More on MRSA and the new flu

Constant readers, I admit it: I am a bad blogger. The wave of news on the novel H1N1 (AKA the Virus Formerly Known as Swine) has been just overwhelming. Apologies for disappearing.

Out of the crashing surf, though, I picked up an interesting tidbit that speaks to our concerns about MRSA. Here's some background: If you have been following the swine flu story, you'll have noticed that one of the puzzles has been why the Mexican experience has been so different from the United States or from the other countries where this flu has appeared briefly. (North America so appears to be the only area in which there is sustained transmission.) Among the hypotheses:

• There is a difference in the medical care that victims are receiving.
• There is a statistical artifact: The serious cases are a tiny percentage of the mild cases, and the US has not seen enough cases to, probabilistically, experience significant serious cases yet.
• Or, corollary to the above: Mexico has many more cases than its surveillance systems have been able to count, and that is why we have seen that (unknown but presumably tiny) percentage that become serious cases appear there but nowhere else.

(For more on this, here's a CNN story from a few days ago, quoting me and people much more distinguished than me.)

But a commentary by a global-health expert raises another hypothesis, one that brings this outbreak around to our concerns: the possibility that the serious flu cases in Mexico are being complicated by secondary pneumonia caused by MRSA or other bacteria.

We've talked about this issue before (see this post about the importance of MRSA in a flu pandemic and this paper by, among others, Dr. Anthony Fauci, director of NIAID, and Jeff Taubenberger, PhD, co-discoverer of the virus of the 1918 flu). MRSA pneumonia secondary to flu infection is the etiology of the necrotizing pneumonia cases that kill children very quickly, and is the reason why I keep haranguing you regarding flu shots.

Is bacterial pneumonia playing a role in the current epidemic? It's too soon to tell; there is not sufficient clinical data. But it is an interesting speculation and one that we should keep in mind as this goes forward.

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).

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.

Cautionary tale: Unintended consequences, ripple effects

New story by me, up at the news website of the Center for Infectious Disease Research and Policy, where I am a contributing writer. It's on flu, not MRSA, but it contains lessons that apply to MRSA too.

Gist: This flu season turned out unexpectedly badly, with physicians across the country saying offices and ERs are overwhelmed with very sick patients. In ERs in particular, the dominos fall like this: More patients than usual come in for help; with some of them seriously sick, other patients get pushed further back in the triage queue; while the seriously sick wait in the ER for hospital admission, other patients back up in the waiting room; diversion (turning ambulances away) is called to relieve some of the pressure; and patients are taken instead to another ER, where the process begins again.

The irony here is that flu is an at least partially preventable disease: Under normal circumstances, get a flu shot, sharply reduce your chance of getting the flu. However, this year the flu vaccine and the circulating flu strains don't match well, and many people who stepped up and got the shot still developed flu. And why did the shot not match? It was partly a failure of luck — flu's perpetual genetic drift is unpredictable — but it was also a failure of infrastructure: Federal health planners knew a year ago that one strain was drifting, but that virus didn't grow well enough under lab conditions to get an isolate to vaccine manufacturers in time for it to be included in last fall's vaccine. (See Dr. Nancy Cox's comments in this CDC press briefing; the FDA discussions she refers to are archived here.)

And why did it have to be given to the manufacturers a year ago? Because it still takes 6 months to make commercial quantities of flu vaccine, using a technology that is essentially 50 years old. This despite either 10 years or 32 years of concern over the possibility of a flu pandemic (depending on whether you start counting from the appearance of avian flu H5N1 or the aftermath of the 1976 swine flu).

And why is any of this of concern for MRSA? Because many researchers and clinicians say that the only way to combat MRSA effectively is with a vaccine. Improving flu vaccination has been top of the public health wish-list, and a target of significant government funding, for years now, and yet it is still a disappointing mess. What chance for a lower-profile MRSA vaccine?