Cancer and Antibiotic Resistance

Bad bugs like MRSA, much like criminals, are opportunistic: they take an 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.

 

A Profile in Courage: 11-year-old Addie Rerecich

“The first thing that crossed my mind was, ‘Am I dying?’” said 11-year-old Addie Rerecich, of Tucson, Arizona.

This was 2011. Addie was bedridden in the hospital. Her body was overcome by a Staphylococcus infection. Her lungs were failing. Without a double lung transplant she would die. But surgery would be tricky because other drug-resistant bacteria were also growing in her slender frame.

Thankfully, Addie would eventually pull through, but her struggle continues.

In the video below the interviewer asks Addie if she would mind showing people her scars. “No, I’m kind of proud of them,” comes the spunky reply. And promptly lifts her shirt to reveal multiple gunshot-looking wounds to her belly. What draws your attention, however, is the deep scar that cuts diagonally across her right hip, the remnants of the Staph infection that began it all, which she describes as “the size of a football at one point.”

Here is Addie in her own words:

We understand life by comparing new events to what we have experienced. For example, when we hear that in the US alone, over 2 million people a year contract an antibiotic-resistant infection – and live, we understand that to mean they go through something like we have, with pneumonia, say.

Addie, now 15, makes her story public because she wants you to know that that’s not how it works. Her mother Tonya, a nurse, describes 3 key differences with drug-resistant infections:

They move quick: “Within 24 hours, my little girl went from happy and healthy to being intubated and hooked to a breathing machine. Her small body was riddled with tubes and wires.”

Drugs don’t work: “Addie’s doctors had run out of the most common antibiotics used to treat these serious bacteria so, in desperation, they turned to an antibiotic known as colistin. Colistin is very powerful, but it is also so highly toxic to the kidneys and other organs that doctors rarely use it.  We started saying extra prayers.”

It’s a life sentence: “When we left the hospital, Addie was in a wheelchair. She had lost the use of her left arm, had almost no vision in her left eye, and had restricted vision in her right eye. She had limited use of her left leg. She had suffered a stroke. She had lost 30 pounds, almost one third of her body weight. She was so weak and debilitated that she couldn’t even turn herself side to side in bed. With intensive therapy Addie is improving, but progress is slow, and no one is sure how much function she can regain. My once normal, strong, athletic Addie will need medical attention and therapy for the rest of her life.”

“I’m so grateful that she’s still with us and that we made it through, but my heart aches when she looks up at me and asks, ‘Why me?’, because I don’t have an answer.”

A Father’s Fears

How should we handle this case?

A little south of Cape Canaveral on Florida’s Atlantic coast, 16-year-old Noah Meyers remains confined in his isolation room at the local Merritt Island hospital. One week ago Noah contracted methicillin-resistant Staphylococcus aureus (MRSA). His father, Bill Meyers, a former paramedic, believes it was from Noah’s football equipment: “All I know is that the marks that are on my son’s head, scalp, face, chin and neck. They are everywhere that the football helmet hit him. We can’t even give him a hug. He’s scared,” said Bill. “If people don’t realize how serious MRSA is, they need to.

video platformvideo managementvideo solutionsvideo player

What Bill Meyers wants for his son is what all families of the more than 80,000 MRSA-sufferers (in the U.S. alone) want: “I just want to make sure Noah is cured and is better, and I want to make sure that nobody else gets this.”

But there’s a catch: Almost 20% of people with MRSA skin infection will remain persistently colonized, according to new research conducted by Valerie Cluzet, PhD, from the University of Pennsylvania in Philadelphia.

Of the 243 patients Cluzet’s study followed, 48 (19.8%) remained persistently colonized. Furthermore, patients with persistent colonization tended to be older than patients who achieved clearance and were more likely to have a household member with MRSA colonization.

The treatment implication is both clear and novel: “These results give us an idea of who is going to be persistently colonized with MRSA, and will help us better target that population,” said Dr. Cluzet. “We may have to advise not only the patients but also the people they are living with to … get rid of the [MRSA] colonization.”

