The Spread

When antibiotic resistance develops anywhere, it is a threat to people everywhere. That’s the point so nicely illustrated in the graphic below. Using the antibiotic resistance conferring NDM-1 gene as an example, it shows its spread from India (ND = New Delhi) to over 80 countries over a 10-year period.

Genes confer traits in bacteria in much the same way they do in us. For instance, various genes confer in us traits such as height, hair color, and disease propensity. Similarly, in bacteria, genes confer traits for survival such as an increased resistance to antibiotics, increased virulence, and bugs that are more contagious. In fact, those are the exact traits found in a deadly new strain of pneumonia in China that scientists say “is likely just a matter of time” before it too escapes its country of origin.

 

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Another antibiotic resistant gene of interest is MCR-1, which we profiled last year. Like NDM-1, it’s also on the move. A report last month by the Center for Disease Research and Policy at the University of Minnesota noted that in China, “MCR-1-harboring bacteria, mainly E. coli, were detected in 71% of water samples, 51% of farm animal fecal samples, 36% of food products, and 28% of human subjects.”

The question, then, is what can we do to protect ourselves. One of the best reports ever done on antibiotic resistance remains the 2013 Frontline piece, Hunting the Nightmare Bacteria. One its segments, Eight Ways to Protect Yourselves From Superbugs, offered some good news: “Everyone may be at risk, but the chances of catching a drug-resistant bug outside of the hospital are small for most. For the average healthy person walking down the street? Those organisms are not much of a threat.”

However, that was before the detection and spread of the MCR-1 gene, and the emergence of the new and deadly strain of pneumonia mentioned above which NPR reported on here. And so the preventive measures that Frontline offers – e.g., proper hand washing with soap and water, getting the annual flu shot, and taking antibiotics only if you absolutely have to – would seem to be even more important now than before.

 

 

 

 

 

Harvard Med: To Prevent Pneumonia if You’re Over 65 – Get Vaccinated

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As cold & flu season approaches so does pneumonia season. That’s because the cold & flu make it harder to fight infection, especially for the elderly. In fact, says the Harvard Medical School, adults age 65 and older have a higher risk of death from pneumonia hospitalization than for any other reason.

But Harvard’s point isn’t to scare you – it’s to tell you of a way to avoid pneumonia in the first place: Get vaccinated.

There’s two vaccines that offer “sound protection” against pneumonia. They do so by building immunity against the different types of bacteria that cause it. One vaccine is Pneumovax, which protects against 23 common types of bacteria; the other is Prevnar, which protects against 13 types. If you’re 65 and older, Harvard says you should receive Prevnar first, followed by Pneumovax six months to one year later.

Vaccination thus prevents those dreaded flu-like symptom from appearing: fever, muscle aches, headache, fatigue, and cough. However, with pneumonia, the cough often produces yellow, green, or even bloody mucus. And you may also have trouble breathing and experience pain when taking a deep breath.

One more thing. Harvard warns us of people over 65 who are especially at risk: those that smoke, and those with a serious medical condition such as asthma, chronic obstructive pulmonary disease (COPD), or heart disease.

The American Cancer Society adds a further wrinkle: by smoking tobacco, they say, you not only make yourself more vulnerable to each of these illnesses – and others – but when you get them they will be worse. This happens for a number of reasons, for instance:

  • Smoking damages (scars) the airways and small air sacs in your lungs.
  • The risk of COPD goes up the more you smoke and the longer you smoke.
  • It causes “Smoker’s cough”: Tobacco smoke has many chemicals and particles that irritate the airways and lungs. When a smoker inhales these substances, the body tries to get rid of them by making mucus and coughing. Over time the airways become swollen and the cough becomes chronic (long-lasting).
  • Smoking tobacco damages your heart and blood vessels, causes high blood pressure, and makes your blood more likely to clot.
  • Smoking can cause or worsen poor blood flow to the arms and legs. This is called peripheral vascular disease or PVD. It can cause pain in the legs when walking.
  • Smoking causes decreased immune system function, increased risk for cataracts (clouding of the lenses of the eyes), higher risk of developing rheumatoid arthritis, increased risk for age-related macular degeneration, and an increased risk of peptic ulcers.
  • And then there’s cancer: Wherever smoke – including secondhand smoke – touches living cells, it does harm.

