Child deaths from flu + MRSA, an update

As predicted earlier this week: The Centers for Disease Control and Prevention (CDC) has announced more deaths of children from flu, and from flu followed by MRSA pneumonia.

My colleagues at the Center for Infectious Disease Research and Policy are tracking the case count, and here's what they said this evening:

The CDC received eight reports of influenza-related deaths in children during the week ending Feb 21, bringing the seasonal total to 17. Four of the deaths occurred in Texas, 2 in Colorado, and 1 each in Arizona and Massachusetts.
Bacterial coinfections have been confirmed in 10 (59%) of the 17 children. Staphylococcus aureus was identified in 8 of the 10 children—3 of the isolates were sensitive to methicillin, 4 were not, and results were not reported for 1. Eight of the 10 children who had coinfections were age 12 or older. (Byline: Lisa Schnirring)

Just to recap, that's four deaths so far this flu season from flu+MRSA, twice the number we knew of last week.

And just to remind: The CDC and its Advisory Committee on Immunization Practices now recommends flu shots for all children and adolescents, up through the age of 18. A flu shot is one defense against MRSA pneumonia. It is worth considering.

Terribly sad story from Florida

Cody Shrout, a 12-year-old 6th-grader who lived in Daytona Beach, Fla., was found dead in bed a week ago today by his 8-year-old sister.

His death was initially put down to chickenpox, which was circulating in his school, but the Volusia County medical examiner determined Tuesday that his death was due to MRSA.

Two weeks ago, he scraped his knee skateboarding, subsequently spiked a 103+ degree fever, was treated at a local ER and sent home. The story describing his treatment quotes his grandfather in a way that suggests the scrape was treated as a sports injury, with ice and ibuprofen.

Cody lived with his mother, sister, 3-year-old brother and grandfather. His mother, who is single, could not afford a funeral. With extraordinary generosity, Heather and Jason Jenkins, who own a plumbing business in Apopka, Fla., have paid for the funeral. He will be buried Tuesday.

An odd tidbit in this very sad story: Ten months ago, according to the Daytona Beach News-Journal, he was treated at that same medical center for a staph infection. The story doesn't say whether he was an admitted patient or seen in the ER, and also doesn't say whether it was MRSA or drug-susceptible staph. Interesting, though.

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).

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:

• Williams, AZ
• two Cleveland, OH schools
• a Tucson, AZ high school
• five Tempe, AZ schools
• an Edmond, OK high school
• a Knoxville, TN high school
• Bedford County, VA
• Uniontown, PA
• schools in Commack and Westhampton Beach, Long Island, NY
• Bath and Ferryhaven, MI
• central NY state
• Copperopolis, CA
• and Northhampton, PA.

The importance of MRSA in a flu pandemic

Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I've been following since writing the first story in the American media about avian influenza H5N1 (in August 1997; find it on this page.)

And people concerned about MRSA realize that flu and MRSA have an important overlap: For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we've been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA (blogged here and here). Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place. Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Of course we would never have thought of that.

A new paper in the Annals of Internal Medicine suggests an astounding technique for figuring out whether patients experienced an adverse event while in the hospital:

Asking them.

No, really.

The study by Massachusetts researchers (from University of Massachusetts, Brown, Harvard, Massachusetts Department of Public Health and Massachusetts Hospital Association) looked back at the experience of more than 2,600 patients in 16 Massachusetts hospitals during 6 months in 2003. The researchers started from the assumption that the medical-records review done by many hospitals to spot adverse events was not capturing enough information — and that the interviews that some hospitals do with patients after discharge were asking the wrong questions because they focus only on satisfaction.

So the team did a 20-minute phone interview 6 to 12 months after discharge for 2,600 patients, asking about "negative effects, complications or injuries," and also reviewed the medical records of 1,000 patients who agreed to their charts' being released for review. For each arm of the study, two physician-reviewers checked results to be sure what was scored as an adverse event actually qualified as one.

