We Typically Don’t Treat MRSA-Colonized Patients. Instead, We Let Them Run The Risk of Acquiring A Serious Infection. Why Is That?

Swabbing a patient to see if they're MRSA-positive. But what happens next?

Canada has the second highest health-care associated infection rate in the world compared to other high-income countries. Every year at least 200,000 people become infected after they go to a hospital. Somewhere between 8,000 and 12,000 of those people will die as a result. And Canada’s Chief Public Health Officer says it appears that these numbers are rising. For example, the healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infection rate increased more than 1,000% from 1995 to 2009. If we were at war and suffering these kinds of casualties it would be front page news and we would be doing all we could to stop the bleeding.

Whether we’re doing all we can to stop the harm caused by infections contracted at hospitals has arisen in the context of the MRSA-colonized patient. Infection is a 2-step process that begins with the patient being “colonized” by the bad bug: the bug gets into open areas of the body’s exit sites such as the tips of the nostrils but the patient isn’t yet infected – they haven’t become ill – so far. But since studies show that between 1 in 4 and 1 in 7 patients who become colonized also become infected, good health care practice would suggest that you should get rid of the bad bug as soon as you know it’s there – you “decolonize” the patient.

Surprisingly, though, most hospitals do no such thing. For example, Prairie Mountain Health Authority in western Manitoba does not recommend treatment for colonization by MRSA. Dr. Greg Large, a general physician there, explains that the golden rule in medicine is “First, do no harm.” So if someone isn’t infected it means that no harm is being caused by the colonization – so leave the person alone. Because when you treat/decolonize you run the risk of creating irritation, toxicity, and antibiotic resistance; and it taxes hospital resources. Therefore, since 75 – 85% of the patients who are colonized never become infected, why risk harming them?

Hospitals covered by the Winnipeg Regional Health Authority confirmed by email that they do not have a policy specific to the decolonization of MRSA-colonized patients: “The decision to decolonize MRSA from a patient would be made by the clinical team on a case by case basis in order to protect the most vulnerable patients from infection. Those patients who present to hospital repeatedly with invasive infections would be significantly more at risk of becoming infected and, as a result, would be most likely to be decolonized.”

The most recent research on the subject demonstrates the high stakes that are involved. It found that of the 840 patients studied, 125 died (1 in 7) within six months of MRSA acquisition. Of patients surviving to discharge, 1 in 4 required multiple admissions for complications due to their MRSA infection. And surgery within 30 days as well as admission to an ICU were associated with MRSA infection.

Accordingly, the researchers conclude that “targeting interventions such as decolonization therapy and enhanced efforts to prevent device-associated infection to reduce development of infection in patients who newly acquire MRSA colonization may also have a key role.”

The Vancouver General Hospital took an important step in this direction. In 2012 they began decolonizing all of the roughly 7,000 surgical patients they have every year. As a result, surgical-site infections are down by almost 40%, which also saves the hospital about $2 million a year that it would otherwise have to spend to treat those infections.

Changing how we conceptualize the colonization issue may help as well. For example, we vaccinate healthy people all the time so they don’t run the risk of catching a disease, some a lot less serious than what a MRSA infection can do to you. So why not think of a policy of decolonization as a kind of “vaccination,” a way of preventing the risk of serious harm?

Finally, what about involving the patient in the decision to decolonize? If you were told you were MRSA-colonized and therefore faced a 15% chance of death, the risk of surgery, the need for care in an ICU, and multiple hospital admissions to deal with complications cause by the infection, what would you do?

Two-Thirds of Hospital-Acquired Infections are Preventable

The new understanding: these people are now considered a vital part of your hospital health-care team.

About 7,000 Canadians die every year that don’t have to.

This is according to Dr. Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto’s University Health Network. In a statement to CBC’s The Fifth Estate last year he said we have the ability to prevent “about two-thirds of hospital-acquired infections (HAIs).”

The reason this matters so much is the staggering number of people who become infected after they go to a hospital: at least 200,000 a year. Tragically, between 8,000 and 12,000 of those people will die from those infections – each year. In other words, applying Dr. Gardam’s two-thirds statement to the numbers, it means that on average 7,000 Canadians die needlessly every year due to infections they acquire at hospitals across the country.

