Category: MRSA

What Killed Hugh Hefner?

TheBlast.com

 

On September 27 this year, Hugh Hefner “died of natural causes at the Playboy Mansion in Las Angeles,” read the headlines announcing his death. And while that’s true, there’s also a deeper story in play that increasingly involves all of us: Antibiotic Resistance – the bugs are beating our drugs.

The way to understand what happened to Mr. Hefner is to look at his death certificate – excerpted above; in full here – and read the four-step chronology that led to his demise like four dominos that fell:

(1) The problem began when Mr. Hefner contracted a strain of E. COLI that was HIGHLY RESISTANT TO ANTIBIOTICS, which led to

(2) A life-threatening bloodstream infection, SEPTICEMIA, where the blood conveys E. coli to bodily organs which the bugs then attack, which led to

(3) RESPIRATORY FAILURE, where the lungs were attacked and succumbed, compromising their ability to move oxygen, resulting in

(4) CARDIAC ARREST, the “immediate cause” of death.

In other words, what drove Mr. Hefner’s death was an antibiotic-resistant E. coli infection that he contracted, the certificate shows, six days before his death. The fact that this strain of E. coli was “Highly resistant” means they threw every drug they had at it yet it beat them all back – that’s antibiotic resistance in action.

It’s crucial to understand that while Mr. Hefner’s age may have factored into why E. coli proliferated in him in the first place – bypassing his body’s natural defenses – his age had nothing to do with why the many antibiotics they gave him didn’t work: that’s a function of the (biochemical) interaction between the bug and the drug.

Earlier this year the World Health Organization published its first ever list of antibiotic-resistant “priority pathogens” – a catalogue of 12 families of bacteria that pose the greatest threat to human health – and E. coli was nowhere to be seen. So as bad as E. coli can be, there’s at least 12 other groups of pathogens out there that are worse (Staph aureus is in the group posing a “High” risk to our health).

There’s one more thing to notice about Mr. Hefner’s death: the only reason we know about the infectious disease component is because California, unlike many states, lists the underlying causes – plural – of a person’s death, i.e., (1) to (3) above. This matters because that’s exactly how infectious disease so often shows its hand – as an initiating factor: but for the infection, there wouldn’t have been a death.

This issue was the focus of a major investigation by Reuters last year, “The Uncounted,” which found that because death certificates are poorly written – asking only for the immediate cause of death – tens of thousands of “superbug” deaths in the U.S. are going uncounted every year.

But that wasn’t the case with Mr. Hefner: His death, like his controversial life, counted.

 

 

 

 

 

 

 

 

 

Report Card on Fast Food Restaurants

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Cheating catches up with you.

We’re seeing that now in how we raise food animals – cows, chickens, pigs, and turkeys – on our factory farms. We routinely feed them antibiotics not because they’re sick, but to speed their growth (thus saving costs) and to prevent disease outbreaks (illness can spread like wildfire between the animals because of their densely packed living conditions). To understand how wrong this practice is, imagine if we raised children this way: sure, we’re different species, but the biological effect would nonetheless be the same.

And the biological effect is this: antibiotics kill off susceptible bacteria in the animals, leaving the resistant bacteria to thrive: they’re now reproducing and filling the niches formerly occupied by the now dead bugs. The problem for us is they don’t stay there: these antibiotic-resistant bacteria in the guts of the animals begin to move through the environment and enter other animals and people. Result: the CDC says a few million Americans become severely infected with these “superbugs” and at least 23,000 of them die – each year. Which raises a troubling question: if we agree this is the case, then are we not knowingly engaging in the manufacture of disease?

Yet despite this knowledge, and unlike in Europe, US and Canadian governments refuse to put a stop to it. To fill the breach, public interest organizations have banded together to put pressure on 25 fast food restaurant chains to stop buying meat from producers who misuse antibiotics. These chains are singled out because they’re huge buyers of meat and poultry; McDonalds, for example, is the largest buyer of beef in the United States. The explicit threat is that consumers and shareholders will take their dollars to restaurants that don’t put the public health at risk.

And so each year a report card is prepared that ranks America’s 25 largest fast food chains on their antibiotic policies. Released yesterday, here it is. You know what to do.

 

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After the Hell and High Water: You have to engage in medical self-defense

Harvey’s gone, Irma’s coming, others will follow. But after the hell and high water, like night follows day, comes disease: a veritable one-two punch. And so it’s every bit as important to protect yourself during those long days as it was during the furious days of the storm.

You may be dealing with, for example, “Infectious diseases [that] could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp.” Or, because the pathogen count in general is so high there’s “the potential for sewer plant malfunction or sewer plant continuing to discharge untreated or partially treated waste.”

So we’re reprinting a terrific article from Medscape Infectious Diseases that lays out the A B C’s of medical self-defense in the aftermath of a natural disaster. But first, to get a better feel for how a hurricane can turn “entire neighborhoods into contaminated and potentially toxic rivers,” – and thus the need to protect yourself – check out this revealing Times video that winds you through a flooded Houston neighborhood (be sure to click on “Watch in Times Video”).

 

 

From Medscape:

                                             What patients Should Know and Do

As people are able to return to their homes, here’s what they can do to help protect their health, officials say.

