Antibiotic Overuse Threatens Modern Medicine: Experts

Kate Kelland
Tue Nov 10, 2009

LONDON (Reuters) - Overuse of antibiotics in Europe is building widespread resistance and threatening to halt vital medical treatments such as hip replacements, intensive care for premature babies and cancer therapies, health experts say.

Dominique Monnet of the European Center for Disease Prevention and Control's (ECDC) scientific advice unit said the "whole span of modern medicine" is under threat because bugs are become resistant to antibiotics, rendering the drugs useless.

"If this wave of antibiotic resistance gets over us, we will not be able to do organ transplants, hip replacements, cancer chemotherapy, intensive care and neonatal care for premature babies," he told reporters at a briefing.

Antibiotics are needed in all these treatments to prevent bacterial infection. But drug-resistant bacteria are a growing problem in hospitals worldwide, marked by the rise of superbugs such as methicillin-resistant Staphyloccus aureus (MRSA).

Such infections kill about 25,000 people a year in Europe and around 19,000 in the United States

On top of the risks to future treatments, Monnet said the costs of antibiotic resistance were already hurting -- and may hit healthcare budgets across the European Union yet harder if the problem is not addressed.

The six most common multi-drug-resistant bacteria -- often referred to as superbugs -- cause around 400,000 infections a year in Europe, killing around 25,000 people and using 2.5 million hospital days a year.

The ECDC, which monitors and advises on disease in EU, calculates that with a hospital day costing an average of 366 euros ($548), superbug infections are already sucking up 900 million euros a year in extra hospital costs, and a further 600 million euros a year in lost productivity.

"Across the European Union the number of patients infected by resistant bacteria is increasing and that antibiotic resistance is a major threat to public health," the ECDC said.

Britain's government was criticized by a parliamentary committee on Tuesday for failing to tackle the majority of hospital-acquired infections by narrowing its focus to two high profile ones -- MRSA and Clostridium difficult.

The ECDC conducted an "antibiotic awareness" campaign in November to urge doctors to stop overprescribing antibiotics.

Patients demanding antibiotics for viral infections often are not aware that they will not work, it said, but doctors are and should stop giving in to pressure.

Sarah Earnshaw of the ECDC's communications unit, pointed to a 2002 survey that showed 60 percent of patients do not know that antibiotics do not work against viruses like flu and colds.

"Patients often demand antibiotics," she said. And doctors often think, she said, that giving in is a quicker way to deal with a demanding patients than persuading them otherwise.

(Editing by Louise Ireland)

Antibiotic Overuse? Not in Norway

Associated Press Writers

OSLO, Norway (AP) -- Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.

Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospitals of Europe, North America and Asia this year, soaring virtually unchecked.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway's public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world prove that Norway's model can be replicated with extraordinary success, and public health experts are saying these deaths -- 19,000 in the U.S. each year alone, more than from AIDS -- are unnecessary.

"It's a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort," said Jan Hendrik-Binder, Oslo's MRSA medical adviser. "But you have to take it seriously, you have to give it attention, and you must not give up."

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by The Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway's simple solution, there's a glimmer of hope.

Dr. John Birger Haug shuffles down Aker's scuffed corridors, patting the pocket of his baggy white scrubs. "My bible," the infectious disease specialist says, pulling out a little red Antibiotic Guide that details this country's impressive MRSA solution.

It's what's missing from this book -- an array of antibiotics -- that makes it so remarkable.

"There are times I must show these golden rules to our doctors and tell them they cannot prescribe something, but our patients do not suffer more and our nation, as a result, is mostly infection free," he says.

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What's here? Medicines considered obsolete in many developed countries. What's not? Some of the newest, most expensive antibiotics, which aren't even registered for use in Norway, "because if we have them here, doctors will use them," he says.

He points to an antibiotic. "If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail," he says, "and rightly so because it's useless there."

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

"We don't throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better," says Haug.

Convenience stores in downtown Oslo are stocked with an amazing and colorful array -- 42 different brands at one downtown 7-Eleven -- of soothing, but non-medicated, lozenges, sprays and tablets. All workers are paid on days they, or their children, stay home sick. And drug makers aren't allowed to advertise, reducing patient demands for prescription drugs.

In fact, most marketing here sends the opposite message: "Penicillin is not a cough medicine," says the tissue packet on the desk of Norway's MRSA control director, Dr. Petter Elstrom.

He recognizes his country is "unique in the world and best in the world" when it comes to MRSA. Less than 1 percent of health care providers are positive carriers of MRSA staph.

But Elstrom worries about the bacteria slipping in through other countries. Last year almost every diagnosed case in Norway came from someone who had been abroad.

"So far we've managed to contain it, but if we lose this, it will be a huge problem," he said. "To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can't prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics."

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics. Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares to 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

In the U.S., cases have soared and MRSA cost $6 billion last year. Rates have gone up from 2 percent in 1974 to 63 percent in 2004. And in the United Kingdom, they rose from about 2 percent in the early 1990s to about 45 percent, although an aggressive control program is now starting to work.

About 1 percent of people in developed countries carry MRSA on their skin. Usually harmless, the bacteria can be deadly when they enter a body, often through a scratch. MRSA spreads rapidly in hospitals where sick people are more vulnerable, but there have been outbreaks in prisons, gyms, even on beaches. When dormant, the bacteria are easily detected by a quick nasal swab and destroyed by antibiotics.

Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway's solutions in varying degrees, and his agency "requires hospitals to move the needle, to show improvement, and if they don't show improvement they need to do more."

And if they don't?

"Nobody is accountable to our recommendations," he said, "but I assume hospitals and institutions are interested in doing the right thing."

Dr. Barry Farr, a retired epidemiologist who watched a successful MRSA control program launched 30 years ago at the University of Virginia's hospitals, blamed the CDC for clinging to past beliefs that hand washing is the best way to stop the spread of infections like MRSA. He says it's time to add screening and isolation methods to their controls.

The CDC needs to "eat a little crow and say, 'Yeah, it does work,"' he said. "There's example after example. We don't need another study. We need somebody to just do the right thing."

But can Norway's program really work elsewhere?

The answer lies in the busy laboratory of an aging little public hospital about 100 miles outside of London. It's here that microbiologist Dr. Lynne Liebowitz got tired of seeing the stunningly low Nordic MRSA rates while facing her own burgeoning cases.

So she turned Queen Elizabeth Hospital in Kings Lynn into a petri dish, asking doctors to almost completely stop using two antibiotics known for provoking MRSA infections.

One month later, the results were in: MRSA rates were tumbling. And they've continued to plummet. Five years ago, the hospital had 47 MRSA bloodstream infections. This year they've had one.

"I was shocked, shocked," says Liebowitz, bouncing onto her toes and grinning as colleagues nearby drip blood onto slides and peer through microscopes in the hospital laboratory.

When word spread of her success, Liebowitz's phone began to ring. So far she has replicated her experiment at four other hospitals, all with the same dramatic results.

"It's really very upsetting that some patients are dying from infections which could be prevented," she says. "It's wrong."

Around the world, various medical providers have also successfully adapted Norway's program with encouraging results. A medical center in Billings, Mont., cut MRSA infections by 89 percent by increasing screening, isolating patients and making all staff -- not just doctors -- responsible for increasing hygiene.

In Japan, with its cutting-edge technology and modern hospitals, about 17,000 people die from MRSA every year.

Dr. Satoshi Hori, chief infection control doctor at Juntendo University Hospital in Tokyo, says doctors overprescribe antibiotics because they are given financial incentives to push drugs on patients.

Hori now limits antibiotics only to patients who really need them and screens and isolates high-risk patients. So far his hospital has cut the number of MRSA cases by two-thirds.

In 2001, the CDC approached a Veterans Affairs hospital in Pittsburgh about conducting a small test program. It started in one unit, and within four years, the entire hospital was screening everyone who came through the door for MRSA. The result: an 80 percent decrease in MRSA infections. The program has now been expanded to all 153 VA hospitals, resulting in a 50 percent drop in MRSA bloodstream infections, said Dr. Robert Muder, chief of infectious diseases at the VA Pittsburgh Healthcare System.

"It's kind of a no-brainer," he said. "You save people pain, you save people the work of taking care of them, you save money, you save lives and you can export what you learn to other hospital-acquired infections."

Pittsburgh's program has prompted all other major hospital-acquired infections to plummet as well, saving roughly $1 million a year.

"So, how do you pay for it?" Muder asked. "Well, we just don't pay for MRSA infections, that's all."

Martha Mendoza is an AP national writer who reported from Norway and England. Margie Mason is an AP medical writer based in Vietnam, who reported while on a fellowship from The Nieman Foundation at Harvard University.

MRSA Leads to Worse Outcomes, Staggering Expenses for Surgical Patients

ScienceDaily (Dec. 17, 2009)

Post-surgical infections significantly increase the chance of hospital readmission and death and cost as much as $60,000 per patient, according to Duke University Medical Center researchers who conducted the largest study of its kind to date.

"We conducted a multi-center study of multiple surgical procedure types among 659 patients to determine clinical and financial outcomes of surgical site infections that are directly attributable to MRSA (methicillin-resistant Stapylococcus aureus)," said Deverick J. Anderson, M.D., MPH, an infectious diseases specialist at Duke University Medical Center and lead author of the study. "We found the impact of methicillin-resistance on surgical patients is substantial and that preventing a single case of surgical site infection due to MRSA can potentially save hospitals as much as $60,000."

