November 2008 Archives

Hospitals need to come clean about infections and what's causing them.

copyright Jessica Snyder Sachs, as originally appeared in The [Newark] Star-Ledger

Our neighborhoods are in a panic over news reports about MRSA, or methicillin resistant Staphylococcus aureus. There's no doubt that this nasty bug has moved into our communities and our schools. But the deadliest threat from MRSA--and an alphabet soup of other drug-resistant bacteria--remain behind the doors of our local hospitals. Eight-five percent of MRSA infections occur during or following a stay in a healthcare facility.

Illustration by Paul Lachine

The sad truth is that our hospitals have become dangerous places to be sick. Even routine surgical procedures bring the risk of potentially deadly infections involving hospital-bred bacteria. Infections picked up in health-care settings kill an estimated 99,000 Americans each year, more than twice as many as die in car crashes. It's a problem that has grown dramatically worse by the decade, as our antibiotic-infused medical centers became breeding grounds for drug-resistant bacteria.

In addition to MRSA,  other increasingly common hospital superbugs include a viciously toxic strain of Clostridium difficile, bred from the bacterium that commonly causes post-antibiotic diarrhea; vancomycin resistant enterococcus (VRE), a virtually untreatable bug bred from a harmless member of our intestinal microflora; and Actinobacter baumannii, another near-unstoppable microbe, this one recently introduced into our hospitals in the infected wounds of soldiers returning from Iraq, Afghanistan, and before that, Kuwait.

The good news is that a half century of dangerous secrecy is starting to come to an end. This year New Jersey joined New York and Connecticut in the ranks of at least 22 states with some sort of mandate for the reporting of hospitals infections. These laws represent a step in the right direction. But few ask hospitals to differentiate infections caused by "ordinary" bacteria and those caused by highly drug resistant superbugs. New Jersey is one of these exceptions, with a new law on the books requiring specific reporting of hospital MRSA.

The importance of such reporting laws goes beyond a consumer's desire to steer clear of a medical center plagued with abysmal infection control. Worse, fifty years of secrecy have left public health officials guessing as to the arrival and spread of deadly new strains of drug-resistant bacteria in our hospitals.

The current situation with C. difficile illustrates the problem. Since 2003, C. difficile deaths have dominated news in Canada and the United Kingdom. British tabloid headlines like "Toe Nail Surgery Nearly Killed Me" refer to the common scenario wherein someone checks into the hospital for a routine procedure, receives antibiotics, and promptly contracts this drug-resistant invader.

Public outcry in Canada and the UK produced tremendous political pressure to address the problem in those countries. Even today, British lawmakers are quick to call the government's health minister before Parliament for public castigation when quarterly hospital reports of either MRSA or C. difficile rates fail to show improvement.

Ironically, in 2005, medical detectives traced the origins of the toxic C. difficile strain wreaking havoc in Canada and the U.K. to the United States, where hospitals had been heedlessly experiencing deadly outbreaks for at least six years. "We had no idea what was going on," admitted the chief of infection control at the University of Pittsburgh Medical Center, which in 2005 belatedly reported that its own C. difficile death toll had begun a dramatic ascent in January 2000.

Once forced to examine and deal with their superbug problems, hospitals can make great strides. This month, a once-chastened University of Pittsburgh Medical Center reported that it has brought its C. difficile rates down by more than 70 percent with an aggressive combination of tactics that include requiring doctors to get permission from an antimicrobial management team before prescribing the kind of powerful antibiotics known to raze the body's good bacteria and, so, leave a patient vulnerable to C. difficile and other drug-resistant bacteria.

Once their dirty secrets are out, other medical centers can likewise begin sharing and comparing infection control efforts. To that end, the first round state laws requiring hospitals to report infections in a general way do not go far enough. Our state legislators need to ride the current wave of public concern about supergerms to pass further legislation requiring hospitals to report on infection problems on a bug by bug basis--starting with their most dangerous and drug-resistant bacteria.

Jessica Snyder Sachs, a contributing editor to Popular Science and Parenting magazines, is the author of Good Germs, Bad Germs: Health and Survival in a Bacterial World.

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Many of us are in the danger zone, and we don't realize it. What to do right now.

by Jessica Snyder Sachs, as first appeared in HEALTH magazine

How's your cholesterol? Here's a guess: If you're healthy, you probably have no idea. New surveys show women tend to be clueless about their risks of heart disease, especially when it comes to managing their cholesterol.

