30 October 2008

Microbes in US meat, but no MRSA

The ICAAC-IDSA meeting has ended, but there are still many abstracts that I have not been through. While I pore over them, though, an interesting paper has just been published that somewhat contradicts earlier research on the presence of MRSA in meat. (Earlier posts are here, here, here, here, here, here, here and here.)

The researchers, from the Warren Alpert Medical School of Brown University and Rhode Island Hospital, bought ground beef, boneless chicken breasts and pork chops from 10 stores in and around Providence. Two stores offered both conventional and "natural" choices, so they bought both, giving them 36 (=[10+2]x3) samples all told. They cultured for MRSA, vancomycin-resistant Enterococcus, extended-spectrum beta-lactamase producing Gram-negative bacteria and E. coli 0157:H7.

And they found... almost nothing. Only one samples grew a resistant microbe, the ESBL Gram-negative Serratia fonticola. A secnd level of testing, however, uncovered four samples carrying S. aureus — but all methicillin-sensitive, not MRSA.

So are we in the clear? Not necessarily. It is, as they say themselves, as small study, in which only a third of the samples were pork, though pigs are the animals most associated with MRSA via the strain ST398. And the presence of S. fonticola is troubling, because it not only causes disease directly (in animals and in humans), but also harbors a plasmid that can transfer resistance to other bacterial strains.

Nevertheless, it is a comforting reminder that, though MRSA has been found in meat, it has not been found everywhere. (Or at least, not in Providence.) Still, we shouldn't let our personal vigilance lapse. The hypothetical danger from MRSA in meat is not that we'll swallow it, but rather that we'll be colonized if we handle the raw meat without being careful enough about kitchen hygiene. So keep raw meat away from other food, wash your cutting boards and counters, and (say it with me, now), wash your hands, wash your hands, wash your hands.

The cite is: Philip A. Chan, Sarah E. Wakeman, Adele Angelone and Leonard A. Mermel, Investigation of multi-drug resistant microbes in retail meats. Journal of Food, Agriculture & Environment, Vol.6 (3&4), July-October 2008.

27 October 2008

Outbreak of Zyvox-resistant staph (breaking news from ICAAC 2)

Physicians from Madrid reported today on what's believed to be the first outbreak of MRSA caused by a strain that was resistant to linezolid, usually known as Zyvox, a relatively new and costly drug that is used for complicated MRSA infections and when older drugs fail.

Linezolid resistance in single cases has been recorded before — the first isolate I can see in a quick scan of the literature dates to 2002 — but this appears to be the first outbreak.

Dr. Miguel Sanchez of the Hospital Clinico San Carlos said the outbreak was discovered April 13, 2008 in an ICU patient and subsequently spread to 11 other patients in the ICU and two elsewhere in the hospital. The patients, 8 men and 4 women, had been in the unit for at least three weeks for a variety of reasons; they were intubated, had central venous catheters, and had been receiving broad-spectrum antibiotics. None of them were colonized with MRSA on admission. The outbreak went on for 12 weeks, until June 27.

It was eventually shut down by a combination of strategies: taking the patients off linezolid in favor of other anti-staph drugs (vancomycin and tigecycline); drastically restricting linezolid use, a policy that is already followed by many US hospitals; checking the patients very frequently for colonization; and cohorting them, which means grouping them together physically, away from uninfected patients, and putting them under isolation.

In a quick briefing with reporters, Sanchez seemed to suggest that the hospital does not believe its infection control failed. The hospital swabbed 91 environmental surfaces (such as bed rails and room furniture) and the hands of 47 health-care personnel and found only one sample that grew the linezolid-resistant strain on a culture. A case-control study to find the cause is being conducted, he said.

Half of the patients died, he said, but not as a result of the linezolid-resistant strain.