Both the Harvard and Cancer Society articles are worth reading in full (they use plain language). But if you don’t have time the short point is simple: pick up the vaccine … and put down the cigarette.

 

Our pets get antibiotic-resistant infections too

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Antibiotic-resistant bacterial infections in companion animals – dog & cats especially – are rising at an alarming rate across the country, says Dr. Jason Piper of the University of Illinois College of Veterinary Medicine. “If you averaged it out over time, every day in the clinic we’re seeing about one case of methicillin-resistant S. pseudintermedius,” which is found on the skin. He’s also seeing “difficult” Pseudomonas ear infections, as well as antibiotic-resistant E. coli, Enterococcus and Salmonella infections in the gastrointestinal and urinary tracts.

When you’re backed into a corner with a resistant-infection the vet is forced to use last resort or “big gun” antibiotics – those that increase the risk of harmful side-effects. “I’m dealing with one dog that has a liver issue right now from an antibiotic I used because its infection was not responding to other treatments, including antibiotics,” says Piper.

The reason for this rise in resistant-infections has a familiar ring to it: giving antibiotics to animals when they’re not necessary. For example, don’t give an antibiotic just because you do a skin biopsy, cautions Piper. Instead, he says, you want to take the same approach with animals as you do with people:

We have decreased the incidence of methicillin-resistant bacterial infections in people largely by using antibiotics more responsibly. I remember a time when I would always be prescribed antibiotics for the flu. Now, physicians are not prescribing antibiotics for viral infections, which don’t respond to antibiotics.

I feel the veterinary community needs to take a lesson from this and also start practicing the responsible use of antibiotics. If an animal’s skin is inflamed, test the site to determine whether antibiotics are needed. I see way too many cases where such tests are not performed and the doctors give out antibiotics no matter what. This is perpetuating the problem.

 

Not quite ready for primetime medical reporting: GomerBlog

Who knew: Apparently the medical community has its very own version of The Onion. Over at GomerBlog: Earth’s Finest Medical News, you can find such satirical gems as “To Control Patient Volumes, Hospital Takes Down Hospital Signs Within 5-Mile Radius.” (Has Health Canada tried this?) But the article we’re reprinting – currently making the rounds in the ID community – is about the vexing problem of antibiotic stewardship (e.g. ” … 75 percent or more of antibiotic use is unnecessary”). Oh, and be sure to click on some of the links. They’re from  …  wait for it … Gomerpedia: The Medical Encyclopedia.

                         

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            Why Not: CDC Recommends Adding Vanco & Zosyn to the Water

ATLANTA, GA – Finally accepting the reality that antibiotic stewardship among health care professionals is just a pipe dream, Acting Director of the Centers for Disease Control and Prevention (CDC) Dr. Anne Schuchat officially said “F**k it” and just add vancomycin & Zosyn (piperacillin-tazobactam) to the water supply.

“No matter what we try, patients keep asking for antibiotics for viruses and doctors keep prescribing them to protect against litigation, so there we are,” Schuchat explained, adding that she is crafting a message to the nation’s pharmacists to make sure that state, local, and national supplies of vancomycin and Zosyn in drinking water is renally dosed.  “Since cutting back didn’t work, might as well go balls to the wall and be like Oprah: everybody gets vanc & Zosyn!”

According to data collected from the CDC, the average hospitalized patient receives anywhere between 3 and 180 days worth of broad-spectrum antibiotics despite negative culture data.  Seeing this as an opportunity for cost-savings, Schuchat believes the time is right for home antibiotics, and not through a PICC and home health services: but through sterilizing the water supply.

“I was sincerely hoping that scaling back on antibiotic use would help curb the development of multi-drug resistant microorganisms like carbapenem-resistent Enterobacteriaceae,” continued Schuchat, “but since no one else cares besides me apparently, bottoms up, and hope everyone enjoys a future laden with C. diff.

Overall the next several weeks, Schuchat plans to work hand-in-hand with several major players in the food beverage industry – think Coca-ColaPepsi, and Tyson Foods – as well as the Food & Drug Administration to expand antibiotic use in other beverages and make sure, for example, your next can of soda has a label indicating antibiotic content and side effects.