Threats in the Water and Air

A woman trudges through the water in Texas.

Floodwaters carry germs, so anything that’s come in contact with those waters could harm your health, according to the CDC.

Exposure to bacteria and germs in floodwaters can cause diarrhea, wound infections, and conditions such as trench foot, the CDC says. Traveling through standing water can make you more likely to be exposed to hazardous chemicals. Floodwater, too, is a breeding ground for mosquitoes, which can transmit disease. Use insect repellent.

Your tap water may not be safe, either. Turn to local officials or the news to see if you can drink tap water or use it for washing. If you need an alternate source:

  • Use bottled water if you can.
  • If you have access to a stove, bring water to a rolling boil for one minute. Or, you can add 1/8 teaspoon of new, unscented liquid bleach to a gallon of water and stir. Let the water sit for a half-hour before drinking it.
  • Use water-purifying tablets, following the maker’s directions carefully

Clothes that are exposed to floodwaters must be thoroughly cleaned. Some clothing may have to be thrown away, especially if exposed to hazardous chemicals, sewage, or fiberglass insulation.

Before using your washing machine, make sure the water supply is safe and sewer systems are running. Run the machine for a cycle with no clothes but with detergent and bleach to sanitize it. Wash clothes on the hottest setting recommended, and use bleach if fading is not an issue. Use a pine-oil disinfectant instead of bleach on colored clothing.

Threats in Food

When possible, take inventory of your food.

  • If power is out, keep the freezer and refrigerator doors closed as much as possible; put a block of ice in the refrigerator if possible.
  • Food that has partially thawed can be cooked or refrozen if you can see ice crystals or if it is still at a temperature of 40 F or lower.
  • Discard cans that have opened or are damaged or bulging. All undamaged cans must be thoroughly washed and disinfected.
  • Throw away all medicines, cosmetics, and other toiletries exposed to floodwater.
  • Throw out food that smells strange or has an odd color or texture.
  • Be especially careful to keep meat, eggs, fish, poultry, and leftovers cold to avoid spoilage.

Other Threats in Your Home

 Once the storm has passed and cleanup is possible, be aware of major threats to your health around the home, such as gas leaks, electrocution, and mold. Here’s how to manage these threats:
  • If you suspect a gas leak, go outside right away. Do not turn appliances or electrical switches on or off. If you turned your gas off, you need a licensed professional from the gas company or elsewhere to turn it back on.
  • Do not touch any electrical equipment while you are wet or in water; instead, call an electrician to evaluate your system. Stay away from downed utility lines, and always assume the power there is live and dangerous.
  • Before cleaning up, get the gear you need, such as hard hats, heavy work gloves, waterproof boots, and earplugs or headphones if you are using noisy cleanup equipment.
  • Be on the lookout for mold, which needs to be cleaned up quickly to prevent health issues. Ideally, if possible, clean up and dry out your home within 24 to 48 hours after the storm passes. To clean mold, mix a cup of household bleach with a gallon of uncontaminated water. Or, lightly mist mold spores with rubbing alcohol. In some cases, you might need a professional mold service.
  • Open all doors and windows to air out your home, and use fans to dry wet areas.
  • For kids’ toys exposed to floodwaters, mix a cup of bleach with 5 gallons of uncontaminated water. Clean the toys and let them air dry. Throw away stuffed animals and toys that can’t be cleaned.

Minding Your Mental Health

Once your house and life are back in order, you may still feel emotionally “spent,” and mental health experts say that’s not unusual. Disasters such as hurricanes are typically sudden and unexpected, and that can be overwhelming, according to the American Psychological Association. Among the common responses, the group says, are:

  • Feeling anxious, nervous, or filled with grief. Moodiness and irritability can happen, too.
  • Changed eating and sleeping patterns — either sleeping more or less, or eating more or less
  • “Triggers” that remind you of the event, such as heavy rain, and feeling anxious
  • Trouble getting along with family, friends, and co-workers
  • Physical problems such as headaches or nausea, or existing medical conditions that seem to be worse

While there’s no “typical” timeline for feeling better emotionally after a disaster, you might speed things along by talking about your experience, joining a local support group, focusing on healthy habits, and getting back to regular routines as soon as possible.

If things are not back to normal within a few months, consider getting professional help from a mental health expert.

Hurricane Harvey: A “slow-motion rolling disaster” of disease has just begun

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“Infectious diseases could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp,” reports Newsweek.

Natural disasters turn real estate into virtual playgrounds for pathogens. Numerous factors combine: Advancing dirty floodwater – sewage, chemicals, tiny sharp objects of metal and glass – eventually becomes a stagnant, breeding ground for mold & bugs. A boil water advisory issued this week means tap water is contaminated – but many people won’t hear about it. Large swaths of power outages began last weekend and so air conditioning & refrigeration are gone and food will be lost. Stores are closed. Roads are underwater. Public transportation = a boat. People are unable to work and earn an income. Homes are destroyed. People are scared. All this and more at a time of sub-tropical August heat & humidity during – of all things – mosquito season.