Previously published research on surgical site infections provided conflicting conclusions. For the Duke study, researchers looked at the 90-day postoperative period for patients over a five-year period in one tertiary care center and six community hospitals in the Duke Infection Control Outreach Network (DICON). Created in 1997, DICON assists community hospitals in improving quality of care and enhancing patient safety, while minimizing the costs associated with non-evidence based approaches to infection control.

The researchers compared hospital readmission, mortality, length of hospital stay and hospital charges for patients in three groups. Some had surgical site infections due to MRSA, some were infected with methicillin-susceptible Staphylococcus aureus (MSSA), and some were uninfected. The study evaluated deep-incision and organ/space infections, which are more severe than superficial infections at the site of incision. The findings are published in PLoS ONE.

"We found that patients with surgical site infections due to MRSA were 35 times more likely to be readmitted and seven times more likely to die within 90 days compared to uninfected surgical patients," Anderson said. "These patients also required more than three weeks of additional hospitalization and accrued more than $60,000 in additional charges."

The researchers found most of the outcomes for MRSA compared to MSSA were worse, as anticipated, however one finding was surprising, according to Anderson. "Our findings show that methicillin-resistance contributed to longer hospital stays and increased hospital charges but did not increase the risk of mortality," he said. The data shows that patients with surgical site infections due to MRSA compared to MSSA on average required six more days of hospitalization and incurred $24,000 in additional charges.

"For the seven hospitals we looked at, the total estimated cost resulting from surgical site infections due to MRSA was more than $19 million," Anderson said. "That's a staggering amount, which demonstrates an area of cost-saving potential for these institutions and other community hospitals."

The Duke study provides the first cost impact data tied to post-surgical MRSA infection in a large group of hospitals. "Given our estimated cost of one MRSA case, we can conclude that a $60,000 intervention to prevent even one of these infections would be cost-effective for an institution," Anderson said. "With this new financial data, greater emphasis should be placed on an effort to design and evaluate specific preventative interventions."

Other researchers involved in the study include Luke F. Chen, Kenneth E. Schmader, Yong Choi and Daniel J. Sexton of Duke University Medical Center; and Keith S. Kaye, formerly of Duke University Medical Center now at Detroit Medical Center.

MRSA Infections Nearly Doubled Over Last 10 Years: Study

Published: November 27th, 2009

U.S. researchers indicate that there has been a 90% increase in antibiotic-resistant “superbug” infections since 1999, as strains circulating both in hospitals and the community continue relatively unabated.

The study, published in the CDC’s Emerging Infectious Diseases medical journal, pulled data from 300 microbiology laboratories. Researchers at the University of New Jersey found that not only is methicillin-resistant Staphylococcus aureus (MRSA) spreading outside of hospitals as well as within, but that outpatients being admitted to hospitals were major contributors to infections spread within hospitals as well.

According to the U.S. Centers for Disease Control and Prevention (CDC), there are more than 2 million hospital infections acquired each year, resulting in about 90,000 deaths annually. Another 1.5 million long term care and nursing home infections occur every year.

Methicillin-resistant Staphylococcus aureus, commonly referred to as a MRSA infection, has accounted for more than 60 percent of hospital staph infections in recent years. The CDC reports that about 126,000 hospital MRSA infections occur each year, resulting in about 5,000 deaths. But the researchers suggest that the number of deaths from MRSA in the U.S. is closer to 20,000 annually.

The rate of community-acquired infections (CA-MRSA) increased by about 33% annually, researchers found, resulting in an overall MRSA increase of 10% every year. And those infected individuals often made their way into U.S. hospitals, where they then infected hospital staff and other patients, even while hospitals slowed their own rate of infection, the study found.

“Outpatients, who outnumber inpatients by [about] 3:1, may play a major role in the spread of CA-MRSA strains from the community to the hospital through their interaction with hospital staff or use of similar hospital resources, such as surgical rooms,” researchers stated.

As more hospitals and medical facilities have begun to follow protocols designed to reduce the risk of hospital infections, those that have not established the standards or enforced the rules have been found by juries in medical malpractice lawsuits to be providing care that does not fall within the ordinary standard of care for the industry.

University of New Jersey researchers said that the community strains now entering hospitals are not replacing hospital strains, but instead are adding to the numbers of people infected, and said that strategies for prevention of infection and treatment of patients needs to be coordinated at the local level.

“Infection control policies should take into account the role that outpatients likely play in the spread of MRSA and promote interventions that could prevent spread of MRSA from outpatient areas to inpatient areas,” Researchers concluded.

Staph infections have risen by more than 90 percent, study finds


Published: Monday, November 30th, 2009

The number of cases of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased by more than 90 percent over the last decade, according to recent research led by University scholars.
Ramanan Laxminarayan, a visiting scholar at the Princeton Environmental Institute, and Eili Klein, a visiting specialist in the ecology and evolutionary biology department, co-authored a paper on the spread of MRSA infections from 1999 through 2005.

In 2006, there were 278,203 reported cases of MRSA-related infection, more than double the number in 1999, according to the paper. As many as 17,280 people infected with MRSA died in 2005, more than the number of people who died of AIDS that year. The paper, published in the December 2007 issue of the journal Emerging Infectious Diseases, stressed that MRSA should be “considered a national priority for disease control.”

These infections are caused by the bacterium Staphylococcus aureus, which usually lives on the skin and in the nasal passages and can be harmful if it enters the body through a sore or cut.

The growing number of MRSA cases reflects the increasing resistance of Staphylococcus bacteria to antibiotics over the last few years. The researchers discovered that resistance to various antibiotics like ampicillin and erythromycin increased by more than 20 percent between 1999 and 2005, and the researchers said the widespread use of antibiotics in the past few decades has made their use less effective.

Klein explained that the increase in MRSA cases has consequences beyond health risks. People who have infections resistant to treatment face a number of extra costs because they “tend to stay longer in hospitals and may need more expensive drugs,” he said. For instance, the cost of treating MRSA infections can range between $3,000 and $36,000 more than a methicillin-sensitive infection, according to his research.

Klein added that he believes there is a need to reduce the inappropriate use of antibiotics, which helps the bacteria develop their resistance. For example, instead of prescribing antibiotics to patients who are sick and insist on being prescribed drugs to “make them feel better,” doctors should explain to their patients when they don’t need antibiotics, Klein said.

“Every time somebody uses an antibiotic, that reduces the number of times the antibiotic can ever be used because it’s going to create resistance,” he explained.

Laxminarayan referred all requests for comment to Klein.

The researchers also discovered another important trend in their data. Hospital-associated MRSA infections, occurring mostly in patients with weakened immune systems, have been more common than community-associated MRSA infections, occurring among those who pick up the bacteria in fitness centers, common restrooms and other public places. The researchers found that the percentage of hospital outpatients who reported community-associated MRSA infections had jumped drastically from about 10 percent to roughly 50 percent between 1999 and 2005. They concluded that community-associated MRSA infections are currently spreading more rapidly, and that they are possibly making their way into hospitals.

To prevent transmission between people in the outpatient and inpatient units, Laxminarayan and Klein, in their paper, called for stringent hand-washing and other infection-control practices in hospitals.

Let Me See You Wash Your Hands


One of the heroes of SuperFreakonomics is Ignatz Semmelweis — who crunched numbers in the 1840’s to champion the benefits of doctors washing their hands.

“The reason why unusual interventions are necessary is simply because voluntarism wasn’t working.” (I’ve written a bit about him myself and, for some odd reason, I just love to pronounce “Ignatz” out loud.) It has taken the medical profession a long, long time to get religion on hand sanitization.

But there is good news: Clean Hand programs are now the norm at hospitals. SuperFreakonomics explains how hand-hygiene compliance at Cedars-Sinai Medical Center “shot up to nearly 100 percent” after the hospital started using disgusting pictures of the bacteria found on the palm prints of physicians as screensavers. I can verify that other hospitals are copying this solution.

A couple of weeks ago, one of my coauthors had a health scare and was hospitalized for a night in New Haven. Her hospital ward was plastered with color photocopies of disgusting, bacteria-laden palm cultures.

I’m also impressed with the increasing practice of hand-sanitation in front of the patient. Many health care workers show you that they have just applied hand gel as they are coming in to examine you. We’re slowly getting to the point where patients might start calling out doctors who don’t sanitize in their presence.

Indeed, in addition to the disgusting hand cultures, hospitals might do well to post notices asking patients to challenge anyone who tries to treat without sanitizing in their presence. (This idea is a bit like the restaurants that say “your food is free if you are not given a receipt.”)

The reason why unusual interventions are necessary is simply because voluntarism wasn’t working. Giving health care workers the unaided choice resulted in too many people bypassing the hand-washing opportunity. Sadly, hand sanitation is a classic non-durable precaution. To be effective, it needs to be done repeatedly. Psychologically, it needs to become routine for us to have a chance of making the practice stick. (That’s how I finally got in the habit of using a seat-belt.)

Having won the day with hospitals, we should turn our attention toward schools. Sadly, most schools are at best stuck in voluntary regimes where students can wash their hands if they want to. My concern is that not enough students avail themselves of this option. Even if 80 percent regularly choose to sanitize (a pipe dream), the persistence of a recalcitrant 20 percent might undermine the public health benefits of sanitation.

If your school or place of business has public hand-sanitizers, I’d love to learn how often you have to refill the dispensers. If we know the rate of use and the number of people in the building, we can know the average rate of sanitation. I bet we’d find that the rate of sanitation would be very low. (I bet we’d find a similar result if we compared toilet paper use to soap use in school toilets. We should be very scared if there are 100 sheets of toilet paper used for every dose of hand soap.)

