Cook County Jail Tied to Increase in Drug-Resistant Illness

By Judith Graham
Tribune staff reporter

Dangerous, drug-resistant bacteria are spreading rapidly in Chicago's poor, urban neighborhoods, posing a growing health risk in crowded public housing and an increasingly alarming public-health challenge, according to research published Monday.

Cook County Jail -- a hot spot for the bacteria, known as MRSA -- appears to be contributing to the infectious menace, as hundreds of inmates cycle in and out of the facility daily. The threat was described Monday in the Archives of Internal Medicine by Chicago researchers who documented a sevenfold increase in patients with MRSA infections at Stroger Hospital's emergency room and Cook County medical clinics between 2000 and 2005.

At greatest risk were African-Americans, people jailed in the last year, and residents of public housing on the Near West Side, the study found. "MRSA is becoming epidemic in the community," warned Dr. Bala Hota, the lead author and assistant professor of infectious diseases at Rush University Medical Center.

MRSA stands for methicillin-resistant staphylococcus aureus, a potentially virulent bacteria that doesn't respond to several antibiotics used to treat common staph infections. People struck by the bug frequently develop painful skin boils or abscesses and, in rare circumstances, deadly pneumonias, blood infections and other life-threatening conditions.

"This is a pandemic in the making and the source of an enormous increased burden of disease across Chicago," said Dr. Robert Daum, a specialist in MRSA and professor of pediatrics at the University of Chicago.

Until the late 1990s, MRSA was found exclusively in hospitals. When Chicago researchers reported finding the bacteria in previously healthy, non-hospitalized children in 1998, they were met with disbelief. But after further investigation, it became clear that a new type of superbug, known as community-associated MRSA, had evolved.

This formidable bacteria, with more potential toxins than hospital-acquired MRSA, is the focus of the Cook County study.
Researchers identified 2,346 patients with staph infections in skin, soft tissue, joints or bones who likely picked up the bacteria in their neighborhoods. Of those, 41 percent had MRSA. All patients were seen in Stroger Hospital or county clinics.

When results were analyzed over time, a stark pattern became evident: the incidence of community-associated MRSA infections climbed dramatically, from 24 cases per 100,000 people in 2000 to 164.2 cases per 100,000 in 2005.
By contrast, data from three major U.S. cities available to date, published in 2005 in the New England Journal of Medicine, uncovered community-associated MRSA rates of 18 to 26 cases per 100,000.

There are more questions than answers about the MRSA strain that's dominant in Chicago, known as USA 300.
"It's unknown why USA 300 is so good at spreading in communities or where it comes from or even how it's transmitted," Hota said. Researchers think the primary mode of transmission is person-to-person contact. More than 2 million people are thought to carry MRSA in their noses without knowing it. Also, the bacteria appear able to live on surfaces such as counter-tops for days if not weeks.

Scientists speculate that an important reservoir of infection might be County Jail, an overcrowded, unsanitary environment where MRSA can easily flourish. The bacteria can be passed between inmates on mattresses, on towels and soap -- which are often shared -- or through other means, experts said.

About 96 percent of skin and soft tissue infections currently identified in jail inmates are caused by community-associated MRSA, according to the University of Chicago's Daum.

With as many as 350 inmates entering and leaving the jail every day, the opportunities for transmitting MRSA in the broader community are enormous. Many of these inmates return to poor neighborhoods and public housing complexes, raising the risk of infection.

In turn, this is the population least likely to get routine health care and most likely to show up ill at county clinics and Stroger Hospital's ER. The situation would seem to call for a vigorous public health response. But for the most part, doctors and hospitals aren't required to report MRSA infections to public health departments in Illinois.

The Chicago Department of Public Health is working on an electronic reporting system for MRSA, but at the earliest it expects that to be up "in one institution" in a year or two, said Dr. Susan Gerber, medical director for communicable diseases. Public health officials are targeting MRSA educational campaigns at medical providers, who are being asked to culture skin infections and prescribe appropriate antibiotics.

Daum called the public health response "woefully inadequate" and said "it's like waving a straw in a hurricane."

"Clearly, there's more we can do," said Michael Vernon, director of communicable disease control for Cook County's Department of Public Health. The new Cook County research will focus attention on measures that should be undertaken in housing projects and at the jail, he predicted. "What I'd like to see is jail officials, public health officials, and researchers get together and come up with a plan to institute surveillance and control measures," Vernon said.

The findings evident in Chicago are occurring nationwide. Last August, researchers reported in the New England Journal of Medicine that community-associated MRSA has become the most common cause of skin and soft tissue infections in emergency rooms in 11 cities.