The number one way to prevent HAIs has focused on hand hygiene, i.e. doctors and nurse should carefully wash their hands before and after each patient visit. But a new Canadian study says we have made a big mistake by overlooking the crucial role played by hospital cleaning staff – or ‘Environmental Services’ (ES) as the study calls them.

The research, published in the American Journal of Infection Control, found that one-third of the respondents – lead infection control professionals – in 119 health-care facilities across Canada, did not rate their hospital’s ES as adequately trained to clean to standards.

What does “clean to standards” mean? It means that if you or I were hired to clean hospital rooms we’d get it wrong. We wouldn’t know, for example, what surfaces to focus our efforts on (the bedrail not the floor), what disinfectants and cleaning products to use, how much we can re-use, say, a cleaning rag – is it actually cleaning surfaces or merely dragging germs from the previous dirty surface and wiping them onto the next one?

The kind of picky detail needed to fix the problem is seen in this example: the use of color-coded housekeeping carts to ensure the appropriate cloths are used on the appropriate surfaces. There are four different colored buckets and clothes – red, yellow, blue and green. Red buckets are for bathrooms only, yellow for isolation rooms, and so on.

However, these kinds of solutions require expertise which can only come from the infection prevention and control people (IPAC), i.e. the highly trained specialist physicians in infectious disease who have to pass their knowledge onto the cleaning people.

And that’s what the study looked at: whether there was a good working relationship between IPAC and ES, if ES are being properly educated and directed by IPAC, and do ES know how to do their job properly.

The one-third statistic mentioned above was disappointing. As was the finding that 37% of hospital infection control experts believe their hospital is not clean enough to prevent the spread of MRSA and other potentially lethal organisms.

“We’re just not achieving the results we need,” said the study’s lead author, Dr. Dick Zoutman, an infectious disease specialist and professor in the school of medicine at Queen’s University in Kingston, Ont. People can get infected if they touch contaminated surfaces, including “high-touch” surfaces such as toilets, bed rails, bedside tables, call bells and door handles, and then their mouths. Hospital staff can  then spread the infection between patients if their hands are contaminated from these surfaces.

Dr. Gardam concludes that a major factor in preventing HAIs is the job done by their cleaning staff. “People don’t really think of them as part of the team, but if you think about how infections are spread in hospitals, they’re actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room.”

The bottom line is that hospitals generally undervalue the importance of cleaning staff, Dr. Gardam said.

To see the subtle way that germs travel in hospitals and the important role played by cleaning staff, watch this  highly “infectious” video – “The Bug Zone” – made by some imaginative doctors at Winnipeg’s Health Sciences Center.

Cut Them Off at the Pass: Obama’s Budget for Bugs Takes the Fight to Them, and it’s About Time

"Just trying to get the bugs out."

First, some background. President Obama unveiled his fiscal 2015 Budget last week and we see that he proposes to double federal funding to fight the emerging problem of antibiotic resistant infectious disease in the United States

The numbers alone warrant the close attention of any budget-meister because antibiotic resistance germs continue to cause more than 2 million illnesses and 23,000 deaths in the United States every year. MRSA alone kills a minimum of over 11,000 people and causes over 80,000 severe infections – again, every year. (Canada, population adjusted, has a similar infection rate of about 200,000 a year, but 2 ½ times the death rate – about 8,000 every year.)

To appreciate the scope of the problem, consider that over the next 5 years there will be more deaths caused by antibiotic resistant germs than there weredeaths by combat in the Vietnam War and the American Revolutionary War, combined (115,000 deaths from resistant disease; 110,848 from the 2 wars).

Given these monstrous numbers, the president therefore proposes (p.82), to double the funding to the Centers for Disease Control and Prevention to $30 million annually for the next 5 years.

The CDC says that with this increased funding they could achieve a 30% yearly reduction in invasive MRSA infections alone, and reductions of anywhere between 25 and 50% for 4 other kinds of infections, for an overall harm reduction of 37%. That would save a lot of pain and a lot of lives.

So how, exactly, does the CDC plan to do all this?

Press reports like this one and the CDC website tell us there will be construction of a country-wide 5-area regional Lab Network that will allow for early detection of outbreaks and thus quicker and more effective treatment. And we’re told that hospitals will be part of this network and they will have new programs to reduce the spread of bacteria.

Now be honest, what does that really tell you?