Schools should experiment with mandating routine, public hand sanitation. As a beginning, they might put hand gel dispensers in science class and ask the teachers to make sure that their students dose their hands at the end of class.

Mandating hand-sanitation might reduce sick days by as much as 20 percent. In fact, that’s what this 2002 study of 18 elementary schools (located in Delaware, Ohio, Tennessee, and California) found. The study protocol required multiple sanitations per day:

[T]he students were instructed to also use the waterless alcohol gel hand sanitizer when entering and leaving the classroom, especially first thing in the morning, before and after lunch, after recesses, after use of the restroom, and before going home. Students were also encouraged to use the sanitizer when they sneezed or coughed. Crucially, the study made teachers responsible for ensuring that the protocol was followed.

Compared with paired control group schools, students who were forced to clean their hands ended up with 19.8 percent fewer sick days (the full article is behind a firewall here; similar studies are abstracted here). And teachers’ absenteeism dropped by 10.1 percent. These figures ignore the beneficial effects on moms and dads and others who probably got sick less too.

As our nation suffers through another flu season, the spirit of Ignatz Semmelweis calls out to us across the decades for less discretionary hand sanitation.

Drug Resistant MRSA has Increased by 90% Over the Past Decade

Featured TNM Health Update

A recent study conducted at the Princeton University has revealed that cases of the drug resistant bacterial infection MRSA have rapidly increased by as much as 90% over the past decade, and are still spreading at an alarming rate outside hospitals.

Researchers, led by Ramanan Laxminarayan, analyzed data on laboratory tests of a countrywide network of 300 microbiology laboratories across the US for the sake of study, and reported that two new strains of MRSA have been recently found circulating in patients, which are completely different from those discovered earlier.

"We found during 1999-2006 that the percentage of S. aureus infections resistant to methicillin increased more than 90 percent, or 10 percent a year, in outpatients admitted to U.S. hospitals. This increase was caused almost entirely by community-acquired MRSA strains, which increased more than 33 percent annually", shared the researchers.

Researchers discovered that a large number of people were now being diagnosed with MRSA, and the strains found in those patients were not replacing their older counterparts, but simply adding to them, thereby making the infection worse and more difficult to combat.

It has been estimated that nearly 20,000 people die every year in the US after contracting MRSA, and the infection's treatment can cost anywhere from $3,000 to over $35,000 per case.

Rougly 50% Of Patients In Intensive Care Suffer Infections

Washington (SmartAboutHealth)

According to a new study, roughly 50% of patients who are in intensive care units suffer from infections.

The new study was carried out by researchers led by Dr. Jean-Louis Vincent of Erasme Hospital in Belgium.

The study analyzed data from one single day, May 8, 2007. The day consisted of looking at data on adults who were 18-years-old an dup from over 75 different countries.

There were over 13,000 patients involved in total that were put in over 1,250 intensive care units around the world.

Researchers confirmed from this data that 51% of those patients in an ICU were suffering from an infection.

32% of patients who were in an ICU for a day or less suffered from an infection, compared to 70% who spent seven days or more.
On top of that, they found that 71% were being treated with an antibiotic for an infection.

Breaking down the infections further, researchers confirmed that the majority of the infections, 64%, took place in the lungs.

South America was found to have the highest rate of infection.

The study has been published in the December 2nd issue of the Journal of the American Medical Association.

Lawmakers set to make healthcare changes

The Washington Times
By Jennifer Haberkorn
December 2, 2009

Bracing for a lengthy debate that has been rambunctious since day one, lawmakers are preparing dozens of additional changes to Democrats' health care overhaul legislation.

Everything from the major flashpoints -- government-run insurance, Medicare spending and abortion -- to lesser-known topics such as hospital reimbursements and an in-home insurance plan are likely to face intense scrutiny on the Senate floor in the form of amendments.

Sens. Susan Collins, Maine Republican, and Joe Lieberman, Connecticut independent, plan to offer amendments to reduce the rate of hospital-acquired infections and change the way the small-business tax credits are structured, according to a Senate aide.

"I'd like to see more of a penalty for [government-backed] reimbursements to hospitals that have high rates of hospital-acquired infections," Ms. Collins told reporters on Tuesday.

Ms. Collins discussed both issues with White House health care "czar" Nancy-Ann DeParle in her Senate office on Monday, signaling just how closely Democrats are listening to her in hopes of getting bipartisan support for their bill.

Mr. Lieberman is also a swing vote, meaning that his and Ms. Collins' amendments are likely to get more than a glance from Democratic leaders. He is an independent and caucuses with Democrats but said he would support a Republican filibuster if the legislation contains a public insurance plan at the end of the debate.

Any amendment that significantly changes the legislation could change the dynamic of attracting 60 votes. Changes that pick up the support of some members could come at the cost of others. For instance, if an amendment to remove the public option passes, one or two moderate Republicans could come on board, but it could make liberal Democrats revolt.

The debate over the first two amendments has already been contentious. The Republicans' first amendment -- a proposal to eliminate nearly $500 billion in Medicare cuts -- was dubbed a "huge big belly-flop flip-flop" by Senate Majority Leader Harry Reid of Nevada.

Mr. Reid said Sen. John McCain's amendment was merely "one big earmark to the insurance industry" and not in line with the Arizona Republican and former presidential candidate's disdain for members of Congress favoring specific companies or industries in legislation.

Democrats say the proposed cuts would merely eliminate waste and fraud and not have an impact on benefits. But Mr. McCain and Republicans say there is no way to make such cuts without reducing seniors' care.

The Democrats' first amendment, from Sen. Barbara A. Mikulski of Maryland, was co-sponsored by Sen. Olympia J. Snowe, Maine Republican. It would give the health and human services secretary the authority to require insurers to cover additional preventive screenings for women. Just last month, controversial recommendations to limit screenings sparked worry that the Democrats' plan would ration care.

The debate is expected to last at least through the end of the year, with dozens of amendments offered by both sides.

Sen. Ben Nelson of Nebraska, one of the Democrats most skeptical of the legislation, said he plans to introduce amendments to insert abortion restrictions, strip the CLASS (Community Living Assistance Services and Supports) Act -- a program to fund in-home care for disabled Americans that some say has questionable funding -- and "deal" with the public insurance plan.

He declined to say how he plans to address the public plan, but said he prefers a state-based approach and would consider a plan in which states can "opt in" instead of opt out, as the bill currently is written.

Mr. Nelson said he would have a hard time voting for a health bill that doesn't have abortion restrictions similar to what the House passed last month. Their plan, with an amendment from Rep. Bart Stupak, Michigan Democrat, would prohibit patients on the public insurance plan from obtaining abortions without separate insurance. It sparked a firestorm from supporters of abortion rights who said the language went too far.

Other expected amendments include a repeal of the insurance companies' antitrust exemptions, from Sen. Patrick J. Leahy, Vermont Democrat, and cost-cutting measures from a group of moderate freshman Democrats.

Hospital infections disturbingly common worldwide News Staff
Date: Wednesday Dec. 2, 2009 7:23 AM ET

A huge new study finds that about half of all patients in intensive care wards around the world are battling some kind of infection.

The study, led by Dr. John Marshall of St. Michael's Hospital in Toronto looked at data from 1,265 intensive care units in hospitals in 75 countries.

It found that in one 24-hour period in 2007, more than half of the over 14,000 patients in ICUs that day had infections. Of those infected:

60 per cent had pneumonias
20 per cent were infections inside the abdomen
15 per cent were infections of the urinary tract
The longer the patients stayed in intensive care, the bigger their risk of becoming infected, the study findings suggest. The infection rate increased from 32 per cent for patients with an ICU stay of one day or less, to more than 70 per cent for patients with an ICU stay of more than seven days.

Not surprisingly, infected patients had longer ICU and hospital lengths of stay than those not infected.

Patients in ICUs who were battling infections were more than twice as likely to die than non-infected patients (25 per cent vs. 11 per cent). Their in-hospital death rate overall was also higher than non-infected patients (33 per cent vs. 15 per cent).

It's been well-documented that infections can increase the risk of death in the hospital. But the authors estimate they also account for about 40 per cent of total ICU health care costs.

"One of the things that this study actually allows us to do, is to begin to get a sense as to how much of the burden of infection is an added burden on a patient who is already at risk of dying because of the underlying diseases that led them to be in the intensive care unit," Dr. Marshall said in a statement.

Countries in Central and South America had the highest infection rates while more developed countries such as Australia and New Zealand had the lowest rates.

There are a number of things doctors could do to limit infections in hospital, write two doctors in an accompanying editorial, Dr. Steven M. Opal, of Warren Alpert Medical School of Brown University in Providence, R.I., and Dr. Thierry Calandra, of Centre Hospitalier Universitaire Vaudois and University of Lausanne in Switzerland.

Firstly, doctors should work to combat antibiotic resistance by limiting the use of antibiotics to patients who clearly have bacterial infections and then discontinue their use when their possible benefits have been obtained.

But even more important, new drugs need to be developed to replace the increasingly obsolete classes of antibiotics that currently exist, they insist.

"A 'post-antibiotic era' is difficult to contemplate but might become a reality unless the threat of progressive antibiotic resistance is taken seriously," the authors write.

GOP lawmaker wants tougher penalties for hospital infections

By Matthew DoBias
December 1, 2009

A key Republican being courted as a possible swing vote on healthcare reform by Senate leaders and the White House said she would press for stricter penalties against hospitals that have high rates of hospital-acquired infections.