A separate report, in the March 2006 issue of the Annals of Internal Medicine, found that community-obtained MRSA accounted for the majority of staph-related skin infections in Atlanta's public hospital ER and its clinics. It's not just that patients are walking into clinics or ERs with the bacteria; the settings themselves are harboring the superbug.

Last September, Johns Hopkins Hospital found that patient exam tables, countertops, computer keyboards, and patient chairs in a busy AIDS clinic tested positive for MRSA, posing "a greater potential risk to staff and patient safety than previously thought," according to a statement from the institution.

The study calls for "increased vigilance" in hygiene and infection-control practices in hospital outpatient settings, said Dr. Cecilia Johnston, a specialist in infectious disease who led the investigation at Johns Hopkins.

Study Reveals Pomegranate Juice Effective in Fighting Bacteria

Recent preliminary research by Milton Schiffenbauer, PhD, a biology professor at Pace University in New York, indicates that 100 percent pomegranate juice and POMx liquid extract (pomegranate polyphenol extract), made from the Wonderful variety of pomegranate grown in California, have antiviral and antibiotic effects. His findings were introduced May 22 at the American Society for Microbiology’s annual meeting in Toronto in a presentation titled, “The Inactivation of Virus and Destruction of Bacteria by Pomegranate Juice.”

In this exploratory study, Schiffenbauer tested 100 percent pomegranate juice and POMx liquid extract and the effect each had on a bacterial virus T1 and several bacteria over various periods of time, in various conditions and with the addition of other ingredients. The titer of T1 virus (a model system) which infects E.coli B decreased up to 100 percent within 10 minutes of the addition of 100 percent pomegranate juice or POMx liquid extract. The research was funded by Pace University and POM Wonderful LLC, and was conducted using POM Wonderful pomegranate products.

Both were also found to be effective in the destruction of bacteria S. mutans, known to cause cavities, S. aureus, the most common cause of staph infections, and B. cereus, a common cause of food poisoning. Schiffenbauer’s findings also indicate that 100 percent pomegranate juice and POMx liquid extract inhibit the spread of methicillin-resistant Staphylococcus aureus (MRSA), having widespread implications in the treatment of these potentially pathogenic microorganisms.

The addition of the POM products to various oral agents, including toothpaste and mouthwash, gave these agents an antimicrobial effect. This work comes on the heels of earlier studies conducted by Schiffenbauer that found that white tea and green tea extracts also have antimicrobial effects. According to Schiffenbauer, pomegranate has achieved even better results than the teas.

Source: Pace University

Information is New Tool in Fight Against Hospital Infections

By KIM BREEN / The Dallas Morning News - LAWRENCE JENKINS/Special Contributor

Four days after Carla Mullins' seemingly routine heart procedure, she awoke at her Hurst home with a 105-degree temperature and excruciating pain in her back and feet.

'I don't think people are aware of what goes on in hospitals,' said Carla Mullins of Hurst, who got an infection that made her feet black after a 2003 heart procedure. The effects linger. She spent the next month at a Tarrant County hospital's ICU fighting a blood infection that turned her feet black and nearly killed her. She had to quit her job, couldn't walk for three years and expects to be taking pain medication for the rest of her life. It never occurred to Ms. Mullins, 68, that she would leave the hospital after stent surgery in 2003 sicker than when she arrived.

"I don't think people are aware of what goes on in hospitals," she said. "I was very naïve. I just trusted everybody and everything."

An estimated 99,000 people die each year in the United States from infections they contract in hospitals, according to the Centers for Disease Control and Prevention. About 2 million such infections happen each year, at a cost of at least $4.5 billion. With an estimated 5 percent of people hospitalized contracting at least one infection, that translates to about 130,000 Texas cases each year.

On Wednesday, the Texas House passed legislation already approved in the Senate to make hospital infection rates public – a move to bring a historically secret problem to light. Growing attention to health-care-related infections has sparked similar legislative action across the country.

"People need to know when they're ill and going into the hospital that they're not going to leave with an illness that they picked up when they were there," said Sen. Jane Nelson, R-Lewisville, who sponsored the bill.

Consumer advocates and health professionals say the upcoming data, if reported fairly and consistently, will drive innovation and better communication among hospitals.

Hospitals have access to national data on infections for benchmarks, but the new reporting would be the first time area hospitals could compare numbers. It also would give prospective patients the opportunity to shop around and research hospitals.

