The Resistance Movement: Cancer, like infectious disease, also develops resistance to the drugs used to treat it

Infectious Disease is not alone in its resistance to therapeutic drugs: cancer behaves much the same way. For instance, when we say that a chemotherapy patient relapses, what’s happening is that the cancer cells have developed resistance to the chemo drug, thus rendering it useless, allowing the cancer cells to grow back.

The relationship between antibiotic therapy and chemotherapy dates back to the origins of chemotherapy, some 70 years ago. Sid Mukerjee, M.D., in his 2011 Pulitzer prize-winning book, The Emperor of All Maladies – A Biography of Cancer explains that in the late 1940s, the idea of chemotherapy – a drug that could cure cancer – began to take hold. The timing was no accident. This was on the heels of the birth of the Antibiotic Age that began with the widespread use of penicillin by American and British Forces during WW ll. The use of the drug was so successful that it spawned the idea in oncologists to look for “a penicillin for cancer.”

Cancer cells mutate quickly in response to chemotherapy, thus a never-ending “cat-and-mouse game” between the two. And so “we are forced to keep running merely to keep still.”

Cancer cells mutate quickly in response to chemotherapy, thus it’s a never-ending “cat-and-mouse game” between the two. 

Cancer cells mutate quickly in response to chemotherapy, thus a never-ending “cat-and-mouse game” between the two. “This is our predicament with cancer: we are forced to keep running merely to keep still.”

So it came as little surprise that the first ant-cancer drug was, in fact, an antibiotic – actinomycin D – that was repurposed to act as an anti-cancer agent. This was the summer of 1955 and the drug worked – to a degree. It caused remissions that lasted months – but only months – in a rare form of kidney cancer in children.

More drugs soon followed that treated other cancers. However, not only did the problem of resistance always emerge, something even worse happened: In one trial, for example, people treated with multi-drug chemotherapy for Hodgkin’s disease would relapse; not with Hodgkin’s disease, but with a second and different cancer – typically an aggressive drug resistant leukemia – caused by the chemotherapy.

The lesson soon leaned by the cancer community was the one already learned by the infectious disease community: the cell – whether it’s a human cell, a cancer cell, or a bacterial cell such as MRSA, – is built to adapt and survive, even when attacked by poisons such as antibiotics or chemotherapeutics.

The chart on drug resistance is instructive. While it focuses on bacterial mutation and resistance, it works the same way with cancer cell mutation and the resulting resistance to chemotherapy:

drug resistance

Author, researcher, and infectious disease specialist Brad Spellberg, M.D., in an interview with NPR, “Bacterial Infections Defy Treatment,” echo’s Mukerjee’s sentiments on the “cat-and-mouse game” of drug resistance. He phrases it as a constant trade-off between “our wits versus their genes”:

So let’s quote Joshua Lederberg, Nobel laureate, who in 2000 wrote that the future of humanity and microbes would likely evolve as episodes of our wits versus their genes.

This is what bacteria [e.g. MRSA] do. They’re just being bacteria. They become resistant to stuff, they adapt. We have to accept that’s never going to stop. No matter how perfect our stewardship is, no matter how prefect our infection control is, they’re always going to adapt. So, yes, we are never going to win in the end. But … we know steps that we can [adopt] to get back ahead in the race.




The Crime Boss, Part 4: Mr. Parnell Goes to Prison

This past Monday, Stewart Parnell, former head of the Peanut Corporation of America, was sentenced by a federal court judge in Georgia to 28 years in prison. At age 61, Parnell will spend the rest of his life behind bars. (Two others at PCA were also sent to prison, one for 20 years, the other for 5 years.)

This case directly implicates how we treat people colonized with infectious pathogens such as MRSA. It suggests that the law could play a greater role in policing the problem, not just in the traditional sense of using the civil law to sue, but there’s now more than a hint that the criminal law could be used as well. But first, some background.