Sen. Susan Collins (R-Maine) is readying an amendment that would subject hospitals to a higher penalty—and earlier on in the process—than is currently included in the Senate's health reform package.

Under the current bill, starting in 2015, hospitals in the top 25th percentile of rates of hospital-acquired infections would be subject to a 1% penalty under Medicare. Collins' provision, however, would move up the penalty date two years to 2013 and could increase the actual penalty as well.

Collins discussed the measure with White House officials. “That's one specific idea that we requested that they seemed interested in helping us on,” she said, referring to administration officials Nancy-Ann DeParle and Jeanne Lambrew.

Additionally, Collins said that she's considering amendments that deal with affordability, small-business tax credits and a raft of other provisions.

Collins' recommendations, however, could have added traction. A moderate, Maine Republican—like her counterpart Sen. Olympia Snowe—is seen as a possible swing vote for a legislative package that so far is backed only by Democrats. Having a handful of Republicans on board would give Democrats more wiggle room to pass a bill that requires 60 votes in the Senate.

Collins said she continues to oppose the legislation as it is currently written but left the door open for a change of heart. “There would have to be substantial changes, but I certainly hope that would be possible,” she said. “I think there is unease on both sides of the aisle about specific provisions in this bill and that it's possible that we can come up with alternatives that will garner bipartisan support.”

Half of World's ICU Patients Have Infections: Study

By Maggie Fox, Health and Science Editor
December 1, 2009

WASHINGTON (Reuters) - Half of all patients in intensive care units around the world have infections, and more than 70 percent are being given antibiotics -- a trend that could help more drug-resistant superbugs emerge, researchers reported on Tuesday.

Patients who had infections were more likely to die, especially of bloodborne infections known as sepsis, the survey of more than 13,000 patients found. They also spent more time in the ICU at greater expense to hospitals and patients.

But one of the biggest concerns was the widespread use of antibiotics in patients who were not infected -- a practice that has been shown to lead to antibiotic resistance, when germs defy common drugs.

"Importantly, the incidence of sepsis is increasing, as is the number of consequent infection-related deaths," Dr. Jean-Louis Vincent of Erasme University Hospital in Brussels, Belgium and colleagues wrote in the Journal of the American Medical Association.

For the study, Vincent's team surveyed 13,796 adults in 1,300 intensive care units in 75 countries on one day -- May 8, 2007.

The analysis took some time and revealed that 51 percent of the patients had infections and 71 percent were receiving antibiotics, either as treatment or to prevent infection.

In 64 percent of cases, the lungs were infected, and infections of the abdomen and bloodstream were also common.

The most common bacteria was Staphylococcus aureus, but E. coli and a family of bacteria called Pseudomonas were also common.

"Infection and related sepsis are the leading cause of death in noncardiac ICUs, with mortality rates that reach 60 percent and account for approximately 40 percent of total ICU expenditures," the researchers wrote.


Dr. Steven Opal of Brown University in Rhode Island and Dr. Thierry Calandra of Vaudois Hospital Center in Lausanne, Switzerland, who were not involved in the study, saw several troubling trends.

For instance, a type of bacteria known as gram-negative now account for 63 percent of infections. "This is not a favorable trend, because resistance among gram-negative bacteria is increasing and the number of therapeutic alternatives to treat these infections is diminishing," they wrote in a commentary.

The heavy use of antibiotics in ICUs can make such units into epicenters for bacteria to mutate into drug-resistant forms and to spread, they added.

But critical care doctors have little choice, they noted.

"Early intervention with appropriate antibiotics is lifesaving in patients with severe infection, yet the profligate use of antimicrobial agents contributes to progressive antimicrobial resistance," they wrote.

Doctors are penalized if they fail to treat with an antibiotic, but little happens if they over-treat patients.

And few good tests are available to tell if a patient is really infected or just carrying a germ. "With few alternatives available, it is understandable why intensivists opt for liberal antibiotic use and rely heavily on these therapeutic agents to carry patients through critical illness to recovery," Opal and Calandra wrote.

Without some "radical" new technology, such as vaccines or immunotherapy, there is little hope for the situation to improve, they added.

Swine Flu Seen as Cresting

NOVEMBER 23, 2009

The current wave of swine flu may have peaked in most of the U.S., but the illness remains widespread and the threat of another wave remains, officials said Friday.

The news came as officials in Norway reported a mutation of the flu virus in two patients who died and one who became severely ill. The mutation, while seen before, appeared to make the H1N1 virus cause infection deeper in the respiratory system than the regular swine-flu virus, a possible explanation for the more-severe cases, Norwegian scientists said.

Swine-flu cases appear to be declining in most of the U.S., the Centers for Disease Control and Prevention said Friday. Flu activity is widespread in 43 states now, down from 46 last week and 48 two weeks ago. Flu cases also appear to have peaked in the U.K. and parts of Western Europe, but are on the rise in Eastern Europe and parts of Asia, the World Health Organization said. But pandemics occur in waves. In the 1957-58 flu pandemic, one wave peaked in the fall and was followed by a second wave in January.

Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases, warned that more flu is circulating now than at the height of many flu seasons, and holiday travel could bring more infections. "It is so early in the year to have this much disease," she said at a news conference. "We don't know if these declines will persist, what the slope will be, whether we'll have a long decline or it will start to go up again."

The CDC estimates at least 22 million Americans have been infected with H1N1 flu, with 3,900 deaths. Dr. Schuchat said 21 U.S. children had died from influenza in the past week, with 15 confirmed to have had H1N1. A total of 171 pediatric deaths have been confirmed since April, although the CDC estimates that more than 500 children have died of the disease.

The Norwegian Institute of Public Health reported on its Web site that it found the change in only three of 70 virus samples from Norwegian cases that they examined, and said it didn't appear to be circulating widely. The mutated virus "might be a result of spontaneous changes which have occurred in these three patients," said Geir Stene-Larsen, the institute's director general.

The WHO and CDC said the mutation has been seen since April in six other countries, doesn't always cause severe disease, isn't widespread, and responds to vaccine and the antiviral medications. "This mutation has been seen sporadically here and around the world," Dr. Schuchat said. Some of the cases were mild, and the H1N1 virus has caused severe lower-respiratory infections without the mutation, she said.

"To date, no links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread," the WHO said in a statement. "Although further investigation is under way, no evidence currently suggests that these mutations are leading to an unusual increase in the number of H1N1 infections or a greater number of severe or fatal cases."

U.S. vaccine deliveries picked up after a slowdown last week, with more than 11 million new doses shipped this week to warehouses where they are available for ordering. To date, 54.1 million doses have been shipped to warehouses since early October -- still well behind the government's prediction in August of a delivery of 45 million to 52 million doses by mid-October and 20 million doses weekly for the next several weeks after that.

Health officials are also investigating reports of a growing number of patients with H1N1 viruses that are resistant to oseltamivir, an antiviral drug marketed by Roche AG as Tamiflu. Seasonal H1N1 viruses are widely resistant to the drug, and the WHO has reported 57 cases of oseltamivir resistance in the new H1N1 flu.

The U.K.'s Health Protection Agency said it is investigating likely person-to-person transmission of oseltamivir-resistant swine flu on a hospital ward in Wales. Nine case were reported, and five have been confirmed as resistant to the drug, the agency said in a statement. The cases occurred in people with immunosuppression, which can cause Tamiflu resistance, the agency said. It said the drug-resistant virus wasn't any more virulent than the regular virus. "At present we believe the risk to the general healthy population is low," the agency said.

The CDC and North Carolina officials are investigating four cases of tamiflu-resistant H1N1 flu that occurred over the past six weeks at Duke University Hospital in Durham, N.C. All four patients were in an isolated unit on one floor of the hospital, and were seriously ill with severely compromised immune systems and other medical conditions, officials said.

Write to Betsy McKay at
Printed in The Wall Street Journal, page A7

Cases of Tamiflu-resistant H1N1 causing new concern

By Steve Sternberg, USA TODAY

The momentum of the H1N1 flu outbreak has fallen off, but flu activity is still high and Tamiflu-resistant virus may have begun to spread. USA TODAY'S Steve Sternberg asks experts for their perspective.

Q: How bad is H1N1 now?
A: Forty-three states are reporting widespread cases, down from 46 last week, says Anne Schuchat, director of the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases. "We are beginning to see some declines in influenza activity, but there's still a lot of influenza everywhere."

Q: Has the flu peaked?
A: "I wish I knew," Schuchat says. "Influenza is unpredictable, and it's so early in the year to have this much disease."

Q: Is the vaccine supply improving?
A: Yes, she says. As of Friday, 54.1 million doses of H1N1 vaccine were available for states to order, 11 million more than a week ago. By Wednesday, states had ordered 93% of the amount that was available to them. About 94.5 million doses of seasonal flu vaccine also have been distributed nationwide.

Q: What is the latest about Tamiflu-resistant cases?
A: Four patients at Duke University Medical Center in Durham, N.C., and at least five in an unidentified hospital in Wales have become infected with H1N1, or swine flu, viruses that no longer respond to treatment with Tamiflu. Flu viruses swap genes as part of their normal evolution; that means resistant viruses could quickly spread worldwide, says Duke's Daniel Sexton.

Q: Why should I worry about Tamiflu-resistant cases of flu?
A: Tamiflu and Relenza are the most effective antiviral drugs for treating flu. H1N1 is still largely vulnerable to both drugs, unlike many seasonal flu viruses, which are now broadly resistant and more difficult to treat. Most people will get well with rest and fluids. A hard-to-treat virus can be deadly for some patients, such as pregnant women or children with asthma or cerebral palsy, who need effective treatment because they account for a disproportionate number of deaths caused by swine flu.

