| Natalie Shaw |
March 23, 2005
Natalie Shaw said it started like the flu.
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On a Wednesday morning more than a month ago, the 17-year-old Central High School senior woke with a cough. By Thursday, she had a 103-degree fever.
By Saturday, she was hacking up blood.
An X-ray showed spots on her lungs - pneumonia. A specimen went to the lab. She went home with antibiotics.
The initial lab results showed normal bacteria in the lungs. But Natalie's dad - Dr. Byers "Bud" Shaw Jr., the Nebraska Medical Center's chief of surgery - asked for another look. He'd spoken with an infectious disease specialist, concerned about the bloody cough.
By Monday night, it was clear that Natalie didn't have a run-of-the-mill pneumonia. She had a super strain, caused by an organism called methicillin-resistant staphylococcus aureus, or MRSA.
It used to be that this kind of bacterial infection - resistant to the penicillin class of antibiotics - cropped up mainly in hospitals, nursing homes and among the very sick.
But, increasingly over the past several years, even young and otherwise healthy people are getting sick from the bacteria. And they're getting it outside of health care settings.
"It's been phenomenal the last two years how this has really taken off," said Dr. Robert Muelleman, chief of emergency medicine at the Nebraska Medical Center.
It's not clear how many cases result in pneumonia, but Nebraska laboratory reports suggest that MRSA cases in Douglas County more than doubled from 2001 to 2003. The Centers for Disease Control and Prevention estimates that roughly 130,000 people are hospitalized with MRSA each year.
There are reports, locally and nationally, of the bacteria causing flesh-eating skin infections in athletes, prison inmates and others who are in close contact on playing fields or in locker rooms.
Sports Illustrated recently highlighted MRSA as a problem among college and professional football players and other athletes.
"And I have had some calls about clusters in families or in sports teams here," said Dr. Mark Rupp, professor of infectious diseases at UNMC.
Muelleman said he sees MRSA skin infections at least once or twice a week in the emergency room. He said MRSA is still in the minority, though, when it comes to causes of pneumonia.
Because the bug is resistant to the penicillin-like class of antibiotics, it can be hard to shake.
And because it often starts out like a seemingly benign problem, patients might not seek treatment and doctors might not test for it right away - giving it a good head start before the right drugs are tried.
Natalie's fine now. But it took a second look at her lab work, five kinds of antibiotics, four days in the hospital and missing the metro swim meet to get over her MRSA pneumonia. She took the last of the antibiotics on March 8 - 27 days after she woke with a cough.
Rupp said most MRSA infections can be treated with Vancomycin, an antibiotic given by injection. And older sulfa drugs like Bactrim sometimes work on MRSA infections acquired outside hospital settings.
Rupp said a quarter to one-third of healthy people carry normal, drug-susceptible staphylococcus aureus on their skin or in their noses and mouths.
"It doesn't make you sick until it gets an opportunity," he said. "Usually, it's when you have some sort of break in normal immunity."
In the case of skin infections, the bacteria can enter a tiny scrape on the skin and spread through the blood. In the case of a lung infection, bacteria already in your mouth or nose might get into your lungs after a viral infection rips up your airways.
Dr. Nancy Cornish, a pathologist and microbiologist at Methodist Hospital and Children's Hospital, said most pneumonias are caused by bacteria already in the body.
"Usually somebody has an upper respiratory tract infection first," she said.
So how do drug-resistant staph bacteria get into the non-hospital community?
Rupp said the gene that allows drug resistance in MRSA has become mobile. It can hop from the staph bacteria found in hospitals to the normal strains carried by healthy people.
Scientists theorize that modern society's reliance on antibiotics - in using microbial soaps and taking antibiotics for every runny nose - is part of the problem.
Cornish said inappropriate use of antibiotics can kill the "normal flora" of the body, making room for drug-resistant bacteria.
Muelleman said the rise in community-acquired MRSA is prompting doctors to change how they prescribe drugs and how often they order lab work to find the cause of infections. He said he now orders lab cultures on every skin infection he sees in the ER.
Unfortunately, Rupp said, there's not a whole lot most people can do to avoid contracting MRSA. Following good basic hygiene - washing hands, covering any open wounds, not sharing towels or other personal items, and using antibiotics only when necessary - is a start.