But this kind of ignorance is anything but bliss. The reason: The artery clogging that makes heart disease the number-one killer of women late in life begins much earlier--in your 20s, 30s, and 40s--and that's when your cholesterol numbers may be sounding alarms. So, are you ready to start paying attention? Here, the things all women need to know now.

1. High cholesterol is surprisingly common in premenopausal women.
Researchers with the Framingham Heart Study recently delivered a nasty surprise: Nearly a quarter of women in the study who are in their early 30s have borderline-high levels of bad cholesterol, as do more than a third in their early 40s and more than half in their early 50s. A third of women in all three age groups have low levels of good cholesterol.

Bad cholesterol, also known as low-density lipoprotein (LDL), contributes to heart disease by laying down artery-clogging plaque; good cholesterol, or high-density lipoprotein (HDL), helps clear it away. "The double whammy of high LDL and low HDL is particularly dangerous," says Framingham researcher Vasan Ramachandran, MD, of the Boston University School of Medicine.

2. Your doctor may miss the problem.
Though women are better than men about seeing a doctor regularly, the care they receive isn't as good when it comes to preventing and treating cardiovascular disease, according to new studies. "Perhaps doctors still haven't gotten the message that women need to control cholesterol," says Chloe Bird, PhD, author of one of these studies and a senior sociologist at the nonprofit RAND Corporation. Bird found that doctors are less likely to monitor and control cholesterol in women than in men, even when the women are at superhigh risk of heart attack.

Part of the problem, she says, may be that many women see only a gynecologist. This isn't to say that OB-GYNs can't be good primary care doctors, but you have to make sure the doc is willing to monitor your heart health, especially if you already have diabetes or a heart issue. That means she should order cholesterol checks as part of your regular blood work and discuss the results with you. What does "regular" mean? See "How Often Do I Need a Checkup?"

3. Your numbers may trick you.
Many people misunderstand the roles of so-called good and bad cholesterols, according to cardiologist and lipidologist Pamela Morris, MD, of the Medical University of South Carolina in Charleston. "What we've learned is that HDL and LDL are independent predictors of a woman's heart attack risk," she explains. "We see women with high HDLs having heart attacks when their LDL is also high, and we also see heart attacks in women with very low LDL but also low HDL."

What that means to you: It's important to keep track of both. A woman wants to keep her HDL above 60 (the level at which HDL helps prevent disease) and her LDL below 100. If your HDL drops below 50 or LDL rises above 160, you need to take immediate action. That may include an LDL-lowering drug such as a statin, and it definitely includes a commitment to a heart-healthy diet and lifestyle.

4. You may need an "inflammation" test.
The math used to estimate your heart disease risk is a little misleading. If your LDL rises above the danger line of 160 or your HDL drops below 50, the math says you have an elevated risk of a heart attack within 10 years. But that warning may actually underestimate your risks beyond 10 years, Morris says. So when she has a female patient with cholesterol numbers in the intermediate range--LDL above 130 or HDL under 60--she often takes a close look at the woman's whole-body inflammation level.

You can't see this kind of inflammation, but it's actually an independent measure of heart attack risk. You measure it by adding a test for high-sensitivity C-reactive protein (hs-CRP) to the usual cholesterol blood work. CRP, essentially a body chemical, usually rises anytime your body becomes inflamed. And since artery clogging is associated with inflammation, high CRP is viewed as a marker for clogged arteries. That means your C-reactive protein levels may help you and your doctor decide how aggressively you need to control borderline-high-cholesterol levels with drugs, diet, and exercise.

5. These foods are your best friends.
Certain classes of food chemicals can actively and powerfully lower a person's bad cholesterol. Two--soluble fiber and phytosterols--have so much science behind them that they've become part of standard medical prescriptions for treating high cholesterol. But dietitian Janet Brill, PhD, RD, author of Cholesterol Down, also recommends regularly eating almonds, ground flaxseed, apples, soy protein, and olive oil. Preliminary research suggests they all have cholesterol-lowering powers. "Each one works in a slightly different way," Brill says. "So together, you get a synergy that can dramatically lower cholesterol."

