Non-medical use of antibiotics: A whole new problem with ethanol

Constant readers, we've talked frequently about the emerging recognition that the enormous use of antibiotics in agriculture is fueling the development of resistance, both directly in the case of specific organisms such as MRSA ST-398, and indirectly in that it pushes the evolution of resistance factors that bacteria then trade amongst themselves. (For a superb overview of the antibiotics/agriculture problem, see this article in the June issue of the Johns Hopkins (University) Magazine. Hopkins is the home of the Center for a Livable Future, which is doing excellent research on this issue.)

And we've also talked about the related issue of antibiotic residues elsewhere in the environment, in sewage and wastewater supplies.

But here's a whole new peril: Antibiotic resistance generated by ethanol production, that vast corn-based industry that has been pitched as a homegrown biofuel alternative to foreign oil.

Food-policy blogger (and farmer and chef) Tom Philpott has been doggedly following this story for more than a year at Grist. And in a study published last month the Institute for Agriculture and Trade Policy brings some important numbers-based analysis. The gist of the problem is this:

• Ethanol production uses yeast to convert corn starches into alcohol
• Bacterial contamination, usually by lactobacilli, can hijack the process and covert the starches to unusable lactic acid instead
• To prevent that from happening, ethanol producers dose their corn mash with antibiotics
• Because contamination is frequent and persistent, producers use increasing amounts of antibiotics to overcome bacteria that have become resistant
• After ethanol is extracted, the mash residue remains tainted with those resistant bacteria and with antibiotics — including penicillin, erythromycin and streptogramin (an analog of the human antibiotic Synercid)
• The dried mash residue is sold to farmers as livestock feed, exposing livestock to resistant bacteria and dosing them with unsuspected additional antibiotics as well.

If there is any good news in this, it is that (according to the IATP), some of the faltering ethanol industry is aware of the problem and working on it, with about 45% of plants now working on non-antibiotic alternatives. The bad news is that 55% — more than 90 of the 170 ethanol facilities in the United States — are not.

Another death from H1N1 flu + MRSA

Thanks to a commenter who alerted me to this sad story: A teenager in Austin died of a combination of H1N1 flu and MRSA pneumonia. Constant readers will know that we have been watching for this for a while; MRSA pneumonia is a known and dangerous complication of any flu infection.

For stories for CIDRAP and the Annals of Emergency Medicine, I've been talking to ER physicians about their expectations for the fall, when the regular flu season begins and H1N1 is expected to intensify. (A friend's school already has cases circulating.) It's fair to say that emergency departments are unsettled about the possibility of severe complications from this flu.

One more set of recommendations

... and then next week I'll be back to analyzing the medical literature: A stack of interesting new journal articles is threatening to topple and bury my computer.

For the moment, though:

First, the Hearst newspapers chain has conducted a nationwide investigation into medical errors that should be required reading for anyone who wonders why hospitals can't do a better job controlling hospital-acquired infections. It is a 7-part series focusing on the 5 states (New York, Texas, California, Connecticut, Washington) where there are Hearst papers, and hosted on the site of the San Francisco Chronicle. The introductory article says:

Ten years ago, a highly publicized federal report called the death toll shocking and challenged the medical community to cut it in half — within five years.
Instead, federal analysts believe the rate of medical error is actually increasing.
A national investigation by Hearst Newspapers found that the medical community, the federal government and most states have overwhelmingly failed to take the effective steps outlined in the report a decade ago.
... in five states served by Hearst newspapers — New York, California, Texas, Washington and Connecticut — only 20 percent of some 1,434 hospitals surveyed are participating in two national safety campaigns begun in recent years.
Also, a detailed safety analysis prepared for Hearst Newspapers examined discharge records from 1,832 medical facilities in four of those states. It found major deficiencies in patient data states collect from hospitals, yet still found that a minimum of 16 percent of hospitals had at least one death from common procedures gone awry — and some had more than a dozen. (Byline: Cathleen F. Crowley and Eric Nalder)

From that opening statement, the investigation goes on to explore many patient stories that individually are tragedies and collectively — as we here know all to well — are a scandal.