Sanchez' data slides were not available to reporters this evening. (More precisely, they were delivered to the press room, but in a format that wasn't readable). I'll update with more details if/when we get access to them. Meanwhile, the cite is: M. De la Torre, M. Sanchez, G. Morales et al. "Outbreak of Linezolid-Resistant Staphylococcus aureus in Intensive Care." Abstract C2-1835a.

26 October 2008

ST 398 in New York City - via the Dominican Republic?

Here's a piece of MRSA news from the ICAAC meeting (see the post just below) that is intriguing enough to deserve its own post.

US and Caribbean researchers have found preliminary evidence of the staph strain ST 398, the animal-origin strain that has caused human illness in the Netherlands and has recently been found in Ontario and Iowa, in Manhattan. How it may have arrived: Via the Dominican Republic.

Th researchers (from Columbia University and Montefiore Medical Center in New York, three institutions in the Dominican Republic and one in Martinique) examine the influence of an "air bridge" — very frequent household travel — that is bringing MRSA and methicillin-sensitive staph back and forth between the Dominican Republic and the immigrant Dominican community at the north end of Manhattan. They compared 81 staph isolates from Dominican Republic residents and 636 from Manhattan residents and, among other findings, say that 6 Dominican strains and 13 Manhattan strains were ST398.

It is the first time ST398 has been found in Manhattan or in the Dominican Republic. (Most likely also the first time anyone has looked.)

The authors observe with some understatement:
Given the history of ST398's rapid dissemination in the Netherlands, its history of methicillin-resistance and its ability to cause infections in both hospital and community, it will be important to monitor its prevalence in these new regions.
It is important to note that these ST398s were not MRSA — they were MSSA, methicillin-sensitive. However: Earlier this year, the Dutch researchers who have delineated the emergence of ST398 in Holland commented on the diversity of ST398 they have found on different pig farms and hypothesized that the resistance element has been acquired several different times by methicillin-sensitive staph. (van Duijkeren, E. et al. Vet Microbiol 2008 Jan 25; 126(4): 383-9.)

So it is possible to hypothesize that this strain arrived in Manhattan from the more rural Dominican Republic, though with the growth of hobby urban farming in NYC, one could also make the case that transmission went the other way. And it is also possible — I emphasize possible — that this could be a precursor to ST398 MRSA emerging in Manhattan. An interesting thought.

(This research is not online, because it is a poster presented at a medical meeting. For reference, the cite is: C. DuMortier, B. Taylor, J. E. Sanchez et al. "Evidence of S. aureus Transmission Between the USA and the Dominican Republic." Poster C2-224. 48th ICAAC-46th IDSA, Washington DC, 24-28 Oct 2008.)

Breaking MRSA news from the ICAAC meeting 1

There are 15,000+ people at the 48th Interscience Conference on Antimicrobial Agents and Chemistry (known as ICAAC - yes, "Ick-ack") and 46th Infectious Diseases Society of America Annual Meeting, and at least half of them seem interested in MRSA. At the keynote address last night, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at NIH, referred to MRSA as a "global pandemic."

Here are some highlights — a few of very, very many — from the first two days:
  • MRSA is truly a global phenomenon: Researchers here are reporting on local epidemics in Argentina, Australia, Botswana, Canada, Colombia, Ecuador, Greece, Japan, Nigeria, Peru, South Korea, Sweden and Taiwan.
  • In the United States, USA300 — the virulent community strain that is crowding out all other community strains — continues its dominance. It first appeared in the San Francisco jail in 2001 and now is the only cause of community MRSA infections there. (Tattevin, P. et al. "What Happened After the Introduction of USA300 in Correctional Facilities?" Poster C2-225.)
  • And MRSA continues to demonstrate its protean ability to cause unexpected forms of illness: The number of cases of sinusitis caused by MRSA seen at Georgetown University tripled between 2001-03 and 2004-06. (I. Brook and J. Hausfeld. "Increase in the Frequency of Recovery of Methicillin-Resistant Staphylococcus aureus in Acute and Chronic Maxillary Sinusitis." Poster C2-228.)
  • Meanwhile, treatment options are shrinking. Hospitalization for vancomycin-resistant pathogens (that is, resistant to vancomycin, the drug of last resort for MRSA) doubled between 2003 and 2005 according to national healthcare utilization databases. (A.M. Ramsey et al. "The Growing Burden of Vancomycin Resistance in US Hospitals, 2000-2005." Poster K-560.)
  • But, new drugs are beginning to emerge from the pipeline. Early results from a privately held company called Paratek Pharmaceuticals (co-founded by resistance guru Dr. Stuart Levy) showed that their new tetracycline relative PTK 0796 scored as well or slightly better than linezolid (Zyvox) in safety, tolerability and adverse events, and is advancing to a full Phase 3 trial. (R.D. Arbeit et al. "Safety and Efficacy of PTK 0796." Poster L-1515.)
More as the meeting goes on.

