Let’s Talk Turkey

In this era of antibiotic resistance and foodborne illness, getting Thanksgiving right means more than just deciding who to invite for dinner. These days, it means proper preparation and cooking of the turkey to prevent food poisoning. The good news is that it can be easily accomplished; but first, some background.

Outbreaks of food poisoning occur most often in November and December. Meat and poultry account for 92% of outbreaks with an identified single food source – and turkey has become one of the usual suspects.

Turkey 2For example, just last month a report came out that found MRSA in 3 out of 10 turkey farms: and 5 of 11 farmers on those 10 farms were MRSA-positive, as well as 2 of 32 family members, and 15 of 49 samples from the home residences. Worse still, is a report by CBS that dangerous bacteria were found on 90% of ground turkey.

Now for the good news: proper preparation and cooking of our Thanksgiving turkey will virtually eliminate problems with these pesky pathogens; so says the US Centers for Disease Control and Prevention, who recommend this 4-step plan:

  1. Thawing the turkey. No, not on the counter silly! Because when the turkey is left out at room temperature for more than two hours, its temperature can creep into the danger zone between 40°F and 140°F, where bacteria can grow rapidly. Ergo, thaw thy turkey in the fridge!
  2. Handling the turkey. Thoroughly wash your hands, utensils, and work surfaces to prevent the spread of bacteria to your food and family. Okay, that’s easy.
  3. Stuffing the turkey. Do it just before Use a food thermometer to make sure the stuffing’s center reaches 165°F. Bacteria can survive in stuffing that has not reached 165°F, and possibly cause food poisoning. So, remember 165°F because it will come up again!
  4. And finally – Cooking the turkey. Set the oven temperature to at least 325°. To make sure the turkey has reached a safe internal temperature of 165°F, check by using a food thermometer inserted into the center of the stuffing and the thickest portions of the breast, thigh, and wing joint.

Of course, the CDC aren’t the only ones to consult for our Thanksgiving dinner. This one seems particularly yummy:

Quiz Time!

The World Health Organization needs our help.

Here’s the issue: “The rise of antibiotic resistance is a global health crisis, and governments now recognize it as one of the greatest challenges for public health today. It is reaching dangerously high levels in all parts of the world,” says Dr. Margaret Chan, WHO Director-General, in a statement released on Monday.

Margaret Chan, MD: We need the public in on this

Margaret Chan, MD: We need the public in on this

The thing is, when we hear such statements from on high we think there isn’t anything we can do. To the contrary, says Dr. Chan: “There’s an urgent need to improve our understanding of antibiotics and how our misuse of them contributes to the rising plague of antibiotic resistance.”

In kicking off World Antibiotic Awareness Week, which runs November 16 – 22, the WHO has released its just-completed worldwide survey that identifies four areas where we, the public, need to change our behavior:

1. This is the Big One: 64% of respondents believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses.

2. 43% think it is acceptable to insist that your doctor give you the same antibiotics, if you are sick and antibiotics helped you get better when you had the same symptoms before.

3. 32% of people surveyed believe they should stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.

4. 25% of respondents across the 12 countries included in the survey think it is acceptable to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness.

Now for the fun part. To help explain these issues the WHO has put together a neat little 6-question quiz. As we enter cold and flu season it makes for timely lunch time office conversation. Be sure to click on “Check your answers” to get helpful user-friendly explanations that tell you everything you need to know about using antibiotics the right way. Cheers:

It Takes a Village: Herd Immunity, Contagious Disease, and the Duty to Vaccinate

Should health care workers be required to have a flu shot as a condition of their employment?

That was the question posed by Eric Bow, MD, in his presentation to a province-wide audience of HCWs at Bug Day, Winnipeg Health Sciences Center’s annual conference on infectious disease.

Underlying the question is the principle of herd immunity, i.e., since vaccine’s prevent illness, the more people in a community who are immune through vaccination the less people will get sick, therefore the smaller the risk that those who are not immune – because they didn’t vaccinate – will come into contact with an infectious individual.

Herd Imm 1


The reason herd immunity matters is that for medical reasons a whole lot of people cannot be vaccinated. These are people with weak immune systems; for example, infants, the elderly, cancer patients, and those with HIV/AIDS – in other words, the very people you find in hospitals. Hence the issue of whether hospital workers should be required to be vaccinated against the flu.

The issue, however, goes beyond the hospital and reaches each one of us. Take, for example, the measles outbreak at Disneyland in California last December where, as of February 11 this year, a total of 125 measles cases had been confirmed among U.S. residents in an ongoing outbreak, 45% of whom were unvaccinated.