Stewart Parnell

Stewart Parnell

Parnell’s company caused a U.S.-wide salmonella outbreak in 2008 – 09 that killed 9 people, including children, and infected over 700 more. Parnell was more than just the guy in charge; internal company documents show that he knew they were shipping peanut butter laced with a bacterial poison – salmonella — to retailers across the country. What’s more, when he found out, he didn’t care: “… just ship it,” he said, “… these lab tests are breaking me/us.”

U.S. District Judge W. Louis Sands wanted to hear from the victims and their families before he pronounced sentence on Monday. Gabriel Meunier, on behalf of her son Christopher told Judge Sands, “My 7-year-old son told me that he was in so much pain that he wanted to die.” Jeff Almer, who attended most of the trial hearings last summer, stared at and talked directly to Parnell. In a haunting tone, he said, “Stewart Parnell, you killed my mom [Shirley Mae Almer].” Peter Hurley, whose son, Jacob, was sickened by PCA peanuts, flew in from Portland, Oregon, to say, “Stewart Parnell, you gave some people deathsentences. Luckily, you are not being sentenced to death.”

The idea that a corporate executive, in the context of causing infectious illness, could be thought of as a murderer and thus eligible for the death penalty is gaining currency with more people than just the victims and their families. For example, award-winning science journalist Julia Belluz, the 2013-14 Knight Science Journalism Fellow at MIT, asked attorney Bill Marler, who represented some of the victim families:

If someone took a gun and killed seven people, he would get the death penalty. Why did Stewart Parnell get away with 28 years?

Get away with 28 years?”

U.S. Attorney Michael Moore of Georgia’s Middle District, whose office prosecuted the case, called it “a landmark [case] with implications that will resonate not just in the food industry but in corporate boardrooms across the country.” (My emphasis.)

Which brings us to the question: Which boardrooms?

Take a look at this study of people colonized with MRSA and what happens to them. It says that 1 in 7 people who acquire the bug at the hospital become infected by it: i.e., they get sick, require surgery, multiple readmissions to the hospital, stays in the ICU, and many die. This happens fast, usually within a month. Here’s a similar study, but it says the infection rate is actually much greater, that 1 in every 4 people who are MRSA-colonized get sick.

So when a hospital discovers that a patient is colonized with MRSA they do the prudent thing and “decolonize” them, right?

Surprisingly, most don’t even though they could; moreover, the patient is neither warned of the risks nor involved in the decision making. Various reasons are given including the fact that “it taxes hospital resources.” And there’s the rub.

Shirley Mae Almer (in the chair)

Shirley Mae Almer (in the chair)

So here’s what we’ve got: An inherently dangerous situation; that puts completely unaware and innocent people at grave risk of life and limb; the ability to do something about it; and the refusal to do so. Are we talking about Parnell, poisoned peanuts, and the public; or hospitals, pathogens, and patients? The answer is both, but there is one crucial difference: foodborne illnesses hospitalize 100,000 people a year and kill 3,000; but infectious illnesses resistant to antibiotic treatment exact a far greater toll. They hospitalize 3 million people a year and kill over 23,000. MRSA alone is responsible for almost half of those deaths.

So let’s rephrase Julia Belluz’s question. Let’s say you’re a doctor or you’re in hospital management. You know or should know that between 1 in 4 and 1 in 7 people who are colonized with MRSA become infected; i.e., they get sick, some seriously, some will die. Nevertheless you don’t decolonize. Instead, you discharge them knowing the risk they face. So here’s the question – the kind of question that lawyer’s ask at trial:

What’s the difference between that and giving a patient a gun with a bullet in 1 of the 6 chambers and telling them to go home and play with it? If they shoot themselves, shouldn’t you go to prison? More to the point, suppose you did this year in and year out, and as the body count mounted you still didn’t change your polcy. Shouldn’t you go to prison now?

No, the analogy to Parnell’s case isn’t exact. But the relationship between law and medicine is shifting. Doctors and hospitals aren’t as immune to the law as they once were. So before another forward-thinking prosecutor considers whether or not to reach into your office, you may want to look at any policy affecting people’s lives that’s driven by anything that resembles “it taxes hospital resources.”

