Hospital MRSA - should healthcare institutions be forced to report it?

I'll be moderating a panel exploring that contentious issue at the Association of Health Care Journalists' annual meeting in March. On the panel:

• Carmela Coyle, senior vice president for policy, American Hospital Association
• Betsy McCaughey, Ph.D., CEO and chair, Committee to Reduce Infection Deaths
• Carole Moss, executive director, Nile's Project
• Chesley Richards, M.D., M.P.H., deputy director, Division of Health Care Quality Promotion, U.S. Centers for Disease Control and Prevention

A number of states have passed laws in the past few years that require public disclosure of hospital-acquired infections, and a half-dozen have added provisions that specify reporting HA-MRSA. It seems like a no-brainer: Shame is a great motivator.

But some citizen-advocates are concerned that clever or well-funded institutions will be able to game the system. And some researchers who have evaluated infection-reporting regimes warn that surveillance often misses patients and reporting regimes are not standardized from state to state.

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.

MRSA article in Health magazine

After a long wait, some freelance articles that I've written on MRSA while researching the book have finally begun to be published! Here is the first, in Health magazine: an "as-told-to" by a Boston-area woman who struggled for more than a year with recurrent skin infections that just kept coming back:

The Truth About Staph
by Jilly Jackson* as told to Maryn McKenna
One woman’s harrowing tale of dealing with a dangerous infection called MRSA. How she got it and how it spread.
When I heard that high schools were closing and teenagers were dying because of the MRSA superbug, I felt lucky. Since the middle of 2006, I’ve had methicillin-resistant Staphylococcus aureus six times and somehow managed to avoid the worst: I’ve never been hospitalized and don’t fear for my life.

Link here and sidebar here.
Also, a CNN.com version — which has generated some great new leads for me! — here.

Rumors of the blog's death are only slightly exaggerated

Yes, I vanished. Yes, I had a good reason: For the past few months, I've been neck-deep and sinking into a massive project for the infectious-disease website CIDRAP News, examining the search for a vaccine against pandemic influenza. Very short version of the many conclusions: Let's hope the pandemic takes a long time to arrive, because we are nowhere near ready, and the obstacles are both formidable and largely of our own making.

The entire project ran to seven installments. Read the first installment here. At the bottom, you'll find links to the other installments, and to the more-than-100 cite bibliography. The series has been well-received in the flu-blog world:

• "This is clearly one of the most important contributions CIDRAP has made to the H5N1 issue (and that is saying a lot)." H5N1
• "Ms. McKenna (author of Beating Back The Devil) proves, once again, why she is one of the best science writers in the business." Avian Flu Diary
• "Another excellent offering from Maryn McKenna." A Journey Through the World of Pandemic Influenza

Plus, a Very Important National Magazine has been in touch to, umm, suggest that it gave them some ideas.

Meanwhile, while I was away, there was a ton of news on the MRSA front. We'll be taking a look at some recent developments in the next few days.

Yes, it is everywhere

Via the journal Emerging Infectious Diseases, a report from a multi-country European team that surveyed CA-MRSA isolates from around the world to determine their ability to produce Panton-Valentine leukocidin, the potent toxin blamed for CA-MRSA's unique ability to cause eruptions on healthy-appearing skin.

Deep-seated infections due to PVL-positive S. aureus can be extremely severe. For example, necrotizing pneumonia carries a mortality rate close to 75%.

Research published in 2003 found that some clones of CA-MRSA were "continent-specific," confined to some extent to particular locations or countries. That appears no longer to be the case.

The ST1 clone USA400 is now detected in Europe and Asia. Some PVL-positive clones, such as ST1 and ST30, can now be considered pandemic, as they are detected in America, Europe, and Asia. Second, on a given continent, PVL-positive CA-MRSA have spread from country to country. For instance, in Europe, PVL-positive CA-MRSA were recently detected in Slovenia, Romania, and Croatia. Third, new PVL-positive CA-MRSA clones are emerging in strains with different genetic backgrounds. While most of the clones described in 2003 by Vandenesch et al. (4) had an agr3 background, the newly described clones are agr1 or agr2. Fourth, PVL-positive CA-MRSA, which were initially susceptible to most antistaphylococcal antimicrobial agents, have acquired new antimicrobial resistance determinants, to gentamicin and ofloxacin, for instance.

The isolates were gathered between 1999 and 2005 and sent to the French National Reference Center for Staphylococci, where the work for this paper was conducted. Yes, 2005. That gap between the obtaining of the isolates adn this analysis underlines one more time the critical need for comprehensive national and global suveillance to track MRSA's movement and evolution. If we don't know where it is, or how it is changing, how can we begin to talk about control?

Link to the full-text paper here.

7-fold increase CA-MRSA in parts of Chicago

Via the Archives of Internal Medicine, a new study from Cook County Hospital and Rush University Medical Center in Chicago. Betwen 2000 and 2005, the incidence of CA-MRSA at the hospital and its neighborhood clinics increased 6.84 times. Notably, meth-sensitive staph (MSSA) did not decrease - this was a true addition, not a substitution of one strain for another. And 79% of the strains identified were USA300. Important clues to the rapid spread of the bug: Those infected were more likely to have been incarcerated more than once (carrying the bug from the known epicenters of jails and prisons back out into the community) or to live in public housing (possibly because of overcrowding as Chicago demolishes its old-style projects and moves the people who live there into its remaining public housing). The paper raises but can't answer the question of a synergy between those factors: People coming out of jail may be returning to households in public housing creating a bridge between a known epicenter and a population whose living conditions put them at greater risk.

Find the paper here.

Got (wallaby) milk?

Researchers in Melbourne, Australia report finding a broad-spectrum antimicrobial compound in the milk of the Tammar wallaby, which lives on islands off Australia's south and west coasts. Like other young, wallabies are born with an undeveloped immune system yet seem notably resistant to infection; the compound, AGG01, may be why.

Using advanced computer systems, researchers at the state of Victoria's Department of Primary Industries in Melbourne, Australia, found more than 30 potential bug-fighting compounds in the milk of the Tammar Wallaby (Macropus eugenii). One compound, known as AGG01, was particularly potent said lead researcher and animal geneticist, Ben Cocks.

Some experiments showed small amounts of a synthetic form of the drug were able to kill all bacteria in 30 minutes. "We found in lab tests that AGG01 is very effective against multidrug-resistant gram negative bacteria, including those that are most difficult to treat," he said.

Next research step: Designing a wallaby-milking machine.

Full text: Anti-superbug weapon developed from wallaby milk

(Hat tip to Boing Boing.)