But here’s the interesting thing: the December measles virus wasn’t confined to California. A few children and adults from the small religious community of L’esprit Saint in Quebec went to Disneyland last Christmas. Unknowingly, they brought the virus back to their community – where no one was vaccinated. The result: the virus infected 119 children and adults, and counting, as of this past March.

The root principle at work in herd immunity is that we have a duty to protect others. That duty is at its highest with HCWs because they are entrusted with the care of our most vulnerable. The singular importance of this principle is why herd immunity has been broadened to mean we have an ethical duty to undertake any affirmative action – such as vaccination – to prevent the spread of disease. So for example, with highly contagious MRSA, hospitals have an affirmative duty to provide a clean and sterile environment by mandating best practices for hand hygiene and decolonization protocols. As we wrote in these pages a year ago:

Changing how we conceptualize the colonization issue may help as well. For example, we vaccinate healthy people all the time so they don’t run the risk of catching a disease, some a lot less serious than what a MRSA infection can do to you. So why not think of a policy of decolonization as a kind of “vaccination,” a way of preventing the risk of serious harm?

The primacy of prevention in medicine is why “Prevention is the Cure” is the title of Part Four of The Emperor of All Maladies, Dr. Siddhartha Mukherjee’s 2010 Pulitzer Prize-winning book on the history of cancer. It’s the same idea advanced by Hillary Clinton in her 1996 book, It Takes a Village: And Other Lessons Children Teach Us. She believes that people and institutions outside the family – schools, community centers, hospitals, and so on – also determine a child’s well-being.

So whether it’s measles or MRSA, promoting child development or arresting cancer, our best and brightest agree that the best medicine is to act preemptively. And as the case of herd immunity teaches us, it takes all of us working together – it takes a village.


















NFL Player Daniel Fells Seems to Have Overcome MRSA. But That Doesn’t Mean it’s Over

You can be in your physical prime, as strong as they come, have access to the best of medical care in the country, and still be hit hard – real hard — by methicillin-resistant Staphylococcus aureus (MRSA). That’s the case right now with New York Giants tight end Daniel Fells.

On Oct. 2, Fells, 32, appeared in an emergency room with a 104-degree temperature. Doctors diagnosed a MRSA infection in his ankle and admitted him to hospital. He was immediately given antibiotics but they couldn’t control it. The concern, therefore, was that the MRSA would spread. Not just to the bone and tissue in his foot, which would then require amputation; but if it got into his bloodstream it could be fatal. So Fells was transferred to the ICU and underwent a series of five surgeries to save his foot and his life.

Daniel Fells

Daniel Fells

So far so good – sort of. Daniel Fells is still in hospital but he is out of ICU. His foot seems to have been saved from amputation but he may require further surgeries. And the NY Daily News is reporting that his football career is likely over because of the extensive damage to his foot.

Fells is not alone among athletes with his MRSA. A 2007 ESPN report, MRSA Has Sidelined Careers, Even Caused Deathsays MRSA is endemic in professional sports and mentions several high profile athletes who contracted it including Grant Hill of the Orlando Magic, Junior Seau of the New England Patriots, Paul Pierce of the Boston Celtics, Drew Gooden of the Cleveland Cavaliers, and Braylon Edwards of the Cleveland Browns. Since the ESPN report came out there’s been further outbreaks in the NFL in Cleveland and Washington, and in Tampa where MRSA has recently ended the careers of Buccaneer players Carl Nicks and Lawrence Tynes.

And there’s this: One in 4 patients discharged from the hospital after being treated for MRSA will have to go back, often more than once, to the ICU and require further surgery. That’s because MRSA is easily spread to most surfaces you’ve had contact with and so you can easily pick it up again. That’s why the Giants, for example, hired infection specialists to clean their facilities. But Daniel Fells wasn’t taken to the ER from the team facilities, he was taken there from his home. Where, recent science also tells us, among households with people recently treated for it, MRSA is regularly found and spread to the other people who live there.

Daniel Fells lives with his wife and 2 young children.

