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MRSA: Bug of the year?
The new JAMA report on MRSA will likely constitute a baseline against which future increases or decreases in invasive MRSA infections can be measured.
Easily the most astonishing thing about the October 17 Journal of the American Medical Association publication by Klevens, et al titled “Invasive methicillin-resistant Staphylococcus aureus infections in the United States” was the amount of media coverage this paper received.
The basic information derived from this study is detailed in the article "Most MRSA infections in the United States are health care-associated" from this issue of Infectious Disease News. The study was carried out in nine surveillance sites scattered throughout the country, including one entire state, several counties, several metropolitan areas and one mostly inner-city population. Perhaps not surprising, but still quite striking, was the sharply higher rate of both community-acquired and health care-associated MRSA infection in an inner-city population, which happened to be in Baltimore. The rate there was threefold to fivefold higher than in the other sites. I suspect comparable rates could be found in other inner-city populations.
Media “hoopla”
Note that this report is essentially a case count; no new insights into the pathogenesis, means of transmission, treatment or prevention of MRSA infections were presented. Viewed from that perspective, the level of media hoopla was all the more surprising.
Soon we learned of the death of several young adults with CA-MRSA infections in high school settings, school closures for cleaning and decontamination, mandatory reporting to appropriate public health jurisdictions and the like.
The fact that 19,000 MRSA deaths were more than the number of AIDS deaths in the United States in 2005 was trumpeted in the media, and it was yet another example of the “my issue is bigger than your issue” game that Americans apparently like to play with health statistics. None of this was new information, of course, since we as physicians have been learning since the turn of the century about the increasing frequency of invasive CA-MRSA infections.
This report does constitute a baseline against which future increases or decreases in invasive MRSA infections can be measured.
Important points
Apparently lost in all the media hype, however, were several important points to be made. First, the MRSA deaths occurred almost totally among patients with HA-MRSA infections; few deaths occurred among patients with CA-MRSA infections. The latter deaths almost always make the headlines, of course, especially if in children or young adults, whereas the former deaths make the headlines infrequently. The HA-MRSA infections, as we know, mostly occur in patients with one or more other comorbidities and immunocompromising conditions that may contribute to death rather than directly causing death.
Second, personal hygiene is critically important, particularly hand hygiene. A great deal of MRSA transmission and subsequent colonization/infection can be averted by careful and conscientious hand hygiene. We know it works in the hospital setting; it will work in community settings also. It particularly needs to be available and used in settings where people gather in relatively close quarters; examples include schools, prisons, military barracks and certain community gathering centers.
Third, although we have not yet run out of drugs to treat MRSA infections, the spread of vancomycin-resistant MRSA would bring us much closer to the edge. Furthermore, we are already over that edge in the case of certain other multiply-resistant organisms, such as some strains of vancomycin-resistant enterococci and a number of gram-negative bacilli. The new drug pipeline, as has been pointed out so frequently, does not look promising at this time. The IDSA was not just blowing smoke with its “Bad Bugs, No Drugs” initiative; perhaps all this MRSA coverage can be used as more ammunition in the IDSA campaign for governmental/congressional action to “incentivize” (how I detest that word!) the pharmaceutical industry to redevelop plans for new antimicrobial development. There is no further time to waste!
Finally, new diagnostics are urgently needed. We are still for the most part reliant on mid-20th century technology for microbiologic diagnosis and antimicrobial susceptibility testing. When confronted with a new patient, we need to be able to identify MRSA as well as other multi-resistant organisms within one or two hours at the most, rather than the 48 hours or more using existing methods. Only then can we use antibiotics in a more judicious and targeted way, and only then can we apply the appropriate infection control precautions in a more meaningful way.
Scott Gottlieb, MD, a former Deputy Commissioner of the FDA, made some of these points as well as others in an op-ed piece in The Wall Street Journal on Oct. 30, 2007, titled “Attack of the Superbugs.” If you are able to locate it, it is well worth the time to read it. He views the evolution of antimicrobial resistance as akin to an arms race, which we are presently losing. We must escalate this arms race or be in danger of losing not only the battle but also the entire war.