And they found: That twice as many adverse events were uncovered when patients were asked about their experience. Among the interviewees, 23 percent reported an adverse event; when records were reviewed, only 11 percent of patients were judged to have experienced one.

Now, let's be clear: I'm very glad these researchers had the courage to do this study. Anything that supports better care, more transparency in care and more responsiveness to the patient's experience is a good thing and I support it.

But when I think of the dozens of hospital patients and family members who have told me about their experiences with poor infection control — lack of hand-washing, lack of housekeeping, bloody gauze on floors — and with being completely unable to get anyone in those hospitals to pay attention, it just makes me want to beat my head against a wall. Coming up with the idea of asking the patients about their experience... this is so hard?

As one of the co-authors, Saul Weingart of Dana-Farber Cancer Institute in Boston, said in an accompanying press release: "It's pretty clear that they can teach us important things about improving patient safety, if only we ask them."

The cite is: Weissman, JS et al. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med 2008; 100-108.

Studies: gator blood, sudden infant death syndrome

I blogged earlier on new research that alligator blood may contain potent antimicrobial compounds. Now the Miami Herald has done a nice long story that thoughtfully explores the possibilities and limitations of that research. (Hat tip to KSJ ScienceTracker for noting the story.)

And via the BBC, here is a report that British researchers believe some vases of Sudden Infant Death Syndrome (which the English call " sudden unexpected death in infancy (SUDI)") may be due to undetected bacterial infections.

The researchers took samples from 470 babies who had died suddenly, and tested them for the presence of bacteria, particularly those capable of causing illness, such as Staphylococcus aureus or E. coli.
In some cases, the cause of death was known to be a bacterial infection, or completely unrelated to infection, for example a heart defect or accident. The rest were entirely unexplained.
Among those known to have died from a bacterial infection, 24% of the bacteria found were potentially harmful, compared with only 11% of those found in the non-infection group.
However, among the "unexplained" group, the figure was 19%, with 16% of bacteria found in this group identified as Staphylococcus, compared with 9% in the non-infection group. (Emphasis added.)

The authors theorize that toxins produced by staph could interfere with breathing or affect the nervous system. The paper, just published by The Lancet, is here and a Lancet-produced podcast (.mp3) is here.

Child deaths from flu + MRSA

Steve Smith of the Boston Globe (who is really good, and I say that as someone who used to compete against him) has a story up regarding state and national concern over children's deaths from MRSA pneumonia. There have been two such deaths in Massachusetts this year. These are the sort of deaths that make headlines, as they did last October with the death of 17-year-old Ashton Bonds in Virginia: The pneumonia is very fast-moving and very destructive of lung tissue, and young children have died from it in less than 24 hours.

The CDC is concerned about this: Twice in two years (last May, blogged here, and last January), the agency pushed out an advisory to state health departments, asking them to report any children's deaths in which flu played a role. Surveillance for pediatric flu deaths is a relatively new thing for the CDC — the agency set up a system after the bad early flu season of 2003-04, in which more than 150 children died — so there is relatively little history to draw on. But MRSA has played a role in child deaths in each of the past three years, according to that January bulletin:

From October 1, 2006 through September 30, 2007, 73 deaths from influenza in children were reported to CDC from 39 state health departments and two city health departments. Data on the presence (or absence) of bacterial co-infections were recorded for 69 of these cases; 30 (44%) had a bacterial co-infection, and 22 (73%) of these 30 were infected with Staphylococcus aureus.

The number of pediatric influenza-associated deaths reported during 2006-07 was moderately higher than the number reported during the two previous surveillance years; the number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase. Only one S. aureus co-infection among 47 influenza deaths was identified in 2004-2005, and 3 co-infections among 46 deaths were identified in 2005-2006. Of the 22 influenza deaths reported with S. aureus in 2006-2007, 15 children had infections with methicillin-resistant S. aureus (MRSA).

Among MRSA researchers, concern over these necrotizing pneumonia cases has been growing for a few years. Some surveillance suggests that such cases may be increasing, though that could be an issue of, "once you start looking for something, you find it." And the cases are undeniably severe: 56% of children with MRSA pneumonia die, according to a 2007 paper.

