How Concerned Should We Be With the Continuing Deadly Outbreak of Antibiotic Resistant ‘Superbugs’ That Killed 58,000 Infants in India Last Year?

How we assess threats depends on where we live in the world. For example, a Pew Research Center report from last month tells us that if you live in Sub-Saharan Africa you see Aids and disease as our greatest threat. In the Middle East it’s religious and ethnic hatred, and in the US and Europe it’s inequality.

But our recent experience with Ebola may have changed that. This Wednesday the New York Times ran the story ‘Superbugs’ Kill India’s Babies and Pose an Overseas Threat. It was on the front page and two days later at 8:00 this morning it was still on the most viewed and most emailed lists, reaching as high as number 3 yesterday. That’s a first. Apart from Ebola, stories on infectious disease in the US and Canada are generally ignored.

But not the Times report, which says that India’s infants are born with bacterial infections that are resistant to most known antibiotics, and more than 58,000 died last year as a result. That if these “resistant infections keep growing … it would be a disaster for not only India but the entire world.”

Quoting health officials, the Times reports that the infections are in fact growing rapidly: “Five years ago, we almost never saw these kinds of infections. Now, close to 100 percent of the babies referred to us have multidrug resistant infections. It’s scary.” And these resistant infections have already begun to migrate elsewhere “… reaching just about every country in the world … including … the United States.”

So are Times readers right to keep this story front and center?

Let’s ask one of our foremost experts on infectious disease, Tom Frieden, MD, Director of the US Centers for Disease Control and Prevention. You may recall Dr. Frieden as the guy who, in the midst of the great American Ebola freakout, was telling the President, the Congress, the media, and the public, that “I have no doubt that we’ll stop this in its tracks in the U.S.” And as we know he was proven absolutely right.

But this past July in a talk to the National Press Club in Washington, DC – a talk that got zero publicity – Tom Frieden told us what we will not stop in its tracks in the US:

But the next pandemic is not likely to be MERS … But maybe the next thing that we are most at risk for is not the thing that we don’t know, but something that’s hiding in plain sight, something that could kill any of us, something that could undermine our ability to practice modern medicine, something that could devastate our economy and something that could sicken or kill millions … Antibiotic resistance…

I’m an infectious disease physician. I’ve treated patients for many infections and I’ve also treated patients for whom there are no antibiotics left. I felt like a time traveler going back to an era before antibiotics. We talk about the pre-antibiotic era and the antibiotic era. If we’re not careful we’ll soon be in a post-antibiotic era. And, in fact, for some patients and some pathogens, we’re already there.

And what does this post-antibiotic era look like? It looks like India, right now; that’s the compelling story in the Times that its readers, rightfully, aren’t letting go of. They seem to intuitively grasp, perhaps because of our recent Ebola experience, what Frieden says explicitly: “A disease outbreak anywhere is a disease risk everywhere.”

Riddle Me This: What’s an Infectious Disease?

Infectious disease?

I came across this brain-teaser in David Quammen’s masterful book Spillover: Animal Infections and the Next Human Pandemic.

In general terms, we’re pretty comfortable with what a disease is. And we certainly know the difference between an attack by bacteria versus that of a lion, say. But not so fast. Here’s Mr. Quammen’s take:

Infectious disease is all around us…. It’s one of the basic processes that ecologists study…. Predators are relatively large beasts that eat their prey from the outside. Pathogens (disease-causing agents, such as viruses) are relatively small beasts that eat their prey from within. Although infectious disease can seem gristly and dreadful, under ordinary conditions it’s as natural as what lions do to wildebeests and zebras, or what owls do to mice.

So are a pack of wolves – or human cannibals – the functional equivalent of a bunch of pneumonia bugs?

Perhaps after dinner and over a glass of wine we could discuss it. Oh wait … how would we characterize what we just did to that side of beef?

What’s safer: a stint in your local hospital or a stint in the Iraq war?

A nursing group in Texas sent us a compelling (disturbing?) chart on hospital safety which we’ve posted below (original source: ). Notice how it refers to preventable deaths and that a full 25% of these are due solely to infections you pick up simply because you’re in a hospital.

And no, this isn’t just a U.S. phenomenon. In fact, Canadian numbers may be worse. For example, a CBC Fifth Estate investigation found that about 1 in 10 patients admitted to hospital in Canada contract hospital-acquired infections (versus 1 in 25 in the U.S.), and that between 8,000 and 12,000 of these patients die from them each year.

So it turns out that we’re not as safe in hospitals as we think. But that we’re even less safe in our hospitals than in the entire Iraq theater of war … what’s going on?