Q: Does that mean H1N1 will become as deadly as the 1918 virus?
A: There's no evidence to suggest the virus is getting more virulent, Schuchat says. But it may become harder to treat.

Q: Will Thanksgiving have any impact on the epidemic?
A: "We've seen with a lot of respiratory infections that there are increases in January right after the Christmas holiday," Schuchat says. "All the kids get together with their grandparents. There's an exchange of a lot of warmth and love, but there's a little exchange of viruses, too. We think its critical that if you're sick, stay home. And if your child is sick, to keep them away from others."

Hand Washing Not a Priority for Docs

According to the Centers for Disease Control, an estimated 2 million patients get a hospital-related infection every year and 90,000 die from their infection. With only only 40 percent of doctors reportedly washing their hands after patient contact, it is evident that hand hygiene needs to be more of a priority in hospitals.

In December 2008, the Joint Commission Center for Transforming Healthcare began work on its first improvement project: addressing failures in hand hygiene. in the latest edition of the Medical Journal of Australia states that only 60 percent of doctors are washing their hands after patient contact. This does not seem to be an issue just in one country, but worldwide. In the United States, the number is only slightly higher, with about 50% of doctors washing their hands after examining a patient.

According to the World Health Organization, poor hand hygiene in hospitals and other health care settings is a major contributor to patients contracting infections while in the hospital. In the United States alone, the annual cost of taking care of these patients is over $6.5 billion dollars and contributes to over 90,000 deaths each year.

Hand hygiene compliance takes a great deal of sustained work and resources at all levels in the medical field. By January 2010, the Joint Commission Center for Transforming Healthcare will have the data to demonstrate whether the solutions can be sustained to achieve a 90+ percent compliance rate.

The commission has targeted several areas that are major causes of doctors not cleaning their hands:

*Ineffective placement of dispensers or sinks
*Hand hygiene compliance data are not collected or reported accurately or frequently
*Lack of accountability and just-in-time coaching
*Safety culture does not stress hand hygiene at all levels
*Ineffective or insufficient education
*Hands full
*Wearing gloves interferes with process
*Perception that hand hygiene is not needed if wearing gloves
*Health care workers forget

Hand hygiene is critically important to safe, high quality patient care. Unfortunately, many infections are transmitted by doctors and other health care personnel. Hopefully a comprehensive system will be established to to make hand washing a priority for medical professionals around the world. With the rate of hospital-related infections rising, hand washing needs to be a priority.

Cheryl Phillips
Exclusive to

sources: ABC Australia, World Health Organization, JCCTH

Who’s most likely to spread infection in the hospital?

NOVEMBER 2, 2009
Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

Good hand hygiene among healthcare workers is an important factor in preventing the spread of disease, but exactly how important depends on an individual’s job, researchers said.

In a mathematical model, so-called “peripatetic” workers — such as therapists or radiologists — were most likely to spread pathogens if they neglected hand hygiene, according to Laura Temime, PhD, of the Conservatoire des Arts et Métiers in Paris, and colleagues.

In contrast, so-called “assigned” workers — typically nurses and doctors — were less likely to spread pathogens, Temime and colleagues said online in Proceedings of the National Academy of Sciences.

In many nosocomial disease outbreaks, a single individual transmits the pathogen to a large number of patients — so-called “superspreading events,” Temime and colleagues said.

Using modeling techniques, they tried to pin down which types of healthcare workers were most likely to contribute to such events. They modeled the effects of neglecting hand hygiene by three different types of healthcare workers:

* Those who had frequent contact with a few patients, such as nurses
* Those with less frequent contact, but who saw more patients, such as doctors
* Those who typically saw all patients once a day, such as therapists

The first two types were classified as “assigned” in that they had responsibility for a specific set of patients; those in the last category were “peripatetic” and saw all patients.

The model tracked what would happen over a month if a single colonized patient were introduced into an 18-bed ward, under various assumptions about noncompliance with hand hygiene rules.

When all healthcare workers were compliant, the researchers said, the model predicted between 1.5 and 5.8 new cases over the month, depending on how transmissible the pathogen was.

The size of the outbreak increased from 13 to 17% if a single worker neglected hand hygiene — to between 1.7 and 6.8 cases on average over the month.

But the results were highly dependent on which workers neglected their hygiene, Temime and colleagues found.

For a worker such as a doctor, who saw many patients but infrequently, the increase ranged from 2% to 7%. But for a noncompliant peripatetic worker, the increase ranged from 73% to 238%.

Indeed, a completely noncompliant peripatetic worker produced disease spread similar to what was predicted if all staff neglected hand hygiene after 23% of patient contacts, the model showed.

One implication of the finding, Temime and colleagues said, is that measuring average compliance with hand hygiene rules, such as by overall use of hand rub products, may not be a good indicator of the real risk of spreading disease.

Peripatetic workers, they said, can play a “disproportionate role in disseminating pathogens in a hospital ward,” making them “potential superspreaders.”

USA 600 Strain

(HealthDay News) -- New research holds bad news for health officials worried about a potentially lethal infection called MRSA that haunts hospitals: A strain that infects the bloodstream is five times more deadly than other strains.

To make matters worse, the USA600 strain appears to be at least partially immune to an antibiotic that's used to treat the condition, the researchers have found.

A full half of patients infected with the strain died within a month, according to a study scheduled to be presented at the annual meeting of the Infectious Diseases Society of America, held Oct. 29 to Nov. 1 in Philadelphia. That's nearly five times the death rate of other people infected with MRSA, and 10 to 30 percent of those who acquire MRSA infections in the bloodstream die within a month, the study found.

MRSA, or methicillin-resistant Staphylococcus aureus, causes infections in the skin and bloodstream. It can also infect surgical wounds and cause pneumonia. In most cases, it sickens people in the hospital, but cases are becoming more common outside the health-care community, according to information in a news release from the Henry Ford Health System.

Researchers think it's possible that the USA600 strain is unique. But they don't know if other factors -- such as the age of patients -- could be at play.

Those who developed the USA600 strain tended to be older than those who acquired other MRSA strains, averaging 64 compared with 52 years old, the study noted.

"While many MRSA strains are associated with poor outcomes, the USA600 strain has shown to be more lethal and cause high mortality rates," Dr. Carol Moore, the study's lead author and a research investigator at the Henry Ford Hospital's division of infectious diseases, said in the news release.

"In light of the potential for the spread of this virulent and resistant strain and its associated mortality," she said, "it is essential that more effort be directed to better understanding this strain to develop measures for managing it."

MRSA is challenging to treat because strains can be immune to many medications. The USA600 strain appears to be more immune than other strains to the drug vancomycin, which often still has the power to vanquish MRSA.

More information

The U.S. Centers for Disease Control and Prevention has more about MRSA.

Antibiotic research: the kryptonite of superbugs

By Barry Eisenstein

HOSPITAL-ACQUIRED infections are a scourge that kill and injure patients and impose a heavy cost burden on the nation’s health care system, so much so that policy makers are debating the idea of rewarding hospitals that reduce their infection rate and punishing those that don’t. This makes sense, but it will not solve an important corollary public health crisis - the shortage of antibiotics to treat the current and the coming wave of superbugs.

The incidence of infections from drug-resistant bacteria such as MRSA (Methicillin-resistant Staphylococcus aureus), commonly known as “staph’’ infection, continues to rise in hospitals and in community settings. In 1980, roughly 3 percent of staph infections were diagnosed as MRSA; today that number has reached 60 percent.

The Centers for Disease Control and Prevention reported that nearly 19,000 deaths were associated with MRSA in 2005. And in a disturbing new development, the CDC has reported evidence of a link between bacterial infections such as pneumonia caused by MRSA and the H1N1 virus among patients who have died from the virus.

While the incidence of MRSA rises, the treatment landscape is shrinking. Today, many of our antibiotic medications are not as effective as they once were. Every use of an antibiotic, including the widespread use of some for non-therapeutic purposes in livestock and poultry, increases the selection of naturally resistant bacteria, the rare bacteria that mutate to the resistant state, and the transfer of resistance genes to formerly susceptible pathogens. As these organisms survive and multiply over time, the once small number of resistant organisms becomes dominant, resulting in an increasingly dangerous number of drug-resistant bacteria.

In the face of the rising wave of drug-resistant bacteria, one would think that drug manufacturers would be busy trying to develop new antibiotics. Sadly, this is not the case. Right now there are very few new antibiotics being developed in the United States or elsewhere. This dearth of new treatments was the subject of a recent report from the London School of Economics and Political Science. It warned that “only a handful of new antibiotics are in development, and all in the early stages.’’

What has brought us to this perilous situation? Since doctors now recognize the need to be prudent with antibiotic use, newly approved antibiotics do not have the commercial success they once might have had. As a consequence, drug manufacturers have abandoned antibiotic development in favor of more commercially reliable medications, particularly ones given for chronic (rather than acute) diseases.

To confront this crisis Congress needs to take strong steps to increase the supply of new antibiotics. First, Congress should establish a federal anti-infective review board to guarantee antibiotics stewardship. Stewardship programs aim to ensure proper use of antibiotics in order to provide the best treatment outcomes, to lessen the risk of adverse effects (including antimicrobial resistance), and to promote cost-effectiveness. The review board would be responsible for compiling data on antibiotic use and setting guidelines, based on evidence-based medicine, for when certain drugs should be used or held.