24 October 2008

MRSA and pets - any experience?

Constant readers, I'm working on a chapter on MRSA in animals and would be curious to hear from anyone who has had experience with MRSA in a pet, whether as an owner/companion or on the veterinary side.

If this is you, please get in touch! Your options are: via the email address in the right-hand column; or via comments here. (I moderate all comments, which means that I see them before they post; so I can read a comment and remove it without its going public, if you prefer.)

Erratic posting ahead

Constant readers: I am headed to the ICAAC/IDSA meeting. (For those not into medical acronyms, that's the Interscience Conference on Antimicrobial Agents and Chemotherapy, which is the biggest infectious-disease conference of the year that isn't exclusively about HIV, and which this year is combined with the annual meeting of the Infectious Diseases Society of America, the second biggest. Yes, it's an infectious-disease geekgasm.)

Posting is likely to be erratic: I expect there to be a ton of MRSA news, but no time to write about it. However, I'll be throwing things up here as I can, and will also be filing flu news to CIDRAP — though, since CIDRAP doesn't publish on weekends, don't expect anything there til Monday or Tuesday.

See you on the far side.

23 October 2008

Much new news on hospital-acquired infections

There's a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on "search and destroy," the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. "Search and destroy" has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:
  • the design and implementation of state HAI public reporting systems,
  • the initiatives hospitals have undertaken to reduce MRSA infections, and
  • the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)
The report is too thick to summarize here, but here are some key points:
  • No two places are doing this the same way — which means that data still does not match state to state
  • Experts are still divided about how much MRSA control is necessary
  • Hospitals that have undertaken MRSA-reduction programs have taken different paths
  • But MRSA control does work: It does reduce in-hospital infections, but at a cost.
This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don't really know how much MRSA - in hospitals or in the community - we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!

21 October 2008

MRSA in sports

I am possibly the most sports-impaired person on the planet (a consequence of growing up with the lovely but impenetrable game of cricket), but even I noticed these stories recently.
  • University of North Carolina-Asheville basketball center Kenny George has lost part of his right foot to amputation as the result of a staph infection.
  • Cleveland Browns tight end Kellen Winslow has emotionally gone public — to the displeasure of his coaches — with the news that he was hospitalized for three days for a staph infection. Winslow has been struggling with MRSA since 2005, when he had a motorbike accident, had surgery, and developed a post-surgical infection. Four other Browns players — Braylon Edwards, Joe Jurevicius, LeCharles Bentley and Brian Russell — have had MRSA as well.
MRSA in sports is not new news, but the prominence of some of its victims has brought great attention to the bug: For instance, Redskins defensive tackle Brandon Noble, who was sidelined for a season, and eventually ended his career, over a MRSA infection following arthroscopic knee surgery. And it is not limited to pro players: Lycoming College senior Ricky Lanetti died in 2003 from an overwhelming MRSA infection that began as a pimple-like "spider bite" lesion.

There has been so much concern about MRSA among schools and parents that the CDC has issued specific advice for sports programs. Some of the reasons why athletes may be vulnerable are well-understood: They work in crowded conditions, they undergo a lot of skin-to-skin contact, they are likely to get scraped and injured, and they may not get clean immediately (especially high school players — does anyone shower after high school sports any more?).