Most medium-size and large hospitals already collect most if not all of the required infection-rate data, though it will take work to compile it in the right way once all the rules are set. "We stay on top of it all of the time to see if we're having problems," said Shirley Shores, director of infection control at Parkland Memorial Hospital.

Patients in the Dallas area should expect to see more measures to stop the spread of so-called superbugs when they check into the hospital, such as nasal swabs used to test for increasingly troublesome and potentially deadly bacteria – methicillin-resistant Staphylococcus aureus, or MRSA.

"Just having this law in place is going to lead to improvement," said Lisa McGiffert, director of the Stop Hospital Infections project for Consumers Union, which has been pushing nationally for legislation. "For the first time, hospitals will see how they compare. That is a huge motivator." Many see it as a first step.

Bob Beeley, a first responder for a fire department near Houston, had knee surgery in 2005 after twisting his ankle while attending to an accident victim. He checked into the hospital for minor day surgery "disgustingly healthy," but days later his knee swelled and turned red. He said he contracted an MRSA infection at the hospital. The infection spread, and he spent the day after Christmas on an operating table and two weeks in the hospital. "There was a time in the hospital when I was almost a goner," he said. When he went home, he had to treat himself with intravenous antibiotics three times a day for six months.

Beyond reporting infection rates, Mr. Beeley said the system needs improved financial accountability. He said his health bills have piled up because of someone else's mistake. The cost has reached well into six figures, of which he is responsible for at least 20 percent after insurance. "The dollars that I'm out of pocket are nothing compared to what it did to my family," he said. "I know that people make mistakes. My theory is if I make a mistake, I expect to pay for it."

The law would require hospitals to report rates of several infections, including some bloodstream infections as well as surgical site infections from procedures including colon, hip and knee surgeries and hysterectomies. Infections used to be seen as inevitable in hospitals, but no longer, experts said. "There's a whole move nationally from our profession of zero tolerance," said Ms. Shores of Parkland. "Don't make excuses, don't accept that you're no worse than you were last year or worse than anybody else. Continually try to improve."

At Hospital Corporation of America hospitals, which include Denton Regional Medical Center, Medical City Dallas Hospital and Medical Center of Plano, posters urge patients to take ownership of the oldest – and most important – infection prevention tactic.

The posters feature a germy green hand. "Stopping MRSA is in your hands." The hospitals are urging patients and visitors to wash their hands, and to ask caregivers to do the same. "Our goal is to eradicate preventable health care associated infections," said Dr. Jonathan Perlin, chief medical officer for HCA. Compulsive hand washing is part of a five-pronged campaign that kicked off in January. Studies have shown routine hand washing in hospitals happens far too infrequently, Dr. Perlin said. Aside from the posters, hand sanitizers in HCA hospitals are everywhere.

The hospital system has also ventured into a more modern infection prevention tool – screening high - risk patients for MRSA. At Methodist Health System hospitals, including Methodist Dallas Medical Center and Methodist Charlton Medical Center, high-risk patients are screened for several organisms, including MRSA. Most hospitals consider patients who are coming from nursing homes or who have been hospitalized recently among those at a high risk for MRSA and other bacteria.

"We're finding anywhere from 20 to 30 percent of patients we're doing cultures on are positive for organisms," said Virginia Davis, vice president of quality services for Methodist Health System. "At least half had no history of them." The testing began at Charlton more than a year ago and has led to a "marked decrease in the rate of health-care-associated infections," she said. Ms. Davis said so-called surveillance costs extra, but so do hospital-acquired infections, which lead to longer hospital stays: "It's a cost avoidance, but we're doing it because it's the right thing for the patient."

At Texas Health Resources hospitals, including Presbyterian Hospital of Dallas, a group of 10 employees spends a week inspecting hospitals every 12 to 18 months for safety in 10 areas, including infection control. They monitor hand washing, and when a patient is in isolation, they watch to see if employees wear the right gowns before stepping into the room. They check to see if intravenous lines are changed in time to prevent bloodstream infections.

Dr. Michael Deegan, chief clinical and quality officer for THR, said technological improvements for infection prevention will likely follow the legislation. "When people measure things and are transparent about it, it tends to lead to improvement." Presbyterian Hospital of Dallas currently has a pilot program for screening intensive care unit patients for MRSA.

Making the information public creates a business incentive to decrease infection rates, Ms. Shores said. But pride among health-care workers also will play a large part for motivation. Many patients do not have unlimited choices when it comes to hospital care, she said. "But it can help the consumer make choices," Ms. Shores said. "I think it makes the consumer more educated. I think it makes them ask questions." Ms. Davis noted that patients can log on to the U.S. Department of Health and Human Services Web site, www.hospitalcompare.hhs.gov, to compare the way hospitals care for heart attack patients.