Here’s the way to think about it, using a war analogy that compares bad bugs to an invading army.

In 1775 the British launched attacks against a loosely organized band of American colonists at various points along the eastern seaboard from Lexington and Concord, Massuchesetts in the north to Chesapeake Bay, Virginia, some 560 miles south. At each point of attack the colonists would rally and do what they could to fight back, each colony operating on their own and largely unaware of what was happening at other outposts. Reports of the fighting would filter back to General George Washington after the event. From there, strategies, such as they were, were hastily cobbled together.

Now imagine, instead, that the colonists were an organized group of professional soldiers with a coordinated chain of command, a sophisticated communication system, and a network of spies. These things would allow them to know when the British were coming, where they were, what direction they were headed, how many there were, what kind of weapons they had, and so on. Such early detection and information immediately shared amongst the colonists would have permitted a coordinated rapid response, precisely tailored to meet each threat as it materialized along with the ability to constantly monitor the invaders. In other words, this enhanced capacity would have told Washington exactly where to attack, when, and with what force and weaponry. And thus a 37% reduction is American casualties would have been reasonable to expect – the same reduction the CDC is looking for based on the changes envisioned in the Budget.

The crucial change is  the proposed Lab Network that would be strung across the bug battleground that is the whole of the United States.  For the  CDC and its partners, now armed with the latest technology, it would mean the ability to engage in rapid diagnoses, a precision and coordinated response, early and more effective treatment, and a continued monitoring of any abnormal bug presence – and a 1/3 reduction in harm to Americans that would otherwise have been caused by bugs that antibiotics can’t touch.

The present system, however, can be described as every man – or hospital – for himself, and is in the sense described in the war analogy, an 18th century throwback..

Dr. Brad Spellberg, author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them," has been arguing for years to enact the measures proposed in the Budget."

Dr. Brad Spellberg is an infectious disease specialist and leader in the field of developing ways to combat drug resistant infections. In a wide-ranging interview with Frontline (in bold) last October he basically indicted the current system:

Is the government doing enough? Is the kind of action that we see up to the nature of the crisis?

“When reporters like you ask me how many resistant E. coli infections do we have, it’s pretty sad that I have no idea what the answer to that question is. It’s not that the government agencies are not aware of the problem and are not doing anything. It’s that we have not had a comprehensive plan for how to deal with antibiotic resistance. We don’t have reporting mechanisms like they do in Europe to know where resistance is occurring. Who is using the antibiotics. Are we overusing them?

You’re telling me we don’t know the answers to the extent of the problem? We don’t have the data?

That is correct, that is correct. I do not know how many resistant infections are occurring right now. I don’t know what the frequency of resistance in different bacteria are. We do not have those data. They are not presented publicly. They are not gathered on a large scale.

There are pieces of data acquisition, but there is not a concerted, coordinated effort to gather the information and make it available. Nor is there a concerted effort to apply financial or regulatory constraints to overuse, either in humans or in animals.

… It is frankly embarrassing that we as a country do not know where resistance is occurring, how bad the problem is for various organisms, or who’s using what antibiotics when. Europe has taken great strides to solve this problem, and we haven’t.”

These, then, are exactly the problems that the proposed Budget aims to correct. It could be a game changer. Of course there is one obstacle that remains – our friend, the Congress – perhaps the greatest bastion of resistance that we have today.


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CDC Report Alleges Nation-Wide Hospital Misuse of Antibiotics

Will doctors listen to what's in the CDC report?

Poor prescribing practices are putting patients at unnecessary risk for super-resistant infections, and errors in prescribing decisions also contribute to antibiotic resistance, making these drugs less likely to work in the future, says a report released last week by the U.S. Centers for Disease Control and Prevention.

Those strong words are based on the following specific findings by the CDC:

1. About 1 out of 3 times, prescriptions for the critical and common drug vancomycin, which is used to treat MRSA, included a potential error – given without proper testing or evaluation, or given for too long.

2. Antibiotic prescribing practices vary widely. For example, doctors in some hospitals prescribed up to 3 times as many antibiotics as doctors in similar areas of other hospitals. This difference suggests the need to improve prescribing practices.

3. Patients getting powerful antibiotics that treat a broad range of infections are up to 3 times more likely to get another infection from an even more resistant germ.