A Tour of A Hidden Universe

“Most of life is invisible. Everything that you can actually see with your eye is just the smallest sliver of life on this Earth,” says Bonnie Bassler, professor of microbiology at Princeton University.

But here’s the thing: we’re immensely affected by this hidden universe of tiny creatures. Look no further than the front page news these past few months and witness the effect that the Ebola virus is having on us.

The Tree of Life depicts every living organism that we know about on Earth. The only ones we are able to see, however, are depicted at the top right – the animals (that’s us), the plants, and a few of the molds and fungi. For all the rest we need magnified pictures.

But those magnified pictures can fool us because they typically don’t provide contrast. Instead, they represent all micro-creatures to be roughly the same size. Which is akin to showing a child similar size pictures of ants and elephant’s, thus leaving the impression they’re roughly the same dimension! What you need of course is contrast, i.e. a picture of the ant (standing!) beside the elephant.

The same holds true for us and our understanding of the Hidden Universe. So here’s a really neat animation that solves the problem. It lets us peek into the unseen universe of bugs and things and see not only what they look like and how they compare in size to each other but – and here’s the trick – it lets us compare them to something we’re very familiar with as all the various life forms are sitting side-by-side on the head of a pin.

So explore the secret world of Ebola, E. coli, staph aureus, blood cells, and so on, and notice how many thousands of times bigger, or hundreds of thousands of times bigger, one is from the other.

Click on “Start the Animation …” and enjoy the tour!

The Hospital’s Duty of Care

Arlene Wilgosh admits that hospitals have a duty to protect their patients from acquiring "super bacteria."

Twenty people died in Canada today – but they didn’t have to. They were all in healthcare facilities, hospitals mostly, and the reason they died had nothing to do with what brought them there. They died because of an infection they picked up while in care. And they picked up the infection because the hospital wasn’t following its own hygiene rules – and they admit it.

These preventable deaths happen every day in Canada, all across the country. By the end of the year – and every year — more than 8,000 people die in care, making Hospital-Acquired Infections (HAIs) Canada’s fourth leading cause of death. But it doesn’t stop there as more than 200,000 people are made sick by these infections, often seriously, as lifelong scars or a missing limb attest to.

This past Tuesday, Winnipeg’s Health Sciences Center held it’s (18th) annual “Bug Day,” an event that brings together experts from across the country who publicly address various aspects of HAIs. It played to an attentive and overflow crowd of healthcare workers. The take-home message was the same as it was last year: “Wash your damn hands,” as Winnipeg Regional Health Authority CEO Arlene Wilgosh put it, as 80% of these infections are spread by healthcare workers, or patients and their visitors.

But there’s a problem: the golden rule of washing your hands between every patient visit isn’t followed. Around 70% of nurses comply and a paltry 38% of doctors – if that. It’s been suggested that even these numbers are inflated because staff know when the hand washing police are watching and will thus “buckle up.”

Then came the stunning bit: Arlene Wilgosh said she didn’t know why these compliance numbers are always so low. The admission was stunning because even the nursing student seated next to me said: “We just don’t have the staff. There’s too many patients for each nurse to look after and there’s just too much to do.”

And that’s the dirty little secret that none of the presenters at the day-long event were willing to give voice to.

Not even Arlene Wilgosh, who seemed so compassionate. A former frontline nurse herself, she admitted that staff have a duty of care to their patients and candidly asked the audience: “If these patients were our loved ones, would we still not wash our hands and take proper precautions?”

According to Ms. Wilgosh, the hospital infection issue “poses a … very significant risk to those we care for,” and therefore “Something new has to be done to address it.”

But what is that “something new”? Because if our healthcare leaders aren’t even willing to acknowledge a major cause of HAIs, then where are we supposed to look for a solution?

Is this where we're headed?

How about the law. A sharp-eyed CBC report filed this month put it this way:

Our concern about the WRHA … is the lack of acknowledgement of the systemic nature of the true solutions, apparently devoid of a plan to marshal the required resources.

Under the Manitoba Workplace Safety & Health Act, Sec. 43(1): “A worker may refuse to work or do particular work at a workplace if he or she believes on reasonable grounds that the work constitutes a danger to his or her safety or health or to the safety or health of another worker or another person.”

Who … will be the first health care provider to draw the line and say, “I have too many patients, and

not enough time to follow proper hand hygiene protocols. I am refusing this work on the grounds that it constitutes a danger to the health of another person.”

Will it then be labor legislation that ultimately compels the minister of health and the WRHA to properly resource a systemic solution that will keep patients safe?