But some factors, such as the role of artificial turf, are still murky. An investigation of eight MRSA infections among the St. Louis Rams in the 2003 season (first author Sophia Kazakova) found that linemen and linebackers were more likely to develop MRSA, possibly because they ended up with more turf abrasions. On the other hand, an investigation of 10 infections among players at Sacred Heart University in Connecticut (first author Elizabeth Begier) found that, while turf burns played a role, a contaminated team whirlpool — and sharing razors for shaving body hair — did too.

20 October 2008

How to wash your hands, a tutorial

More still to come on hospital-acquired infections. (No, really. I mean it.) But first:

Somehow I sadly missed that last Wednesday, Oct. 15, was Global Handwashing Day, sponsored by the World Bank, CDC, UNICEF and a number of other organizations including several soap manufacturers. Here's a BBC story describing massive social mobilization efforts that were supposed to take place across South Asia last week. (Can any Asian readers report in whether they saw anything? Mumbai and Hyderabad readers, I'm looking at you.)

Though we missed the festivities, here's an excellent take-away: A great series of videos produced by the Grey-Bruce Health Unit, a local health department northwest of Toronto, about the right way to wash hands with soap and water and/or alcohol gel.

14 October 2008

Sign of the times: Taking your own cleaning materials to the hospital

There are several new and important reports out on hospital-acquired infections (HAIs) that I hope to get to this week, but I spotted something today that I just had to highlight first:

Constant readers may know that I've done a lot of reporting in the developing world. In parts of Asia and Africa, it is assumed that patients or their families bring food to the hospital. People do not trust the hospitals to feed them, with good reason: Hospitals can't afford it. Provision of food in the hospital, which we take for granted, is not part of the health-care culture. (In particularly poor countries, the family may feed not only the patient, but the health care workers taking care of the patient as well.)

Here now is an industrialized-world version of that developing-world practice. A company in England (which, as we've discussed, has ferocious rates of hospital MRSA and C. difficile) has begun marketing the PatientPak, the "world's first personal anti-superbug kit." It's a $28 sample-sized collection of antimicrobial hair and body wash, hand wipes, hand sanitizer and a germ-killing spray for sheets and cubicle curtains, along with lip balm, bar soap, and a disposable nail brush and pen.

It's entirely possible that using products like this might protect a patient from some hospital-acquired infections; the company suggests that a patient use the wipes and the hand spray when going to and from the bathroom or after touching any surfaces. But the difficult reality, of course, is that most hospital-acquired infections are not the patient's fault: They are due to infection-control breaches by hospital staff, something over which a patient — with antimicrobial wipes or without — has little control.

This company will probably sell quite a few of these kits — and I don't know that I can criticize them for doing so. If one of my family members was being admitted to hospital, I might well send something like this with them. But what a sad commentary on our own health-care culture that any of us would consider this necessary.

08 October 2008

New MRSA group discussion, caveat lector

A UK-based site called iCareCafe posted a link in the comments to the previous post, inviting readers who are MRSA patients or caregivers to visit. Per my rules I'm elevating it to post status so that you can see it and I can comment on it.

Here is their post:
...The icarecafe has been set up to provide a space for patients, carers and their supporters online.
Some of the members have set up a discussion group on the subject of MRSA. The group has asked lots of questions which are still in the process of being answered. So we thought it appropriate if we invited people from other MRSA discussion group and blogs to ask if they wished to participate.
To have a look at the discussions so far please have a look at http://www.icarecafe.com/?page_id=1107&group_id=71
Best wishes
Belinda Shale
Moderator – the icarecafe
My due diligence:
  • As you'll see in the right-hand sidebar, I am a sympathetic member and promoter of authentic communities online. However, as I have warned before, I am skeptical of sites that exist mainly to sell products to patients.
  • The iCareCafe appears to be an authentic discussion forum that covers numerous diseases and conditions, though a few of the members are using what appear to be "stock art" pix of models to represent themselves; make of that what you will.
  • The MRSA forum currently has 6 threads running; in a few, people are sharing their stories, and in a few others, people are aggressively pushing nutritional regimens and recommending cleaning products.
  • The iCareCafe is backed by a marketing company, as it discloses here:
    ...The icarecafe is a project from The Patients Voice (which is itself part of Healthcare Landscape. By way of earning our living we provide our clients with medical market research services. Or to put it another way we run surveys and focus groups and things of that nature so that we can provide patients with a voice.

