MRSA research at Society for Healthcare Epidemiology of America meeting

As promised, a round-up of some of the research presented at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA), held last weekend in San Diego. (Disclosure: I was on the faculty for the meeting; in exchange for co-hosting a session, SHEA will be reimbursing me for airfare and hotel. I wasn't otherwise paid, though.) There were 143 presentations on MRSA; here are a few.

I'm going to put in links to the online abstracts — I have SHEA's permission to do this — but I can't guarantee how long they will stay up. For those outside the science world, what happens at these meetings is that research is presented, in slide/PowerPoint sessions or in a poster, as a preliminary step to getting it published in a journal. Once a journal expresses interest, a cone of silence descends, the researchers are asked not to discuss the research until the paper is printed, and the abstract will probably be taken offline.

So, efforts to control hospital MRSA are showing some success:

• Invasive hospital-onset MRSA infections declined 16% from 2005 to 2007, and hospital-associated community-onset infections went down almost 9% — probably, though not provably, because of in-hospital prevention campaigns. (A. Kallen et al.)
• MRSA control in a small ICU (22 beds) leads to MRSA reductions throughout a 270-bed Montana community hospital. (P.J. Chang et al.)

But those efforts face some complexities:

• Swabbing the nose and culturing the swab, the classic test to check for MRSA colonization, misses 30% of positive patients because they are colonized in the groin or armpit. (C. Crnich et al.)
• If a hospital does not use AST (active surveillance and testing, or "search and destroy") it may seriously underestimate its MRSA incidence, though it may be able to detect general trends. (P.J. Chang et al.)
• But medical centers of similar size and situation that did v. did not use AST achieved similar reductions in hospital infections. (K. Kirkland et al.)
  

Community strains are moving into hospitals:

• Most of the cases of MRSA colonization identified in a Delaware healthcare system were found so soon after admission that they must have begun out in the community and were not due to hospital transmission. (K. Riches et al.)
• The proportion of MRSA bloodstream infections caused by community strains (proven microbioogically) doubled at Chicago's main public hospital between 2000 and 2007. (K. Popovich et al.)
• One out of every 7 ICU cases of MRSA in Atlanta's major public hospital involved a community strain. (H. Blumberg et al.)
• The number of MRSA infections brought to a Chicago-area ER increased 566% between 2002 and 2007, and was seasonally clustered (D. Buchapalli et al.)

And at the same time, hospital strains are moving out into the community:

• Hospital-associated community-onset cases accounted for 58% of all invasive MRSA in the US between 2005 and 2007, with patients undergoing dialysis or those who have been in long-term care the most vulnerable. (J. Duffy et al.)

More on MRSA pneumonia, flu and ER delays

Folks, yesterday I posted the very sad story of 39-year-old Robert Sweitzer of Tucson, who died of MRSA pneumonia after being triaged to an 8-hour wait, in an overcrowded emergency room, during the height of flu season.

As a follow-up, I want to emphasize that while necrotizing pneumonia may seem an unusual circumstance, there is one thing in his story that is very, very common: The ER wait.

Emergency departments all over the country are suffering extraordinary stresses thanks to a confluence of factors: The unfunded mandate of mandatory ER care or at least treatment and stabilization, through the federal legislation known as EMTALA. The closure of large numbers of in-hospital beds, which make it more difficult to get patients admitted. The lack of adequate primary care, which drives people to seek ER care because they cannot get into a regular doctor's office. The extraordinary percentage of Americans who have no health insurance — a percentage that is likely to increase as the economic meltdown continues.

How crowded are emergency departments? On average in the United States, an ambulance is diverted — denied admittance because an ER is too full to take new patients — once every minute.

To quote a bumper sticker that got a lot of use over the past few years: If you aren't outraged, you're not paying attention.

(Disclosure: I was a Henry J. Kaiser Family Foundation fellow in 2006-07, and spent an average of eight nights a month, for a year, as an ER observer. So ER overcrowding is something I both have witnessed up close, and feel passionately about.)

I mention all this in order to let you know that the American College of Emergency Physicians released today a state-by-state "report card" on the condition of ER care in the United States. Our average national grade? C-. (If you don't have time for the full report, the New York Times sums it up here. If you want to do more research, three Institute of Medicine reports on the issues, from 2006, are here.)

So, again: While Robert Sweitzer's death may seem end-of-the-curve extraordinary, the conditions that contributed to his death — a crushing overload in a community-hospital ER — are very, very common. And that should frighten all of us.

It's flu season: Watch for MRSA pneumonia.

Via the (Tucson) Arizona Daily Star, I've just caught up with the very sad story of Robert Sweitzer, a Tucson resident who died on his 39th birthday, of MRSA pneumonia.

Sweitzer died last Feb.10, but his name is in the news now because a lawsuit filed by his wife Rachel against the hospital where he died has just been scheduled for a Sept. 2009 trial.