Comparing data in Texas before and after public reporting shows remarkable improvement, she said, adding that she thinks the same will happen with infection rates.

"After they start seeing what others are doing ... they want to start learning from each other," she said. "It forces an escalation of shared best practices."

Medicare Says NO to Mistakes

Article by INDYSTAR Reporter David Lee

Medicare says it might no longer pay for many of the mistakes made by hospitals. Medicare might cease paying for certain conditions acquired by a patient after he or she is admitted to a hospital. Among the proposed conditions to be dropped are:

1. Catheter-associated urinary tract infections.
2. Bed sores.
3. Objects left in after surgery.
4. Air embolism, or bubbles, in bloodstream from injection.
5. Patients given incompatible blood type.
6. Bloodstream staph infection.
7. Ventilator-associated pneumonia.
8. Vascular-catheter-associated infection.
9. Clostridium difficile-associated disease (gastrointestinal infections).
10. Drug-resistant staph infection.
11. Surgical site infections.
12. Wrong surgery.
13. Falls.

Late next year Medicare plans to stop paying hospitals for costs incurred from some of the most common and preventable medical errors suffered by patients. It could be getting a bloodstream infection from a caretaker not thoroughly washing his or her hands. Or it could be developing a dangerous bed sore because a patient's skin was not inspected or cleaned as recommended.

The proposed change could have a far-reaching impact because Medicare is the largest single payer of medical bills in the nation. Commercial health insurers, such as Anthem Blue Cross and Blue Shield, often follow Medicare's lead when determining their own reimbursement policies.

"It is something we will want to look at and try to follow," said Eric Schmitz, director of provider contracting for Anthem. However, he added that Anthem is waiting to see how the final policy looks before making any decisions. The Federal Centers for Medicare and Medicaid Services, which operates Medicare, is taking public comment on the proposal through June. The changes are scheduled to take effect in October 2008.

Medical mistakes are deadly and expensive. Infections acquired in hospitals account for about 90,000 deaths and $4.5 billion in extra spending each year, according to the U.S. Centers for Disease Control and Prevention.

Preventing such problems is an ongoing effort among hospitals, doctors and organizations focused on health-care quality.
The Indiana Patient Safety Center was formed last year to help hospitals develop reliable systems to prevent harm to patients. Indiana also has a mandatory medical-error reporting system requiring that hospitals disclose certain mistakes, such as objects left inside a patient during surgery.

But unlike many other efforts, Medicare's proposal holds the potential to hit hospitals in their pocketbooks by changing the way they are paid for providing care. Under the change, hospitals no longer would receive payment for costs stemming from certain complications if those conditions did not exist when the patient was admitted into the hospital.

Medicare is looking at 13 specific conditions that include everything from urinary-tract infections related to catheters to a patient receiving an incompatible blood type during a transfusion.

The CDC reports more than 561,600 catheter-associated urinary tract infections a year, according to Medicare's proposal. In 2006, 11,780 Medicare patients had the infection as a secondary diagnosis during a hospital stay.

According to Medicare, those infections add an estimated $676 to a hospital bill. Some hospital-acquired conditions can be much more expensive.

The cost of treating pressure ulcers, or bed sores, can run anywhere from $500 to $40,000 a patient, according to the Institute for Healthcare Improvement. In 2006, 322,946 Medicare patients had a pressure ulcer as a secondary diagnosis.
St. Vincent Health, which operates hospitals across Indiana, said the proposed Medicare changes are in line with other initiatives to improve patient safety.

The American Hospital Association, which represents almost 5,000 hospitals and other health-care providers, said it welcomes efforts by Medicare and others to reduce errors and improve health-care quality.

"There's not a doctor or nurse who comes to work in the morning and wants to make a mistake," said Carmela Coyle, the AHA's senior vice president of policy. "I don't see nonpayment as an incentive to try to do better." She also said it is important to make sure that the conditions included in the Medicare policy change are indeed preventable and in control of the hospital.

MRSA Increasing in Children

May 7, 2007 (Toronto) — A study presented in Canada shows that children are increasingly being infected with community-acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) and that recent hospital admission heightens their risk of infection.

“[CA-MRSA] is a major public health problem,” said Dr. Edward Ziga, MD, MPH, a resident in pediatrics at St. Joseph’s Hospital in Paterson, New Jersey, and one of the study’s investigators. “Many studies have shown that colonization precedes infection, so we should be looking for an explosion in colonization.”