4. Although antibiotics save lives they can also put patients at risk for a Clostridium difficile infection, a deadly diarrhea that causes at least 250,000 infections and 14,000 deaths each year in hospitalized patients.

5. Decreasing the use of antibiotics that most often lead to C. difficile infection by 30% (this is 5% of overall antibiotic use) could lead to 26% fewer of these deadly diarrheal infections.

The second most common type of infection for which hospital clinicians wrote antibiotic prescriptions were for infections caused by drug-resistant Staphylococcus bacteria, such as MRSA (17% of the total).

The reason this matters is that the more you use antibiotics the less effective they become. This is the problem of antibiotic resistance and it means that future patients will pay with their lives for today’s overuse of antibiotics.

Dr. Brad Spellberg is an infectious disease specialist and leader in the field of developing ways to combat drug resistant infections. In an interview with Frontline last fall he gave us uncommon insight into the problem of resistance and how it’s beating us in our fight against infections:

Frontline: Was there a moment when you came to this realization about resistance? Tell me a little bit about your own personal discovery.

Dr. Spellberg: Antibiotic resistance is something that all infectious disease practitioners think about, know about and deal with. But the moment I guess where the power of the resistance was brought home to me was when I was a fellow in training and for the first time encountered a patient that was infected with bacteria that was not treatable, that was resistant to every antibiotic we had.

Do you remember that moment? What was it like?

This was a young woman who had leukemia, and she had gotten an infection, and you look at this computer screen, and what you see on the computer screen, or what I saw, was all the names of the different antibiotics we have, and then next to the names [was] “R” for “resistance” — R, R, R, R, R. And I kept looking down going, “Where is the ‘S’ for ‘susceptible’?” But there wasn’t any “S” for “susceptible.”

And so what do you say to that patient’s family member? There was nothing I could do. That was a very difficult conversation.

How did you feel then?

Sort of astonished that in the 21st century we could run out of drugs, that we had bacteria running around that had developed resistance to everything. We had nothing left.

Bugs Without Borders

How MRSA gets around - no boarding pass required!

Suppose we find a huge increase in MRSA someplace in the world, far away from us, in Ireland, say. We would obviously be concerned for their health, but would an outbreak there have any bearing on our life here, thousands of miles and an ocean away?

I ask the question because a report out of – you guessed it, Ireland – yesterday tells us they have discovered a huge rise in MRSA over a 10 year period ending in 2011.

The report is based on a study by researchers at University College Dublin who have documented a 44-fold increase in the prevalence of MRSA – identifying 16 distinct clones (different types) of MRSA – as well as finding a six-fold increase in the number of MRSA samples resistant to multiple antibiotics.

In other words, they’re discovered a greater overall number of Bad Bugs, more different kinds of Bad Bugs, and more Bad Bugs that antibiotics won’t work on.

Prof David Coleman of UCD, one the authors of the report, says their findings constitute an “unprecedented level” of change that is a “worrying development” and therefore it is “vital to ensure that these strains do not spread and become more established.”

Spread where, here?

You betcha. And the explanation is globalization – we are One World now – and specifically, this includes the country-to-country spread of MRSA.

Professor Coleman puts it this way: “It is not a phenomenon unique to Ireland,” because “international travel increases the mixing of different community strains, helping to cause the very high level of [MRSA] diversity.”

Dr. Thomas Frieden, Director of the Centers for Disease Control in the U.S. agrees. He expressed his concern in an editorialSafer Countries Through Global Health Security, in The Lancet. The title itself tells the story: health, now, is viewed from a global perspective.

Look at SARS (severe acute respiratory syndrome), he says. What began as an outbreak in 2002 and 2003 in southern China caused an eventual 8,273 cases and 775 deaths in multiple countries around the world including Canada.

“Disease is just a plane trip away, and an outbreak anywhere is a threat everywhere,” says Dr. Frieden.

MRSA Outbreak at PEI Hospital

The QEH

On February 3 the Queen Elizabeth Hospital in Charlottetown, PEI realized it had a MRSA outbreak on its hands. Over the ensuing days seven patients in one ward, a medical nursing unit, tested positive for the pathogen, one of whom became infected.

In response, the affected patients were isolated from other patients, received treatment to destroy the MRSA, and their new rooms were subject to enhanced cleaning and infection control protocols such as the mandatory wearing of gowns, gloves and masks by staff who interact with them.