Bill Meyers believes his son’s MRSA didn’t come from the family, it came from the school’s football equipment. On the other hand, the school district isn’t so sure, saying that the helmets were just reconditioned and sanitized, were not shared between players, and they are looking into it.

Remember, the chief finding of the study isn’t that the MRSA necessarily came from a household member. It’s that once MRSA attaches itself to you, there’s a 1 in 5 chance it will remain on your body – and thus available to be given to others – even after you’re “cured” and sent home from the hospital.

So getting back to what Bill Meyers so reasonably wants – for Noah to be cured and for no one else to have to go through what his son did – and given the findings of Dr. Cluzet’s study, what should we do in this case?

Order follow-up MRSA decontamination procedures for Noah – and if so, for how long? Years? And what about the rest of the people in the household?

If this were your family, what would you want?

If you smoke cigarettes, you’re turning MRSA into a super-superbug

smokingThe way we think about smoking and disease is that cigarette smoke causes illness by harming the smoker, for example, by weakening human respiratory and immune cells, by destroying organs such as the lungs, and so on.

While that’s certainly true, researchers at the University of California at San Diego have shown us a second and completely different way in which cigarette smoking will cause disease: by strengthening the pathogen that causes the illness.

The pathogen they used to test their idea was MRSA (Methicillin-resistant staphylococcus aureus). Their method was to prepare 2 batches of it: the “regular” kind, and a second batch of MRSA that was exposed to cigarette smoke. They then infected human cells grown in a lab and live mice with the 2 kinds of MRSA to see if the effects were the same or different. Here’s what they found:

  1. The smoke-exposed MRSA were 4-times harder to kill than regular MRSA.
  2. The effect was dose-dependent, meaning that the more you exposed the MRSA to smoke, the more resistant it became.
  3. The smoke-exposed MRSA were better at invading human and mice cells and causing death. For example, 40 percent of mice infected with the smoke-exposed MRSA died of pneumonia, compared with 10 percent of the mice infected with regular MRSA.

In other words, smoking causes MRSA to be better at both offense and defense: it will kill at a much higher rate, and it’s harder to kill.

In humans, MRSA is typically – and conveniently – found in the nose and airways leading to the lungs. So when you smoke, what you’re doing is you’re bathing these bacteria in the smoke produced by the cigarette, thus turning them into the more potent pathogen that the UCSD experiment demonstrates.

In the fifty years since the first U.S. Surgeon General’s report in 1964 warned us about the link between smoking and lung cancer, nearly 21 million people (the population of Australia) have died prematurely because of smoking or exposure to secondhand smoke.

Or so we thought. In a study reported this February in The New England Journal of Medicine, researchers have added five more diseases and 60,000 deaths a year to the toll taken by tobacco in the United States. For example, compared with people who had never smoked, smokers were about twice as likely to die from infections and respiratory ailments, that were not previously linked to smoking.

Which entitles us to ask a question: What human behavior, including war, causes us more harm than smoking tobacco?

smoking-deaths

 

 

 

 

 

You Can’t Go Wrong by Eating Fish – Can You?

When it comes to healthy eating the usual advice goes something like this: Get as much of your nutrition as possible from a variety of completely unprocessed foods: fruit, vegetables, meat, fish, poultry and eggs.

So whenever I see fish on the menu I know I’m good – or so I thought.

An investigation by Consumer Reports found that 60 percent of 342 samples of frozen shrimp contained harmful bacteria such as Salmonella, Vibrio (80,000 illnesses a year in the U.S.), Listeria, or E. coli.  And 2 percent tested positive for MRSA (methicillin-resistant staphylococcus aureus), which is already responsible for almost half of all deaths caused by drug-resistant bacterial infections in the U.S. (p.77).

CR took their samples from popular stores like Walmart, Costco, and Albertson’s, in 27 cities across the U.S.