There is just one notable MRSA story in the mix, the death of a retired hospital president who contracted the bug in his own hospital. But they are all worth reading.

Second, an executive and apparently new writer named David Goldhill has written for The Atlantic a passionate and well-thought out piece on his father's death from a hospital-acquired infection and on what needs to change for such deaths to never happen again. "My survivor’s grief has taken the form of an obsession with our health-care system," he writes:

My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

You may not agree with his conclusions, but it is worth reading through to the end to experience how one intelligent citizen from outside health care understands and attempts to re-think our broken system.

Catching up on some reading: health care reform, food bugs, vaccine, MRSA+flu

Folks, while I was caught in travel hell, some excellent stories and blogposts were released. Here's a quick round-up of recommendations for a rainy weekend:

• At Roll Call (covers Congress like a blanket), Ramanan Laxminarayan, PhD MPH, of the rational-use-of-antibiotics project Extending the Cure and infection-control physician Ed Septimus, MD make a strong argument for including control of hospital infections in health care reform. Hard to argue against when you realize that HAIs cost the United States more than $33 billion each year.
• At Meat Wagon, a blog of the online magazine Grist, the always-excellent Tom Philpott digs into the ongoing outbreak of antibiotic-resistant Salmonella in hamburger meat. Key quote: "Outbreaks of [antibiotic-resistant foodborne illnesses] are really ecological markers — feedback that our way of producing meat is deeply unsustainable and really quite dangerous."
• The Associated Press reports that the long-in-development staph vaccine made by Nabi Pharmaceuticals may have received a second life: It's been purchased by international pharma giant GlaxoSmithKline in a $46-million deal.
• And finally and sadly, the Sacramento Bee reports that a California nurse who died of H1N1/swine flu also had MRSA pneumonia. Karen Ann Hays, 51, died despite being extremely healthy: she was a triathlete, skydiver and marathon runner. No one yet has been able to say whether she caught the flu — or MRSA — at work (though her partner believes that to be true), but her death has fueled disquiet among members of the California Nurses Association, who are protesting a lack of protective equipment for nurses.

For those of us concerned about MRSA pneumonia — and we have been talking here since the start of the H1N1 pandemic about the danger of MRSA co-infection — that last item about Hays' very sad death should underline a vital point. Public health authorities have been stressing that H1N1 is most deadly when the infected person has a pre-existing condition: pregnancy, heart disease, obesity, diabetes, cystic fibrosis. It is possible that MRSA infection is also a pre-existing condition that will put anyone infected with flu at risk of deadly complications.

If you have had MRSA, even a minor skin infection — and especially if you have experienced recurrent infections — you should probably discuss with your personal physician whether you should take the H1N1 vaccine when or if it becomes available. It could be the step that prevents a minor case of flu from tipping over into something much more serious.

Recommending a new MRSA site

Constant readers, I've been away on travel. Apologies for dropping out of sight, but I always worry about saying in advance that I am going away; it seems not-secure to me. At any rate, I'm back. There's tons to catch up on in the MRSA world, but here is something to get us started.

I want to recommend to you a new, comprehensive MRSA site. It has been put up by the MRSA Research Center of the University of Chicago, who are the research team (headed by Robert S. Daum, MD) that first identified the emergence of community-associated MRSA in the mid-1990s. (Disclosure: These folks play a prominent role in the book, but we have no relationship other than that of reporter and source.)

The site has channels for researchers, infection-control professionals, and MRSA patients and their families. It is broad and deep and well worth a look. I'll add it to the blogroll on the right.

Federal plan to reduce HAIs: public meetings

Let's switch back for a moment to MRSA and other infections in hospitals. An estimated 1.7 million healthcare-associated infections (HAIs) occur in the US each year. Approximately 99,000 of the infected die. Care for the infected costs the health care system $33 billion (yes, with a B) each year.

The US Department of Health and Human Services (parent agency of the CDC, USDA, Center for Medicare and Medicaid Services, etc.) in late June issued a draft of a National Action Plan to Prevent Healthcare-Associated Infections. The plan is here (.pdf, 116 pages). It calls for more research, changes in regulation of health care, more disclosure and significant simplification of the more than 1,200 actions for reducing HAIs that are currently recommended in government documents (yes, 1,200.)

