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Drugs Versus Bugs

Covering outbreaks of antibiotic-resistant infections

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When several infectious disease doctors tipped me off about an outbreak of aggressive skin infections among gay men around Los Angeles in 2002, they initially suspected they might be seeing a new sexually transmitted disease.

The truth was far simpler, yet also far more complicated.

The source of the skin boils, abscesses and inflammation first noticed among gay patients in late 2002 eventually was identified as a strain of methicillin-resistant staphylococcus aureus, commonly known as MRSA. For decades, the skin bumps and boils caused by staphylococcus aureus (staph for short) were easily treated with antibiotics like penicillin and amoxicillin. But newer strains had emerged that most antibiotics couldn't eliminate. The resistant microbe the L.A. doctors encountered wasn't just entering the body via small breaks in the skin, but also penetrating intact skin.

The article I wrote for the Los Angeles Times Health section of Monday, Jan. 17, 2003, "Skin Infection Spreads Among Gay Men in L.A," marked one of many times I've written stories explaining how the bugs are outsmarting the drugs.

With the rise in these MRSA infections, the few that prove dangerous or deadly invariably make headlines or lead the evening news. Because even basic reporting can stir panic each time a cluster of infections arises, journalists should take extra care to present these stories with context and perspective.

In the 2002 outbreak, I had reported after interviews with doctors at the L.A. County Department of Public Health and researchers with the federal Centers for Disease Control and Prevention in Atlanta that the strain seen among gay men matched the strain found among a small group of newborns, some high school athletes and a large institutionalized population that county officials weren't yet ready to identify. Its occurrence among babies, teens and adults argued against it being a sexually transmitted infection, or one restricted to gay men.

The day my story ran, county officials revealed that the institutionalized population they'd held off identifying was a cluster of 1,000 county jail inmates – the perfect population for rapid spread.

A problem that can be prevented

The involvement of inmates helped make an important public health point. Because staph usually lives harmlessly in the nose, armpits and groin, basic hygiene (such as washing hands and laundering towels and clothes that come into contact with infected areas), covering infected areas with a clean bandage, and not sharing personal items such as washcloths or razors can curb, if not prevent, its spread. In the close quarters of jails, these practices easily fall by the wayside.

But the ease with which these infections can usually be prevented is often not the message the media convey.

When MRSA outbreaks occurred among high school athletes in Maryland and Virginia in the fall of 2007, some television stations ran video of custodial workers donning masks and hazmat suits to clean school lockers, bleachers and doors. Those images were misleading, said Dr. Elizabeth A. Bancroft, a medical epidemiologist with L.A. County's public public health department. Speaking to journalists on March 1, 2008 at a workshop sponsored by the California Endowment Health Journalism Fellowships, she said those stories should have mentioned that the suits were needed to protect the workers from bleach and disinfection chemicals, not from MRSA.

Every journalist who does stories about MRSA infections should know that there are two basic varieties. Those that draw the most media attention occur on the skin and are transmitted in the community, but account for only a small percentage of cases of major disease and death. The greater toll comes from MRSA infections acquired in hospitals and other health institutions. They enter the bloodstream through catheters, intravenous lines, ventilators and surgical sites, posing particular danger to the elderly and those with weakened immune systems. Infections in these patients account for most of the 18,000 annual deaths estimated by the CDC. Even though there have been deaths among young, otherwise healthy athletes, Bancroft noted that school-age children are at the lowest risk from invasive MRSA infections.

The rise in these infections has spurred individual hospital campaigns to boost infection control among health workers by ensuring that they use gloves and masks and disinfecting their hands when they move between patients. Health insurers are testing programs to detect and treat infected patients before they can become germ-spreaders. An added incentive to take action is a Medicare decision in the fall of 2008 to stop reimbursing hospitals for the costs of treating eight infections it deems preventable. On top of all this, several states have adopted reporting and tracking requirements for these infections.

When California officials announced in February 2008 that they would begin monitoring severe antibiotic-resistant infections acquired in community settings, such as gyms and schools, consumer advocates and disease experts pointed out that the policy was ignored by the hospitals and nursing homes that constitute the predominant sources of serious infection. Legislators responded. In September 2008, Gov. Arnold Schwarzenegger signed legislation requiring hospitals to test hospitalized patients at high risk for MRSA within 24 hours of admission and report their infection rates to the state. The legislation also boosted public health agencies' monitoring of hospitals.

While public and private institutions try to reduce infection rates, scientists and public health experts are observing an increasing number of bacteria becoming impervious to a limited antibiotic arsenal. Doctors see more cases of infections with so-called intermediate resistance to Vancomycin--once called the drug of last resort--which means they can't count on it for successful treatment. In some cases, they are going back to some of the older drugs after having microbiology laboratories test samples for their susceptibility to various antibiotics.

Bugs to watch for

It's not just staph that's outsmarting the drug arsenal. Other increasingly resistant microbes that bear watching include:

•Clostridium difficile, or C. difficile, a diarrhea-producing bacterium that's usually contracted by patients receiving antibiotics, hospitalized patients or nursing home residents. In the Oct. 7, 2008, issue of the Canadian Medical Association Journal, McGill University researcher researchers reported that among hospitalized patients 65 and older who contracted C. diff (as it's often called) outside hospitals, more than half hadn't been exposed to antibiotics in the 45 days before they were admitted. That suggested that despite the common view that these infections stem from antibiotic use, more than half the infections that arose in the community lacked that link.

C. diff is transmitted by airborne spores that can survive on surfaces for months or longer, and can easily be spread via the hands of health care workers. It's also tough to kill; alcohol-based disinfectants don't work, nor do many cleaning solutions. Relapses are common.

• Klebsiella pneumoniae, a bacterium that's a source of pneumonia and is often spread by the hands. Resistant strains have been a problem on the East Coast, particularly in New York and New Jersey. While not yet a major problem yet in California, Klebsiella is one to watch for, according to Janet Hindler, a UCLA clinical microbiologist and consultant for the Association of Public Health Laboratories.

• Acinetobacter baumannii. This microbe, which can be found in soil and water, lives on the skin and can survive in the environment for weeks. Drug-resistant strains have garnered some attention because of cases contracted by wounded soldiers who have served in Iraq, leading to the nickname "Iraqibacter." The PBS program NOVA scienceNOW aired a story on July 9, 2008 that noted that among those who had contracted Iraqibacter was ABC News reporter Bob Woodruff, who also suffered severe brain injuries and other wounds in a January 2006 Iraqi bomb attack.

• Researchers also warn that hospital-based strains of other microbes, such Escherichia coli (E. coli), which is responsible for problems like urinary tract infections, could move over into the community and wreak new havoc.

As the bugs continue changing their genetic structure just enough to make once-effective drugs ineffective, there is fear that one day, the arsenal will be empty. But until that day comes, reporters, editors and producers should inject some needed sobriety into the discussion of these emerging threats to public health.

Jane E. Allen, a former reporter with the Los Angeles Times, is a freelance medical reporter in Los Angeles.

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