Britain Unveils its Back-to-School Plan to Fight Antibiotic-Resistant Infections

It’s suppertime. And you’re going to do the right thing: skip that fast food joint too-conveniently located around the corner and prepare that healthy homemade pizza everyone loves. As you’re congratulating yourself on your choice in walks your 10-year old who politely asks if you have washed your hands. Not quite willing to fess up that you haven’t you try an artful dodge: Um, why do you ask, young lady? To which you get something like:

child drBecause germs on your hands can spread to Daddy and me through the food you’re touching. And if a bad bug gets in your bloodstream it’s serious. I even know how it works:

“Each microbe has special markers or antigens on their surface which is special to just that microbe. Specific white blood cells see these microbes and their antigens. And make specific antibodies to attach to that particular antigen. These antibodies lock onto the microbe with the corresponding antigen. The antibodies then mark the harmful microbe for destruction. And stay in the bloodstream to fight that antigen should it ever return.”

No, your 10-year-old probably wouldn’t put it that way. However, those are the exact words used in the computer animation “Counter Attack,” which is 1 of 14 computer games designed for British school children, ages 7 – 11. That’s not a typo: this stuff is for kids. It’s part of the new British health authority guidelines released this week aimed at teaching students, age 7 though university, about drug-resistant bugs. In addition to games, the e-Bug website has home science experiments, quizzes, a disease fact file (explaining MRSA, for example), and a Fact of the Week: “Scientists believe that there are more bacteria in your body than the actual number of cells in your body.”

We saw this coming. Last year, Prime Minister David Cameron warned the public that “We are in danger of going back to the Dark Ages of medicine to see infections that were treatable not be treatable and you would see many thousands of people potentially die from these infections.”

Following that announcement his government released a report at Christmastime predicting drug resistant infections will kill an extra 10 million people a year worldwide – more than currently die from cancer – by 2050 unless action is taken. And so the health guidelines released Tuesday constitute, in part, that action.

So if you’re having trouble convincing your 10-year-old that hand washing before meals is important, I suggest the interactive e-Bug game “Soapy Soakers”(click on “Horrid Hands”). You’re shrunk down to microbe size and placed onto an unwashed hand. Armed with a soap gun and confronted with gnarly-looking bugs, your job is to knock’em dead. Can you figure out how to chase the critter, jump in the air and shoot him, all at the same time? So cool!








Are We As Smart As We Think?

A popular story in the New York Times this week is No, You Don’t Have to Drink 8 Glasses of Water a Day. It says that contrary to conventional wisdom it’s not true that you have to drink that much water; there’s just no science behind it. In fact, it turns out to be a myth that traces back to a 1945 Food and Nutrition Board recommendation that said people need about 2.5 liters of water daily. But everyone forgot the sentence that followed: “Most of this quantity is contained in prepared foods.”

smartAnother interesting myth is that we only use 10% of our brain: not so again; recent evidence tells us we use pretty much all of it.

While these myths seem relatively harmless, there are a number of “truths” floating around in the field of infectious disease that do cause harm.

For example, we generally believe hospitals to be safe places. Yes, they’re staffed by dedicated professionals and we only go there when we have to, but hospitals are not as safe as we think. Incredibly, twice as many people die of preventable hospital deaths every week in the US – some 8,400 people — than died in all of the Iraq War. And about 25% of these deaths occur because of infections you contract at the hospital.

Perhaps the biggest misconception we adhere to is that antibiotics cure sore throats, runny noses, chest colds, and pneumonia’s. For the most part antibiotics don’t work on these things because they’re caused by viruses and antibiotics only kill bacteria.

And when you use antibiotics inappropriately you inadvertently create another problem for yourself: you increase your chance of getting an infection. That’s because most antibiotics kill ALL bacteria, the “good” and the “bad.” Your good bacteria operate in conjunction with your immune system to protect you from disease. So if you knock them out with an antibiotic and are then exposed to a disease-causing germ, the chance of that germ making you sick goes up – way up. As one specialist puts it: “Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?”

Then there’s the myth that we’ve conquered diseases that we actually haven’t. Take for example the biggest contagion in human history – the Black Death, also known as the Bubonic Plague, or simply the Plague, that in the 14th C knocked off as many as 200 million people.

Since April of this year 11 people in the US have become infected with the Plague and 3 have died, which is about triple the normal rate.

We don’t hear much about the Plague because with early intervention antibiotics can treat it. But there’s a catch: we’re approaching what the World Health Organization and others call a post-antibiotic era where, increasingly, these drugs just aren’t working anymore. So much so that a recent UK government report predicts that antibiotic resistant infections will cause more deaths – about 10 million a year — than cancer by the year 2050.