HHS is taking the plan on the road: Before Labor Day, there will be public meetings to air the plan in Denver (tomorrow, July 25), Chicago (July 30) and Seattle (Aug. 27). If you are concerned at all about HAIs and government and health care industry response to them, these meetings would be a good place to be.

The HHS statement about the plan and the meetings, including contact information to sign up to attend, is here. Go, already.

Decolonization: disappointing news

I know that many of you who are MRSA patients, especially with recurrent infections, are especially interested in the issue of decolonization, the grueling regimen of antibiotic nasal gel (containing mupirocin; usually sold as Bactroban) combined with body washes with chlorhexidine (Hibiclens) that is believed to eradicate MRSA carriage in the nose and on the skin. Decolonization is an essential part of the "search and destroy" measures practiced by zero-tolerance hospitals who want to detect any MRSA transport in their institution, and it is a last-ditch hope in recurrent community-strain infections. (I told the story of several women's struggles with recurrent infections in SELF and Health magazines.)

It's disheartening, then, to realize that decolonization is not a universally agreed-upon measure, and there is relatively little research that can say in which setting (household, hospital, ICU) it works best, and why. There have been a few studies, and a few review papers summing up studies, on the role that decolonization can play in reducing the risk of infection in already hospitalized, colonized patients — ones about to undergo surgery, for instance. A meta-analysis by the Cochrane group, of 8 trials, found that decolonization in the hospital did reduce the likelihood of infections in surgical patients.

The role that decolonization can play in short-circuiting community infections is much less clear, though there are many, many people who have suffered recurrent infections and testify that it worked for them. (Please speak up in the comments if you are!) One problem is that outside hospitals, there is no one recommended regimen: One physician might tell her patient to use mupirocin and chlorhexdine only, whereas another might tell his patient to also take bleach baths, or bleach all the laundry or household surfaces. The CDC has so far declined to put its muscle behind decolonization in community-strain infections, recommending only that frustrated patients with recurrences seek the advice of an infectious-disease specialist. (See this flowchart of treatment options (.pdf) that the CDC published in 2007.)

Comes now the infectious-diseases division of Evanston Northwestern Healthcare, whom some of you will recognize as being among the most successful and evangelical practitioners of "search and destroy" in the United States. (ENW has recently been renamed NorthShore University HealthSystem and is affiliated with Northwestern University. Disclosure, in case you care: I went to grad school at Northwestern, though not in medicine.) In a paper published in Infection Control and Hospital Epidemiology, the group evaluates the use and success rate of decolonization in ENW/NorthShore's 3 hospitals and finds, well, not such good news: a temporary reduction in patients' being colonized with MRSA, but no success in preventing infection.

This is an important and troubling finding, because decolonization comes with costs. There is the obvious cost to hospitals (and the follow-on cost to insurance companies and consumers) of paying for mupirocin and chlorhexidine themselves. But there is also a hidden cost that we here should be particularly sensitive to: Because mupirocin is being used so lavishly, mupirocin resistance is rising.

In the same issue of ICHE (which, yes, is pronounced Itchy), a related editorial by Dutch researchers reviews the difficulty of conducting decolonization trials, but summarizes the ENW/NorthShore study as not an endorsement of decolonization regimens:

It is clear that staphylococcal carriage is an important risk factor for infection and that eradication of carriage has proven successful for patients who are undergoing elective surgery. For other groups of patients, it is still unclear what the benefits are. It is obvious that indiscriminate use of mupirocin is associated with development of resistance. Therefore, additional studies are warranted to define the optimal MRSA decolonization strategy, including what should be given, to whom, and at what moment and who should guide and supervise the regimen.

The cites are:
Robicsek A, Beaumont JL, Thomson RB Jr et al. Topical therapy for methicillin-resistant Staphylococcus aureus colonization: impact on infection risk. Infect Control Hosp Epidemiol. 2009 Jul;30(7):623-32.
Kluytmans J, Harbarth S. Methicillin-resistant Staphylococcus aureus decolonization: "Yes, we can," but will it help? Infect Control Hosp Epidemiol. 2009 Jul;30(7):633-5.