It’s not an argument that sits well with jury’s, not when it’s balanced against the life of a child.

We have followed the Parnell case and its implications for the practice of medicine since its inception. Earlier columns are The Crime, The Victims, and Rethinking Crime.








What’s the Greatest Threat That We Face?

The New York Times ran an interesting piece yesterday asking who, or what, threatens the U.S. the most. It offered up the usual suspects: the Joint Chiefs of Staff say it’s Russia, the FBI says it’s the Islamic State, and President Obama says it’s nuclear terrorism.

However, the president of the Council on Foreign Relations, Richard Haas, weighed in with an unusual suspect, saying that it might be, among other things, “an Ebola-like pandemic.” He didn’t elaborate and the implication was that whatever this pandemic might be we haven’t yet seen it.

Dr. Davies: The risk of antibiotic resistance is "just as important and deadly as international terrorism."

Dr. Davies: The risk of antibiotic resistance is “just as important and deadly as international terrorism.”

But the health community say otherwise. For example, the UK’s chief medical officer, Dr. Sally Davies, said in an interview with the CBC this year that antibiotic resistance (ABR) – the idea that bacteria are so adaptable they have developed immunity to drugs (antibiotics) devised to kill them – is at least on par with our top threats.

CBC host Michael Enright: “You’ve compared the threat of ABR to the threat of terrorism … and nation-states are activating their resources to counter that. Why are governments so slow to seriously tackle this problem?”

“Let’s be clear,” said Dr. Davies, “In the West and actually across the world far more people are dying of ABR than of terrorism. But somehow it doesn’t seem so shocking. Already, about 50,000 people in Europe and the United States are killed each year by bacteria and other microbes that have developed resistance to the drugs we throw at them.”

And these numbers are expected to climb Davies says: by the year 2050 drug-resistant bacteria could cause as many as 10 million extra deaths globally, surpassing cancer deaths.

Commenting on these numbers, Mr. Enright offered an astute perspective: “If the headlines were about Ebola and not ABR that was going to kill 10m people a year, surely to God there’d be global governmental action.”

“Absolutely,” said Davies. “And if you look at the number dying every year of ABR – how have we let the public become complacent about it? We need to do something.”

But Davies cautioned that solutions won’t come easy.

“What we have to do – it’s a complex, wicked problem – is work on every level: public awareness, government awareness, with the professionals so they don’t overprescribe, the public education about not demanding them when they don’t need them, and see how we can resolve that market failure in the R&D pipeline. This is a really difficult problem.”

“I sometimes lie in bed at night,” Davies continued, “and wonder whether the families of these people who died knew that these were needless deaths, that we should have done something about it.”

Germ Warfare

The most combat deaths that the United States ever suffered — by far — was during World War ll. Almost 292,000 troops died from the time the US entered the war after the bombing of Pearl Harbor on December 7, 1941, to war’s end in 1945. Averaged over the 4 years that’s almost 73,000 American deaths a year.

Now take a look at the number of deaths that occur each year in US hospitals due to infections that patients acquire while there: 75,000. Add to that 573,000 people who will develop hospital infections and will not die, but who will undergo surgeries, lengthy and repeated hospital admissions, limb germ warfareamputations, physical and psychological suffering, and so on.

Simply put, “Hospitals need to stop infecting their patients,” says Doris Peter, PhD, director of the Consumer Reports Health Ratings Center. “Until they do, patients need to be on high alert whenever they enter a hospital even as visitors.” What’s more, “We’ve reached the point where patients are dying of infections in hospitals that we have no antibiotics to treat,” says Arjun Srinivasan, MD, who oversees the CDC’s efforts to prevent hospital-acquired infections.

But what does “high alert” mean? Are there actually concrete things that patients and their families can do to make a hospital stay safer?

The answer is an unqualified Yes: According to this month’s excellent cover story in Consumer Reports, America’s Antibiotic Crisis – How hospitals can make you sick, there are 10 things patients have to take the initiative on:

Consider MRSA testing. A nasal swab can detect MRSA and allow medical staff to take precautions, such as having you wash with a special soap before your procedure.