Visitors to the affected patients were restricted to 2 members of the immediate family for only 15 minutes. All visitors to the hospital are warned to clean their hands before and after entering a patients’ room, a ward, and upon entering and leaving the hospital.

Dr. Rosemary Henderson, Medical Director of the QEH, told me in a telephone conversation yesterday that everything now seems under control as every hospital patient has tested negative for the past 2 weeks. One more week of testing and they will be confident that the problem has been solved. And the patient who became infected is now fine and has been discharged from the hospital.

The previous MRSA outbreak at QEH happened this past July when 10 patients in a general medical unit tested positive for MRSA.

Before that, in November 2008, 9 babies in the nursery unit and one of their mothers tested positive for MRSA. Because this was a more serious outbreak, in addition to the standard precautions mentioned above, any staff member who had contact with the nursery was tested – doctors, nurses, cleaners, dieticians … anybody.

This caused a lot of stress at the hospital. The local newspaper reported that staff felt as if they were living under a microscope and were afraid of being blamed for the outbreak and were even afraid of being fired.

And it appears there was yet another outbreak that year prior to November. Rick Adams, CEO of the QEH, said at the time “We’ve had a tough year no doubt about it. We had our battles this year with MRSA and VRE (vancomycin-resistant enterococci) in some of the other units and now this.”

But this story is not about the QEH per se. Here’s what’s crucial to understand: the QEH is just like any other hospital with its history of MRSA. The QEH case simply illustrates the serious nature of the MRSA problem in hospitals across the country.

How serious?

1 in 12 adults in Canadian Hospitals are colonized or infected with MRSA (the biggest offender, representing 67% of the total), VRE or C difficile, according to a study published last summer by a team of Canadian infectious disease experts.

Second, the rates of health care-associated infections caused by MRSA, which can cause life-threatening pneumonia, plus wound and blood infections, “increased more than 1,000% from 1995 to 2009” (the last year for which numbers are available), says Canada’s Chief Public Health Officer, Dr. David Butler-Jones, in his 2013 Report on the State of Public Health in Canada.

One of the main reasons for this serious state of affairs is extraordinarily counter-intuitive: it is that the hospital is an inherently dangerous place.

Dr. Brad Spellberg, a highly qualified infectious disease specialist at the Harbor-UCLA Medical Center in the U.S. explains(begin at the 2:00 minute mark):

“I do think that people need to understand that the hospital is an inherently dangerous place and it’s not because hospitals are dirty or doctors are lazy or anything like that. Think about it this way. You’re taking the sickest people in society, crowding them into one building, tearing new holes in their bodies that they didn’t use to have by placing plastic catheters in their bloodstream, their bladder, putting tubes into their lungs that can breathe for them, and we’re using very large quantities of antibiotics to treat infections. So that’s a perfect breeding ground to generate antibiotic resistant bacteria [like MRSA].”

MRSA Outbreak at PEI Hospital

The QEH

On February 3 the Queen Elizabeth Hospital in Charlottetown, PEI realized it had a MRSA outbreak on its hands. Over the ensuing days seven patients in one ward, a medical nursing unit, tested positive for the pathogen, one of whom became infected.

In response, the affected patients were isolated from other patients, received treatment to destroy the MRSA, and their new rooms were subject to enhanced cleaning and infection control protocols such as the mandatory wearing of gowns, gloves and masks by staff who interact with them.

Visitors to the affected patients were restricted to 2 members of the immediate family for only 15 minutes. All visitors to the hospital are warned to clean their hands before and after entering a patients’ room, a ward, and upon entering and leaving the hospital.

Dr. Rosemary Henderson, Medical Director of the QEH, told me in a telephone conversation yesterday that everything now seems under control as every hospital patient has tested negative for the past 2 weeks. One more week of testing and they will be confident that the problem has been solved. And the patient who became infected is now fine and has been discharged from the hospital.

The previous MRSA outbreak at QEH happened this past July when 10 patients in a general medical unit tested positive for MRSA.

Before that, in November 2008, 9 babies in the nursery unit and one of their mothers tested positive for MRSA. Because this was a more serious outbreak, in addition to the standard precautions mentioned above, any staff member who had contact with the nursery was tested – doctors, nurses, cleaners, dieticians … anybody.

