Mrsa
 

I don't want to hijack the thread about Kevin's fight with MRSA.

Instead, I wanted to start a separate thread about the bacteria itself.

Specifically, has the over prescription of antibiotics led to the evolution of this drug-resistant bacteria?

I think so. Overprescription has certainly hastened its spread. But people are people, and human contact has also made its spread evolve quicker.

Look at it this way. We have been kicking the snot out of bacteria for over 60 years now. Bacteria are just like any other living thing, they will adapt to survive. Thus you have the emergence of drug-resistant bacteria like MRSA.

By the way, MRSA is getting a lot of press now but it has been a problem for at least the last 10 years or so.

It's an arms race with the bacteria, we have to develop new ways to kill them because they will adapt to make the old ones ineffective.

And to answer your question, yes, inappropriate antibiotic usage exposes the bacteria to the antibiotics more and thus allows them to gain more resistance unneccesarily. Both doctors and patients are to blame, think of how many times you might have gone to the doctor and wanted anti-biotics for a cold (which is viral and antibiotics have no effect on). If you haven't done it, I assure you lots of others have.

Last time I was prescribed anti-biotics was 1993--when I was bit by a neighbor's dog. I still have scars...

I think it's the health care industries dirty little secret. Although the death certificates don't say it, it killed both my elderly parents within 10 months of each other. I don't think they are telling us everything.

When my sons were in the ICN they had what the parents called the cootie room. I do not think they lost one child the whole time we were there.

There is a very clear correlation between use of antibiotics and bacterial resistance toward it. It is a very nice, classic, example of Evolution in motion. Survival of the fittest. First, different types of bacteria have inherently different types of resistance. The sensitive types will die, leaving more life space to the resistant ones. Bacteria also have a phenomenal capacity for changing their protein synthesis, with random mutations producing even more resistant strains. Basically, the more antibiotics and particularly broad spectrum AB´s (kills several types of bacteria), the more the bacteria have to come up with ways to protect themselves. This is a fact for almost all kinds of bacteria, MRSA being just one, albeit numerous.

There is statistically a very close correlation between number of individuals treated with antibiotics and level of resistance.

In Sweden we are still lucky. We have had a very strict policy for decades, not to prescribe any AB´s if not really necessary. Hence we have still a very 'virgin' flora of bacteria. It is still often possible to treat outpatients with simple Penicillin for ear infections and pneumonia.

On the other hand, in many souther European countries, that has become almost impossible. They now need broad spectrum AB´s for most infections. This leading even more resistance, craving even broader antibiotics. It is a vicious circle.

In a word, Yes.

For years, pedi docs(no offens meant Markus, sounds like you have a more rational approach in the land of the midnight sun) have written antibiotics when they knew the odds were 95% it was a viral problem and they would not help a bit.

Methicillin Resistant Staph Aureus is just that, resistant to methicillin(a hot rodded penicillin that is not used much any more) also resistant to a lot of other stuff. They are different ways bacteria defeat antibiotics, but if they are never exposed to an antibiotic, they are more likely to be sensitive to it. MRSA is mainly treated with Vancomycin, a drug only available intravenously, which is a lot more expensive than a pill.

In the recent past, Vancomycin(pretty cool name eh?), which is nasty stuff, was held in reserve and you had to satisfy certain requirements(MRSA or other rare infections that give the infectious disease specialists hard ons, a short list) before you could institute treatment with this drug and it was watched very closely.

Now, it is being used routinely as a prophylactic antibiotic prior to orthopedic surgery involving an implant. Starting to see more resistance. VRE(vanco resistant staph epidermidis, don't ask me why it is not VRSE) has been identified and I personally have been involved with a few cases. Seeing more VISA(S. Aureus with intermediate sensitivity to Vanco)

Here is something that will, or should, get your attention. A large percentage of people are colonized with MRSA in their nares(nostrils), not infected, but carrying it, a la Typhoid Mary. A bit more sunshine for your day; 10-15 years ago, the vast majority of MRSA cases were hospital aquired, it was unheard of for someone who was not a total train wreck hospital victim turned up with it, ie dialysis patient who used to be a heroin addict. Latest numbers I have seen(Sacramento area only), the majority of new MRSA infections are community aquired, which is a little terrifying to me, and I don't rattle easy.

I think my dad picked up MRSA in his port before he died.