And so the usual suspects will get to work: E. coli, Shigella, Vibrio illnesses (cholera-like illnesses), mosquito-borne pathogens like Zika and yellow fever, and even Legionnaire’s disease, inducing intestinal illness in the form of diarrhea, vomiting, fever, stomach pain and dehydration. Now imagine life in an overcrowded shelter if one of these illnesses took root. Or in your home where it’s sweltering and there’s no air conditioning and running water. Then multiply that over the whole neighborhood: that’s Newsweek’s concern of a city turned into a “pathogen-infested swamp.”

 

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There’s more. Science journalist @Maryn Mckenna who grew up in Houston and covered Katrina, wrote an eye-opening thread on Tuesday observing that: “Natural disasters have a long, long tail.… The result is a slow-motion rolling disaster in which people lose care and lose the proof they’re entitled to care, while they get sicker.” Lost is access to clinics, hospitals, pharmacies, medical records and doctor’s orders that people depend on to stay healthy – and stay alive. For instance, those requiring cancer chemo, or transplant care, or people with COPD or diabetes.

Mckenna gave special mention to dialysis patients:

Out of my experience covering Katrina and the aftermath, here’s what’s haunting me today: the average time between dialysis treatments … Houston’s floods began three days ago. That’s a normal time between treatments for someone on dialysis. Missing treatment = getting sick … In Katrina, bus convoys of dialysis patients drove out of the city to get to places where they could continue treatment uninterrupted … These were people who were not flooded out, who still had working cars (though sometimes no power, and the water in Nola wasn’t safe) …

 

She was backed up by a Houston physician speaking with NPR the following day: “If they don’t dialyze three times a week, they … can become very, very sick.” Muscles, including the heart, can stop functioning correctly. “Over so many days, they can’t survive.” Even if patients do make it to the clinic they may not be treated: “Many of our nurses are locked in, flooded out of their homes, and they’re either somewhere else, or they can’t get out of our neighborhoods…. As a consequence, we don’t have enough nurses to dialyze the numbers of patients that are coming here.”

Many others are at risk too: trapped seniors, disabled, and the bedridden; children separated from parents; mental health patients who run out of meds; stranded pets & other animals; and so on.

All told, this is “one of the largest disasters America has ever faced,” said Texas Gov. Greg Abbott, as he warned against expecting anything resembling recovery any time soon, or a return to the way things were. “We need to recognize it will be a new normal, a new and different normal for this entire region.”

The new normal is rapidly unfolding. Just this morning The New York Times reports a whole new kind of public health threat: a series of small explosions – “and a threat of additional explosion remains” – at a chemical plant in Crosby, Tex., about 30 miles northeast of Houston. More than a dozen Harris County deputies went to the hospital after inhaling fumes. Residents within a 1.5-mile radius have been evacuated.

Similarly, Democracy Now reports that “an environmental crisis is unfolding as oil and chemical industry spew toxic pollutants into air.” One specific case: “… gas leaks … in La Porte [30 mi. E. of downtown Houston; pop. 34,000] that resulted in a very, very dangerous chemical, anhydrous hydrogen chloride, and this gas mixed with the moisture in the air to produce hydrochloric acid, a corrosive that can damage respiratory organs, eyes, skin and intestines.”

Since Houston is home to the country’s largest refining and petrochemical complex this is an issue to watch.

As we move into the Labor Day weekend there is something we can do – help Harvey victims with a donation. ABC News is reporting that up to 40,000 homes have been destroyed and more than 32,000 people are in shelters. The Times has an excellent article on how to help, called “Where to Donate to Harvey Victims (and How to Avoid Scams),” available here.

 

Closing the Courthouse Door on Nursing Home Residents

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The Trump administration has drafted a binding arbitration rule that prevents nursing home residents from having their cases heard in a court of law. The Trump rule reverses Obama era policy forbidding nursing homes from doing this on the grounds that it preys on the elderly. His team was influenced by the death of 100-year-old Elizabeth Barrow.

In 2009, Mrs. Barrow (pictured above) was found murdered at her nursing home in South Dartmouth, Mass., strangled and suffocated, with a plastic shopping bag over her head. Her 97-year-old female roommate was charged with the homicide, but because of her dementia she was deemed unfit to stand trial and committed to a state hospital.

Her family didn’t have a problem with that: “It’s like charging a 2-year-old who happened to take a gun off a table and shoot a sibling,” her son told The New York Times. But he did want justice for his mother’s death because, among other things, he said the nursing home knew the roommate was dangerous. For example, file notes described her as being “at risk to harm herself or others.”

So he filed a civil suit on his mother’s behalf alleging wrongful death. But the court refused to hear the case because his mother’s contract with the nursing home contained a clause that forced any dispute into private arbitration; i.e., no judge or jury – the “judge” is some private entity, typically a law firm – and the proceedings are hidden from public scrutiny. So the case was referred to arbitration.

However, the notoriety of the case coupled with the industry wide practice of requiring vulnerable people to give up their right to sue if they want into a nursing home, resulted in the Obama administration enacting a rule forbidding the practice.

But that was then. This past June the Trump administration decided to make America arbitrate again on the basis that it’s simpler, fairer and faster for all parties concerned.

