others.

I have to say that working in one of only 2 ICU's in a 300 mile range, there have been VERY few people that die (at my hospital, at least) of resistant bacterial infections. Death by MRSA is very rare. Like Warpy said, it can be a long-haul treatment but rarely is it fatal except in the elderly, young, those with compromised immune systems, those with nutritional or other physiologic deficiencies, and those that don't follow the prescribed medications once they get home.

To be dead within a week is, frankly, not very common especially in the young and healthy crowd (as I would assume your cousin was if he was a football coach). I'm not saying I don't believe your story, but I have talked with RN's I work with about this thread and EVERYONE is just shocked that a young boy that is suspectibly healthy would die within a week because of a MRSA scratch. I can say that it certainly doesn't happen very often, as RN's with 30 years of ICU and CCU experience have never heard of it happening.....

[philb]

16. My cousin was in Live Oak Florida, this was in the local papers.

my father's office coworker worked for a state agency in Tallahassee, he had a minor conditions but got resistant staff in the TMH hospital, which has a huge epidemic of such, as is also in the local paper.

[cosmik debris]

18. Well, My brother-in-law

Has a friend whose room mate heard about this guy....and it was in all the local papers.

Do you realize how much you sound like an article in Snopes Urban Legends?

:rofl:

[Heddi]

19. I searched the Live Oak Fl newspaper

and I found 3 articles about MRSA, none of them dealing with a death.

Also, all of them state that the MRSA outbreak was at SCHOOLS....not hospitals.

http://www.suwanneedemocrat.com/archivesearch/local_story_305180058.html

November 01, 2007 06:00 pm print this story email this story comment on this story

Drug-resistant staph at local schools

Infected students have all recovered
By Robert Bridges, Editor


Five cases of drug-resistant staph have been confirmed in Suwannee County schools. The students were infected with methicillin-resistant staphyloccus aureus, or MRSA, said Margaret Wooley, director of health services for county schools. All five have recovered, she said.

MRSA is responsible for the deaths of two students nationwide, one in New York and one in Virginia. However, Dr. Patrick Woloszyn, medical director of the Suwannee County Health Department, said the threat has been somewhat overblown.

===

http://www.suwanneedemocrat.com/archivesearch/local_story_310175949.html

November 06, 2007 05:59 pm print this story email this story comment on this story

STAPH: 2 more cases confirmed

A total of 7 cases of drug-resistant staph, or MRSA, have been recorded in local schools since August
By Robert Bridges, Editor

[email protected]

Two more cases of drug-resistant staph have been confirmed in county schools, school officials said Monday, bringing the total since August to seven.

A student at Suwannee High and one at Suwannee Middle School have been infected with methicillin-resistant staphyloccus aureus, or MRSA, officials said. Both are undergoing treatment and are expected to recover fully.

Four of five students previously infected have all recovered. The fifth is undergoing treatment and is expected to recover fully. Three of the students attend Suwannee Primary School and two attend Branford High.
---

http://www.suwanneedemocrat.com/archivesearch/local_story_311152655.html

November 07, 2007 03:26 pm print this story email this story comment on this story

Seven cases of staph reported

IN SUWANNEE COUNTY SCHOOLS
By Robert Bridges, Editor

Two more cases of drug-resistant staph have been confirmed in county schools, school officials said Monday, bringing the total since August to seven.

A student at Suwannee High and one at Suwannee Middle School have been infected with methicillin-resistant staphyloccus aureus, or MRSA, officials said. Both are undergoing treatment and are expected to fully recover.

Five students previously infected have all recovered. Three of the students attended Suwannee Primary School and two attended Branford High.

Although MRSA is responsible for the deaths of two students nationwide, health officials say the infection is easily treatable and rarely does serious harm to young people and those in good health. MRSA is resistant to some antibiotics, but responds to older, less commonly used drugs. Officials attribute the increase in MRSA cases nationwide to overuse of antibiotics, which created a resistance to the drugs in certain strains of staph.

---

Sorry, nothing about a death but seeming alot of what I and others said--generally very uncommon for the young and healthy to die of MRSA< and most likely got from school/gym than from the hospital....

[philb]

22. My cousins death was several years ago.

his last name was Self then I believe, he was a captain on his football team
His mom and dad were divorced and his mom had remarried
they lived in Live Oak, she and his sister still do.

[dropkickpa]

17. MRSA is rampant in HS sports

All over the place in football, wrestling, etc.

See -

http://www.reuters.com/article/pressRelease/idUS155674+08-Jan-2008+PRN20080108

10 Million Square Feet of Turf Set to be Treated in 2008 in Response to MRSA
Outbreaks Nationwide

ROCHESTER HILLS, Mich., Jan. 8 /PRNewswire/ -- CSG/SportsCoatings, today
announced approximately 10 million square feet of synthetic turf will be
treated with its industry-leading antimicrobial coating, TurfAide(TM), in 2008
-- up from 1.5 million square feet in 2007.
The exponential increase in demand for TurfAide has been attributed to
several factors, including a 2007 report in the Journal of the American
Medical Association that found MRSA (methicillin-resistant Staphlycoccus
aureas) is responsible for more than 94,000 serious infections and nearly
19,000 deaths each year. MRSA, a potentially deadly skin infection, is caused
by staph bacteria that can survive on surfaces for days. The antimicrobial
technology in TurfAide is proven to inhibit the growth of bacteria, fungi and
mold for years with just one application.
According to three studies conducted by the Texas Department of State
Health Services, the MRSA infection rate among football players is 16 times
higher than the average person. Texas has synthetic turf at 18 percent of its
high school fields.
"Schools, professional teams and recreation centers are recognizing the
growing threat of sports-related infections," said CSG/SportsCoatings CEO
Craig Andrews. "More synthetic turf systems will be treated with TurfAide than
all other antimicrobial products combined in 2008; because it's a proven and
powerful technology that's been safely used in medical and consumer goods for
over 30 years."

[Heddi]

15. Yes, you can diagnose C-diff by nose....

My husband is in nursing school and I told him that he should feel proud of the day that he can walk onto the floor and know which rooms have C-Diff and which have GI bleeds just based on the smell in the hall......

[CurlStudentNurse]

20. Great into

I have just be working on my papers due for nursing school,
but got distracted with the need to understand MRSA a little
more. I enjoyed your input, found it to have great information
yet it was expressed at a level that almost anyone could
understand. Have you thought about teaching, or could you talk
with some of my instructors on how to teach to learn not show
off with big fancy words? 
Confused Nursing Student

[xchrom]

21. the last years of my dad' life was marked by repeated bouts of c-diff.

he was elderly frail -- and if anything happend that required a stay in a nursing home -- he would get it.

then i would have to get him out of there and treat him at home.

the mess, the constant showers, the accidents -- repeat.

we're allgoing to get older and old -- let's hope that isn't a signifyer for all of us.

p.s. and when i say it went on for years -- i'm not kidding.