Insist on cleanliness. Ask to have your room cleaned if it looks dirty.

Take bleach wipes for bed rails, doorknobs, and the TV remote. Insist that everyone who enters your room wash their hands.

Keep your own hands clean. Wash regularly with soap and water.

Question antibiotics. Make sure that any anti­biotics prescribed to you in the hospital are needed and appropriate for your infection.

Watch out for heartburn drugs. Medications such as Nexium and Prilosec increase the risk of developing C. difficile symptoms by reducing stomach acid that appears to help keep the bug in check. So ask whether the drug is needed and request the lowest dose for the shortest possible time.

Ask every day whether ‘tubes’ can be removed. The risk of infection increases the longer items such as catheters and ventilators are left in place. If you’re not able to ask, be sure a friend or family member does.

Say no to razors. If you need to be shaved, use an electric hair remover, not a razor, because any nick can provide an opening for infection.

And when you return home from the hospital:

Watch for warning signs. They include fever, diarrhea, worsening pain, or an incision site that becomes warm, red, and swollen. People at particular risk include adults older than 65 as well as infants, anyone on antibiotics, and people with a compromised immune system.

Practice good hygiene.  Take extra precautions to make sure that your infection doesn’t spread. So clean frequently touched surfaces with 1 part bleach mixed with 10 parts water. Reserve a bathroom for the infected person. If that’s not possible, use the bleach solution to disinfect surfaces between uses. And don’t share toiletries or towels; use paper towels rather than cloth hand towels.

This 5 minute video dives deeper into the above points:

Did You Hear the One About the Corporate Spy who Infiltrated the Nursing Home?

It’s always good to know who the bad guys are.

Imagine, for example, that you work at a nursing home. You see things that are wrong. Filthy conditions, neglect of residents, or worse, outright abuse of the elderly leading to injury. You decide to do something about it – take photos or a video perhaps – and turn them over to authorities. But before you can do that, management catches you and calls the cops, and you end up being the one arrested.

No way, right?

Amy Meyer: The Accused

Amy Meyer: The Accused

Well consider the case of Amy Meyer, a 25-year-old animal rescue worker in Salt Lake City, Utah. Concerned about deplorable conditions at the local meat packing plant, she stood outside their fenced property and took a cell phone video capturing what she believed to be a “downer” cow, i.e., sick or too weak to stand but still processed, for example, for school lunch programs.

Spotted by plant management, they called police. Seven – seven — squad cars showed up within minutes wanting to know what she was up to. They were investigating Amy pursuant to state “Ag Gag” laws. These laws make it a crime – in Utah you face 6 months jail — for employees to document abuse or to lie about their association with animal advocacy groups on job applications for farm or meat packing employment.

Though Amy was released at the scene – she was neither a plant employee nor on their property – the prosecutor’s office nonetheless later filed Ag Gag charges against her. So she had to hire a lawyer and attend several court hearings. Even though the charges were eventually dismissed, the life of an Accused is fraught with anxiety. Take a look, for example, at Amy’s encounter with police which she captured on her cell phone camera.

Why does Amy’s case matter? Because the conditions of factory farms and meat packing plants are notorious the world over for contaminating the meat with pathogens and making us sick. For example, a recent report in the Guardian of London documented a new form of MRSA present in 9 of 100 samples of pork randomly selected from 4 major grocery chains in the UK. This is consistent with research in the US that found significantly increased rates of MRSA in people who live near to or work on these factory pig farms in rural Pennsylvania.

So industry is fighting back with legislation – these Ag Gag laws – aimed at keeping prying noses out of their businesses, and locking you up in the process if necessary. And they mean it. Take a look at the “model legislation,” drafted by the business advocacy group, American Legislative Exchange Counsel, that’s being distributed to lobbyists and lawmakers across the country. It’s called The Animal and Ecological Terrorism Act, which criminalizes, among other things, “entering an animal or research facility to take pictures by photograph, video camera, or other means with the intent to commit criminal activities or defame the facility or its owner.” It also proposes the creation of a “terrorist registry” that would contain the names, addresses and photographs of those convicted under the proposed law.