Fairer? The CDC says that about half of nursing home residents have Alzheimer’s disease or other dementia. Second, the arbitration agreement may be just one page in a voluminous contract of 30 to 40 pages. Thus, according to one federal court judge who blocked enforcement of an arbitration contract:

Most of the people who come to me have no idea they’ve even signed an arbitration agreement…. the practice of executing arbitration contracts during the nursing home admissions process raises valid concerns … since many residents and their relatives are ‘at wit’s end’ and prepared to sign anything to gain admission.

 

There’s an important infectious disease tie-in because nursing homes are a hotbed for infections, especially drug-resistant ones. For instance, according to James A. McKinnell, MD, an infectious disease specialist at the Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute:

Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 30,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.

 

Mckinnell’s research also found that: (1) Almost half (47.5%) of the people in nursing homes are colonized with at least one drug-resistant bacterium (2) Nursing homes themselves are awash with superbugs: 88% of the rooms are contaminated with at least one, and (3) The big dog is Methicillin-resistant staphylococcus aureus (MRSA). They were found in almost 2/3 of the rooms (65.2%).

 

So what legal mechanism best protects our health: the age-old one of full access to a court of law, or the newer one of binding arbitration that’s forced on you – or you’re denied admission to the nursing home – at a vulnerable time in your life?

Elizabeth Barrow knows the answer. The arbitrator ruled against her and in favor of the nursing home. However, according to a report in the Times, only later did the Barrow attorneys learn something outrageous: the private firm running the hearing had previously handled more than 400 arbitrations – everyone of them for the very same law firm that represented the nursing home.

 

 

 

 

 

 

So wrong, for so long: No, you don’t have to finish that long course of antibiotics. Stop when you feel better and do so in consultation with your physician. Better yet, get yourself a short course of antibiotics instead.

Prescription

 

To borrow from the great Patsy Cline: “I’ve been so wrong, for so long … I was wrong, oh, so wrong,” could well be a new meme for docs across the country when it comes to their advice about taking antibiotics. We all know the rule: Always finish your course of antibiotics even if you’re feeling better because it’ll ensure that you kill all those bad bugs and, (not that you care) it helps prevent antibiotic resistance.

And that’s flat wrong. Compelling evidence from a group of scientists published July 26 in the prestigious BMJ says it’s not only wrong – the exact opposite is correct:

We … encourage policy makers, educators, and doctors to stop advocating ‘complete the course’ when communicating with the public. Further, they should publicly and actively state that this was not evidence-based and is incorrect …

The key argument for changing how we discuss antibiotic courses with patients is that shorter treatment is clearly better for individual patients. … In hospital acquired pneumonia, for example … data indicate that short treatment strategies have equivalent clinical outcomes to longer courses and are associated with lower rates of infection recurrence and antibiotic resistance. (My emphasis)

 

Good grief – so how did we get it so wrong for so long?

Enter Brad Spellberg, MD, an infectious disease specialist and chief medical officer of the mighty Los Angeles County + USC Medical Center, and who, as you might expect, comes with a sterling resume. But here’s the thing: When deciding how much weight to attach to the words of guys like Spellberg (this is, after all, a paradigm shifting issue) understand that his views are really the synthesis of the best and brightest, not just in his hospital or even across the country but across the world. If somebody’s doing interesting ID work in, say, Boston, New York, London, Paris, or Tokyo, he can call them and inquire – and they’ll take his call asap. And I suspect this has been the case much of his storied professional life – RHIP.

So, what does he say?

That we’ve made two mistakes. The first was to misinterpret a foundational study on the subject, which he said almost a year ago in this paper.:

The modern concept that we should continue treating bacterial infections past the time when signs and symptoms have resolved can be traced to 1945. Meads et al wrote that they administered penicillin to patients with pneumonia, ‘until there was definite clinical improvement and the temperature had remained below 100°F for 12 hours…then given for another two to three days.’ The perceived need to treat beyond resolution of symptoms was driven by a desire to prevent relapses. However, the recurrent infections seen in the case series were caused by isolates with distinct bacterial serotypes, indicative of reinfection rather than relapse. It is unclear how this confused desire to prevent reinfections subsequently transformed into the illogical dogma that antibiotic resistance could be prevented by continuing therapy beyond resolution of symptoms.

 

So how does this big misread turn into a come hell or high water ritualistic 7 or 14-day course of antibiotics? This second mistake turns on how our species tracks time. It’s both funny and sad and deserving of Spellberg’s mockery:

The truth is, we do not know how long a course of antibiotics is necessary to treat most types of infections. Even in the modern scientific era, the primary basis for the duration of most courses of antibiotics is a decree Constantine the Great issued in A.D. 321 that the week would consist of seven days. That’s why your doctor gives you seven or 14 days’ worth of antibiotics!

If good old Constantine had decreed four days in a week, doctors would be prescribing antibiotics in four- or eight-day courses, rather than seven- or 14-day courses. I refer to seven- or 14-day antibiotic courses as “1 or 2 Constantine units” to underscore the absurdity of the basis for these durations.

 

That’s from his piece this week in the online journal The Conversation. And of the 3 articles mentioned above, this one is easily the most readable. The best part is that he concludes with spot-on practical advice on how we should handle this “to stay the course or not” issue, reprinted below. But before we get there we need to consider this looming storm cloud called antibiotic resistance, which the BMJ paper spent most of its time on. Yes, we’d all rather go clean our oven than get into this, but it’s a Huge Deal, so we’ll try an analogy (and no fancy words).