This caused a lot of stress at the hospital. The local newspaper reported that staff felt as if they were living under a microscope and were afraid of being blamed for the outbreak and were even afraid of being fired.

And it appears there was yet another outbreak that year prior to November. Rick Adams, CEO of the QEH, said at the time “We’ve had a tough year no doubt about it. We had our battles this year with MRSA and VRE (vancomycin-resistant enterococci) in some of the other units and now this.”

But this story is not about the QEH per se. Here’s what’s crucial to understand: the QEH is just like any other hospital with its history of MRSA. The QEH case simply illustrates the serious nature of the MRSA problem in hospitals across the country.

How serious?

1 in 12 adults in Canadian Hospitals are colonized or infected with MRSA (the biggest offender, representing 67% of the total), VRE or C difficile, according to a study published last summer by a team of Canadian infectious disease experts.

Second, the rates of health care-associated infections caused by MRSA, which can cause life-threatening pneumonia, plus wound and blood infections, “increased more than 1,000% from 1995 to 2009” (the last year for which numbers are available), says Canada’s Chief Public Health Officer, Dr. David Butler-Jones, in his 2013 Report on the State of Public Health in Canada.

One of the main reasons for this serious state of affairs is extraordinarily counter-intuitive: it is that the hospital is an inherently dangerous place.

Dr. Brad Spellberg, a highly qualified infectious disease specialist at the Harbor-UCLA Medical Center in the U.S. explains (begin at the 2:00 minute mark):

“I do think that people need to understand that the hospital is an inherently dangerous place and it’s not because hospitals are dirty or doctors are lazy or anything like that. Think about it this way. You’re taking the sickest people in society, crowding them into one building, tearing new holes in their bodies that they didn’t use to have by placing plastic catheters in their bloodstream, their bladder, putting tubes into their lungs that can breathe for them, and we’re using very large quantities of antibiotics to treat infections. So that’s a perfect breeding ground to generate antibiotic resistant bacteria [like MRSA].”

Does it matter if you are colonised with MRSA? Yes… It matters a ton!

Medscape recently published the results of a study ( http://www.medscape.com/viewarticle/819498_6) entitled Progression From New Methicillin-resistant Staphylococcus aureus Colonisation to Infection, which answers the question “Does it matter if you’re colonised (not infected) with MRSA?” Undeniably, the answer is yes, it does matter. In fact, it matters a ton if you are a patient about to have surgery.

This study found that patients are indeed at a much greater risk of a serious life-threatening infection if they are colonised with MRSA, and further found some other upsetting outcomes:

  1. 15% of the patients colonised with MRSA became infected (it cites another study where the rate was 33%);
  2. Mortality was over fivefold higher in MRSA colonised patients who developed clinical infections compared with those who did not; and
  3. Most of the infections had developed after the patients went home thus upping the re-admission rate of this group of people.

Why this matters? It matters because this study is yet further evidence that the current practice of not screening for MRSA carriers in pre-surgical patients results in greater costs to society as well as the health care system. The study suggests that hospitals should screen, identify and decolonise all patients presenting with MRSA, implying that anything short of this constitutes medical negligence.

Manufacturing MRSA on Our Factory Farms

A federal judge in Denver, Colorado on Tuesday sentenced the two owners of the cantaloupe farm that caused a deadly Listeria outbreak in 2011 to five years probation, six months home detention, and $150,000 each in restitution fees to victims.

As we wrote last November, brothers Eric and Ryan Jensen owned Jensen Farms in Colorado, where they grew the cantaloupes that sickened at least 147 people with Listeria and killed more than 30, making it one of the deadliest foodborne illness outbreaks in U.S. history.

The case has been a landmark in foodborne illness litigation, becoming one of the first instances in which food producers faced criminal charges for their contaminated food.

The Factory Farm

The reason this case matters to us is that researchers are now reporting that MRSA, too, is coming to us via the food production system. As we said in our November post: It’s crucial to understand that this is not a case [just] about listeria, it could have been any pathogen that found its way into the nation’s food supply and ended up hurting people. And … there is a rising tide of foodborne illness – the pathogen studied was MRSA – infecting the community because of the new way we are producing our food, the so-called factory farm system.