Almonds and olive oil are high in monounsaturated fats, which are thought to blend with LDL molecules in a way that speeds LDL's clearance from the blood by the liver. Flax is high in both soluble fiber, which lowers LDL by absorbing cholesterol from both food and bile inside the intestines, and omega-3 fatty acids, which studies show have anti-inflammatory effects. Other foods especially high in soluble fiber include oat bran, oatmeal, and apples. (Soluble fiber is different from insoluble fiber, the kind found in whole-grain bread and bran cereal. That's good for you, too, but it won't affect your cholesterol.) Soy may mimic natural estrogens in their LDL-clearing effects. Phytosterols are the plant version of animal sterols (a.k.a. cholesterol) and lower LDL by competing with it for absorption into the body. They're found in supplements or phytosterol-enhanced margarine such as Benecol.

You don't need any of these foods if your LDL is low, but experts still recommend them for everyone. What about steak, eggs, and cheese? They sure won't help your cholesterol, because they all contain a lot of it. But it's more important to focus on foods that lower your numbers rather than simply avoiding the bad stuff, experts say.

6. Good cholesterol may have a bad side.
The higher your HDL, the better, right? That's been the current thinking, due to HDL's protective effect. But here's a surprise you may have read about in some news reports: Studies are showing that HDL may actually have harmful proteins capable of boosting heart disease risks. A test to determine if your HDL has the harmful proteins may be available in a few years. In the meantime, if your HDL is lower than 60, it's still OK to raise it a little as long as you don't go overboard. How? Try getting a lot of omega-3s from fish or fish oil, exercising regularly, controlling your weight, and avoiding smoking.

7. Your heart loves long walks.
Walking 10 miles a week brings lasting improvements in your heart health, according to researchers at Duke University Medical Center. The funny thing is, if you jog those 10 miles, you won't get quite as much benefit. "Duration appears to be key," says Duke's Cris Slentz, PhD, an exercise physiologist. "Jogging or walking 10 miles both burned around 1,200 calories, but in our studies, one took about two hours and the other, three."

Longer stints of exercise, even moderate exercise, may burn more belly fat--the little rolls of skin near your navel and the fat deep inside your abdomen. The latter is linked to metabolic syndrome, a condition associated with a host of cardiovascular risk factors including low HDL, high blood pressure, and high triglycerides (a kind of blood fat that contributes to heart disease).

Should you aim for weight loss as well as long walks? If you're overweight, absolutely. But understand that shedding a few pounds will make only a small dent in your cholesterol. Canadian researchers recently found that overweight women who lost about 25 pounds--no easy task--saw their LDL drop about 10 percent and their HDL rise by the same amount.

How Often Do I Need a Checkup?
Starting at age 19 and continuing until menopause, a cholesterol test once every five years is plenty--as long as your numbers fall in the healthy range:

HDL > 60
LDL < 100
Total cholesterol (HDL plus LDL) < 200.

But any time your numbers stray into unhealthy territory (and during and after menopause, when heart disease risk rises), get tested annually and work out an action plan with your doctor.

Writer Jessica Snyder Sachs is the author of Good Germs, Bad Germs, out in paperback this fall.

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MRSA infects 94,000 Americans a year, and the superbug is no longer confined to hospitals. Here's what you need to know to protect yourself and your kids.

copyright Jessica Snyder Sachs, as first appeared in BEST LIFE magazine

It started one morning last June, when 14-year-old Max Yardley felt a little tenderness in his elbow. The arm looked fine, so Max's dad, Rockie, an explosives specialist with the Edmond, Oklahoma, police department, figured the problem was soreness left over from the lifeguard training Max had just completed. But that night, Max woke up his parents at 3 a.m. The pain had become excruciating.

"This is a kid who doesn't normally complain," says Yardley. "He'd been sick all of five days in his life." The Yardleys raced to the emergency room. Over the next 24 hours, Max's temperature soared to triple digits and his blood pressure plummeted. When doctors ran the usual laboratory tests, it came back positive for methicillin-resistant Staphylococcus aureus, or MRSA. A bacterial infection had infected the bone of Max's upper arm and was racing through his body, shredding up his lungs, liver, and spleen.

"One morning we had a perfectly healthy boy. Twenty-four hours later, the doctors were struggling to keep him alive long enough for the antibiotics to start working," recalls Yardley, who, as a former paramedic, understood enough about his son's vital signs to call the family's priest.