Second, Congress should create a number of economic incentives specifically designed to foster innovation in antibiotic development. These incentives should include tax credits for research and development, which would enable manufacturers to take on the risks and costs associated with developing new treatments that otherwise may not be undertaken. These credits would also alleviate some of the hesitations manufacturers have about bringing a new product to market.

In the same context, Congress should extend the right of a manufacturer to be the sole producer of an antimicrobial product from the current five years to 10. Granting a manufacturer a longer period to offer a product increases the likelihood it can recoup its costs and in turn reinvest in delivering the next generation of antibiotics.

Taken together, these steps would help protect the current supply of antibiotics, and encourage more drug developers to invest in this crucial area of research. This is not a matter of industry economics, but of having the ability to protect public health from the threat posed by the current and future wave of drug-resistant bacteria.

Dr. Barry Eisenstein is senior vice president for scientific affairs at Cubist Pharmaceuticals and a clinical professor of medicine at Harvard Medical School.

Excerpted from Globe Newspaper Company.

MRSA presents a growing danger

"World MRSA Day” was celebrated this month. What are Onslow Memorial Hospital, Onslow Health Department, Onslow Caring Community Clinic, local doctors and nurses, Onslow schools, Coastal Carolina Community College, as well as local, state, and federal government officials, television and newspapers doing to educate the public about this deadly disease?

I don’t have an answer, do you?

MRSA is an acronym for methicillin-resistant staphylococcus aureus. It has been described as “Superbug” because it is resistant to most antibiotics. The disease can cause deadly infections in patients in health care facilities and in the community. The disease can enter through cuts and abrasions in the skin and some research investigators believe it can enter just through the skin alone just by touching contaminated surfaces and items or skin-to-skin contact with someone who is colonized with MRSA.

MRSA can be transmitted sexually or by a handshake. It can cause skin infections that may look like a spider bite, a pimple, rash or a boil and even large abscesses. They may appear red, swollen, painful or have pus or other drainage. Some people may have chills and fever, feel nauseous and acute pain. In serious cases, the patient may feel lethargic (fatigue) and headaches.

MRSA infections can cause other ranges of symptoms depending on the part of the body that is infected, such as bloodstream infections, pneumonia and urinary tract infections. It may also enter the bone marrow, causing osteomyelitis, and destroy heart valves, causing endocarditis. And it can cause septicemia, toxic shock and death.

The disease is easily spread in areas where people share crowded living conditions such as hospitals, nursing homes, schools, gyms, military barracks, prisons and call centers, but it can also be contracted anywhere people share items. Anyone of any age can be infected.

Approximately 2 percent of the U.S. population is now colonized with MRSA, which means they are carrying the infection in their bodies.

Unfortunately, the cases of MRSA are not being recorded in most states as they should be. In North Carolina, the N.C. Communicable Disease Manual states that individual MRSA infections are not reportable under N.C. law; however, outbreaks, defined as two or more cases linked in time and place, should be investigated by the local health director if they represent a significant threat to the public health. Also, colonization surveys are time and resource intensive and are not generally necessary to direct control or prevention efforts. In short, North Carolina thinks it costs too much to keep accurate records. Other states may think similarly; however, the CDC has been able to get enough information to record that this deadly disease killed 18,650 people in the U.S., compared to 16,000 people who died from AIDS in 2005.

There is no vaccine, or cure, but there is some treatment, which may not last since the disease has mutated into at least 16 strains and some reports say it may be about to become an airborne disease. Also, there is research going on about the disease, but since it has been around since 1960 and with lack of reporting of cases and lack of knowledge about the disease, many people will continue dying from MRSA.

Until the medical research community and funding for such research decides to commit to education and research to eliminate MRSA, instead of such things as finding the latest erectile dysfunction pill, the public will continue suffering from this epidemic and we are left with what seems to be the be-all and end-all of treatment — the phrase “wash your hands.”

Maybe Tony Shalhoub’s Adrian Monk character is not as crazy as people think.

Jimmy E. Gay

Findings of the International Nosocomial Infection Control Consortium (INICC)

Health-care associated infections rates, length of stay, and bacterial resistance in an intensive care unit of Morocco ...

Most studies related to healthcare-associated infection (HAI) were conducted in the developed countries. We sought to determine healthcare-associated infection rates, microbiological profile, bacterial resistance, length of stay (LOS), and extra mortality in one ICU of a hospital member of the International Infection Control Consortium (INICC) in Morocco.

Method: We conducted prospective surveillance from 11/2004 to 4/2008 of HAI and determined monthly rates of central vascular catheter-associated bloodstream infection (CVC-BSI), catheter-associated urinary tract infection (CAUTI) and ventilator-associated pneumonia (VAP).

CDC-NNIS definitions were applied. device-utilization rates were calculated by dividing the total number of device-days by the total number of patient-days.

Rates of VAP, CVC-BSI, and CAUTI per 1000 device-days were calculated by dividing the total number of HAI by the total number of specific device-days and multiplying the result by 1000.

Results: 1,731 patients hospitalized for 11,297 days acquired 251 HAIs, an overall rate of 14.5%, and 22.22 HAIs per 1,000 ICU-days. The central venous catheter-related bloodstream infections (CVC-BSI) rate found was 15.7 per 1000 catheter-days; the ventilator-associated pneumonia (VAP) rate found was 43.2 per 1,000 ventilator-days; and the catheter-associated urinary tract infections (CAUTI) rate found was 11.7 per 1,000 catheter-days.

Overall 25.5% of all Staphylococcus aureus HAIs were caused by methicillin-resistant strains, 78.3% of Coagulase-negative-staphylococci were methicillin resistant as well.

75.0% of Klebsiella were resistant to ceftriaxone and 69.5% to ceftazidime. 31.9% of E.Coli were resistant to ceftriaxone and 21.7% to ceftazidime.

68.4% of Enterobacter sp were resistant to ceftriaxone, 55.6% to ceftazidime, and 10% to imipenem; 35.6% of Pseudomonas sp were resistant to ceftazidime and 13.5% to imipenem.LOS of patients was 5.1 days for those without HAI, 9.0 days for those with CVC-BSI, 10.6 days forthose with VAP, and 13.7 days for those with CAUTI.Extra mortality was 56.7% (RR, 3.28; P=<0.001) for VAP, 75.1% (RR, 4.02; P=0.0027) for CVC-BSI, and 18.7% (RR, 1.75; P=0.0218) for CAUTI.

Conclusion: HAI rates, LOS, mortality, and bacterial resistance were high. Even if data may not reflect accurately the clinical setting of the country, programs including surveillance, infection control, and antibiotic policy are a priority in Morocco.

Author: Naoufel MadaniVictor RosenthalTarik DendaneKhalid AbidiAmine Ali ZeggwaghRedouane Abouqal

Credits/Source: International Archives of Medicine 2009

Hospital bug rate at record low

Eleanor Bradford, Health correspondent

Clostridium difficile rates are down 42% on the same period last year Rates of infection from Clostridium difficile and MRSA in Scotland have been cut, figures have shown. Infections of elderly people caused by C. diff have fallen to a record low, according to the quarterly Health Protection Scotland report.

And cases of illness caused by the drug-resistant so-called superbug, MRSA have also dropped. The decreases were welcomed by Health Secretary Nicola Sturgeon, but she warned against complacency.

C. diff rates have fallen 42% compared with the same period last year, while MRSA rates are down 25%. The latest figures show there were 996 new cases of C. diff in people over 65 between April and June, compared with 1,152 in the previous quarter.

There were also 311 cases in people aged 15-64, but this was the first time statistics for this age group had been collected and officials said the figure should be treated with "caution".

Today's figures showing record lows in clostridium difficile and MRSA are good news, but we're not out of the woods yet.

Look a bit closer and you see that today's figures only give us part of the picture. C. difficile infections have only been counted since 2003, by which time we knew we had a problem.

We are also only comparing the figures for C.diff in the elderly. We've only just started counting C.diff amongst the under-65's. There were 311 cases between April and June alone.

When it comes to MRSA there's more evidence of an established decline - but only in MRSA infections in the blood. We're not counting wound infections or the worrying emergency of MRSA in the community.

If we're doing the right things we should see a fall in C.diff and MRSA across the board.

Good hygiene is important, but our over-use of antibiotics caused this problem in the first place and that's what we need to tackle to have any hope of bringing it under control.

A Scottish government spokeswoman said that within the new age group being monitored for C. diff, the overwhelming majority of cases recorded were in the upper end of the age range.

The equivalent quarter of last year saw 1,732 cases of C diff in the over 65s.

Meanwhile cases of MRSA fell from 171 in the first quarter to 145 in the second.

A spokeswoman said MRSA figures have been monitored since the start of 2003, while C. diff has only been centrally monitored since the last quarter of 2006.

Ms Sturgeon said: "I have made tackling hospital infections a top priority and I am encouraged that today's figures show our strenuous efforts appear to be reaping rewards.

"We are confident that we now have the right initiatives in place and the figures back this up. We are seeing significant and sustained reductions in infections which is good news for patients throughout Scotland."

Various efforts have been made to cut infection rates with a national MRSA screening programme, more careful prescribing of antibiotics and reminders for people to wash their hands.

Ms Sturgeon added: "However, there is no room for complacency. I want us to continue this excellent progress as we drive to eliminate all avoidable infections from our hospitals."

But Scottish Labour's health spokeswoman Cathy Jamieson said rates of C. diff in NHS Grampian, NHS Borders and NHS Orkney are rising.

She said: "I am very concerned that the rate of C. difficile cases is still rising in some parts of Scotland.