07 October 2008

Five-fold increase in flu+MRSA deaths in kids

I have a story up this evening at CIDRAP News about a new paper in the journal Pediatrics that analyzes the incidence of child deaths from pneumonia caused by the combination of MRSA and flu, a sad and scary development that we've talked about here, here and here.

(NB: CIDRAP News is the original-reporting and news-aggregation arm of the Center for Infectious Disease Research and Policy at the University of Minnesota, an infectious disease research center headed by noted epidemiologist Michael Osterholm, PhD. I have a part-time appointment there. CIDRAP News is the best-read infectious-disease website you have never heard of, with about 10 million visitors a year, and is a notable resource for news on seasonal and pandemic flu, select agents and bioterrorism, and foodborne disease.)

It is bad netiquette and not fair use to reproduce another publication's entire story here, even if I wrote it. Here though are the highlights:
  • 166 children died of influenza in the past three seasons (2004-05, 2005-06, 2006-07) according to 39 states and 2 local health departments (86 this year in preliminary reporting)
  • The proportion of deaths from bacterial co-infection rose each year, from 6% to 15% to 34%, a five-fold increase
  • Almost all of the bacterial co-infections were staph; 64% of them MRSA
  • The rapid rise in MRSA colonization (from 0.8% of the population in 2001 to 1.5% in 2004 — that's more than 4 million people) may be playing a role
  • And, some of these deaths could have been avoided if children had had flu shots — but overall, only 21% of under-2s and 16% of 2- to 5-year-olds get the two shots they need to be fully protected against flu.
Please click through to CIDRAP for more.

The cite is: Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805-11.

05 October 2008

UK: Hospitals' MRSA deaths could bring manslaughter charges

Last Wednesday was the first day of the new federal fiscal year, and therefore the day on which HHS's new "non-reimbursement for medical errors" rule went into effect. Under this new rule (blogged here and here and covered in this New York Times story), the Center for Medicare and Medicaid Services will no longer reimburse hospitals for the increased care that a patient needs after an extreme medical error has happened. While infecting a patient with MRSA is not specifically disavowed in the rule, it outlaws reimbursement as of this year for infections associated with vascular catheters and coronary artery bypass graft surgery, and next year (Oct. 1, 2009) for surgical site infections following orthopedic procedures. (Disappointingly, CMS rejected requests to define staph septicemia and nosocomial MRSA infection as "never events.")

Now, however, it seems that the UK government is willing to go much further than our own. According to a story in The Independent (first flagged here by ace flu blogger Crawford Killian), "tough new manslaughter laws" will allow corporations — including healthcare institutions — to be held accountable for deaths in which corporate behavior plays a role:
Maria Eagle, the Justice minister, told a meeting of more than 100 chairs and non-executive directors of NHS trusts that where managers ignore warnings of health risks, prosecutions may follow. She said: "Putting the offence into context, imagine that a patient has died in a hospital infected by MRSA and the issue of corporate manslaughter has been raised. Could the organisation be prosecuted and convicted? The answer is 'possibly'. (Byline: Robert Verkaik, law editor)
Public attitudes in the UK are ripe for this change. In July, there was significant protest after it emerged — via a government report — that 345 patients died of Clostridium difficile infection at three hospitals, after government warnings, with no punishment to the hospitals. In fact, according to The Independent, the chief executive of the trust that operated all three was allowed to resign with $150,000 in foregone pay, and is now suing for additional compensation.