Dr. Ziga referred to previously published datasets, such as those from the National Health and Nutrition Examination Survey and from a study out of Vanderbilt University, to look at other risk factors that predispose individuals to colonization, such as sex or exposure to a healthcare worker.

In their own research, investigators collected nasal swabs, after obtaining parental consent, from 518 children between 0 and 18 years of age at St. Joseph’s Hospital between September 2005 and May 2006. The median age of the children was 4, and 54% were males. Researchers conducted susceptibility testing on all S. aureus isolates using the Vitek legacy system.

The number of all isolates colonized with S. aureus was 142 (27%). Of that total, 119 (22.9%) were methicillin-sensitive S. aureus, and 23 (4.4%) were MRSA. About one third of MRSA colonization (35%) occurred in children younger than 5 months old.

Investigators identified hospitalization within the previous 6 months as being independently linked to MRSA colonization (odds ratio [OR], 4.9; P = 0.02). The MRSA isolates demonstrated 100% sensitivity to vancomycin, trimethoprim/sulfamethoxazole, and linezolid. The isolates had decreased sensitivities to clindamycin (65%), erythromycin (4%), levofloxacin (70%) rifampin (96%), and tetracycline (96%).

Given these sensitivities, clinicians might need to revise their antibiotic strategies when faced with these isolates, noted Dr. Ziga.

“We saw good results in this group with clindamycin,” said Dr. Ziga. “We are not changing our approach [based on these findings] but, in the future, depending on the patterns or cultures we see, we may need to rethink our approach.”

On the basis of this study’s findings, caregivers should be careful, when caring for infants, to limit the possibility of the spread of S. aureus in locations such as the household, said Dr. Ziga. “That means handwashing, handwashing, and more handwashing,” recommended Dr. Ziga.

The authors concluded that healthcare providers should consider MRSA when treating infections related to S. aureus in children who have had a hospital admission within the 6 months prior to showing any symptoms of infection.

“It’s a national thing that the prevalence of MRSA is going up very rapidly,” said Dr. David Estroff, MD, a clinical professor of pediatrics at the University of Washington and deputy chief of department of pediatrics at Madigan Army Medical Center in Fort Lewis, Washington. “I have experienced the increase in MRSA in my own population, and it’s interesting that physicians are being recommended to think about the possibility of MRSA.”

Awareness of MRSA might lead to different antibiotic strategies in the future, said Dr. Estroff.

“The old standby drugs that we have used in the past, like erythromycin, may not work because we are now dealing with a resistant organism,” said Dr. Estroff.

The authors received an unrestricted grant from Pfizer Inc to conduct the study. Drs. Ziga and David report no relevant financial relationships.

Infections Worry Military Doctors

By JACKIE SPINNER, The Washington Post
Published: Monday, May 7, 2007

WASHINGTON – Like most patients in the infectious disease ward at Walter Reed Army Medical Center, Jon Harris has an “A” written next to his name on the white board by the nursing desk. The 23-year-old Army specialist had a leg amputated below the knee after a roadside bomb attack in Iraq.

But the capital letter indicates another medical problem that increasingly worries military doctors – an infection from a resilient bug known as Acinetobacter.

Harris, who arrived at Walter Reed on April 10, said he is convinced he picked up the infection when he fell to the ground in the attack. “I got dirty from being dropped six to seven feet from the truck,” the soldier from Missouri said one recent day.

However, military doctors say they don’t know exactly what’s causing infections such as the one Harris has, and they are racing to find effective treatments. Four types of bacteria, they say, are causing severe and hard-to-treat infections for many troops wounded in Iraq and Afghanistan: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus.

The infections have occurred in more than 600 injured troops from the two war zones who have had an arm or leg amputated, doctors tracking the cases say, and in other troops with lesser wounds. Such infections also can occur among civilians with traumatic wounds or other health problems, doctors say, but the high rate of infection for injured troops is raising concerns.

In response, the U.S. Army Institute of Surgical Research awarded a $1.6 million grant in February to a University of Missouri research team to work with doctors at Walter Reed in Washington, D.C., and Brooke Army Medical Center in Texas. The researchers’ aim is to simulate the bomb blast wounds that seem especially vulnerable to the infections and to study how the infections respond to antibiotics.

“The outbreak the military has described is very large,” said Arjun Srinivasan, a medical epidemiologist at the Centers for Disease Control and Prevention, which has been working with the Army in its research.

Army Col. Robert Kasper, a doctor with a combat support hospital in the Green Zone in Baghdad, said that military doctors in Iraq are cooperating with U.S. hospitals to identify the sources of the infections.