Imagine – for everyone who lives on your block there’s just one car that has to last for the foreseeable future. It’s a community car so its use is based on need – emergencies first, work or university second, food shopping third and so on. It’s a precious resource because we know that one day it will run down and no longer work. So we have to take good care of it: use only when necessary, keep a record of its use, keep it fueled & maintained, and don’t abuse it – no drag racing. Because one day you might to need to rush your bleeding child to the local hospital a mile away. Should that day ever come you don’t want to jump in turn the key and … uh-oh … it won’t start. It’s out of gas. Now what?

Antibiotics are the only kind of drug on the planet that are a community drug, just like that car is a community car: The more we use them the less effective they become. And that’s because with bugs, the more they’re exposed to the drugs, the more they develop tricks, or “body armor,” to defeat them. Bugs are funny that way, like us they too resist efforts to be killed – except they’re better at it. For example, a blueprint for a new anti-antibiotic weapon that one bug develops can be shared with his buddies and suddenly they’re all invincible. A cartoon nicely captures this unique biological ability (if you’re curious, see here).

Horiz transfer 3

 

But this really isn’t funny. Antibiotics are woven into the fabric of the everyday practice of medicine, here and across the world. Just a glimpse: Cancer patients live on antibiotics because radiation and chemo destroys their immune cells along with their cancer cells. For every serious surgery, say an organ transplant or a hip replacement, antibiotics are used to prevent or treat an infection. Neonates & children, and the elderly, are especially at risk for infection because the immune system isn’t fully formed in the young and isn’t as strong as we want it to be in the old.

But a numbers analysis doesn’t capture the heartbeat of the issue. Ultimately it’s a personal, intense reckoning. You’ll notice the shadow over your doctor’s face as he walks to your hospital bed. You tense up. I’m sorry, he says … the antibiotics aren’t working. You put on a brave face: We out of gas, doc?

Spellberg and company are doing their best to avoid that reckoning. But they need help. We the People, have to be antibiotic-smart: Use them only when necessary and even then, a shorter course is better. Here’s his game plan, titled: “So, what should we do about antibiotic courses”?

Medicine in the 21st century is a team sport. You and your physician need to be partners in decision-making. If you are sick and your doctor mentions antibiotics to you, the first thing you should say is, “Hey, doc, do I really need the antibiotic?”

Doctors may otherwise prescribe an antibiotic even when you don’t need one, out of fear that you will be unhappy without the prescription. Flip the script on them. Help them to know that you’d prefer not to take the antibiotic unless it is really necessary.

If your doctor says, “Yes, I believe you have a bacterial infection and you need the antibiotic,” the next question is, “Okay, can we treat for a short course?”

Third, after you begin taking the antibiotics, if you feel much better before you complete the course, give your doctor a call and ask if you can safely stop therapy.

So, the bottom line is, doctors should prescribe as short a course of antibiotics as possible to treat your bacterial infection. If you feel completely well before you finish that course, you should be encouraged to call your physician to discuss if it is safe to stop early.

 

Which means doctors have to be willing to have that conversation. And as Spellberg said to the journal STAT: “You should call your doc and say ‘Hey, can I stop?’ … If your doctor won’t get on the phone with you for 20 seconds, you need to find another doctor.”

Because that, too, would be wrong – oh, so wrong.

 

The Superbacteria are in the Beef … the Chicken, the Pork, and so on ….

Question: What’s wrong with feeding antibiotics to our food animals in order to make them grow quicker? Is it that:

(a) Antibiotic residue, i.e. some of the drug itself, gets into the meat?

Or,

(b) Superbacteria are created – i.e. bacteria resistant to antibiotics –  and they get into the meat?

Answer: (b). This chart from the US Centers for Disease Control lays it out nicely:

 

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The issue is ripe because a major industrial supplier of chicken in the US, Sanderson Farms, is waging an ad campaign that contends: those who claim they’re raising chickens without antibiotics are saying so only as a marketing gimmick, and; the real issue isn’t superbacteria in the meat, it’s antibiotic residue in the meat, and even that doesn’t pose a significant threat.

In response, the National Resources Defense Council posted a hot blog last month that’s being promoted by the science crowd. The tellingly-named piece, “Sanderson Farms: Spreading Deception and Antibiotic Resistance,” levels the charge that the company’s advertising is “… a blatant and unacceptable deception … [that tries] to divert the conversation from the grave and proven threat caused by drug-resistant bacterial contamination in food and the environment.”

The NRDC spells out what that “grave and proven threat” is. Notice that it’s consistent with what the CDC says, above (emphasis in original):

 

Antibiotic residues in meat is not the issue here. The real problem that has alarmed health experts around the globe is the proliferation of antibiotic resistant bacteria. Routine antibiotic use breeds antibiotic resistant bacteria that can leave the farm on the chicken manure (that is typically trucked away and applied to cropland), on colonized workers, on vented air blasted out of poultry houses or in the soil or water, and on the meat itself. Bacteria escaping via these pathways spread in our communities and environment, and can even share the genetic traits which confer antibiotic resistance with other bacteria, further spreading antibiotic resistance.