Unknown just 15 years ago, community MRSA (hospital MRSA's virulent sister) now accounts for more than half the serious staph infections showing up in the nation's emergency rooms. Some children's hospitals see it in more than 75 percent of the staph-infected children they treat.

"Once it arrives in a community, it just seems to take over," says Sheldon Kaplan, MD, chief of infectious diseases at Texas Children's Hospital, in Houston. Pediatric specialists fear that the superbug, which already accounts for 19,000 deaths in the United States each year, could soon become commonplace across the country. The vast majority of community MRSA cases are skin and soft-tissue infections, Dr. Kaplan explains.

But around 5 percent involve potentially deadly pneumonias and internal infections such as Max's. When this bug enters the bloodstream, it can cause severe and sometimes fatal disease, and many of those who survive bloodstream infections sustain severe organ damage, require limb amputation, or both. "A child's growing bones remain particularly vulnerable," says Dr. Kaplan, "because they are open to bacteria circulating in the bloodstream."

Max was one of the lucky ones. After a week on a respirator, he emerged without permanent organ damage. After another two weeks on intravenous antibiotics, he finally went home to complete his recovery and was symptom free after another seven weeks on antibiotics.

Each year, more and more kids aren't so fortunate. MRSA deaths among previously healthy kids began cropping up in the 1990s. "At first we assumed these children had some connection to a health-care setting in which MRSA infections had been confined," explains epidemiologist Jeffrey Hageman, a MRSA expert with the Centers for Disease Control and Prevention, "but it eventually became clear that something else was going on." Antibiotic use outside of hospitals may have bred strains of MRSA distinct from those in medical centers.

And although community MRSA isn't resistant to as many kinds of antibiotics as is hospital MRSA, what it lacks in multidrug resistance it appears to make up for in virulence. Medical experts are just working out how staph in general, and MRSA in particular, wreaks its damage. But new studies suggest that community MRSA strains have the ability to kill the kinds of immune cells that would normally eliminate such microbial invaders. This stubborn persistence, in turn, tends to trigger septic shock, a kind of immune-system meltdown in which body-wide inflammation leads to organ failure, massive blood clotting, and plummeting blood pressure.

Community MRSA has an aggressive tendency to enter through even the smallest of cuts and abrasions. For this reason, it often spreads in locker rooms and gyms, and between members of sports and dance teams, who have frequent skin contact with both other participants' skin and shared surfaces such as athletic equipment and benches, explains Hageman.

Ineed, if you have a child in school or day care, chances are you've received some version of the panic-but-don't-panic note, as in "Dear parents: A confirmed case of MRSA infection has been brought to our attention. Please be assured we are taking appropriate measures." Some schools go so far as to shut their doors for a massive, one-time disinfection--a move that may be as ineffectual as it is overdramatic.

A less overblown but diligent effort is key, say health experts. "Perhaps one of the biggest problems for parents, dads in particular, is deciding when to give your kid Tylenol and send him to bed and when to go straight to the emergency room," says Yardley. "For me, it was the urgency of Max's complaints that raised the red flag."

Here's what you need to know to protect your children from community MRSA:

1. Know When Risk is Greatest
Studies show some of the highest rates of MRSA in groups such as team athletes and those who have had a medical procedure or taken antibiotics within the past year. MRSA is what doctors call an "opportunistic pathogen," a microbe that takes advantage of breaches in the body's defenses. Young children are particularly susceptible because their immune systems aren't yet fully developed. "Staph. aureus can't be eradicated," explains MRSA expert Jeffrey Hageman, of the Centers for Disease Control and Prevention. "Overall, around one in a hundred Americans carries a resistant strain of this bug."

2. Avoid Unnecessary Antibiotics
MRSA infection rates are up to eight times higher among those who've taken antibiotics in the previous year. By eliminating the drug-susceptible competition, antibiotics promote the success of any microbe that can shrug off their effects. "Antibiotics tend to replace your body's protective bacteria with drug-resistant troublemakers," explains Tufts University's Stuart Levy, MD, author of The Antibiotic Paradox. When antibiotics are necessary, ask your doctor for the "narrowest spectrum" (most specifically targeted) antibiotics, which tend to be less disruptive of the body's good bacteria than are "broad spectrum" (big gun) antibiotics.