“These same organisms are a big problem” in many civilian hospital intensive care units, he said, adding that the infections can also be found among some people who have been in car accidents or have gunshot wounds.

But Jason Calhoun, chairman of orthopedic surgery at the University of Missouri at Columbia School of Medicine, who will help lead the four-year study, said there are many unanswered questions about the bacteria and the outbreak of infections among injured troops. “Many are resistant to common types of antibiotics,” Calhoun said. He added in a statement: “Ultimately this research could mean fewer extremity infections, fewer surgeries and fewer amputations.”

The nature of the wounds sustained in Iraq and Afghanistan has complicated efforts to control the infections, doctors said. Darren Linkin, director of infection control at the Veterans Affairs Medical Center in Philadelphia, said that bomb blasts cause a large amount of tissue damage, making infections more likely to occur and harder to treat.

“If there’s not blood flow to the dead tissue, the antibiotics can’t get to the infection,” he said.

In addition, advances in combat gear and battlefield medicine mean that more troops are surviving serious injuries than in past wars. “You have people severely wounded,” Linkin said. “These people are at high risk. The infections cause the patient to stay in the hospital longer, with more complications, and they have a higher risk of death.”

Military officials could not provide information about any cases in which the infections have caused death. Nor could they specify how many of the more than 25,000 troops injured in the two conflicts have been infected, but that question is expected to be addressed in the study.

University of Missouri researchers plan to inject rabbits with an agent that causes tissue damage similar to wounds from bomb attacks. The researchers will then inject the rabbits with bacteria and treat them with antibiotics to learn how to contain the four types of infections.

Military doctors first noticed a high rate of Acinetobacter infections in 2003 at the U.S. military hospital in Landstuhl, Germany, a destination for many wounded troops. Doctors found evidence of the infection in patients with pneumonia.

Acinetobacter is found in soil and can live on open surfaces for a number of days, enabling it to spread. It is rare for healthy people to become infected, but medical experts say that patients on ventilators can be vulnerable.

Pseudomonas aeruginosa thrives in moist environments and is a threat to patients with several kinds of injuries, including burns.

Klebsiella pneumoniae is typically acquired in a hospital setting and is often associated with people with poor nutrition and those with slightly depressed immune systems.

Both Pseudomonas aeruginosa and Klebsiella pneumoniae can live in water, another possible medium for the spread of infection, doctors said.

Some patients with open wounds also seem susceptible to the dangerous Staphylococcus aureus, which is found on skin.

Srinivasan said that infection-control methods used in civilian hospitals often cannot be applied in military hospitals in war zones.

“How do you maintain infection control in a combat setting?” Srinivasan said. “The challenges the military faces are not the same challenges in civilian hospitals. It makes the problem even more difficult to combat.”

Oral Bacteria Linked to Health Problems

By Shari Roan
Tribune Newspapers: Los Angeles Times

May 1, 2007

Gustavo Rodriguez had expected numerous physical exams and blood tests before checking into the hospital last July for a long-awaited kidney transplant. But he was bewildered when told to see a dentist.

"My gums were really bad, but I didn't know that mattered," said Rodriguez, 26, of Long Beach, Calif. "They said I had to be bacteria-free before my surgery. I learned a lot ... like every little thing in your body counts."

And as doctors and dentists now suspect, gum disease is no little thing.

Research compiled over the last five years suggests that gum disease, especially if the condition has persisted for a long time without treatment, can contribute to diabetes, cardiovascular disease and stroke, pregnancy complications, and perhaps even Alzheimer's disease, osteoporosis and some types of cancers. Infections in the mouth also might increase the risk to people undergoing several types of surgery, including transplantation and cardiac-valve replacement.

"For years the mouth was never considered a part of the body," said Dr. Salomon Amar, a periodontist at Boston University. "Gum disease was not considered something that could have any impact."

Migration

But as recently as March, a study published in the New England Journal of Medicine found that treating severe gum disease can improve the function of blood-vessel walls, improving heart health. And in April's Journal of Periodontology, two studies found periodontal bacteria (bugs normally found in inflamed gums) in the arteries of people with heart disease and in the placentas of pregnant women with high blood pressure.

It's still too soon in the evolution of this research to say with certainty that gum disease directly causes other illnesses. But the evidence is compelling enough that it's beginning to unite dental and medical professionals, two groups that have had only a nodding acquaintance.