“If I had to guess,” said Schuchat, “each 12-oz can of Coke or Pepsi will have 1 gram of vancomycin and 3.375 grams of Zosyn, though we’re still in the early stages.  But that’s why I’m writing to pharmacy, to make sure they’re on board.  We might end up recommending checking routine blood work before having any beverage in this country.”

Hurricane Watch: These aren’t ‘natural’ disasters

There’s a smart perspective in The Washington Post this week called Why it’s time to stop calling these hurricane disasters ‘natural,’ by MIT professor of atmospheric science Kerry Emanuel. He argues that it’s really on us because we’re making these disasters worse in two ways: by our flawed coastal policies (e.g., through interest groups manipulating insurance premiums down, thus not reflecting the true risk of coastal living), and by our acceleration of climate change which makes the storms more intense.

Professor Emanuel: “We must first recognize the phrase ‘natural disaster’ for what it is: a sham we hide behind to avoid our own culpability. Hurricanes, floods, earthquakes and wildfires are part of nature, and the natural world has long ago adapted to them. Disasters occur when we move to risky places and build inadequate infrastructure.”

Miami Beach a year before the Category 4 storm of 1926, and this year. The reinsurance firm Swiss Re estimates that a similar storm would inflict more than $200 billion in damage if it hit Miami today. (The New York Times)

Miami Beach a year before the Category 4 storm of 1926, and this year. The reinsurance firm Swiss Re estimates that a similar storm would inflict more than $200 billion in damage if it hit Miami today. (The New York Times)

 

 

Evidence and Empathy

There was a time, says Harvard history of science professor Naomi Oreskes, when governments accepted scientific evidence and used it to make good policy. Interestingly, though, she points out that the disparaging of science and the creation of alternative facts didn’t start with the current occupant of the White House; rather, it goes back to the 1930s and the origins of public relations and mass marketing media and, the tobacco industry had a lot to do with it.

 

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Professor Oreskes was discussing the US response to climate breakdown, but her thesis could just as easily be applied to Washington’s handling of industrial scale livestock production and its role in the creation of the public health crisis we find ourselves in. Science journalist Maryn Mckenna explains: Since at least 1976, she says, we’ve known that antibiotics given to farm animals produce antibiotic-resistant bacteria in the guts of the animals that receive them. Those bacteria then move through the environment and enter other animals and people. And when a few million of us each year become infected with these drug-resistant “superbugs” our illness is one which is harder to treat and often deadly.

But it doesn’t have to be this way. Eveline was a young girl in the Netherlands whose life was threatened by MRSA – which, the evidence showed, she contracted from the pigs on her father’s industrial farm. “This moment changed the life for me,” he says, and, as it turned out, because of a grassroots movement, it also led to a countrywide reduction in the use of antibiotics in food production resulting in healthier animals and people. The Dutch, in other words, driven by the facts, changed their animal food production policy because of empathy – they didn’t want what happened to one young girl to happen to anyone else.

Eveline, fortunately, survived and is interviewed in the story, below. But the question Americans and Canadians have to ask themselves is, why haven’t we made the same beneficial policy shift as the Dutch?

We have the evidence. Where’s the empathy?

 

Future Medicine: Accurate diagnosis of infection in a day

Draw one vial of blood. Sequence the DNA. And within 24 hrs. you get an accurate diagnose of over 1,000 different kinds of infections – thus not all known infections – whether they be bacterial, viral, or fungal.

That’s what happened when a California biotech start-up was called in as a last resort to solve the case of a 3-year old girl with a rash. She had been tested & treated for weeks with no luck and she was getting sicker. The day after the company was called in they had a diagnosis: “rat-bite fever” – likely from her pet rat – and that told them what antibiotic to use. Case solved.

The CDC using standard diagnostics eventually came to the same conclusion – months later. That lengthy time frame is what gives rise to misdiagnoses, faulty treatments, e.g. the wrong antibiotic, patients getting sicker, or worse. So this technology is a huge deal.

The company is hoping to treat chronically ill patients next. They say It will be some time before the test is used in routine medical care. Here’s an interview with the scientist who did the work:

Doctors say this start-up could revolutionize how we fight infectious diseases from CNBC.