But at leaast some of those deaths may be avoisable — or would be if doctors in the community were more attuned to the possibility of MRSA. In a poster at last autumn's ICAAC meeting (first author AJ Kallen) CDC researchers reported thay reviewed charts of all the children admitted with a stah infection at Atlanta's three children's hospitals during the 2006-07 flu season. There were 53 cases of Staph aureus pneumonia; 22 of the children saw a physician an average of 3.5 days before being admitted to the hospital, and THREE of them got drugs that would work against staph.

And yes, you read that right: Active case-finding in Atlanta in 2006-07 found 53 cases of flu-related staph pneumonia; 22 of them, according to the paper, were MRSA. But from the entire country during 2006-07, according to the advisory quoted above, the CDC received reports of 22 flu/staph pneumonias, 15 of them MRSA. Which suggests that flu/MRSA pneumonias in children are more common than current surveillance reveals.

Random MRSA research, ICEID

Came back from the conference and got slammed with work. (Also, snow, three days in succession. What is it about "Spring" that Minnesota does not understand?) So especial thanks to the 15 readers — you know who you are and Google Analytics does too — who have been diligently checking regardless.

I'm going to do a quick wrap on some of the remaining MRSA papers presented at the Emerging Infections conference. (For a wrap-up of flu and foodborne-disease research, see my final conference story at CIDRAP.)

A quick explainer for those who don't make a habit of going to science conferences, you lucky souls you: For many researchers, this is the first presentation of new or incremental findings. Thus, there's no publication to link to — that's why these ICEID posts aren't so content-rich. Many of these papers may end up in a medical journal in the next year, but for now, not even the abstracts are online.

So:

• To generate hypotheses about what leads to CA-MRSA infection, a team from the Minnesota Department of Health and the CDC analyzed the life circumstances of 150 people diagnosed with CA-MRSA or MSSA, and found the strongest correlation was between CA-MRSA and a prior history of boils or prior use of antibiotics. (Lead author: K. Como-Sabetti.)
• In another Minnesota-based report, researchers from the VA Medical Center found that patients who developed MRSA in the hospital had a risk of dying within 6 months that was three times higher than for patients with non-resistant staph. (Lead author: C. Lexau.)
• And, OK, Minnesota trifecta: A team from the MN DoH and the CDC checked the colonization levels of MRSA patients and their household members over a year and found that, even a year after the first diagnosis. one out of every five patients' households had at least one household member who was still colonized — and that use of Bactroban had made no difference. (Lead author: J. Buck.)
• Confirming the hypothesis that MRSA can persist on surfaces and contribute to colonization, Texas researchers swabbed bathroom and common-room surfaces at a university and a jail and found the presence of MRSA was 5 times higher on the jail surfaces (6.1% of samples v. 1.2%). Jails are already known to be hotbeds of CA-MRSA — some of the earliest recognized outbreaks were recorded in jails — and this suggests that in a setting where there is a large amount of MRSA, environmental contamination may keep the bug circulating. (Lead author M. Felkner.)
• An analysis by the Connecticut Department of Public Health of lab-confirmed diagnoses of invasive MRSA between 2001 and 2006 confirms how tricky sorting out HA- and CA-MRSA can be. The incidence of invasive MRSA stayed stable over those five years, but the proportion of community-associated MRSA rose while the proportion of "hospital-onset" (developed no sooner than 48 hours after admission to the hospital) decreased. That makes it sound as though CA-MRSA is increasing overall. But: When the Connecticut state laboratory finegrprinted the strains, they found that 2% of the hospital-onset and 4% of the "hospital-acquired/community-onset" cases were actually caused by community strains, and 76% of the community cases were actually caused by hospital strains. (Lead author: S. Petit.)

That's all on ICEID; tune in two years from now when the conference returns, or stay tuned for more on hospital-acquired infections, mandatory reporting, and disagreements over "search and destroy."