Which brings us to our final myth: given the looming peril these huge numbers indicate we’ll now give antibiotic resistant disease the attention it deserves – or maybe not. Because psychologists tell us that just the opposite happens: “When the numbers [of dead or injured] go up, the amount of sympathy people feel goes perversely down. And with it goes the willingness to donate money or time to help.” Psychologists call this the “collapse of compassion.” It means that “when people see multiple victims, they turn the volume down on their emotions for fear of being overwhelmed.” Put another way: The death of one person is a tragedy; the death of a million is a statistic.

The trick, of course, is to make sure that we don’t fall into that statistic.

Cancer and Antibiotic Resistance

Bad bugs like MRSA, much like criminals, are opportunistic: they take advantage of the vulnerable – the elderly, children, and people who are sick, such as cancer patients.

It works like this. Cancer is treated by surgery, radiation therapy, and chemotherapy – using drugs to destroy cancer cells. Some patients undergo all three.

But as we know cancer treatment comes with side effects. A major one is the increased risk of contracting a serious, often deadly, infection.

cancerAnd when that happens we turn to antibiotics. In fact, many cancer patients need antibiotics during all stages of their treatment.

That’s because, with surgery, at least 5% of patients will develop an infection.

Radiation therapy kills cancer cells but it also kills nearby healthy cells of the hair, skin, mouth and gut linings. When we lose these protective barrier-like cells your risk of getting an infection goes up.

Chemotherapy, used to stop the growth of cancer cells, also weakens the immune system and so it too increases your risk of infection.

The upshot is that cancer survival rates decrease when you can’t control infections due to antibiotic resistance: i.e., the bad bugs have evolved (changed) since antibiotics were first introduced in the 1940s, and now they’re often too tough for the drugs to have any effect on. It’s as if they’ve acquired bullet proof vests and we’re still trying to kill them with 70-year-old six shooters.

This rise of resistance matters because according to the World Health Organization there’s approximately 14 million new cases of cancer worldwide each year. The WHO also tells us that the number of these new cases will go up a whopping 70% over the next two decades.

So is there anything that we can do about what the WHO calls “a problem so serious that it threatens the achievements of modern medicine,” such as cancer treatment?

The UK Global Initiative on Antibiotic Action says that not only is there something we can do, there’s actually something that we must do, and it’s this:

  1. Don’t ask and don’t expect antibiotics for colds, sore throats, or flu—these are caused by viruses so antibiotics don’t work.
  2. Only take antibiotics given to you by your doctor and EXACTLY as written on the bottle and always complete the full course.
  3. Never give your antibiotics to other people.

So the good news is that by doing something very simple, we can do something very good — we can, in a very concrete way, help cancer patients, now and into the future.

People like the girl in the picture, for instance.







Skin in the Game: We Now Have “Super Acne”

Scientists at Britain’s National Health Service told us this week that 4 out of 5 people who suffer from acne now have bacteria that are resistant to three of the most common antibiotics used to treat the condition – erythromycin, tetracyclines, and clindamycin – hence the term “super acne.” What’s more, these resistant bacteria can be spread by direct contact from one person to the next.

acneThis matters because 8 out of 10 teenagers already experience acne and while for most people it will disappear with age, for some it continues well into adulthood. Left untreated, it can have a big psychosocial impact and cause scarring.

And then there’s our old friend Staphylococcus aureus, a common cause of skin infections, among other and more serious things. In a separate study, also released this week, researchers at King’s College Hospital, London, looked at Staph’s resistance to antibiotics and found that it has almost doubled over the last 7 years. Specifically, they found that 30% of samples taken from general dermatology patients in 2014 were resistant to the antibiotic erythromycin. In 2007, only 17% of the samples were found to be resistant.

Commenting on the studies, Nina Goad of the British Association of Dermatologists says: “The growing resistance to antibiotics among skin patients generally and among acne patients more specifically, as highlighted by these two studies, is of concern.”

But there’s a deeper issue here: while the crisis of antibiotic resistance is usually framed as a coming event, it’s actually with us now. Here’s an example of how the issue is typically put, and you’ll notice the reference to the future:

“Many aspects of medicine, if you do not have antibiotics, we will not be able to do: intensive care unit medicine goes out the window; complicated surgery goes out the window; cancer chemotherapy goes out the window; [safely delivering] premature babies goes out the window; organ transplants – all that stuff is only possible to do if you have effective antibiotics.”

These are the words – from the video below – of one of the smartest guys in the room when it comes to this stuff: Brad Spellberg, MD, author of Rising Plague, and professor of medicine and chief medical officer over at the Los Angeles County and the University of Southern California Medical Center.