And it's leading to one of the most sweeping changes in the dental-insurance industry in more than a decade. Several health-insurance companies, particularly those that offer both dental and medical insurance, are beginning to offer free or low-cost "enhanced" dental benefits to certain high-risk patients who might experience broader health benefits by having a cleaner mouth.

Gum problems begin when the bacteria in plaque, the sticky film that forms on teeth, persists long enough to inflame the gums.

Usually, inflammation is considered a positive response to bacteria, a sign that the body is fighting back. But if inflammation rages unchecked, it does more harm than good.

Inevitable

At some point most Americans will have gingivitis, an inflammation of the superficial structure of the gum that can be a precursor to gum disease. Although good brushing, flossing and favorable genetics can limit the extent of gingivitis and keep gum disease at bay, this condition of persistent inflammation affects 30 percent to 40 percent of American adults. Of those, about 10 percent have advanced cases that damage the structures (ligaments and bone) that support the teeth.

Other than bleeding, gum disease has few symptoms and rarely causes much discomfort. "The gums do not hurt until it is too late," Amar said.

Well before the gums or teeth start to hurt, the dual forces of infection and inflammation in the mouth appear to hitch a ride in the bloodstream and travel to other parts of the body, wreaking havoc once there.

One of the most well-established links between gum disease and secondary infection, for example, is among people with mitral-valve heart defects. Doctors have long warned valve patients to take antibiotics before teeth cleanings so that the bacterial disruption in the mouth will not travel through the bloodstream to infect the valve.

The other theory of how gum disease inflicts damage elsewhere in the body involves inflammation. Bacteria in plaque release toxins that cause the immune system to produce chemicals called cytokines. In excess, cytokines can increase inflammation and damage tissues throughout the body. Inflammation in general (no matter how it starts) is now considered a prime culprit in the development of many illnesses, including heart disease and some types of cancer.

"The key in gum disease is chronic inflammation," said Preston D. Miller Jr., president of the American Academy of Periodontology. "When it becomes chronic, it begins to release substances that destroy tissue."

Periodontal Benefits

Although gum disease could worsen many conditions, experts and dental insurance companies are most interested in heart disease, diabetes and pregnancy -- conditions in which successful periodontal treatment could yield ample benefits.

Studies are needed to conclusively prove whether treating gum disease affects various conditions, said Bryan Michalowicz, an associate professor at the University of Minnesota School of Dentistry and lead author of a study showing that treatment of gum disease did not prevent premature birth.

"There are a number of criteria that have to be met before we can conclude that something is a cause," he says.

Super Bug Bill Targets Hospitals

State Measure Could Dictate Fight Against Deadly Bacterium

By Judith Graham
Tribune staff reporter
April 30, 2007

Illinois is poised to become the first state to require hospitals to implement programs combating a dangerous, drug-resistant bacterium that kills thousands of people in the U.S. each year.

Under a bill moving through the legislature, hospitals would be required to test for methicillin-resistant staphylococcus aureus, or MRSA, in all intensive- care and "at-risk" patients, such as those transferred from nursing homes. If it is detected, aggressive measures to prevent transmission would kick in.

MRSA is a potentially virulent bacterium that has developed strong defenses against common antibiotics such as penicillin. People can become infected in community settings such as gyms, but MRSA is most commonly acquired in health-care facilities.

The drug-defying super bug has been spreading rapidly. Nearly 11,000 Illinois hospital patients were infected last year, a 54 percent rise in just three years, according to the Illinois Hospital Association. Nationally, MRSA strikes about 126,000 hospital patients a year and kills at least 5,000 to 17,000.

"More people are infected and die of MRSA each month in hospitals in the U.S. than from severe acute respiratory syndrome [SARS], anthrax, bioterrorism agents [and] avian influenza combined," Dr. William Jarvis, the CDC's former acting director of the hospital infections program, said in written comments to a February hearing in Springfield.

No one disputes that MRSA is a pressing health concern, but the Illinois bill has sparked considerable controversy.

Critics include prominent medical specialists who argue the legislation is too prescriptive and would impair their ability to address emerging crises. Supporters include the Illinois Hospital Association and consumer advocates, who argue that hospitals have done too little to fight MRSA, putting patients' health at risk.

Lawmaker support

Illinois lawmakers have sided strongly with advocates in the first round of votes on proposed legislation. A final vote is expected within the next month.

"Sure, hospitals and doctors don't want to be told what to do," said Jeanine Thomas, who contracted MRSA in 2000 in a Chicago hospital. "But look at how out-of-control MRSA is."

The goal of the Illinois bill is to identify people who are potential reservoirs of infection and to stop them from passing it on. Two percent to 4 percent of people admitted to hospitals carry MRSA in their nose or on their skin without displaying symptoms.