The Force of Nature

tree man

As we just witnessed on a macro-level with Hurricane Harvey, nature can act with overwhelming force. But what’s often lost in the shuffle is that nature can operate just as devastatingly on a micro-level too.

The above picture is of a man’s hand overrun with human papillomavirus (HPV) that turned into “tree man” disease, so-called because the tumors can resemble wood or bark. Fortunately, according to the NPR story, surgeons at a Jerusalem hospital were able to restore his hand to near normal, though the growths will probably return necessitating more surgery.

The story serves as a vivid reminder that when we hear vague phrases such as “pathogen-infested swamp,” referring to the aftermath of Harvey floodwaters; or that “millions of pounds of toxic chemicals” are pouring from damaged Houston area petrochemical plants — that these invisible-to-the-naked-eye substances will also have real-world consequences, every bit as much as the viral-induced growth seen on the hand.

The difference, however, is that with Harvey so many more people will be affected.

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After the Hurricane: Harvey Floodwaters are Loaded with Pathogens

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As we reported last week, “Infectious diseases could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp.”

Now the details are starting to come in and the news isn’t good. CNN is reporting that “unfortunately the numbers are stunningly high … especially bacteria, especially fecal bacteria.” For example, the number of viable E. coli cells in public water should be zero, yet CNN found as many as 8,600 such cells (colony forming units) in their small-sized samples – and they’ll continue to multiply, exponentially.

And because the pathogen count in general is so high there’s “the potential for sewer plant malfunction or sewer plant continuing to discharge untreated or partially treated waste.”

What you should therefore do: “take a bath or shower … as soon as possible after coming out of that water … [and] get rid of the clothes you had on because just washing them will not destroy the harmful bacteria.”

How to Raise a Child Without Antibiotics

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Since this Atlantic article was tweeted by @BradSpellberg you know it’s worth a careful read. It’s the unusual case of a 14-year old boy who, though he had been sick, had never been given an antibiotic. That’s because his parents understood the foundational rule: That antibiotics only work on bacterial-driven infections not viral-driven ones. Thus, for example, when you have the cold or flu antibiotics are not for you.

But this can be hard to follow in practice especially when facing your sick child. The article nicely explains why:

 Take a cold, for example, or bronchitis. Our friends know on one level that these are usually caused by viruses, but after a week or two of yuck and snot they’ve had it — so they call the pediatrician for an antibiotic. The harried doctor knows it’s likely viral but doesn’t want to fight with yet another parent about antibiotics — so out comes a prescription. “Just in case this thing’s bacterial, let’s cover our bases,” the doctor says, and moves on to the next patient. The child takes the antibiotic, and around the same time the cold would run its course anyway, the child gets better. Everyone is happy, right? No harm done. Except there’s lots of harm done.

 

So to avoid falling into this trap, there’s 5 refrigerator-door rules to know & follow:

  • Antibiotics are unnecessary for colds or bronchitis, even when they last longer than two weeks. Colds and bronchitis often take more than two weeks to resolve, so if there are no signs of pneumonia, then antibiotics can be withheld safely.
  • Green sinus discharge and green sputum does not mean you require antibiotics. Sinus discharge, sputum, and phlegm all turn various colors as the body fights infection, and many studies have shown that green sputum is as likely to be viral as bacterial.
  • Ear and sinus infections don’t always require antibiotics. Medical guidelines for sinus and (hot off the presses) ear infections suggest that patients without red flag symptoms can be observed without antibiotics; your doctor can help ensure this is safe.
  • If your child gets a prescription for antibiotics, ask your doctor to explain why.
  • The diagnosis of pneumonia — a legitimate indication for antibiotics — can not be made without a chest X-ray. Since the symptoms and physical examination can be the same in bronchitis (which is usually caused by a virus) and pneumonia (often bacterial), a chest X-ray is needed to determine if the diagnosis is really pneumonia, and therefore if antibiotics are needed. Don’t accept a prescription for antibiotics for pneumonia without a chest x-ray.

There is, of course, one other factor – luck. As the author points out: “Granted, we have been very lucky. Our son has never been in a major accident, needed surgery, or contracted any major illnesses. He was born healthy, he was breastfed, and he got his vaccines. He’s had his fair share of colds and a particularly scary case of flu, but never, not even once, required antibiotics.”

 

 

 

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