Rep. Szoka: Spy Games

Rep. Szoka: Spy Games

Just last month, North Carolina – the second largest pork producer in the country – passed its version of an Ag Gag law, called “The Property Protection Act.” It establishes an employer’s civil right of action against any employee caught recording wrongdoing. The law calls this a – wait for it – breach of the person’s “loyalty to the employer,” and allows the employer to seek $5,000 per day in damages for every day that “violations” continue. In other words, the law is meant to bankrupt you.

So back to the nursing home story: The NC law isn’t restricted to factory farms or slaughterhouses. For example, according to the AARP, the law “applies to any business’s employees who may seek to reveal illegal and unethical practices … including nursing homes … group homes … daycare centers, and so forth.”

So let’s give the final word to the people who passed the NC law and hear how they justify it. Representative John Szoka, who sponsored the legislation, said it’s wrong to call it an Ag-Gag bill. “There are Ag-Gag bills out there, but this is not one of them,” he told VICE News. “It certainly does cover food processing,” he said, but “the aim of the bill is to stop corporate espionage — like someone stealing information from a rival business.”

Cheap Meat

An endangered species?

What’s the hidden cost?

The true cost of cheap meat – beef, chicken, and pork – is slowly making its way into the public consciousness. A recent example comes from the Guardian of London, published last Thursday.

The issue arose because newborn babies in a British hospital were found to have a deadly form of bacteria called Livestock Associated – MRSA (LA-MRSA) in their umbilical cords. This sparked an 18-month investigation by the Guardian to find out why. Their report revealed the following:

(1) This is not hospital-MRSA but a cousin of you will, animal-MRSA. This particular type of MRSA is now well established in UK farms. But how, exactly, it found its way to these babies remains a mystery.

(2) LA-MRSA has contaminated the British food supply. The Guardian tested 100 samples of pork from 4 major supermarkets and found 9 of them contained the MRSA, a result they say is “significant” and “shocking.”

(3) The root problem is our “insatiable demand for cheap meat.”

(4) To meet this demand – which grows with world population – we’ve turned to a different kind of farming altogether: the large-scale industrial farm. Such “farms”: (a) Pack their animals together (b) In unsanitary conditions – in filth (c) Wean piglets early so sows can be quickly impregnated again. The stress of early weaning increases the risk of disease (d) In an effort to prevent disease the use of antibiotics is rampant (e) The use of antibiotics has backfired: we are breeding “superbugs” resistant to the antibiotics – often the same ones we use  – which is fueling a “crisis” that’s part of the global problem of antibiotic resistance.

(5) The solution lies in more natural farming. Better conditions for the animals means less disease and less drugs. Inevitably, consumers will have to pay a higher price for their bacon and eggs and so on because the price of cheap meat is too dear.

The Guardian video report is well worth looking at because it contains undercover footage of the conditions the pigs are raised in. Think cows, chickens, and turkeys as well. You don’t have to be a scientists to understand why this is a hotbed for disease.

So, about that pork chop …

Earlier this month the Obama family changed its diet. It was announced that the Presidential Food Service will serve meats only from sources that follow responsible antibiotic use. (Presumably, though, there’s still this loophole.)

The White House concern is that the overuse of antibiotics in food animals is making us sick. While that’s true, there’s also a deeper story in play here, which the President has so far shied away from.

Others, however, not so much. As F. Scott Fitgerald once observed: “Let me tell you about the very rich. They are different from you and me … They have more money.”

The gutsy filmmaker and RFK Jr.

The gutsy filmmaker with RFK Jr.

And he could add, if he were around today, they make fearless films. A case in point is actress turned aristocrat turned activist Tracy Worcester (nee Ward, and sister of actress Rachel Ward).