The CBC may be on to more than it knows. When professionals breach their duty of care to their patients, and serious, foreseeable, and preventable harm results, year in and year out, there’s a name for what happens next – it’s called a lawsuit. And a class action suit filed on behalf of close to 250,000 patients would not be out of the question for an imaginative and resourceful law firm.

Arlene Wilgosh began her address to us with these words about hospitals and infections: “It’s like going to war every day,” she said. She, too, may be on to something. Because if hospitals carry on shirking their duty to their patients, they will find themselves engaged in yet another theater of war, only this time they’ll be the ones in need of help. And they will dearly hope that the legal professionals in whose hands they’ll be in will properly discharge their duty of care.

Look at it this way. Suppose Ebola was killing 8,000 Canadians a year, every year. And on top of that our healthcare leaders publicly admit we could avoid those deaths if only hospital staff would bother to follow their own hygiene protocols. Yet they don’t, and so the deaths of innocent people continue to pile up. How would we feel about a lawsuit in that case? And so to our issue – how is the runaway train of hospital-caused/associated infection any different than that?

The MRSA Map

Dr. Joan Casey

Green acres may not be the place to be.

When Joan Casey was a PhD student she started reading up on the idea that antibiotic use in our farm animals might be making us sick. Research over in Europe told her that MRSA was traveling from pig farms to people, and she wanted to know if the same thing was happening here. Five years later, and now on staff at the UCSF School of Medicine, she believes it is.

Her research (on FRONTLINE) led to Pennsylvania farm country. Using data from about 160 million electronic records on about 450,000 patients in the region, her team found that (1) total MRSA from 2001 to 2009 went up every year, and by as much as 34% (2) people living closer to these farms and to the crop fields that are located nearby were about 38 percent more likely to have a MRSA infection than people living farther away, and (3) the people getting MRSA are not like the ones who used to get it. They’re not old and sick; they’re young and they’re healthy.

Casey’s team put together a map of their findings. Each red dot is the home address of a person that had a MRSA infection. The blue bits are the pig farms.

Now for the tricky part. Industrial farms are an easy target. We know they ply our food animals with antibiotics, not to cure disease, but because antibiotics accelerate growth. So you have a ready to slaughter animal in much quicker time thus saving owners money on feed and care, which in turn keeps the price of our (expensive protein) food down – just the way we like it.

But at what cost? Joan Casey says innocent children in rural Pennsylvania are getting hurt (google “MRSA infection” images) so you can eat cheap meat.

Sacrificing others so we can live comfortably is nothing new. The link between child labor, sweatshops, and affordable goods and clothing, for example, is well documented.

As population numbers rise and land and fresh water become scarce, the demand for cheap food will increase, implicitly egging on whatever our industrial farms can do to provide us with affordable meat. As if that isn’t enough, our new global inconvenient fact, climate change, portending even less arable land due to drought and flooding leading to food shortages, will put further pressure on this industry to cut corners.

Dr. Joan Casey has shown us where that leads. The question for us is whether we will follow.

The Global Village of Infectious Disease: The Beat Goes On

Ever since it became known that Ebola virus disease was in Dallas, Texas, it has been front page news. That remains the case even though health authorities agree it won’t spread to any significant degree, for example, outside of the patient’s immediate family.

But authorities agree on something else too, something vastly more important, because, unlike Ebola, it’s likely to affect you and me: the fact that infectious diseases of all kinds are growing – and moving – worldwide. That is the real takeaway from the Ebola outbreak; from the SARS outbreak before that, and from HIV/AIDS before that – we in North America are not only not immune from the trend, we’re in the crosshairs.

Scientists figured this out at least 6 years ago, and just 3 graphics help us understand the story. The first is a map of the regions of the world where there is a high risk for future or emerging infectious disease events to occur. Notice the prominent role of the US and Europe:

The next point is that not only are infectious diseases on the move, they’re becoming increasingly resistant to standard antibiotic treatment; for example:

And what’s one of the biggest reasons for all this? Global air travel:

Where we and our air cargo go, the bugs go, as we witnessed with the man who brought Ebola from Africa to Texas. We saw the same thing happen with the spread of SARS in 2003 and the pandemic influenza of 2009, where the rapid global spread of disease occurred through major travel hubs.

Today, our world population is just over 7 billion people; by 2050 it’s estimated to be 9 billion, suggesting these disease trends will continue. But there’s one more thing that we haven’t even touched on that may have the greatest impact of all: climate change. Our best scientists agree it will affect the spread of infectious disease – but exactly in what ways, is the (epic?) story yet to be told.