The crappy part is that for folks like me who haven't taken many antibiotics in our lives, we are probably still pretty susceptible to these new resistant strains. Hopefully, not having taken many, that means that we are better prepared to resist them possibly having a greater number or diversity of antibodies.

Way I see it, it's a mixed bag, reward/risk wise. Back in '85, I suffered a burst diverticuli. (Livi will probably agree here) According to the surgeon, I was lucky that some new broad spectrum antibiotics had just become available...otherwise I wouldn't be here to bug you guys in 2007...

Let me tell ya guys...there is nothing like living with a stoma for a few months to make you appreciate your A-hole. To this day, I try to avoid being far from a toilet...missing a chunk of big intestine will do that to a guy. :rolleyes:

I agree and I am happy you are still around to bug us newbies! SmileWavy

Every infection has a more or less correct treatment. In cases like yours no effort should be spared and the heaviest stuff used.

VRE stands for Vancomycin Resistant Enterococcus, there isn't a Vanc resistant staph epi as far as I know.

I may not be reading your post correctly, but the resistance to ABs is not on your part but rather on the bugs'.

If the bug is resistant then it doesn't matter how often a patient has taken the drug. As I say, I may have mis-read your post.

Not too long ago, during my residency, it was not entirely common to have an MRSA patient. Not rare. But certainly the percentage of patients who came down with it as an infection were in the 10% range. A couple years ago, during my fellowship in Boston, I'd have to say that over 80% of patients that came in with abscesses of the hand (which I got called to take care of) had MRSA. Usually, these were drug addict types (or fight bite types). Not boy scouts, by any stretch of the imagination. But it does show the huge swing in antibiotic resistance in just a few years.

There's no conspiracy theory. There's no "medicine's dirty little secret." It's a bacterium. It's fairly prevalent. With time, antibiotic use, easy communicability between people (health care providers, patients, their families, etc), Staph aureus has become increasingly resistant to the common antibiotics we use against it. For healthy people, it's still not an issue, as your immune system will keep it at bay. But for those who become infected by it (i.e. by a cut, burn, or other portal of entry) it has become increasingly difficult to treat. The mainstay of treatment is now Vancomycin. It realistically only comes as an IV form (as the oral pill has very poor absorption, so it's useless except for treating very specific colonic infections like C. diff). That's a problem both of cost (as people either have to be hospitalized or get special home nursing arrangements) and logistics. There are a couple other drugs that seem to treat MRSA, at least on culture sensitivities that come back from the micro lab. Bactrim and Rifampin come to mind. But Bactrim, well, sucks against MRSA in the real world, despite what the micro lab says. And I've never seen anyone try to treat MRSA with Rifampin. Don't know why. I've never asked the ID guys why we don't try it.

The problem is that there are times when even Vanco is not effective against MRSA. Then, our last resort drug is something called Linezolid (or Zyvox). That comes as both pill and IV solution. But it's expensive, and (at least for my former patient population which comprised significantly of inner city not-so-employed or -sober people) sometimes very difficult to obtain. Well, the hospital would suck it up and pay for the IV stuff. But at some point, you have to release a patient, and there would be few funds available to pay for their oral Linezolid.

Massachusetts General Hospital had a couple reports of Linezolid-resistant bugs. That was from a few years ago, so it may be even worse, now.

But if antibiotics are given more frequently, then drug-resistance will evolve more quickly. By using antibiotics, we may be killing the susceptible bugs, but we're also naturally-selecting out the resistant ones. So, of the bacteria that are left behind (after we come swashbuckling through with antibiotics), a greater relative percentage of them are of the resistant type. If we're using antibiotics needlessly (i.e. to treat conditions that aren't caused by bacteria, or if the antibiotic selection doesn't match the bacterium strain responsible for whatever infection we're trying to treat), then we're offering no possible benefit to the patient, but only selecting out (and perpetuating) the resistant bugs already out there.

That's where physicians have a responsibility to the general population. Don't use antibiotics if there's not a proper indication for them. Because it can actually do harm to society, as an evolutionary whole. And as a patient, you've got to understand that if a doctor doesn't prescribe you an antibiotic (for a good reason), they may not be the useless clod you think they are.

So are there steps ordinary folk can do to reduce their risk of this MSRA?

Right, that was my point. I haven't taken AB often, but that probably doesn't mean diddley if I get hit with something like MSRA because it's not me that it's resistant to it's the drugs. I do however suspect that because I haven't/don't take many AB or other drugs, that I may have a more diverse and strong set of antibodies than folks that take AB all the time, so I may actually be more resistant to some of these bugs. But that's just my uneducated supposition.