 

When superbacteria make us sick it means our illness is harder to treat. It means you’re looking at such things as a longer hospital stay, multiple readmissions, the need for Intensive Care, and/or surgery. This happens to over 2 million Americans a year. Even worse, sometimes we can’t be treated at all – at least 23,000 people die each year in the US because they’ve contracted superbacteria.

In the meantime, we have to resort to self-help: use separate cutting boards for meat & vegetables, wash the bacteria off the meat & vegetables before eating and, crucially, make sure to cook the meat at the proper temperature, to destroy the bacteria that’s embedded within. Cooking temps & more are listed in this helpful page from the CDC.

 

“Beyond Foolish”: America’s Healthcare Cuts

Fortune Brainstorm Health Tuesday, November 1, 2016 San Diego, CA 4:35 PM STOPPING GLOBAL PANDEMICS BEFORE THEY START Just a few months after the 2015 outbreak of Ebola was contained, another virus—called Zika—commanded the public stage. It took but 14 months after Zika’s first detection in Brazil for the virus to spread through Latin America and the Caribbean to Florida. So far, the threat has gone unchecked. And to be sure, after Zika, will come another global pathogenic threat—one, that public health experts worry, may do an even better job of outsmarting and overwhelming us. The question is whether technological advances can help us turn the odds. Can big data and genomic virus sequencing help us track emerging diseases, contain their spread and ultimately find antidotes for the next unknown pathology? Can it speed up the hunt for lifesaving vaccinations or drugs? The answers have an urgency like few others. Dr. Michael T. Osterholm,  Director, Center for Infectious Disease Research and Policy, University of Minnesota Dr. Moncef Slaoui, Chairman, Vaccines, GlaxoSmithKline PLC Moderator:  Bryan Walsh, International Editor, Time Photograph by Stuart Isett for Fortune Brainstorm Health

 

The Infectious Diseases Society of America has joined the fight.

Today they sent a letter to Congress warning that the President’s proposed cuts to federal funding for antibiotic resistance “would dismantle our nation’s infrastructure for preventing, detecting, and tracking threats from antimicrobial resistance [AMR] … [which] is in striking contrast to global efforts in this area.” And that “… not only are these infections a threat to public health, but if the patients survive, their lives are often changed forever.”

Zeroing in on the $1.2 billion cut to the Centers for Disease Control and Prevention – a 17% reduction – and especially the proposed cut to the CDC’s Antibiotic Resistance Solutions Initiative, IDSA says:

 

Removing or reducing these funds would disassemble our national infrastructure to fight AMR threats and drastically limit CDC ‘s and state health departments’ capacity to detect and track resistant threats, respond to and contain outbreaks of resistant pathogens, and support prevention and stewardship activities. A cut of this magnitude would impact every aspect of CDC’s work to protect us from AMR, including its support for state public health labs and research collaborations with academic institutions.

 

IDSA’s letter was signed by 60 organizations including the American Academy of Pediatrics, American Veterinary Medical Association, GlaxoSmithKline, Global Health Council, and the March of Dimes.

As we know, cuts to infectious disease medicine are only part of what’s planned for American healthcare overall.

On Monday the American Medical Association weighed in, expressing special concern for our “most vulnerable citizens,” and the “ravaging” impact of public health epidemics. In their letter to Senate leaders they wrote, “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.”

How much harm? Yesterday, a report in the Annals of Internal Medicine gave us a number: “… if you take health insurance away from 22 million people, about 29,000 of them will die every year, as a result.” AIM is the official organ of the American College of Physicians, the nation’s largest medical specialty society.

However, that number doesn’t include the public health epidemics the AMA is worried about.

Michael Osteholm, PhD, MPH, (pictured above) runs the Center for Infectious Disease Research and Policy at the University of Minnesota. He recently penned a commentary in Fortune arguing we’re risking the lives of millions because we’re woefully unprepared for the next pandemic:

 

… at a time when infectious diseases are significantly more capable of wreaking international havoc … Trump has lost sight of the greatest national security threat of them all: a disease outbreak killing millions of people.

Solutions to huge lurking regional threats such as Ebola, mosquito-borne illnesses like Zika, and bioterrorism from anthrax or a genetically engineered smallpox virus are only three, four, and five on our list.

The number one threat—a worldwide lethal influenza outbreak equal to or greater than the 1918–19 Spanish flu pandemic—would literally read like the outline for an apocalyptic horror film. And the H7N9 strain we chose for an imagined but scientifically plausible scenario in our book is currently percolating to the surface in Southeast Asia.

Our number two threat—antimicrobial resistance—is a slow-moving tsunami that within decades could bring us back to the infectious Dark Ages, when a simple scrape could kill and untreatable tuberculosis was rampant.

It is beyond foolish to neglect the danger of infectious diseases on human and animal health. The threat of a killer virus or bacteria wreaking havoc in the U.S. is far greater than any military or terrorist assault …

 

 

 

 

 

Stanford Medical School threads the needle on how to teach infectious disease. Even better – you can take their course.