So far, US protests and citizen action over nosocomial MRSA infections have been within individual states (see this recent post on the new Nile's Law in California). But isn't it interesting to see what coordinated national action — granted, in a smaller country — can do.

03 October 2008

More teen MRSA deaths

I just want to note that there is a sad uptick in news of MRSA illnesses and deaths among teens:
  • 18-year-old Alonzo Smith of Kissimmee, Fla. died this past Monday, Sept. 29.
  • 17-year-old Saalen Jones of Philadelphia died on Tuesday, Sept. 23.
In addition, just in the past two weeks there have been school outbreaks in:

02 October 2008

Non-pharm prevention alternative for MRSA skin infections

Longtime reader and botanical-medicine expert Robyn spotted this new story and study this morning and pointed it out in the comments to a previous post. It's about a product, but it's a product with science to back it, so under my rules regarding commercial products, I am moving it up to post status. (Robyn didn't say, but given the internals of her post I assume, that she has no commercial interest in this. Right, Robyn?)

The product under investigation is an over-the-counter cream called StaphASeptic that contains the natural antimicrobials tea tree (Melaleuca alternifolia) oil and white thyme (Thymus vulgaris — the "white" refers to the preparation not the species) oil, along with the commercial antiseptic benzethonium chloride. That product's effect on isolates of CA-MRSA was compared against two common OTC first aid creams, one containing the topical antibiotic polymyxin B and the other containing both polymyxin B and the topical antibiotic neomycin.

The authors found that the botanical-containing cream did a better job of killing CA-MRSA in a time-kill analysis, finding specifically that it went on killing longer — up to 24 hours — than the other two creams. The assumption obviously is that this non-antibiotic cream would do a better job of protecting superficial wounds and scrapes from MRSA infection than the antibiotic-containing ones, while presumably not promoting resistance.

But the important question, which Robyn raises, is whether the essential oils are not in fact acting as natural antibiotics, possibly synergistically. Let's remember that the majority of antibiotics — including, for instance MRSA drug-of-last-resort vancomycin, and its replacement daptomycin — were initially isolated from natural substances (fungi, in both those cases). Overall, however, botanical products receive much less research attention that pharmaceuticals, so their action and their therapeutic potential remain unexplored.

The cite is: Bearden, DT, Allen GP and Christensen JM. Comparative in vitro activities of topical wound care products against community-associated methicillin-resistant Staphylococcus aureus. Journal of Antimicrobial Chemotherapy (2008) 62, 769–772. NB: The research was supported by an unrestricted grant from StaphASeptic 's manufacturers, Tec Laboratories Inc., and JM Christensen, of the Oregon State University College of Pharmacy, disclosed a consultant relationship with Tec.

CDC educational campaign on antimicrobial resistance

The Centers for Disease Control and Prevention has a long-running educational campaign called "Get Smart: Know When Antibiotics Work."

But with flu season starting, the agency has decided to make an extra push, hoping to prevent parents from asking pediatricians to prescribe antibiotics for colds and flu. (Which are, all together now: Viruses! And are not affected by: Antibiotics! Gold stars all 'round.) So it has named next week, Oct. 6-10, as "Get Smart About Antibiotics Week."

There's a website page specifically for the campaign, which seems to be aimed mostly at health-care institutions and public agencies — places that would mount campaigns and plan activities to reinforce the stewardship message. (The campaign has 14 health-agency and professional-association partners.) If you're in any of those roles, there are scripts, ads, PSAs, pre-written "articles" and web graphics and widgets. Find them here.

If you're looking for more general information that you can, for instance, share with friends, this page has explanations in everyday language.

Here's a question: Are there any readers who are health-care professionals (doctors, nurses, NPs, PAs etc.) who feel you are pressured to prescribe antibiotics? If so, please get in touch via the comments or the email address in the right-hand bio box. I would love to hear from you.