So basically, I haven't taken many AB and I'm still screwed.

wash your hands

don't use needles that you find in alleys

don't have sex with women that you find in alleys

and live in a bubble.

:D

Yes! Conservatives are less susceptible than liberals...,;)

Nobody has been blaming Bush for this so far ?!! :D

Australia had a real problem with this several years ago because of over perscribing of AB's.

I worked for a guy who took AB's everytime he got a cold and we were praying that he would never have a real issue as his body was so used to AB's that the standard treatment would not have done any good.

I take them only when there is no other choice and have consumed them less than 4 times in 10 years.

Problem is that those of us who travel for a living are exposed to all sorts of crap as well as too many people want a magic pill that cures everything.

I notice Kevin didn't have health insurance....

What does someone do who is faced with major invasive surgery in the near future?

Only health insurance I have is what I pay for out of my pocket every month. There are a lot of us in this situation.

As well I know a lot of people who are trapped in their job because they cannot leave and lose their health insurance. As you get older it gets worse...

Along those lines ---

Does alcohol based hand sanitizers help to kill the MRSA related bateria before it gets into the body? Would cleaning wounds, cuts and abrasions with an alcohol swab help? (A nurse type person told Mrs. Z-man that rubbing alcohol doesn't kill the bateria - but I serious doubt those claims...)

As a diabetic, I prick my finger 4-5 times a day for blood tests and take insulin injections. So I have tiny little holes in my fingers due to the blood tests. Would I see signs of infection around these holes if I were infected with MRSA, if the bateria entered my body via these holes?

-Z-man.

Uh oh...

If alcohol doesn't work, I would think that hydrogen peroxide would.

Waiting for the medical professionals to confirm/deny.

I wish doctors would speak more statistically to me. What I mean is, I show up with 'infection'. Doc says "I COULD prescribe AB, but I feel 95% sure this is viral, and it wouldn't have an effect." That would be easier to take than "Drink fluids and pay the nurse $50 on your way out."

I actually have seen both listed in texts, I think you are right though, poor proofreading. Will have to write that guy a letter as I actually looked that up. Thought it was wrong when I typed it.

#1 Wash your hands more frequently
#2 If you get a cut or scratch, treat it no matter how minor it seems
plan to file bankruptcy after

Rammstein, you will never get someone to tell something like that precisely. How you going to defend that in court? Z-man, the alcohol does not sterilize the skin, it reduces the bacterial load. Can't sterilize your skin unless you take it off and cook it.

If you have yellowish pus, you probably have staph of some sort. If you are diabetic, you have several infecting bacteria, which complicates things. Your immune system is not the same as someone elses is, sorry. If it is infected, it usually is a bit red around it, but in a diabetic this is not always the case due to immune compromise and poor inflammatory response. The alcohol based handcleaners are like soap, contact time is important.

The antibiotic effectiveness against MRSA is pretty interesting. Some stuff works in a dish, but not in a person. Linezolid is a great drug, bone penetration is similar with IV or oral form, only one that is true of that I know. This will get overutilized and resistance will rise, just like what happened with Cipro.

You never see Rifampin alone because of rapid development of resistance, or that is what an ID guy told me once.

As far as I know, alcohol does pretty well in killing all sorts of bacteria, MRSA included. There are many alcohol-based surgical hand scrubs and patient preparation solutions. However, the problems with alcohol: it dries the skin (particularly if you're using it repetitively--this part's fact), and there's not much money to be made in it (so soap/pharmaceutical companies aren't that enthusiastic about making a bazillion products with it--this part's my opinion). But alcohol's a pretty good cleansing agent.

edit: Like Tobra points out, it's impossible to completely sterilize your skin--but with proper hygeine and technique, you'll reduce the bacterial load to as low as possible, and let the body's immune system take care of the rest.

For people like Z-man, who have to do multiple fingersticks on a daily basis and worry about that as a portal of entry (as well as the diminished immunological status from the underlying diabetes), that's a good reason for using good sterile technique when you're doing said fingersticks, and good hygeine in general to keep your hands clean.

MRSA is probably all over the place, by now. I wouldn't be surprised if it was colonized on your, and my, and everyone else's skin. But there's a difference between colonization (where the bacteria grows/sits benignly) and infection (where the bacteria is causing a problem). You still have your natural immune system to fight off MRSA, as well as all your body's other barriers to infection (such as your skin, the lining of your gut, etc.). So just because you're colonized with MRSA doesn't mean you're necessarily infected with it, or going to be infected with it.