Vetter

 

Medicine has an image problem. As Malcolm Gladwell told Medscape’s Eric Topol, MD, “One thing that has always motivated me in writing about healthcare is that the world of healthcare does a very bad job of storytelling about itself. It represents itself to the public very poorly. The gap between the reality of medicine and the way the public thinks about medicine is growing, not shrinking.” Dr. Topol agreed: “Storytelling is a big deal, and it isn’t done enough in medicine or science.”

The Stanford University School of Medicine wants to change that. As part of their Re-imagining Medical Education initiative, they’re offering an open online 6-week course on infectious disease to the public called “Stories of Infection.” It “introduces learners to a variety of infectious diseases using a patient-centered, story-based approach. Through illustrated, short videos, learners will follow the course of each patient’s illness, from initial presentation to resolution.”

To get a sense of the course, here’s a partial transcript from the case presentation of the first patient you meet, David Vetter (above photo), whose story you may be familiar with:

“… To understand the importance of the immune system, we’re going to look at the case of a boy who made medical history by surviving for 12 years without a functioning immune system. In the process, David Phillip Vetter talked the medical world not only about his immune deficiency disorder. But also about the ethical dilemmas doctors can face when a temporary medical solution ends up becoming up a permanent one. On September 21st, 1971, David was delivered by Caesarean section at the Texas Medical Center in Houston. And within seconds, he was transferred into a sterile plastic bubble that would become his home for the next 12 years. David suffered from a rare genetic condition called Severe Combined Immunodeficiency, or SCID, that left him without a functioning immune system. The Vetters had lost their first son to an overwhelming infection that resulted from the same disorder. Because SCID is linked to the X chromosome, the Vetters knew there was a 50% chance their second son, David, would also have the disorder. But the prospect of a bone marrow transplant from David’s sister, Catherine, offered hope. Catherine would have been a perfect match for bone marrow transplant in the Vetter’s first son if he had survived long enough to undergo the procedure. So the family and physicians on David’s team saw the potential for a cure, if in fact, David carried the faulty X chromosome …

Three days after David Vetter was born, his diagnosis of SCID was confirmed, meaning that he would be just susceptible to severe infections as his brother. Having lost one child to the disease less than a year before, David’s mother was fearful of reaching into the bubble to touch David using the integrated rubber gloves that hung at regular intervals along the walls of the sterile chamber. She said in an interview, I felt if I could stay distant from him, then if the worst happened, I could handle it better. So I was hesitant to reach into the glove and touch him. But once I did, I was hooked for life.

She soon took on the challenges of caring for her baby boy along with his team of physicians who were confident they could cure him. David’s diapers, clothes and food had to be sterilized and inserted into the bubble through a system of air locks. But Baby David appeared to be thriving and growing in this sterile environment. No one had anticipated that David’s sister would not be a match for bone marrow transplant. And that David would somehow become trapped in the bubble that had been built to temporarily protect him.

As David grew, his awareness of his circumstances did too. And a story that had once held the promise of ending as a medical miracle slowly became an ethical nightmare.

During his years in the isolator, many studies were performed on David’s immune system. At the age of four, he was found trying to poke holes in the bubble. And doctors were forced to explain to him the very real risks that faced him if any microbes were allowed into the sterile environment. Psychologists who worked with David encouraged him to escape the bubble using his imagination. And his mother remembers taking many make believe trips into outer space with David in those early years. Teachers delivered lessons through the plastic walls of the bubble and David turned out to be an exceptionally bright boy. In 1975, engineers at NASA designed a spacesuit that would allow David to leave the hospital. But David was very anxious about being exposed to pathogens outside of his regular environment, so the suit was only worn six times. All of these worries and challenges of living inside the bubble took a took a toll on David’s emotional state as he grew. The isolator was moved from the hospital to David’s home when he was nine years old. And his mother remembers him watching other boys playing outside through a window in their home. And she noticed the downturn in her son.

David became increasingly withdrawn. As the family’s desperation grew in the years that followed, more research from Boston offered some hope. Physicians there had managed to perform form a successful bone marrow transplant using a non-matching donor. Though the procedure was still in its experimental stages, David, who was now 12 years old, received a bone marrow transplant from his sister. At first, the transplant appeared to have been successful. But then several weeks later, and still living inside the isolater, David spiked a fever and developed an intestinal hemorrhage. On February 22nd, 1984, David was removed from his sterile chamber and wheeled into a hospital room where his mother stroked his skin for the first and last time. Like many children who realize they’re going to die, David wanted to know if it was going to hurt and if his loved ones would be there with him. Once he was reassured on those two counts, he courageously faced death as he had faced life, and he passed away …

 

***

Stanford also says “We will … examine the relationship between socioeconomic conditions and infectious disease” – and they aren’t kidding. For example, in Santi’s case, a 3-year old boy who contracted a virulent strain of E. coli by eating a hamburger from a fast food restaurant, the clinical presentation included these pointed words:

Like many commercially produced food products, the hamburger that Santi ate contained meat from many different animals raised in confined animal feeding operations, or CAFOs. Lakes of animal manure frequently surround these factory farms and during slaughter, underpaid workers are all too often forced to rapidly separate the useable meat from waste. Spillage of intestinal content is common in slaughter houses like these and if the resulting meat isn’t completely cooked, dangerous pathogens can be transmitted to humans through food.