The apparently undisputed facts of the case (according to news reports that I cannot usefully link to because they require registration) are:

• Sweitzer was a healthy man, married three years, who worked a full-time job and devoted all his spare hours to animal rescue.
• On Saturday, Feb. 9, he woke up feeling as though he were coming down with a cold, with a cough and low back pain. He and his wife went to a regular volunteer shift at a local cat shelter, but by evening, he was having trouble breathing. They arrived at St. Mary's Hospital ER at 6:30 p.m.
• Sweitzer was triaged within a half-hour, judged to be a low-acuity case, and sent to wait.
• It was February, the height of a bad flu season, and the ER was slammed with 170 patients.
• Sweitzer's breathing and back pain got worse and his wife twice asked unsuccessfully for him to be re-evaluated.
• When he was finally seen at 2:30 am, an X-ray showed his lungs filled up with fluid. He was put on 100% oxygen.
• He arrested twice and was pronounced dead near 7 a.m.
  

Following an autopsy, the Pima County Medical Examiner and the Arizona Department of Health Services asked the Centers for Disease Control and Prevention to evaluate Sweitzer's case; based on the extensive lung destruction, they feared he died of hantavirus. Tissue samples were sent to the CDC, which reported in August that Sweitzer actually died of necrotizing pneumonia caused by MRSA.

We have talked before (here, here, here, here and here) about the particular danger of MRSA infection during flu season, when (it is theorized) micro-trauma to the lungs by flu infection allows MRSA to gain a foothold. Once it begins, MRSA pneumonia proceeds with incredible speed — I have spoken to parents whose children went literally from apparently healthy to dead or close to it, within 24 hours — and it is commonly mistaken either for flu or for community-acquired pneumonia, the usual drugs for which have no impact on MRSA.

So, constant readers: It is flu season. Please get a flu shot. The observations and research on this are still limited, but it does appear that if you prevent flu, MRSA will have a more difficult time gaining a foothold in the lungs. (And if you nevertheless find yourself in a situation similar to Robert Sweitzer's, and you truly believe it is life-threatening for yourself or your loved one, do whatever is necessary to direct clinical attention to you in time.)

Because I cannot link through to the Arizona Star stories, here are the dates and headlines:

• 20 February 2008, "His pet projects: rescuing dogs, cats," byline Kimberly Matas
• 16 March 2008, "39-year-old's ER death leaves a lot of unanswered questions," byline Carla McClain
• 27 August 2008, "Feb. death of Tucson man, 39, tied to staph," byline Stephanie Innes
• 1 December 2008, "Suit over death at St. Mary's ER set for trial in September" (no byline).

Emergency medicine in crisis (important for MRSA also)

Constant readers may remember that, before I began this MRSA project, I spent a year as a media fellow with the Henry J. Kaiser Family Foundation, researching overcrowding and stress in emergency rooms. (Some stories from that project here, here and here.)

So I was particularly interested in and saddened by a post on the excellent blog Health Beat (now in the blogroll!) that explores in good detail why emergency rooms are so crowded and especially what the loss of experienced emergency nurses is doing to the quality of emergency care.

Why is this important for MRSA? Well, if you or a family member is struck with what looks like one of the dramatic presentations of MRSA — bone infection, rapidly progressing pneumonia, even a serious skin infection — where are you likely to take that problem? Yes, to the ER. Even if you have insurance; an increasing number of studies are pointing out that the vast majority of people waiting for care are not the uninsured or undocumented, but insured people who can't get care from their regular doctors.

So be prepared.

New MRSA article in Annals of Emergency Medicine

Well, that was fast: Here's a second article out of the book research, in the News & Perspectives section of the medical journal Annals of Emergency Medicine, where I am a "special contributor."

Brief synopsis: Emergency rooms are early-warning sites for detection of community-associated MRSA. Alert personnel there see the bug in all its manifestations, from minor skin infection to major invasive disease. They have been among the earliest voices warning everyday physicians of the need to change prescribing habits. They also, as the article discusses, may be at risk from the bug.

The story starts with an anecdote from one of my many post-Katrina reporting trips to New Orleans (stay tuned for a big story coming on that next month!):

The patient, a man in his 20s, walked into the emergency department (ED) on an autumn afternoon complaining of pain from a fist-sized lump under the right corner of his jaw.
The residents who had rounded on him recited their findings. He was not febrile. He was having no dental pain. The lump was thick-walled and unyielding and its outer temperature matched the nearby skin. Peter Deblieux, MD, director of emergency services at Louisiana State University Interim Hospital, asked for a syringe to aspirate it. ...
Deblieux masked the syringe with his free hand—the patient had confessed he was terrified of needles—slid the needle in, and smoothly pulled back. The cylinder filled with a creamy, cloudy substance streaked with red.
“It’s pus,” Deblieux said disbelievingly. “I was not expecting that.”
Ten years since it was first recognized as a significant pathogen, community-associated methicillin-resistant Staphylococcus aureus, CA-MRSA, still retains the element of surprise.

Full text is here.

The New England Journal of Medicine has put the full text one of the most important papers about MRSA in ERs (Moran GJ, Krishnadasan A, Gorwitz RJ, et al.. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355:666–674) online for free.