Rammstein brings up a good point. If a patient may potentially have an infectious problem, we live in a society where it's far easier to overprescribe antibiotics and at least look like we're trying to do everything we can to take care of a potentially infectious problem. You (as a patient or family member or parent) most likely would be a lot less pissed if a doc apparently tried all that was available and needlessly overtreated a condition, than if you felt that you were blown off by the doc and NOT given an antibiotic when that's possibly what might have solved the problem. Don't know if that last sentence makes sense. But we seem to live in a society where it's more acceptable to overtreat a condition, than it is to potentially undertreat it (even if the odds are in that 5% category) and possibly result in a complication that could have been prevented had we gone in with guns ablazin' from the get-go. We forget (both docs and patients) that there is actually a big-picture negative to overtreating.

Tobra, Noah -- thanks for the responses. Fortunately, I don't have any yellowish puss or redness anywhere on my body that I can see. And it is reassuring to know that I can take precautionary measures to minimized the chance of infection. I believe that those measures (washing hands, using alcohol pads...etc) are far more effective than using antibiotics - since at this point the bateria hasn't been able to mutate enough to be resistent to such measures.

-Z-man.

This begs a question:

Why do Doctors prescribe an antibiotic to a patient simply because the patient wants it? Who is in charge here, the expert or the patient? Seems as if this "defensive medicine" idea is going too far.

I ask for no medications that are not recommended by the physician, and I question every time one is recommended. Your well being is your responsibility, and the physician is only there to recommend and to assist in your quest to stay healthy.

1. Patient is in charge. Always. I'm just here to advise, and intervene if requested.

2. Patients frequently think they're experts. I get that attitude on a daily basis.

3. We live in a society where it's OK to overtreat, as it looks like you've done everything possible (even doing stuff that wasn't really necessary). But it's not so OK to undertreat, as it looks like you don't know what you're doing. If you overtreat (erroneously provide care where it wasn't truly necessary), there are negatives--but they're long-term items that don't directly impact the patient in the immediate future. If you undertreat (erroneously not provide care where it was indicated), there are also negatives--but the price that has to be paid is much more immediate and personal to the patient. So it's socially easier to "err of the side of caution" and overtreat. You're a lot less likely to get sued for overtreating than the other way around.

A couple of questions:

1. My teenage son has severe acne. This clearly opens his skin to other bacteria in an environment that is rich with opportunities for infection (high school). Does his risk increase by orders of magnitude?

2. I make frequent trips to Afghanistan. I am told to take Doxycycline as a prophylactic against Malaria. Does this frequent use of this drug increase the opportunity for resistant bacteria to thrive? BTW, the area that I spend most of the time in Afghanistan has very high fecal content dust.
Thanks,
Jim S.

Thanks, Tobra. I wasn't referring to a lack of health insurance though. I was more concerned about MRSA.

With regards to alcohol, yes it will kill MRSA. The problem is that straight rubbing alcohol is very drying to the skin and so not really suitable for daily use. The old alcohol rubs were also pretty drying, but they are now coming out with alcohol based cleansers that also have moisturizers in them and don't dry the skin as much. That's what I use at the hospital I work at and my skin doesn't dry out. The bottles are on the walls by the door to the room, get a squirt in the hands on the way in and a squirt on the way out...little dab 'l do ya!

The only bug (that I know of) that won't be effectively neutralized by an alcohol based lotion is Clostridium Difficile, that bug has a spore form which is only effectively removed by good old fashioned soap and water.

MRSA is in the community, it's just a fact at this point. It is not, however, this menace that is waiting to kill you at a moment's notice. It's another bacteria just like other bacteria. It's just more resistant to antibiotics. That doesn't mean that with good hygeine you can't live a full and MRSA free life.

MRSA is the big thing now, but don't think this is the only bug that we will see develop multi-drug resistance. It's up to the pharmaceutical companies to keep pumping out new types of antibiotics that are effective against these resistant bacteria. Of course the other option would be to stop using antibiotics altogether and wait about 100 years. Then they would all probly work again...

Just change your name from Joe to Jose and tell them that you're "not from around here" , then you can get health care for free ;)

High fecal content dust? I think that means the air is full of *****.
Why in the world would anyone voluntarily go to place like that?
I don't even like going to Los Angeles.

It's crappy job, but somebody's gotta do it.