3. Wash Away the Bugs
"Teaching children good hygiene is the single most important thing you can do to protect them," says Hageman. Staph spreads primarily through skin-to-skin contact and frequently touched surfaces. Experts recommend frequent hand-washing with ordinary soap and water or, when that's not convenient, an alcohol-based hand gel. "Staph takes several hours to infect an abrasion," says Hageman, "so there's a window of time when it can be washed from the skin."

Drug-resistance experts such as Levy advise against using antibacterial soaps containing chemicals such as triclocarban and triclosan. They act like antibiotics and, in laboratory tests, promote the rise of drug-resistant bacteria.

4. Keep Exercise Areas Clean Encourage young athletes--or their coaches--to wipe down mats and sporting equipment with soap and water or bleach wipes between uses. Children can also use a personal towel or other barrier between their skin and shared exercise surfaces and equipment. Insist on daily disinfection of locker rooms and weight-room benches, wrestling mats, and other shared athletic equipment as well as the mats used by younger children for napping. The Environmental Protection Agency maintains a list of safe and effective MRSA disinfectants.

5. When in Doubt, Check It Out
MRSA infections don't always look scary. The skin may become red, swollen, and tender. An infected joint, bone, or muscle may look normal but feel painful. Sometimes symptoms include fever, nausea, or weakness, says Sheldon Kaplan, MD, of Texas Children's Hospital. That can make MRSA infection difficult to distinguish from muscle sprains or the flu.

6. Get a Flu Shot
When MRSA and the flu end up in the same body, the result can be life-threatening. "It's the perfect storm," says John Francis, MD, an infectious disease consultant at Yale University School of Medicine. Getting an annual flu shot may help protect against this deadly combination.

Jessica Snyder Sachs is the author of Good Germs, Bad Germs, out in paperback this fall.

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If you're over 30, those childhood shots have probably worn off. Here's what you need to know ...

copyright Jessica Snyder Sachs, as first appeared in HEALTH magazine

Three months before she gave birth last year, Diana Simpson, a dental hygienist in Davison, Michigan, started coughing uncontrollably. The pain in her throat and chest was unbearable. "It brought me to tears," she remembers. Simpson's family doctor tested her for asthma, but she didn't have asthma. She had pertussis, a bacterial infection that usually goes by the name whooping cough because of its distinctive seal-like cough.

Most people are vaccinated against pertussis as kids. But here's a surprise: It's come roaring back since an all-time low in the 1970s, largely due to waning immunity in adults who received shots in early childhood. The Centers for Disease Control and Prevention (CDC) now recommends that all adults get a pertussis booster shot to strengthen their immunity, yet only 2 percent of adults have had their shots updated. Experts say that's just one of several vaccines you may need now. Here's the scoop.

Whooping cough
Vaccine: Tdap

The good news: If you get your regular tetanus-diptheria (Td) booster every 10 years, you won't need an extra jab for pertussis. Vaccine makers have added a pertussis component to that booster, so next time you're due for your Td booster request the Tdap. If you've lost track of your vaccines, ask your doc to contact your previous physicians. And there's no harm in getting the Tdap as long as two years have passed since your last Td booster. Better too soon than too late when a pertussis outbreak has hit your community.

Simpson was too late: She had passed the infection to her mother and her baby, too, landing the newborn in the hospital three weeks after he was born. That's when they all were diagnosed and received the antibiotic erythromycin to keep the infection from spreading further, though they all continued coughing for months. If pertussis isn't caught in the first few weeks, the infection may take three months to run its course. The greatest danger is to babies, who almost always catch it from unvaccinated adults. (The number of U.S. pertussis cases now ranks in the thousands each year, with deaths in the double digits, mostly due to related pneumonia.)

Simpson and her baby, along with her mother (and husband, too), eventually got the shot for future protection.

Chicken pox
Vaccine: Varivax

More than 90 percent of women in their childbearing years are immune to chicken pox because they had it as kids. The rest should be vaccinated before they try to get pregnant because catching the illness during pregnancy can lead to devastating birth defects. Once you get the vaccine (which was introduced in 1995), the CDC says you should delay trying to conceive for at least one month, due to the small risk that the fetus can get the virus from the vaccine. Chicken pox complications are much more frequent and severe in adults than children and can include life-threatening pneumonia and encephalitis (brain inflammation). And people who've had it are also at risk for shingles. Most insurers cover the chicken pox vaccine for adults.