Transmission could occur when a colonized patient rubs her nose before shaking hands with the doctor who comes in for an examination. The doctor could then carry the bacteria to another patient on his hands or on equipment he's handled.

To limit MRSA's spread, patients who test positive would be isolated; everyone entering a patient's room would put on sterilized gowns, gloves and masks; and strict hand-washing regimens would be instituted.

More than 140 studies have shown that the approach, called active surveillance culturing, can reduce MRSA infections in hospitals by more than 70 percent.

Nationally, the strategy is attracting attention. In March, the Department of Veterans Affairs implemented it at more than 150 hospital intensive-care units across the U.S. Several states, including Minnesota, Pennsylvania and New York, are looking at MRSA-control legislation. In January, the Hospital Corp. of America adopted similar MRSA-control measures at 165 hospitals in 20 states.

Dr. Jonathan Perlin, Hospital Corp.'s chief medical officer, said he is confident the effort will pay off by reducing complications that result in expensive patient stays. "Everything we do to eliminate MRSA will eliminate other drug-resistant infections," Perlin said.

Under the Illinois bill, hospitals also would have to report MRSA infections annually to the state Department of Public Health, which would publish statewide data on its Web site. Currently, hospitals do not disclose MRSA infections rates either locally or nationally.

Critics worry, however, that resources devoted to MRSA detection could detract from other important efforts to improve patient safety in hospitals.

Important Tool

Active surveillance for MRSA is "an important tool I want to be able to use, but I don't want to be told where and when I have to use it," said Dr. Stephen Weber, an infectious disease specialist at the University of Chicago Medical Center.

Instead, Weber argued, hospitals should be free to direct resources toward the most compelling concerns in their institutions. For instance, the University of Chicago is focusing on reducing infections at surgical sites, which will help control MRSA as well as other drug-resistant bacteria, Weber said.

"It's probably not a good idea to legislate a one-size-fits-all approach, because hospitals have different problems," said Dr. Gary Noskin, associate chief medical officer at Northwestern Memorial Hospital. "The best approach is to rely on each institution's expertise."

The Illinois bill's sponsors don't buy it.

"The problem is, the hospitals have said they want to deal with this for at least 20 years and the incidence of MRSA infections keeps rising at an alarming rate," said state Sen. Christine Radogno (R-Lemont).

"These infections don't have to happen. We know what we need to do to prevent them. Hospitals just aren't doing it," said Dr. Barry Farr, an infection-control expert and professor emeritus at the University of Virginia.

Systematic testing and isolation of MRSA-colonized patients isn't common practice in hospitals, although many identify hot spots of infection and address periodic outbreaks.

Patients struck by MRSA and those who have lost loved ones say they lost trust in hospitals long ago.

Dayle Stirn, 59, of Crest Hill broke her leg in 2005 after tripping at a church function. Doctors at a nearby hospital operated, and within a week blood blisters began breaking out around Stirn's surgical wound.

Eventually, Stirn learned she had MRSA and returned to the hospital for a second operation to remove infected tissue. "Can someone tell me, realistically, what I'm facing here?" she remembers asking doctors and nurses. Stirn said she never got a good answer.

Today, after another three surgeries, Stirn can walk only with crutches, a walker or a cane. "I went in there as a 57-year-old woman with no health problems and came out like this," she said.

Lost Husband

Loretta Arens of Lansing lost her husband, Austin, to an MRSA infection he acquired in a Chicago hospital after heart surgery in 2003. Within days, the 79-year-old man went from sitting up and talking to lying unresponsive on a respirator.

"It's like a plague, this infection. It ravages your body. Everything shuts down," Arens said, her voice trembling.

"No one would say how he got this infection," she continued, remembering her frustration. "They didn't even want to name it, like it was some kind of secret."

Thomas, the advocate who's been pushing Illinois lawmakers to act, had a similar experience when she contracted MRSA in 2000 after slipping on ice and having ankle surgery.

In terrible pain, with a high fever and a wound that had turned black, Thomas was readmitted to the hospital and almost died.

At no point did doctors tell this former travel executive what kind of infection she had, Thomas said. She figured it out herself when a friend suggested she look into MRSA and later confirmed it by reviewing her medical records.

Over the next year, Thomas had six additional painful surgeries. Once infected with MRSA, people are susceptible to additional bouts of infection.

After launching a support group for MRSA survivors, Thomas turned her attention to educating Illinois lawmakers.

"I figured I survived for a reason," she said.