Ebola Lands in Dallas, Texas: Welcome to The Global Village of Disease

Okay, the Ebola virus is here, and yes, that really matters – but probably not for the reason you’re thinking.

It landed in Dallas, Texas, on a flight from Africa on Friday, September 20th. The person in whose body Ebola hitched a ride began showing symptoms on September 24; on September 28 he was hospitalized and is reported to be in critical condition.

The crucial medical fact about Ebola is this: it can only be transmitted when the patient is sick and showing symptoms and even then only though direct contact with that person’s body fluids, notably blood, vomit, or excrement. Healthcare workers, therefore, need to be very careful, as the African experience shows. But the rest of us will be okay: “I have no doubt that we’ll stop this in its tracks in the U.S.,” says Tom Frieden, Director of the Centers for Disease Control and Prevention. So a local, internal spread of the virus isn’t really the issue.

There is, however, a deeper concern: Is the fact that Ebola made its way here a one-off, or does it portend a future where all bugs, especially those resistant to to antibiotics, although once geographically limited, now have a global reach?

The evidence overwhelmingly supports the latter view. Disease, like us, and because of us, is on the move everywhere; thus: “A disease outbreak anywhere is a disease risk everywhere,” says Dr. Frieden. That is because international travel has grown dramatically and it’s estimated that one billion people are travelling every year, most of them by air. In fact, worldwide tourist travel alone is expected to almost double over the next 15 years:

Since flights take people half way around the world in less than a day, that is well within the incubation period of many infectious diseases. That is why long-distance travel of persons and materials has long been recognized as a factor that drives the emergence of infectious disease; and now, increasingly so, as population levels rise.

The other thing is that germs don’t just attach themselves to people. Like you and me they hitch rides on airplanes too. For example, MRSA, the flu virus, E Coli, and diarrheal bugs are found throughout a plan, as this CNN report tells us. Moreover, the bugs will hang out in the plane for days: MRSA, which kills more than 11,000 Americans every year, was found to last 7 days on the seat pocket, 6 days on the armrest and seat, 5 days on the window shade and tray table, and 4 days on the toilet handle of planes.

The upshot of all this is well put by Dr. Cesar Arias, professor of medicine at the University of Texas: “Bugs don’t have passports. They don’t respect borders. They can travel very easily. And, in fact, this has been shown for MRSA.”

Notice that it’s not just MRSA that’s a frequent flyer. All the bugs on the graphic below – and many more – are joining the club every day.  Welcome to the Global Village of infectious disease.

Seeing the World in New Ways

It seems we humans don’t quite understand our place in the world.

“Everything that you can actually see with your eye is just the smallest sliver of life on this Earth,” says Bonnie Bassler, professor of microbiology at Princeton University, in the New York Times video, “Seeing the Invisible,” posted below. “Most of life is invisible,” she says. “We still have this idea that we’re the most central feature of Earth, [yet] it’s the humans that are the bystanders. But now we get [that] most of life is microbial. If you look at the Tree of Life, only this tiny little part is every single thing you’ve seen.”

In all of life, only Animals, Plants, and some Molds and Fungi can be seen by us (top right). This causes us to overvalue our role in the world and grossly undervalue the role unseen organisms play in our daily lives.

Dr. Bassler continues: “Every higher organism is covered inside and out with bacteria. And humans would not be alive if [if it weren’t for] these little 24/7 partners. And they have all kinds of fabulous behaviors.” For example, they talk (do they gossip?). “We discovered that bacteria can communicate using a molecular language. We used to think that social behaviors were the purview of higher organisms. What we now understand is that bacteria were probably the first organisms on this Earth to ever communicate with one another.”

But why are we “covered inside and out with bacteria”? Should we try and get rid of them? To the contrary; the new understanding is that we need them to be healthy: they aid digestion, build nutrients, and help us fight disease – and more.

Remember, Dr. Bassler described bacteria as our “partners.” And just like when we mistreat our human partners, when we mistreat our bacterial partners, we will pay a price, and a heavy one at that.

A virus that eats bacteria. If we could see these things, would we take infectious disease more seriously?

A case in point is our misuse of antibiotics – poisons – which attack all our bacteria, not just the bad guy, much like cancer radiation therapy attacks all cells not just cancerous ones. So instead of being left, say, bald, weak, thin, and nauseous, we are left more prone to infection, obesity, childhood diabetes, food allergies, celiac disease, and even cancer.

A leading exponent of this new science is Martin Blaser, MD, professor of medicine at New York University. It’s all laid out very nicely in his well-received 2014 book “Missing Microbes: How the Overuse of Antibiotics is Fueling our Modern Plagues.” The “plagues” being the above-mentioned diseases.