Ms. Worcester (pronounced ‘Wuster’) spent 4 years exploring the global pig business, learning where and how pork is produced, and asking who wins and who loses. The result is a gem of a film, Pig Business, which makes its case this way:

(1) On Profit: Worcester uses Smithfield Foods of America as her case study. It’s the world’s largest pork producer (i.e., “farmer”) and processor. With annual sales of almost $12 billion dollars, it processes over 27 million pigs a year, and employs over 52,000 people in 15 countries.

And it slaughters more than hogs. Robert F. Kennedy Jr., who is featured in the film, explains: “Twenty years ago there were 27,500 independent hog farms in North Carolina. Today they’ve been completely replaced by 2,200 hog factories, 1,600 of them owned or operated by Smithfield Foods.”

(2) On Cruelty: On such a vast industrial scale, pigs are no longer seen as animals but as industrial raw material. “We’ve taken the lessons of industrial systems designed to build cars and machines and applied them to living creatures. It’s infinitely cruel and no civilized society ought to countenance it,” says Tom Garrett of the Animal Welfare Institute. As he speaks, the film shows acts of cruelty – briefly, but long enough – least among them, sows in narrow cages during gestation, too narrow to turn around in.

(3) On Health: We are paying the ultimate hidden price: we are getting sick. Because hogs produce 10 times the fecal waste that humans do, the gases coming out of a swine operation are a “toxic brew” of dust, bacteria, and antibiotics, all mixed together with the upshot that:

“One of the big weaknesses of the system is the heavy dependence on antibiotics, and the fact that causes infections that can spread from animals to humans such as … MRSA. [I]n the Netherlands for example, where the most research has been undertaken, 40% of their pigs are carrying a strain of MRSA that can be passed to humans,” says Richard Young, policy adviser to the highly regarded Soil Association in Britain.

Worcester’s film may be 6 years old but she gets it just right. For example, scientists reported last year that people living closer to industrial pig farms – which includes the workers – were 38 percent more likely to have a MRSA infection than people living farther away. And the people getting MRSA are not like the ones who used to get it; they’re not old and sick, they’re young and healthy.

This map of rural Pennsylvania, where the research was done, tells the story. Each red dot is the home of a person with a MRSA infection. The blue bits are the pig farms.


So the pigs lose. We, the consumer, lose. The small farmer and his family who are run out of business lose. The low wage worker the farmer is replaced with loses. And people living downwind or downstream of the industrial farm lose.

So who wins?

Worcester gets to the heart of this business model in her interview with Professor of Economics and former Central Banker, Bernard Lietaer, who says the driving force is return on investment: “The financial institutions are running the show. The governments are all indebted to them. In the U.S. a third of all contributions to political campaigns are done by the financial institutions. So there’s no chance that they would change the rules of the game.” (My emphasis.)

Tracy Worcerster’s film is important enough in its own right. But its central message also serves as a powerful explanation for how the deep structures of capital determine not just wealth and debt, but, in this case, disease as well. Simply put: International corporations too often produce an inferior product at a cheaper price and, in doing so, kick small business – i.e. families – to the curb, trampling over local communities, wreaking environmental havoc and consequent illness. What Mr. Kennedy describes in the film as the “Walmartization of America.”

As Ms. Worcester frames it in an interview with The Guardian of London: “The story of the pig industry was the epitome of what’s going on in every [industrial] sector.”

Compare, for example, the energy sector, where these scholars, among others, argue that “What is needed for climate stability is a systemic transformation based on … changed … corporate and financial power structures.” In other words, on this view, both MRSA and climate change are themselves symptomatic of a common and structural underlying “disease.”

This smart, elegant film, has met with legal opposition from industry players. Many copies, therefore, are truncated or watered-down. Here’s one, though, that seems to be the complete version.

A Tale of Two Studies

Two studies presented at a national medical conference in Orlando, Florida last month reported findings that suggest its authors might want to talk to one another.