"Whilst NHS staff deserve credit for the overall reduction shown by today's figures there are huge regional variations in the performance of Scottish hospitals and there is absolutely no room for complacency."

Swine Flu: What you need to know

Is the vaccine safe? What if one child in a family is sick? What are the symptoms? When should a person go to the hospital? The man in charge answers these and other questions about this fall’s influenza pandemic.

As director of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci is the government's point man for tracking flu and finding answers to it. He and his team have been monitoring the H1N1 swine flu pandemic since its early days this spring. With the flu spreading rapidly now, and a new vaccine arriving this week, Fauci met Tuesday with USA TODAY's editorial board to address the many questions that are on people's minds. The following Q&A is adapted from that session and edited for length and clarity.

Question: Who is at risk? And how much risk is there?

Answer: The H1N1 virus that's circulating now, for 99% of the people, is a relatively mild to, at most, moderate influenza. However, the people who get into trouble are highly disproportionately young people. Generally, about 70% of them have an underlying condition. And about 30% of them are otherwise healthy. So even though the numbers are very small of people who get hospitalized and sometimes die, the striking thing about it is that you never see that in seasonal flu. I've been in infectious diseases for decades and I've never seen, in seasonal flu, a normal, robust healthy person die from influenza. Everyone I've seen die from influenza have been people who were elderly or sick. So this is a tough message here.

Is this a real serious problem? Well, it depends on who you are. But pregnant women get into trouble. There have been 28 deaths so far among pregnant women, and the people who get into trouble are disproportionately young. The other possible thing that's sort of the gray cloud over everything is that the virus can mutate and become virulent. And if it maintains its high transmissibility and mutates to become virulent, then we have a really, really serious problem. Which we don't have now.

Worried about whether you should get the swine flu vaccine? Fauci explains which groups are most at risk.

Find more of the taped Fauci interview here.

The first batch of about 600,000 vaccines arrived (Monday), with about 6 million by the end of the week and then 40 million by middle of October. What is an interesting sociological problem is the attitudes that people have toward vaccines. They perceive this as a new vaccine (and wonder) is it really safe, have you rushed it, is there more danger to the vaccine than the flu?

Q: What's the answer?

A: This really is not a new vaccine. No matter how much we try, it's a tough message to get across. Every year when we put out the seasonal influenza vaccine we change it slightly from year to year to match the drift in the virus in society. In essence, it's what we call a "strain change." That's exactly what we're doing with this H1N1 vaccine. But because it's been billed as a pandemic virus that's new to society, people are perceiving this is an untested, brand new vaccine. One of the problematic issues in biology is that nothing is 100% safe. It is as safe really as any of the vaccines that we take each year with a strain change. But that sometimes is a difficult message to get across.

Q: Has it been tested as much as seasonal vaccines are?

A: Last year, we gave about 100 million doses of seasonal flu vaccine, so you could say, by extrapolation, that it was tested on 100 million people. It was new, but it was given to 80 million people the year before in a little different version. So in the tests that we've done you get a little redness and swelling. Rarely, you get a fever. But there have not been what we call serious, adverse events that are associated with the vaccine.

Q: Has there been testing of the combination of the two vaccines seasonal and swine flu? And should people get both?

A: First of all, there's no problem with giving both together. You get as robust a response if you give one alone as if you give them together. That's the injectable version. There is an exception, that you should not give the flu mist of H1N1 at the same time as the flu mist for seasonal flu because you have the same antigen in the nasal passage competing with each other for the immune response.

Q: What about a combination of one injection and one mist?

A: That's OK. So you could give a flu mist of seasonal flu and a shot of H1N1. That's not a problem.

Q: How long does the shot take to give a person full immunity?

A: We generally say three weeks for it to reach its peak. But in the clinical trials that we did at the NIH, we were seeing very good responses at 10 days.

Q: How long will it be before everyone who wants the vaccine can get it?

A: Logistically, probably late November. There are five target groups that we're trying to get it to. Whereas it's the elderly who are at risk for seasonal flu complications, it's the younger people who are at more risk for pandemic H1N1 complications. The five groups who need to get the vaccine first are: pregnant women, at the top of the list. The caretakers of children less than 6 months old. The reason is you can't vaccinate a child who's less than 6 months because their immune system is too immature. So the way you protect the child is you form a cocoon effect around him by vaccinating the people who are taking care of the child. The third group is health care providers. The fourth group is young individuals from 6 months to 24 years, and the fifth group includes individuals from (age) 25 to 64.

Q: Why aren't the elderly higher on the list?

A: The reason is interesting. Elderly individuals at some time in the decades of their life have come into contact with a virus that has some crossover similarities with the current H1N1, and they have partial immunity to it. Now that could have been people who were vaccinated for the famous swine flu in 1976 or people who were alive and around in the '50s or the '40s, when you had H1N1 still circulating that had some similarity to this. So if you're older, you're relatively protected from H1N1.

Q: You can safely assume that elderly people will be some of the first in line for the shot. Will they be turned away because they're not in the top five risk groups?

A: We're getting the message out to try to get it out to the five target groups first, and when you do that, then go and get the rest. But I have to tell you, I can't imagine if a 75-year-old grandmother comes up to a place and says, "I'd like my vaccine," that somebody will say, "No, go away and come back in two weeks." Somehow I don't see that.

Q: The flip side is people who fear they'll be forced to get the vaccine, such as health care workers. What about them?

A: At the federal level there will be no mandate. But the rationale for health care workers getting vaccinated is quite sound, because there are well-documented cases of health care workers giving influenza to patients. And health care workers who themselves get sick are not able to perform their function very well.

Q: Why do otherwise healthy people die from H1N1 while the great majority recover?

A: Honestly, we don't know. But it follows the pattern of biological variability. It's kind of a bell-shaped curve. There are some people who don't get sick at all and there are some people who get very ill and expire from the illness. And then there's the vast majority of people — in the bell-shaped curve — who do just fine after an illness. I believe that the 30% of the deaths among people who are otherwise healthy is the biological variability among the human species. There may be some genetic factors that are not recognized that don't allow them to respond very well to influenza, even though everything else about them is healthy. And that holds true for a lot of diseases.

Q: Of the fatalities, how many are preventable with early intervention through Tamiflu or some other means?

A: I can't give you a precise number, but there are three things that would help to lessen the morbidity and mortality. First is proper and early diagnosis. The other thing is Tamiflu. Tamiflu helps if you give it early, and the earlier, the better. But from 30% to 40% of the deaths that have occurred thus far have had a serious superimposed bacterial pneumonia, which is highly sensitive to penicillin. So if they had been treated early, they may have survived.

Q: What is the course of the disease for the people who become severely infected? What physically happens?

A: It generally starts off with severe pulmonary disease — difficulty breathing, viral pneumonia, super-imposed in about 40% of them with bacterial pneumonia, and you either recover from it or you progress and you unfortunately and tragically die. When you get very serious pneumonia and you have real difficulty exchanging oxygen, that doesn't stay limited to the lung. Once your system starts to deteriorate, you go into renal failure, you go into heart failure, you get shock, you get super-imposed infections and you get an irreversible situation.

Q: Do you see any disconnect in the federal guidance which seems to be: Don't go to the emergency room unless you're very sick and don't administer Tamiflu unless someone's in a high-risk group. By the time that happens, is it too late for some people?

A: The messaging is difficult. I know, I try it out with people like my sister, who's a really smart non-medical person and she asked a question of me. She said, "Tell me, what do you mean by really sick? How do you determine if you have plain old flu, you should go home, take some anti-inflammatories, take some chicken soup, you don't need Tamiflu, you don't need anything."

But if you look at my children, for instance, their response to being sick is off-the-board variability. One is stoic — she never says anything's wrong — and the other is melodramatic. Everything is. So who's really sick and who is not?

If somebody really understood mild illness, it's that you get a sore throat, you get a low-grade fever, you get some aches, you feel badly, you go home. Over a period of 24 hours, if you don't get significantly worse, you just want to stay in bed. You're coughing a little, but you're not having any difficulty breathing. That's when you stay at home. Don't go to the emergency room. Call up your doctor. You probably don't need Tamiflu. But any difficulty in breathing — where you really feel like you have a problem with breathing — you absolutely go to the emergency room, go to the doctor, you probably get in the hospital and you need Tamiflu.

Q: An otherwise healthy 14-year-old girl in Texas came down with the flu. She went to see a doctor, who citing CDC guidelines sent her home without treatment. She later died. Does this kind of case suggest that you need to revisit those guidelines?

A: The guidelines were made for the purpose of not overwhelming the system with everyone who gets a sniffle and thinks they have the flu going to the emergency room. In such cases, two bad things can happen: Many of the people in the emergency room likely have the flu, so if you didn't have it when you went in, you're probably going to have it when you go out. And the other is, not allowing the health care providers to really take care of the very sick person. The one accident that happens with somebody who really looks like they're OK and then rapidly goes downhill ... that's unfortunate when that happens. But I'm not so sure that would require a changing of the recommendations and the guidelines.

Q: You've mentioned that young people are particularly vulnerable. Why?

A: Two reasons: the very fact that they've only been around for 10, 20, 30 years at the most; those individuals have much less of a chance in their lives to have come in contact with a virus that would give them a degree of cross-protection that we know is clearly protecting the 65-, 70- and 75-year-olds. Point No. 2, demographically, they cluster as opposed to older people who tend to go their own way. Everyone's a social being and interacts, but kids cluster in schools, in gymnasiums, in places like that. So it's a combination of a lack of underlying immunity and the way they live their lives.