 

The course by no means lacks intellectual rigor, hinted at in an email you receive after you sign up: “… these intimate and moving stories … are part of our medical students’ required course on microbiology and immunology.” So for instance, the clinical presentation of MRSA through the story of a 20-year old college football player includes this little nugget:

Methicillin-Resistant Staph Aureus is an example of how bacteria can evolve in the presence of antibiotics to develop resistance. Penicillin and others antibiotics of the beta-lactam family work by binding to penicillin binding proteins, bacterial proteins, which are essential for maintaining the bacterial cell wall. But these bacterial proteins can evolve their structure, so that they are no longer efficiently bound by beta-lactam antibiotics. In the case of MRSA, a gene called mecA encodes a particular form of penicillin-binding protein, PBP2A, which allows the bacteria to grow and divide in the presence of most beta-lactam antibiotics. mecA isn’t located on the bacterial chromosome. It’s located on a mobile genetic element called the staphylococcal chromosome cassette, or SCCmec. This cassette can be passed directly from one bacterium to another through horizontal gene transfer, which allows the population of bacteria to develop antibiotic resistance even more rapidly.

 

Don’t let that scare you. The genetics component of the course is not at all front and center; a graphic that accompanied this case presentation explained it quite nicely, and even better, it was not on the test that followed!

***

When Malcolm Gladwell said we need to use stories to close the gap between the reality of medicine and the public’s perception of it, I assumed he meant something like the usual tale of heroic medical intervention. Where the public remains on the outside looking in, and the feeling can sometimes be akin to voyeurism.

But Stanford had a better idea: they’ve brought us into the medical world and they’ve made us part of the story. Real cases are presented. You really do care about the patient. And that emotion follows you as you work through the relevant biology to make sure this doesn’t happen on your watch – which of course cannot be strictly true. We’re not in it for the M.D. But that’s the whole point – it feels as if we are – and so the difficulties of study almost fade into the background. It leaves you wondering why they’d teach medicine any other way.

 

Antibiotics fail to treat pneumonia 22% of the time – but that may be due to a faulty diagnosis, not an ineffective drug

Pneumonia 3

 

Nearly 1 in 4 patients treated with antibiotics for community-acquired (vs. hospital-acquired) pneumonia required additional antibiotic therapy. Of the 251,947 cases identified, 55,741 patients (22.1%) needed further antibiotic treatment or ended up in the hospital. Failure rates were similar, regardless of the class of antibiotic used.

These were the conclusions of researchers from the LA Biomedical Research Institute at Harbor-UCLA Medical Center in Torrance, California, and presented last weekend at the American Thoracic Society 2017 International Conference, as reported by Medscape Medical News.

The researchers also found that:

(1) Patients older than 65 years were nearly three times more likely to be hospitalized than younger patients.

(2) Treatment for community-acquired pneumonia was more likely to fail if patients had at least one other medical condition.

(3) There were significant regional variations in patient resistance to certain antibiotics; people on the East Coast did better than those on the West Coast. “There might be less antibiotic resistance [on the East Coast as] [d]ifferent antibiotics have resistance in different parts of country,” said James McKinnell, MD, one of the researchers.

“We found it very surprising how frequently treatment fails,” said McKinnell. And, since older patients are more vulnerable they should be treated more carefully, “potentially with more aggressive antibiotic therapy.”

But there’s a problem: What if the failure of the antibiotic had nothing to do with the drug itself but was because the patient didn’t have a bacterial-driven pneumonia – or a pneumonia at all – to begin with?

Shimshon Wiesel, DO, who was not involved in the study and practices internal medicine at Staten Island University Hospital, told Medscape that the data the researchers used was problematic as it only gave the diagnosis entered when the patient was seen:

“It doesn’t tell you how the patient presented, or what workup was done.” The patient might have had bronchitis or a subtle presentation of lung disease; “these are known to fail on antibiotics,” he said. “The biggest reason for treatment failure” is related to diagnostic criteria. [My emphasis.]

The patient may also have had a viral-driven pneumonia, a complication of the viruses that cause colds and the flu, which accounts for about one-third of pneumonia cases.

As it happens, support for Wiesel’s observation can be found in the most read article on Medscape right now, “Making the Correct Diagnosis: The Cornerstone of Antibiotic Stewardship.”

It’s co-authored by the always-enlightening (e.g. here and here) Brad Spellberg, MD, infectious disease specialist and Chief Medical Officer of the Los Angeles County-University of Southern California Medical Center.

He agrees that a basic rule of prescribing is that you have to give the right antibiotic, at the right dose, for the right duration of therapy. But he reminds us that up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate. And what’s overlooked, he says, is a more fundamental principle that must underpin effective antibiotic stewardship: making the correct diagnosis.

Spellberg’s article presents 6 cases that illustrate this critical principle and the impact it has on appropriate antibiotic usage. These cases are based on real patients he has encountered recently. He presents them not because they are unusual but rather because they are typical of clinical situations that happen tens of thousands of times per year in the United States – and typical of how doctors get it wrong. It’s a must-read and an involving-read: with each case presentation, the reader is asked to make the right treatment call. See how you do.

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