The overuse of antibiotics is also driving the rising tide of antibiotic resistance, the idea that we’re going back to a pre-penicillin era because bacteria have  figured out how to outsmart our antibiotics. That matters because, for example, more than 200,000 patients get infections every year while receiving healthcare in Canada and more than 8,000 of these patients die as a result. In the US, where they track individual pathogens, methicillin-resistant Staphylococcus aureus (MRSA) alone (one of many “Gram positives,” on the Tree of Life) causes more than 80,000 severe infections and more than 11,000 deaths every year. So without antibiotics, where will we be?

The solution to this global crisis, says infectious disease specialist Brad Spellberg, MD, will only come if we change the way we think about our microbes: “This whole thing about winning the war against microbes … nah! We’re not going to win a war against organisms that outnumber us by a factor of 1022 , outweigh us by a hundred million-fold, replicate 500,000 times faster than we do, and have been doing this for 10,000 times longer than our species has existed!”

In other words, when it comes to understanding our place in the world we are not who we think we are – and neither are they.

The invisible world made visible:

Overcoming the Disadvantages of Topical Antibiotics is Necessary to Achieve Universal Decolonization

Disinfecting the skin prior to surgery has long been a standard of care. Whether with iodine, chlorhexidine washes or other antiseptic surfactants, reducing the bacterial load on the skin surface has been established as an important mechanism to control the rate of post-surgical infection. The nose, which is a warm, moist environment ideal for bacterial growth, however had been difficult to decolonize.

Up to 30% of patients are carriers of Staph aureus. Colonization rates of the serious antibiotic resistant version of Staph aureus, known as MRSAid (one of the 3 major superbugs), range from 2% in Canada to 80% in Shanghai. Ordinarily, these pathogens do not impact patients until they are weakened by illness or surgery. Post-surgical infection is a risk for patients colonized with this pathogens and therefore has led to the need for removing or reducing the bacterial load carried around by these patients just prior to surgery.

In several studies, the nose has been identified as the key reservoir of Staph aureus and MRSA, representing 40% of the bacteria load in one small area. Because the nose is not washed on a regular basis, unlike other body parts, Staph aureus can easily flourish in the nose and become a source of contamination for other body parts. Because of delicate mucosal tissue and the presence of cilia in the nose, the antiseptic washes used for hardier skin surfaces are not appropriate for use in the nose. Instead, nasal decolonization has been done by topical antibiotics such as mupirocin.

Topical antibiotics have 3 significant disadvantages that have resulted in many infection control experts rejecting pre-surgical nasal decolonization protocols. With sub-optimal patient compliance, infection control experts fear the resulting antibiotic resistance formation brought about by sub-optimal doses of antibiotics that occur when patients stop mid-way through their antibiotic treatments. Poor patient compliance, despite advisories about the severity of MRSA and Staph aureus infections, is the leading disadvantage of antibiotics.

The problem is the inconvenience and unpleasantness of antibiotic creams in the nose. Patients are known to dislike the Vaseline™-type viscosity of mupirocin and often do not comply with the 3 times a day for 5 days treatment protocol. Incomplete doses of antibiotics leads then to antibiotic resistance which in turn adds to, not subtracts from, the risks already present with patients colonized with Staph. This is the primary reason why many hospitals have not opted for nasal decolonization protocols despite the 30-40% reductions in surgical site infection rates demonstrated in clinical trials.

The second disadvantage of antibiotics is the time required to decolonize. On average, decolonization using topical antibiotics requires about 5 days which implies that patients need to be screened and identified early enough for the efficacy of antibiotics to kick in.

The third disadvantage of antibiotics, however, is the inconvenience to patients and the costs to the health care system to culture for and identify Staph aureus and MRSA carriers.  Because of antibiotic resistance concerns, only carriers of Staph and MRSA are given nasal decolonization therapy. New rapid diagnosis technologies have emerged, but prior to Photodisinfection, there was little acceptance of these rapid diagnostics because antibiotics, the decolonization remedy, still required 5 days treatment for effect. The saving of 2-3 days prior to a 5 day treatment protocol did not justify, to many, the additional cost of same-day rapid diagnosis.

Technologies that overcome the disadvantages of topical antibiotics and allow for universal nasal decolonization are going to play an important role in health care associated infection control. These technologies must not generate resistance, must be safe for all surgical patients, even if they are not carriers of Staph aureus or MRSA. Finally, these technologies need to be easy to use, easy for patients to tolerate and fit well into the pre-operative work flow.

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