Q: How many people were in the clinical trials of the current vaccine, and what, if any, side effects did you find?

A: A little bit over 3,000 people (including 600 children). But 100 million people got a strikingly similar vaccine last year, and there's no reason to believe that the safety profile of the H1N1 that went into the clinical trials just over the past couple of months is any different, or will be any different, from the safety profile of the vaccine that we administered last year.

Q: People might be fearful of Guillain-Barré syndrome. Can you talk about that?

A: Guillain-Barré is an autoimmune — meaning the body reacts against its own tissue — neurological disease that's characterized by ascending paralysis. People usually recover, but it's a very serious disease that can cause death. Guillain-Barré occurs in about one of 100,000 people in the United States. On a yearly basis, there's between 5,000 and 6,000 cases of Guillain-Barré. In 1976, there was a very well-recognized, historic incident called the swine flu affair. What happened is that a few hundred soldiers in Fort Dix, N.J., got a virus that was linked to a swine influenza. They isolated it. One soldier died. It was really a case study in why the president of the United States should never get involved in a vaccine program. People were so sensitized to this being another 1918 pandemic flu where 50 million to a 100 million people died worldwide that they said if it spreads throughout the world, or the United States, we could have another catastrophe. So they decided to manufacture a vaccine against this particular swine flu. The problem was that they brought in all of the big health pundits. They had (Albert) Sabin and (Jonas) Salk in the same room, which was very unusual since they hated each other. But they had them actually agree that we needed to make a vaccine, and we needed to administer it once we made it. That was the mistake because it violated a fundamental risk of vaccinology. As they were making it, it became clear that the swine flu never got out of Fort Dix. But nonetheless, they went ahead and vaccinated 40 million people against a pandemic that didn't materialize. So what you were left with was you had all the risk of the vaccine, and none of the risk of the pandemic.

Q: In the spring, schools with swine flu cases seemed uncertain as to when or whether they should close and send students home. Is there a formula school administrators can apply?

A: There were some sections of the country that were quick on the draw to close the schools and others where the parents complained that they didn't close it quickly enough. There is no mathematical formula, but the CDC has revised its guidelines and turned the knob more toward doing what you can within reason to not close the schools, because they found when they did there was a significant disruption of society out of proportion to what they thought the benefit of closing the schools. Namely, children who didn't go to school congregated in places that was almost equivalent to congregating in the schools. They'd go to a mall; they would not socially distance themselves from each other. So you're almost nullifying the very reason for keeping them out of school. And the way the recommendations go now are that if it's mild, encourage parents not to send sick children to school. If it gets worse than in the spring and goes from mild to moderate, you switch to active surveillance of kids who come in. You have somebody standing at the door, looking at the kids.

Q: Say you're a family of five and one of your children has been diagnosed with swine flu. What do you do?

A: If it's mild, then the kids who are in the family, if they don't have symptoms, they should go to school. If they develop symptoms, they don't. It's going to be very difficult for the parent. You just sort of try as best as possible to have few people interacting with the sick person. If it gets severe, and it's widespread, then the recommendation is that the household contacts of a sick person should not go to school or work for at least the 24 to 48 hours to see if they're actually infected.

Q: If you suspect that you've been exposed to swine flu, should you still get vaccinated?

A: Yes, because you just don't know. There are a lot of viruses out there that aren't necessarily influenza. If I had a laboratory test that definitively said, yes, you did get infected with H1N1, I would tell you no, don't get vaccinated because natural vaccination is the best vaccine you can give for yourself. But unless you're sure, I would go ahead and take it.

Q: Are you worried that in the media and in the general population, myths and misinformation are being spread?

A: We are putting in an extraordinary amount of time into messaging. We try to spend as much time as we possibly can with the media, on TV, in meetings like this, putting things on websites to try and dispel myths. I've been doing these public health-type things for a very long time, going back to HIV/AIDS and SARS and the anthrax attacks, and the ability of misinformation to get propagated continually astounds me. I mean, we even had a report that one of the TV programs asked me to dispel the myth that somebody was reporting that there were serious adverse events that occurred from the first H1N1 vaccine that was given to a group of kids about two weeks ago. There was no H1N1 vaccine that was given to anybody two weeks ago.

Q: What scenario keeps you up at night?

A: A lot of scenarios. I don't sleep very well! The thing that worries me the most is the combination of a highly transmissible respiratory infection, which influenza is the most likely, that is combined with a high degree of virulence. That's the thing that worries me the most, because that would out-terror any bioterror attack.

Q: Do you have any expectations that the virus will mutate this flu season in a way that might fit the scenario that you just described?

A: It is more likely than not that it won't, because it doesn't appear there are obvious pressures for it to change. Once it recirculates back, then I would say there's a better chance now that it would change. But when viruses mutate, they don't necessarily mutate toward a more virulent form.

Q: This flu will probably stretch the U.S. health care system. Will we see emergency rooms and doctors' offices overwhelmed?

A: Do I think it's going to be chaos? No, I really don't. Do I think it's going to be challenging to the health care system? Yes. Since most of the people who are getting infected are of the younger age group, I'm encouraged by what I'm seeing schools, particularly the colleges, setting up. Remember, the thing that's disturbing is its propensity to infect young people (but) a very small fraction gets seriously ill or require hospitalization or require respirators. But the number of people who are getting infected, this is a very, very small minority.

Posted at 12:15 AM/ET, October 07, 2009 in Q&A | Permalink

Is Your Beach Contaminated With MRSA?

September, 2009
by Shari Roan
Los Angeles Times

Staphylococcus aureus is a common bug that can cause serious infections. An antibiotic-resistant strain, called MRSA (methicillin-resistant Staphylococcus aureus), has increased dramatically in recent years. It typically spreads in hospitals. But it's also found in healthy people in the community. It spreads from skin-to-skin contact with someone who is infected, or by touching surfaces contaminated with the germ.

Little is known about places in the environment where MRSA can hide. A study presented today, however, is the first to show that public beaches may be reservoirs for the bug. Staph was isolated in marine water and in intertidal beach sand in nine of 10 public beaches in Washington state, and half of the strains were MRSA, according to the study from researchers at the University of Washington. When examined, those strains appeared to be the type that spreads in hospitals rather than community-acquired MRSA.

How beaches are becoming contaminated with hospital-acquired MRSA is unknown, said the lead author of the study, Dr. Marilyn C. Roberts. The study was presented this morning at the Interscience Conference on Antimicrobial Agents and Chemotherapy in San Francisco.

"Where all these organisms are coming from and how they are getting seeded, we don't know," Roberts said. The samples were "grab-and-go" samples, meaning that researchers didn't spend a lot of time thinking about where to collect the samples. And, Roberts said, "the fact that we found these organisms suggests [beach contamination] is much higher than we normally thought."

Another study on beach sand, published in June in the Journal of Epidemiology, found that people who dug in the sand or covered themselves with sand were more likely to have diarrheal illnesses in the following week or two compared with beachgoers who just walked on the beach or lay on the sand. The most likely scenario for MRSA infection, Roberts said, is getting sand in a cut or abrasion. But the risk of getting MRSA at the beach cannot be estimated at this time.

"We don't know what the risk is because nobody's done a good study," she said.

Roberts also tested two beaches in Southern California and did not find MRSA. But that should not reassure beachgoers in California -- or anywhere. Testing of the samples from California beaches was delayed, which may have affected the quality of the test, Roberts said.

The best advice for beachgoers is to cover open skin wounds and wash off sand thoroughly. People who have weakened immune systems because of other illnesses should take special care with open wounds.

"I'm not telling people not to go to the beach," Roberts said. "But if, all of a sudden, you have a skin rash and it doesn't get better, you need to go and be seen."

WHO Says Swine Flu Down in Southern Hemisphere

By ELIANE ENGELER (AP) – August 29, 2009

GENEVA — The World Health Organization said Friday that swine flu infections are declining in the Southern Hemisphere as its seasonal flu period comes to an end and the pandemic shifts back north.

Countries in the Northern Hemisphere that have already had one wave of swine flu should prepare for a second wave, which may be worse, the agency said.

"The H1N1 pandemic virus has rapidly established itself and is now the dominant influenza strain in most parts of the world," WHO said in a statement. "The pandemic will persist in the coming months as the virus continues to move through susceptible populations."

Clinicians from around the world are reporting a very severe form of the disease in young and otherwise healthy people.
"In these patients, the virus directly infects the lung, causing severe respiratory failure," WHO said.

Therefore, countries should anticipate a growing demand for treatment in intensive care units as they prepare for a second wave of the pandemic, it said.

Flu levels remain elevated in South Africa and Bolivia and many of these cases are probably swine flu, it said. But in most of the Southern Hemisphere, flu levels have returned to normal, said WHO spokesman Gregory Hartl.

At least 209,438 people worldwide have caught swine flu and at least 2,185 died of it, according to WHO. The real caseload is much higher because countries are no longer reporting individual cases.

Hartl said the agency was watching flu rates in Japan, where it believes that the high season for infections is starting earlier than normal.

Experts fear that the swine flu virus might mutate into a more deadly strain. A recent outbreak in turkeys in Chile has sparked concern that it might combine with the deadlier H5N1 strain of bird flu and re-infect humans.

WHO said there are no indications that the swine flu virus has so far mutated to a more virulent or deadly form.
Most people who catch swine flu still have a mild case, it said. But "even if the current pattern of usually mild illness continues, the impact of the pandemic during the second wave could worsen as larger numbers of people become infected," it said.

Copyright © 2009 The Associated Press.