A research team from the Ronald Regan UCLA Medical Center, led by Elise Martin, MD, wanted to know what would happen to hospital infection rates if they stopped using routine contact precautions.

Is the hospital gear doing its job?

Does wearing this gear really prevent the spread of infection?

Precautions are used for patients infected with bad bugs such as MRSA (methicillin-resistant staphylococcus aureus), and VRE (vancomycin-resistant enterococcus). They are placed in isolation and healthcare workers (HCW) wear personal protective equipment (PPE); such things as gowns, gloves, masks, and goggles, for each and every patient contact.

There are, however, downsides to the procedure: It’s time consuming for staff to don and doff the gear; patients report feeling that staff avoid them because of the inconvenience of having to put it on; the gear is expensive, for example, it costs the UCLA hospital over $650,000 every year; and besides, say the researchers, there isn’t a lot of data saying this approach works to begin with.

Dr. Elise Martin: The gear makes no difference

Dr. Elise Martin: The gear makes no difference.

So to find out if the effort is worth it, Dr. Martin and her colleagues simply suspended the contact precautions from July through to December last year, and checked the data to see whether there was any effect on hospital infection rates. The result: No difference; i.e., whether you use the contact precautions or not, the infections rates for MRSA and VRE remained the same!

Oh boy. That’s quite a finding because these precautions are SOP across the country, if not the world. And so her work has become a hot topic in the medical community; for instance, it remains the most read article on Medscape Infectious Disease a week after it was first posted.

But there’s a problem.

At that very same conference in Orlando, a research team from the Cleveland Veterans Affairs Medical Center in Ohio, led by Myreen Tomas, MD, presented their study on PPE, which looked at it from a different angle; namely, whether or not HCW are using the gear properly, and if not, do they become contaminated as a result, thereby increasing the risk of contaminating their patients.

Dr. Myreen Tomas: We're not using the gear properly

Dr. Myreen Tomas: We’re not using the gear properly.

The Tomas team say their results were “very surprising”: The skin and clothing of HCW became very contaminated during the removal of the gear; for example, when the PPE gloves were contaminated the workers themselves became contaminated 80% of the time, especially their hands, thus increasing the risk of spreading disease throughout the hospital.

Overall, gown and glove contamination resulted in HCW contamination 46% of the time. The problem, Dr. Thomas says, is improper use of the gear, especially when taking it off. For example, the gown should be removed away from the body, not over the head.

When the researchers made sure that the correct procedures were followed the contamination rate dropped dramatically – all the way down to 5%.

In other words, according to this study, contact precautions do work – if they’re done right.

And there’s the rub. Because outside of the controlled environment of a study, where researchers are there to tell the HCW if they’re donning and doffing the equipment properly, the real word is very demanding of their time and those pressures lead to mistakes.

Ironically, it’s those very demands on HCW time that makes the UCLA study so appealing. Because it offers the service provider the promise of more time to do their job which translates into happy employees and satisfied patients.

So imagine:

You’re the CEO of the Ronald Reagan UCLA Medical Center. Your budget’s tight, your staff say they’re overworked and underpaid, your patients say they want more attention from their HCW – and remember there’s a lot more patients without drug-resistant infections than there are with.

Dr. Elise Martin walks into your office and says she has a sure-fire way of taking care of these concerns – be a pioneer, she tells you, and dump the traditional practice of contact precautions.

What do you say to her?

Guess Where All the MRSA Is?

We have assumed all along that it was the hospital. But a study released just this week says it’s the nursing home. The absolutely stunning bit is just how prevalent MRSA (Methicillin-resistant Staphylococcus aureus) was found to be in the homes: a little more than 1 in every 4 residents were colonized with it.

The research was conducted in 13 community-based nursing homes in Maryland and Michigan. The study found 28 percent of residents (113 out of 403) harbored MRSA.

Hospital MRSA rates are much lower. We don’t have an exact count for MRSA alone, but a 2013 study found that 1 in every 12 patients in hospitals across Canada were colonized or infected with one of three bugs: MRSA, which led the pack with 67% of the cases, followed by CD (Clostridium difficile), and VRE (Vancomycin-resistant Enterococci). Thus the MRSA number would be in the vicinity of 1 in 20 patients.