But what of the present? Do we have evidence that antibiotics are failing us right now? Spellberg gives us one example:

“You get a urinary tract infection and we’re seeing patients that we have to hospitalize to put on IV antibiotics because there’s no oral antibiotics left anymore for these patients.”

As the World Health Organization said last year: “… antimicrobial resistance … is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country.”

In other words, as time passes, more of us are having skin the game – quite literally.


A Healthy Conversation

Life can be overwhelming when it comes to society’s big challenges such as climate change or war in the Middle-East. A typical response may go something like, “So what can I do about it?”

A case in point is the new kid on the block: antibiotic resistance, the rising plague that a UK government report says will cause more deaths than cancer by 2050. To the question, “So what can I do about it?” there is actually a very good answer – talk to your doctor about the harmful effects of antibiotics.

Dr. Eric Howell

Dr. Eric Howell

The suggestion comes to us from Eric Howell, MD, who teaches and practices at Johns Hopkins Medical Center. In his recent essay posted on The Hospital Leader, he says doctors have inadvertently trained their patients to believe that there is an easy solution to almost any common medical problem. And that’s where antibiotics come in: They have been, he says, the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. The problem, however, isn’t so much that these are typically viral-based conditions that antibiotics have no effect on – any more so than on a broken leg, for example; the real problem is that antibiotics have side effects – i.e., they can hurt you.

How so? According to Dr. Howell:

1. Many antibiotics can cause diarrhea.

2. Using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.

3. Use of antibiotics today could make you resistant to antibiotics later in life, when you might really need them. As New York University professor Martin Blaser, MD, has been saying for years: “Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?”

4. Overuse of antibiotics doesn’t only affect the patient, but entire communities as well. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases that the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.

Howell’s essay is premised on the notion that doctors are guilty of over-prescribing antibiotics. For example, he cites a study that says 3 in 10 antibiotics prescribed for hospitalized patients aren’t necessary. So Howell’s message is directed at physicians.

But the other side of the coin is that because patients are trained “to believe that there is an easy solution to almost any common medical problem,” we reflexively seek out antibiotics believing, again, that there are no downsides: If they work, great, but if they don’t then so what, it’s not like they can hurt me. To which the Harvard School of Public Health would say to you, not so fast: antibiotics have a huge downside, so please stop asking for them.

Now for the bonus material: Courtesy of Dr. Howell’s post, for those who want this message delivered hip hop style, check out ZDoggMD’s video, “Dawn of the Diff (C. Diff Rap Zombie Apocalypse)”!

Yes, “ZDogg” is actually a real doctor – UC San Francisco and Stanford, no less.

Peace out.



Actress Leslie Ash Turns the Corner on Her 11-Year Struggle with MRSA

British actress Leslie Ash, best known for her role in the sitcom Men Behaving Badly, and her well-publicized battle with MRSA underscores an important difference between antibiotic-resistant infections and the ones you and I experience: they are too often life-long affairs.

In 2004, while having “energetic” sex with her husband, she fell out of bed, cracked two ribs and punctured her lung. At London’s Chelsea and Westminster hospital, while undergoing an epidural, MRSA entered her body and attacked her spine – leaving her paralyzed.

In the beginning: Leslie Ash and her husband, ex-footballer, Lee Chapman

In the beginning: Leslie Ash and her husband, ex-footballer, Lee Chapman

Without any feeling in her legs, unable to walk, and facing the possibility she would never do so again, her fight began: wheelchair bound, on pain medication, acting career on hold – perhaps permanently, and needing rigorous physical therapy.

Five years later, she described her life this way: “I’ve lived through being hoisted in and out of bed and not being able to sit up, being in terrible pain, being in wheelchairs, on crutches or with this stick. I had the rug pulled from under me and my whole world was flipped up in the air. The one big thing in my life was my career. I’ve worked since I was 15. If there was any chance of getting that back in any way, shape or form, I wanted to do it.”

Six years further on – just this week – Ms. Ash announced she will indeed resume her acting career, that she is finally free of her pain medication, and can, for the most part, walk on her own.

But MRSA has left its footprint. Her spine will be permanently damaged. She has had to hire a specialist physical trainer to continue to build up her strength. In an interview with the Huffington Post she explained:

“Biomechanics is like a neuropathic pathway and that is exactly what I need because of the damage to my spine. I can stand better now and I am working on my strength and my core stability and I can actually walk around without a stick.”

There are 2 million stories of struggle with resistant infections like Leslie Ash’s every year in the U.S. alone.

Not all of them will turn out as well as hers.

Leslie and Lee today.

Leslie and Lee today.


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