Four years ago, I wrote a health feature in The Record on a series of unusual staph outbreaks and the potentially lethal strain known as MRSA, which has been in the news for the last couple of weeks.
It's a long, long piece. But for those of you who are concerned about the reports you're hearing today -- 4 1/2 years later -- I'm running the story on the jump....
It was raining in San Francisco on Dec. 19, when Rudy Pedraza and some friends headed to their local movie theater to see the latest "Lord of the Rings" film. Pedraza, a 36-year-old freelance photographer, wasn't feeling well that night, but he blamed it on the weather. Within hours, though, Pedraza's condition worsened. His temperature spiked to 104, and he felt a sharp pain in his groin.
By the following evening, the pain became so intense that Pedraza needed to call a cab to take him the two blocks from his house to San Francisco General Hospital, where a perplexed team of doctors got their first glimpse at a baffling and highly contagious new strain of staph infection.
Despite several shots of morphine to relieve his pain, Pedraza remained cognizant as doctors examined him. "Several teams from the hospital had come in to look at me, to see if any of them knew what it was," he recalls. "There had been a spot on my upper groin that was blood red, the tissue was gel-like, and it had begun to bloom. They were marking it with pens, and within 10 or 20 minutes, it had gone beyond the boundary they had just drawn. It was spreading in two different directions.
"First, they said they were going to do a sonogram. Then, they said there was no time, they needed to do a CAT scan. But, as soon as I was wheeled into that area, they said no, again, and wheeled me to the O.R. They said, 'We're taking you in now.'"
After removing the affected tissue -- it would later take over 4 feet of surgical dressing to fill the cavities in Pedraza's groin area -- his doctors discovered that Pedraza had been stricken by a highly aggressive and potentially deadly strain of a relatively common staph infection known as MRSA, or methicillin-resistant Staphylococcus aureas.
The infection, which causes large, painful boils and abscesses on the skin, and does not respond to traditional antibiotics such as penicillin or methicillin, had begun spreading among gay men in Los Angeles in the fall. It was also found in a group of 50 high school athletes in a Houston suburb last year, and has struck prison populations in six states.
Although no such outbreaks have been reported in New Jersey, this particular strain of MRSA appears to be as geographically diverse as it is virulent. In addition to Texas and California (where it has been diagnosed in dozens of gay men and others in Los Angeles and San Francisco). clusters have been identified in prisons in Tennessee, Mississippi, Georgia and Pennsylvania.
Untreated, MRSA can lead to toxic shock syndrome and death.
First identified in the 1980s among hospital and nursing home patients, MRSA was then categorized as "nosocomial" -- a term used for a disease or infection picked up in a health care environment, usually following an invasive procedure. Since then, such infections have become increasingly common, including several thousand per year in New Jersey. (In 2001, the U.S. Department of Health and Human Services put the in-hospital cost of treating nosocomial antiobiotic-resistant infections at $1.3 billion annually.)
This latest incarnation of staph aureas is what the Centers for Disease Control and Prevention (CDC) is calling "community-acquired" MRSA. The term refers to infections that appear in clusters in which the patients share common quarters and hygiene facilities, or have other intimate contact.
Dr. Elizabeth Bancroft, a medical epidemiologist with the Los Angeles County Department of Health Services, who has been leading the investigation into the MRSA outbreak at the Los Angeles County Jail since last year, said this strain is unusual for several reasons, the most pivotal being how it appears to be acquired.
In the more common hospital strain of MRSA, Dr. Bancroft said, the staph colonizes a surgical site wound or pressure sore. "It would get into a wound that was already there," she said. "But these are primary skin infections, and that makes this unusual. This may be different in that it may not be something that gets into a cut. This may be something that causes an infection in the first place."
Dr. Bancroft added that the point of primary infection could be anywhere on the body. "We've found it all over," she said. "A lot of people have it on their lower bodies, but we've found it in the armpit, groin, on the leg, hand, chest, neck...everywhere."
Some health officials also fear that this strain may eventually become resistant to the few antibiotics that seem able to fight it.
Vancomycin, an "antibiotic of last resort" was eventually used to treat Pedraza when he did not respond to other medications. So, far, vancomycin is one of three antibiotics that has been successful in combatting this particular form of MRSA. But, vancomycin is no longer the magic bullet it once was. In recent years, a vancomycin-resistant staph strain has also been identified in the U.S., Japan, and elsewhere.
Margaret K. Macali, director of Public Health Nursing Services, in the Bergen County Dept. of Health Services, is among the local health officials urging caution, particularly to individuals who live or work in crowded conditions, and to those who share showers and toilet facilities.
Although the outbreaks have appeared in patients who were both HIV-positive and negative, Macali noted that immune-supressed individuals (which may include the elderly, those on chemotherapy, and recent surgery patients) often have a greater susceptibility to infectious agents, and need to be especially careful.
She added that the best way to avoid staph infections, was to observe good hygiene practices. "Wash your hands, wash your hands, wash your hands, and then wash them again," Macali said.
New Jersey's State Epidemioliogist, Dr. Eddy Bresnitz, concurred that cleanliness is crucial. "When you have an outbreak of MRSA in a jail, or a nursery, in many cases there is a carrier...who is coming in contact with everyone who has gotten sick," said Dr. Bresnitz, who is also the Assistant Commissioner of Epidemiology, Environmental and Occupational Health Programs for the New Jersey Department of Health and Senior Services.
An outbreak within such settings, Dr. Bresnitz said, requires that preventative measures be instituted immediately so that additional people do not get infected. Such measures include appropriate washing of clothing, maintaining a clean environment, frequent hand-washing, and control of person-to-person transmission.