Shingles
Vaccine: Zostavax

If you've had chicken pox, you have a significant risk of developing shingles, a painful reawakening of the chicken pox virus. Worse, in nearly 50 percent of cases in adults in their 50s, shingles progresses to postherpetic neuralgia, an often agonizing form of nerve damage that can linger for years. (The risk increases with age.) But with the recent Food and Drug Administration (FDA) approval of the Zostavax vaccine, you can lower your risks dramatically. In a study of more than 38,000 adults over age 60, the vaccine cut the rate of shingles by over half and reduced the incidence of postherpetic neuralgia by two-thirds.

The vaccine was studied in and approved for people over the age of 60 because they have the highest rates of shingles, says William Schaffner, MD, head of preventive medicine at Vanderbilt University Medical Center. "The rates take off at age 50 and become more steep with each decade," he says. But around half of all shingles cases occur in younger adults.

Insurers won't currently pay for vaccination in people under 60, but that may change because studies in 50-and-overs are ongoing. Younger adults can pay out of pocket for this $150 to $200 shot. (Ask your doctor.) Researchers don't yet know whether the vaccine's protection will prove lifelong, though, so you may need a booster when you get older.

The mumps
Vaccine: MMR booster

The measles-mumps-rubella (MMR) vaccine, a must for kids, is back in the adult-vaccine lineup, too. "Mumps is the problem," reports CDC epidemiologist Andrew Kroger, MD. The number of Americans who caught this viral disease jumped to 6,584 in 2006 from 300 or less in most years. A large mumps outbreak in the Midwest was responsible for most of these cases, and outbreaks continue in Canada and neighboring states such as Maine. The problem may be a spillover from countries like the United Kingdom and Japan, where lagging childhood immunization rates spurred a comeback.

Mumps can be painful and sometimes dangerous. There's the textbook swelling of salivary glands around the neck, but some women also suffer from inflammation of the ovaries. In rare instances, mumps can trigger life-threatening encephalitis.

The CDC encourages all adults to check their status: Do you know whether you were immunized or had the disease as a child? Those born before 1957 are presumed to have been infected or exposed, which provides lifelong immunity. The spottiest protection is among those born between 1957 and 1967, who are less likely to have had mumps or who may have received a less-effective vaccine. A single dose of the current MMR should bring your protection up to date, Kroger says, and it may be covered by your insurance.

Travel Vaccines
Going on a cruise or an organized tour? Consider getting a flu shot, says Schaffner, who reports that influenza outbreaks frequently occur on cruise ships, even during summer voyages to northern destinations like Alaska. "Whenever people are jammed together, influenza is a risk," he explains. 

In addition, visitors to Asia should talk to their doctors about vaccine protection against typhoid and Japanese encephalitis. Visitors to the "meningitis belt" of central Africa should get a meningococcal vaccine. And yellow fever vaccines are important for travelers to much of South America and parts of Africa.

Hepatitis B
Vaccine: Recombivax HB or Engerix-B

Both vaccines protect against the hepatitis B virus, which is spread through sexual contact or contaminated needles and blood. An infection can lead to dangerous liver disease. Each year, more than 78,000 Americans become infected and about 5,000 die of associated liver diseases, including cancer, yet few know that the CDC recommends the vaccine for all sexually active people who are not in long-term relationships.

Flu

Vaccine: Influenza shot or FluMist nasal vaccine

A dangerous bug known as methicillin-resistant Staph. aureus (MRSA) may aggressively attack flu-weakened lungs, according to William Schaffner, MD, head of preventive medicine at Vanderbilt University Medical Center. MRSA was previously confined to hospitals but is spreading into communities nationwide. The link is unclear, but there may be a connection in the way that flu weakens the immune system and MRSA attacks it. MRSA is often marked by nasty skin infections. The strains contracted outside the hospital are now associated with some 13,500 deaths in the United States each year, many involving flu sufferers. "If you need further motivation to get a flu shot," Schaffner says, "there it is."

Jessica Snyder Sachs is the author, most recently, of Good Germs, Bad Germs.

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