The levels found with shrimp are higher than previous CR testing done on chicken, turkey and pork.

So what’s up with the fish?

fish farming 3Apparently it’s not the fish per se, it’s where they come from – down on the farm, and abroad.

Commercial fishing – catching wild fish – is being outstripped by fish farming, or aquaculture – i.e., raising fish populations in confined conditions akin to raising cows in a barn. It’s the fastest growing food system on the planet, and even today about half the seafood we eat is farmed.

And it’s imported: 94% of the shrimp tested by CR came from abroad; places like Vietnam, Thailand, and Bangladesh, and thing is these countries can play by their own rules. For example, by lacing the feed with antibiotics such as tetracyclines, and raising the fish in congested unhygienic pens. The result is the high levels of bacterial contamination. This in turn leads to the spreading of disease among wild fish populations.

Note that these are essentially the same unhealthy practices used in our own food-animal factory farm system, which has also come under heavy criticism.

So is the answer, “Go Wild”? CR says that “of all the shrimp tested, wild shrimp were among the least likely to harbor any kind of bacteria or contain chemicals.” However, even though raw, wild-caught shrimp from Argentina and the U.S. were the least likely to be tainted, they still had bacterial counts of 33 and 20 percent, respectively.

So what can we do?

Proper cooking helps. And if you buy farmed shrimp, imported or domestic, the report recommends looking for these labels: Naturland, Aquaculture Stewardship Council, or Whole Foods Market Responsibly.

CR also tells us that labeling of shrimp or other seafood as “natural” or “organic” should not be relied upon since there are no standards or regulations behind the terms and consequently they don’t mean anything.

Of course, there’s always Plan B:gone fishing

 

 

How we die changes over time

The chart below from The New England Journal of Medicine tells us that how we die is not how we used to die: There has been a fundamental shift from deaths caused by infectious disease to deaths caused by chronic illness – heart disease and cancer.

The chart also implies something very important: If how we die can change, what is in store for us, say, 35 years down the road? Will things remain the same or are we looking at another fundamental shift?

NEJM

Our leading authorities such as the World Health Organization say that infectious disease will make a comeback, so much so that a recent UK government report predicts that drug-resistant infections  – a subset of all infections – will kill more people than cancer by 2050.

The reason? We’re losing our antibiotics, that wall of drugs we built beginning in the 1940s that have until recently kept most bugs at bay. But they haven’t sat idle. The bugs have spent the ensuing years figuring out how to penetrate that wall of drugs – that’s evolution for you – with the upshot that our core practices of medicine such as child birth, routine operations, and cancer treatment, will be compromised.

One more thing. Deaths by infections won’t replace deaths by chronic illness – they’ll simply add to them.

The good news is that in this case knowledge is power. We know how to slow the trend so there will be more time to develop effective drugs and other solutions. But this will involve all of us because it’s our persistent misuse of antibiotics that has accelerated the emergence of these drug-resistant bugs.

So what do we do? Stop Asking for Antibiotics, says, for example, the Harvard School of Public Health.

Sounds easy enough, but, for example, would you reach for antibiotics when the common cold or the flu strikes your family?

 

 

 

The Choices We Make

Here’s two charts that tell an interesting tale.

Britain’s National Health Service, who prepared the first one, tells us that poor diet, lack of exercise and smoking are the main offenders behind the high level of deaths from heart disease.

causes of death

We also know that major causes of death change over time. For example, a report commissioned by British Prime Minister David Cameron found that unless antibiotic-resistant bacteria are stopped, they could kill an average of 10 million people a year by 2050, which would place it ahead of cancer.

The second chart tells us what we’re doing about these things that kill us, at least in terms of where we want the money to go.

President Obama has often said that, “My number one priority continues to be the security of the United States,” referring, in this case, to Iran.

At issue, however, is whether we should continue to define national security as simply a military matter.

The choice is ours.

obama's budget 2

 

 

 

 

 

 

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