A close reading of the Canadian study reveals that the average age of the MRSA-afflicted patients was 70, thus lending support to the high nursing home numbers that were found.

MRSA is easily transmitted by touching: from person to person, or from person to some surface, say a bed rail or table or chair, to a second person. Thus the study raises real concerns for not just the nursing home residents, but for staff and visitors as well.

Down at the Courthouse: A Judge Wants to Know Why a Two-Month-Old Infant with MRSA Died

The Judicial Inquest into the MRSA-caused death of two-month-old Drianna Ross is taking place in courtroom 114 of the Law Courts Building in downtown Winnipeg. Presiding Judge Don Slough is nearing the end of his two-year investigation into Drianna’s death in November, 2011, in the northern Manitoba city of Thompson.

The Inquest was struck because Drianna’s mother and father, backed by community leaders, say that northern medical services are substandard and that’s why their child died.

Drianna Ross

Drianna Ross

The case began when they took Drianna, crying, coughing, and with difficulty breathing, to a local nursing station four times over two days. She was never referred to a doctor; instead, she was sent home with Tylenol. Finally, on her fourth visit to see the community nurse, Drianna was medevaced to Thompson General Hospital. The following day she died from a MRSA-induced septic shock.

The purpose of the Inquest is to examine the adequacy of healthcare in remote northern communities and, if that care is found wanting, to recommend changes in government healthcare practices so cases like Drianna’s don’t happen again. (Judicial Inquests, unlike trials, do not assign blame and do not have the authority to hold anyone legally responsible.)

On the stand yesterday afternoon was Dr. Stasa Veroukis, Pediatric Intensive Care Specialist at the Health Sciences Centre in Winnipeg. She wasn’t directly involved in the case but had reviewed the relevant medical documents in order to offer her expert opinion about the quality of Drianna’s medical care.

A half dozen lawyers from various health authorities questioned Dr. Verooukis, trying to pinpoint where it all went wrong after Drianna got to the hospital.

In Dr. Veroukis’s view the moment of truth was Drianna’s first night in the hospital. By 3:00 a.m. her heart rate had risen to 203 beats per minute, her temperature was a “very high” 39.3 degrees C and, most tellingly, when nursing staff poked Drianna to insert an IV she did not respond – which meant she was unconscious. Stunningly, that’s where it was left — no doctor was consulted to see what they should do next.

Those downward-spiraling vital signs meant that septic shock was setting in, said Veroukis, and as brain and heart cells begin to die off the process quickly becomes irreversible and death inevitable.

Dr. Veroukis was clear: “All the symptoms should have been put together by the nurse and [she should] have called the doctor.” Veroukis could only guess why that wasn’t done: a busy night perhaps, poor communication between nurse and doctor, inexperienced staff, and/or a lack of awareness about what the vital signs meant.

When asked how a two-month-old infant could possibly contract MRSA in the first place, Veroukis told the court there’s “More MRSA in the northern communities. The best option I can offer is the people around her have it.”

The research agrees with her, but with one important qualification: It’s not that MRSA frequents the north more than, say, the south, it’s that remote northern areas are home to First Nation communities and it is First Nation people who are disproportionately affected by MRSA.

For example, in a 7-year study ending in 2002, First Nation patients in Canada were found to be 6-fold more likely to have a Community Associated-MRSA infection than non-FN patients. (Community Associated means the patient picked up the MRSA before going to the hospital.)

And it might be getting worse: A U.S. study of Indigineous populations found that MRSA-associated hospitalizations increased from 4.6 per 100,000 American Indians/Alaska Natives in 1996 to 1998 to 50.6 per 100,000 in 2003 to 2005 – more than a 10-fold increase.

In other words, professional red flags have been waving about the increased prevalence of MRSA in First Nation communities for at least a decade.

Drianna’s death reminds us what happens when those warnings are ignored.

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