The US Environmental Protection Agency defines a factory farm- also called a mega-farm or a CAFO – a confined or concentrated animal feeding operation – as a facility that has at least 1,000 pigs, though most are many thousands larger.

Rows of pigs inside the factory farm

By last summer the science caught up with these factory farms and told us they are incubating disease and spreading it to nearby populations. A report in the Journal of the American Medical Association found an increased incidence of MRSA infections in populations close to factory farms compared to communities not near to them. And a study published in the Public Library of Science compared workers on factory farms to workers on traditional farms (where antibiotics aren’t used) and found significant amounts of livestock-associated MRSA (LA-MRSA) only on workers from the factory farms.

And now it’s being reported that a third study, due out in next month’s Infection Control and Hospital Epidemiology, concludes there’s almost three times the risk of carrying MRSA if you live within one mile of a farm housing 2,500 or more pigs.

In other words, we’re “manufacturing” MRSA because of the way we produce our food. The workers themselves become carriers as do people in nearby communities. And here’s the thing: when any of these people get sick they go to hospitals where they carry and can spread these new strains of MRSA – they bring them from the farms to the cities.

So what does the future hold? As we wrote last November:

The big picture is this: Old MacDonald no longer has a farm. Food production in this century has been taken over by large industrial concerns for the same reason that the production of cars, steel, and oil became dominated by giant corporations last century – there’s just no other way to keep up with the growing demand.  We have entered into a new age of food production and along with it we have given rise to a Third Wave of MRSA [LA-MRSA] that if left unchecked has the potential to outstrip both the hospital  [the First Wave] and the community[the Second Wave] as a source of the pathogen.

Dental Students are at Risk for Increased Exposure to MRSA: What does this mean for their Patients?

Dental student are at a much greater risk of being exposed to methicillin-resistant Staphylococcus aureus (MRSA), the potentially lethal bacteria often found in hospitals and now increasingly in the general community. Known as one of the superbugs due to its ability to resist multiple antibiotics, the mortality rate for a MRSA bloodstream infection is about 20-30%.1  The findings of a recently published study in The Journal of Hospital Infection entitled “Higher prevalence of methicillin-resistant Staphylococcus aureus among dental studentshttp://www.journalofhospitalinfection.com/article/S0195-6701(14)00009-7/abstract  lead to the inevitable conclusion that greater consideration for infection control and prevention is needed for both dental clinicians and their patients.

The study undertaken in Mexico City comparing 100 dental students (exposed to patients for 5-6 years) with 81 non-dental students found that the dental students had a significantly higher rate of carriage of MRSA. The study found that 20% of the dental students versus 6% of non-dental students were colonized with MRSA (odds ratio: 4.04; 95% confidence interval: 1.6–12.6; P = 0.0033). The conclusion of the study is that the dental students were occupationally threatened by exposure to this highly antibiotic resistant pathogen with implications that greater steps are needed to try to address this potential risk to their health. The other worrisome implication of this study is that these dental clinicians are also likely to be vectors for MRSA transmission to their patients if the proper precautions are not undertaken.

A key observation from this Mexican study underscores how widespread MRSA is in Mexico. If our data is to be trusted, North American and UK rates of MRSA colonization are significantly lower than in Mexico…. 2-3% versus the 6% found in the study’s non-dental student population. People colonized with MRSA are at a greater risk of self-infection, especially when immunocompromised as in the case of a surgery or major illness. 20-60% of patients identified as being colonized with MRSA in hospital subsequently develop an MRSA infection 2

Until recently, most antibiotics in Mexico were available over the counter and not by prescription. The ability of patients to self-prescribe (not matching the appropriate antibiotic to the prevailing infection) combined with standard non-compliance practices (taking sub-lethal doses) led to the emergence of high antibiotic resistance rates as evidenced by the finding of this study. Fortunately, there are greater controls over how antibiotics are now dispensed in Mexico which should help to lower antibiotic resistance rates in the Mexican public in the future. A reduction of the overuse and abuse of antibiotics in Mexico should, in the future, contribute to lowering the risk of MRSA colonization in the dental clinician population. In the meantime, however, the results of this study are shocking and must be taken as sign that more must be done to protect the dental clinician and their patients from this potentially deadly superbug.

1. http://jcm.asm.org/content/48/6/2307
2. http://www.ammi.ca/pdf/MRSApositionpaper.pdf

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