Bresnitz said there was no way to predict the possibility of such outbreaks in New Jersey, but noted that a recent report on community-acquired MRSA in the medical journal Morbidity and Mortality Weekly Review, has raised awareness of the strain and its symptoms here, and could help to alleviate misdiagnoses should an outbreak occur.
Last year, the Los Angeles County Jail inmates were initially diagnosed as having spider bites. (In early stages, the lesions associated with MRSA may be as small as pimples.) Exterminators were brought into the jail to help resolve the problem, but as the infections worsened (eventually spreading to 920 inmates by the end of 2002), some inmates were found to have far more serious conditions, including endocarditis, an inflammation of the membranes lining the heart; and osteomyelitis, a bacterial infection of the bone marrow.
"This is another example of why these reports are so helpful," Dr. Bresnitz said. "Now, if a doctor in a jail setting has inmates coming in with skin lesions, instead of thinking spider bites, he may think MRSA."
Pedraza said that when he was first being examined in the emergency room, doctors there also suspected a spider bite. But, as the infection began to spread, they weren't sure what was wrong with him. "At one point," he said, "they even thought it might be fasciitis." (Necrotizing fasciitis, often referred to as "flesh-eating disease," is caused by Group A streptococcus, which also causes strep throat and impetigo. In severe cases, it can destroy muscles, fat and skin tissue, and lead to toxic shock syndrome, and in about 20 percent of the cases, death.)
In addition to maintaining good hygiene practices, Dr. Bancroft suggested that anyone with a boil or abscess -- particularly one that has not healed after a first run of antibiotics -- should make his or her clinicians aware of it, and ask to have the abscess cultured to determine its antibiogram, which would reveal which antibiotics the infection is sensitive and resistant to.
Dr. Bancroft noted, "When doctors see something that looks like a staph infection, they might not necessarily test what the antibiogram is." She added, "We don't have data yet as to how prevalent this form of MRSA is, so doctors should keep a higher suspicion of it."
On Feb. 18, in an effort to help further educate the public on community-acquired MRSA, Pedraza took part in a forum at San Francisco's gay community center, along with three doctors familiar with the infections. In the process, Pedraza also educated himself. On the following morning, exactly two months after his initial diagnosis, Pedraza returned to the emergency room at San Francisco General Hospital.
"I realized by what I heard at the forum, that I still was at risk of becoming reinfected," Pedraza said. "I had an ingrown hair on my right leg that had a pustule on it. I didn't have a fever, but it was red, and there was some pain."
As Pedraza had suspected, he was diagnosed with a second MRSA infection. The pustule was opened and drained, and Pedraza was put on another round of antibiotics.
"This time," Pedraza said, "I was lucky. I had more information, and was able to catch it quickly."
ANTIBIOTICS & MRSA
The misuse and over-prescribing of antiobiotics is believed to be the chief cause of antibiotic-resistant bacteria -- a growing list that includes MRSA, some strains of streptococcus pneumonia, as well as the strain of penicillin-resistant gonorhea found in the 1970s among U.S. servicemen stationed in southeast Asia.
According to doctors, the two most common misuses of antibiotics among patients occurs when a patient terminates the treatment before the prescription has been completed, or when a patient takes leftover -- or, in some cases, "borrowed" -- antibiotics at a later date to treat self-diagnosed symptoms.
Bacteria that survives such incomplete courses of treatment may then develop a resistance to that antibiotic, creating a new strain of "super-bug" that becomes increasingly difficult to treat.
In 1999, the World Health Organization (WHO) created an international task force to monitor the spread of resistant bacteria. That same year, members of the CDC, the National Institutes of Health, and the American Medical Association co-chaired the government's Interagency Task Force on Antimicrobial Resistance, and began working up a plan to combat the spread of resistant bacteria in the United States.
Their report, "A Public Health Action Plan to Combat Antimicrobial Resistance," was released in 2001. Among its recommendations were increased surveillance methods to track such infections; the development of systems to monitor patterns of antimicrobial drug use that includes the use of antiobiotics in agriculture; an education campaign aimed at health professionals and the public to limit the misuse of antibiotics; additional research into the genetic blueprints of mutated microbes; and the development of new medications to treat antibiotic-resistant strains.
Complete text of the CDC's report is available online at www.cdc.gov/drugresistance/.
In September 2004 my father (83 years old) was admitted to HUMC for a persistent cough, which turned out to be pneumonia that had progressed so far he needed surgery to remove 1/3 of his lung. He developed an infection, eventually requiring a wound vac to attempt to clean out the infection, which was so deep it went to his bone. He went back and forth between the hospital and a rehab facility for the next four months, getting sicker and sicker as time went on. He passed away in February 2005, and the first cause of death listed on the death certificate was MRSA. Not interested in assigning blame or pointing fingers, to this day my mother and I wonder in which facility he contracted MRSA, and how it might have been prevented...
Posted by: Maria | October 20, 2007 at 06:00 PM
Very scary stuff. I read this story when it first appeared in a waiting room at Valley Hospital while my mother was having a head CT after a fall. I don't think I've ever washed my hands so carefully in my life as when I got home that day...
Posted by: Evelyn | October 21, 2007 at 12:59 AM
It's scarey stuff alright, and if God forbid you have to be in a hospital and you see that someone hasn't washed their hands or aren't wearing gloves before touching you, don't be afraid to speak up and tell them to do so.
Posted by: Linda | October 21, 2007 at 11:12 PM
staph is a scary problem in many walks of life from the wrestling mat to the operating table
Posted by: Erica | April 09, 2008 at 09:56 AM