By Rob Stein
April 7, 2005
A dangerous germ easily mistaken for an innocuous one has become alarmingly common around the United States, raising concern that seemingly minor boils, pimples and abscesses could increasingly become disfiguring or even life-threatening, researchers reported yesterday.
Because the microbe has become invulnerable to the most commonly used antibiotics, the discovery means doctors should now routinely test all skin infections to identify patients who need urgent treatment with one of the handful of drugs still capable of killing the aggressive pathogen, experts said.
"This should serve as a red flag to doctors whenever they are treating skin infections," said Scott K. Fridkin of the federal Centers for Disease Control and Prevention, who led the study reported in today's issue of the New England Journal of Medicine. "This is a new bug that has emerged in the community. It's a cause for concern."
The widespread emergence of the microbe is the latest manifestation of the growing threat of antibiotic resistance, a trend that has seen an increasing number of microorganisms evolve into strains that defeat many of modern medicine's most important weapons.
"This is just another sign that, unfortunately, the bugs are winning," said Loren G. Miller of the Harbor-UCLA Medical Center, the lead author of a companion paper describing 14 cases of people stricken by "flesh-eating" cases of the infection.
In the first systematic attempt to assess how common the infections have become, researchers did a comprehensive analysis of these methicillin-resistant Staphylococcus aureus (MRSA) infections in Baltimore, Atlanta and Minnesota in 2001 and 2002. They found 2,107 cases in people who had no contact with hospitals, the primary locales where such infections turned up in the past. The non-hospital cases accounted for 8 percent to 20 percent of all such infections identified in the study. Children ages 2 and younger appeared to be especially vulnerable.
"A decade ago, it would have been zero percent," Fridkin said. "We wanted to see if this had become commonplace in the community. The answer is a resounding 'yes.' It's clearly no longer limited to the hospital."
The microbe is a strain of the ubiquitous bacterium Staphylococcus aureus, which usually causes well-known "staph" infections that are easily treated with common antibiotics in the penicillin family, such as methicillin and amoxicillin.
In recent years, small outbreaks of infections with a strain that is impervious to those antibiotics have been reported among athletes, inmates, children and other groups, but otherwise resistant staph strains had been almost exclusively limited to hospitals.
"We're used to resistant staph in the hospital as a problem among patients with heart failure, liver failure, cancer or other health problems," said David N. Gilbert of the Oregon Health & Science University. "It's started attacking normal healthy people, causing serious, often fatal illness."
The germ, which is spread by casual contact, produces potent toxins that kill disease-fighting white blood cells. That rapidly turns minor rug burns, cuts and other skin infections into serious health problems, apparently including "necrotizing" abscesses that eat away tissue. Previously, such cases were thought to be caused only by strep bacteria.
In other cases, the microbe gets into the lungs, causing unusually serious cases of pneumonia, often on the heels of the flu, or spreads into the bloodstream, triggering life-threatening complications.
"This has now become a significant problem in this country," said Donald M. Poretz, an infectious-disease expert at Georgetown University who serves as president of the National Foundation for Infectious Diseases. "We see dozens of these cases in our offices."
The infections can often be treated simply by lancing and draining abscesses and quickly administering less commonly used antibiotics, such as vancomycin. The risk of becoming infected can be minimized by taking common-sense precautions, such as frequent hand-washing. But experts fear doctors, especially in areas where the microbe is not yet well known, will not recognize it.
"Some of our patients had to have very extensive surgery to remove all of the dead tissue, and many of them were quite ill and required intensive care," said Miller of UCLA. "It's an infectious-disease emergency, because without prompt surgery, treatment and antibiotics, people will die."
The resistant strain probably emerged because of the overuse of antibiotics. Public health officials have become increasingly concerned about this trend, especially because little work is underway to develop a new generation of antibiotics.
Experts are also concerned that the shrinking number of effective antibiotics may also be slowly losing their power.
"What people are concerned about is that we'll be losing these drugs one by one until we don't have any effective ones left," said Walter E. Stamm, president of the Infectious Disease Society of America.