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| Originally Aired: October 24, 2007 |
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Two Doctors Explain Drug-resistant Super Bug |
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| A dangerous bacterial infection that's resistant to standard antibiotics killed more Americans in 2005 than the AIDS virus, a recent CDC study revealed. The bug, called methicillin-resistant Staphylococcus aureus, or MRSA, has raised concerns in the public and among the medical community. Two doctors answered your questions. |
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MARGARET WARNER: Welcome to this week's Insider Forum from the Online NewsHour. I'm Margaret Warner. This week, we're discussing a dangerous form of staph infection that's been in the news lately, MRSA, or methicillin-resistant Staphylococcus aureus. Last week, the Centers for Disease Control released a startling report, saying that MRSA kills nearly 19,000 people a year, more than the AIDS virus, in the United States, and causes more than 90,000 serious infections annually. What's more, while MRSA had been thought to be confined to hospitals and other healthcare settings, the report found that 13 percent of the cases aren't related to medical care at all; and, in fact, in recent weeks there have been reports of otherwise healthy students becoming ill from MRSA, and three students in recent weeks have died. Here to help us understand more about this infection and answer your questions on MRSA are two guests. First, Dr. Georges Benjamin is executive director of the American Public Health Association, which promotes disease-prevention activities and health services in all communities. He's the former secretary of the Maryland Department of Health and Mental Hygiene. And Dr. Benjamin also served as the chief of emergency medicine at Walter Reed Army Medical Center. Our other guest is Dr. Stuart Levy, a professor of molecular biology and microbiology at Tufts University School of Medicine in Boston. He's also director of the Tufts Center for Adaptation Genetics and Drug Resistance, and he's a staff physician at the New England Medical Center. What's more, he's president of an organization called the Alliance for the Prudent Use of Antibiotics. And, gentlemen, welcome to you both. Thanks for joining us. DR. STUART LEVY: Thank you. DR. GEORGES BENJAMIN: Thank you. MARGARET WARNER: There's a lot of misinformation out there, even panic, about MRSA, and we could see it in all the questions submitted by our viewers and listeners to the NewsHour -- what it is, that is, and what kind of threat it poses. So, let's start with the basics. And, Dr. Levy, how many people naturally carry MRSA -- that is, the drug-resistant form of this common staph infection -- on their skin? And what triggers it to then become the invasive sort that can move from the skin into the body and attack other organs? DR. STUART LEVY: We'll start by saying that the methicillin-resistant form of staph aureus is the resistant kind. There is the normal staph aureus, which we carry -- about 25 to 30 percent of people carry it on their skin, under their arms, in their noses -- doesn't cause any problem, but it could also cause the disease. But the other form, the one that is cited in this report, the methicillin-resistant staph aureus, is not just resistant to the methicillin, which is a kind of penicillin, but to other drugs, as well. And that can be carried, normally without harm, in about 1 percent -- for the moment, estimated 1 percent of the people. MARGARET WARNER: And then, what triggers it to -- DR. STUART LEVY: What triggers it -- MARGARET WARNER: -- become the invasive sort? DR. STUART LEVY: -- is not totally known, I must say. An abrasion could be -- we know that, in contact sports, when we look at one form of this "mrsa," or MRSA, we know that coming up against another person -- maybe a small laceration in the skin and the bacterium gets in, one doesn't wash it immediately, it can set up an infection. But why some people carry it healthily and without a problem, and others come down with it -- we see it in families, where one member could be sick with it and have these boils, and others in the same family do not. We don't have the answer to that yet. |
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Dr. Georges Benjamin
American Public Health Association |
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 There's a lot of thought that this is a different strain than the one we saw in the hospital, both resistant to the antibiotics, but you see them in both places now, in the community and in the hospital. |
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Symptoms of MRSA
MARGARET WARNER: Well, Dr. Benjamin, that raises the question about whether you think the -- whether you -- we know -- is the incidence of MRSA growing, or are we just hearing more about it?DR. GEORGES BENJAMIN: Well, I think we are certainly seeing an increased incidence of the organism. There was a time in which it was almost totally confined to hospitals, and you often saw those in very, very sick patients in hospitals, but now you're beginning to see it outside the hospital. Now, there's a lot of thought that this is a different strain than the one we saw in the hospital, both resistant to the antibiotics, but you see them in both places now, in the community and in the hospital. And that's -- MARGARET WARNER: So -- DR. GEORGES BENJAMIN: -- one of the challenges. MARGARET WARNER: So, in the hospital it was usually because there was already, what, some sort of incision or wound in the skin, and that's how it got in. DR. GEORGES BENJAMIN: That's right. And also, of course, the fact that you had people who were very sick, who were in the hospital, so their resistance was lower; and so, they were more likely to become overwhelmed by the organism. Many of these are people who had heart operations, hip operations, some of the bigger operations -- not always, but those were the people that tended to get sick. But now we're seeing, as you saw, relatively healthy people out in the community with this disease. MARGARET WARNER: So, Dr. Levy, how does a patient in a hospital contract MRSA? DR. STUART LEVY: It's generally by contact. The history of this organism goes quite a bit back. I must say that, in Australia, in the early '80s, they faced MRSA in a big way in the eastern portion of Australia, and they found it in the hospital, in the linens and so forth, but it was generally passed from one person to another, and the patients were not separated. They handled this by separating the patients, changing how they cleaned their sheets, and so forth. But in the other side of Australia, in Perth, they immediately started this, sort of, search-and-destroy, in which case the patients who entered the hospital immediately were -- had seven or eight sites on their skin, in their nose, tested, and if they had MRSA, they went to a different part of the hospital. So -- and they've been successful to keep the rates -- that is, the numbers of MRSA -- out of these hospitals, as opposed to, once it's let in, as it was happening in the eastern part of Australia. We're now, 20 years later, facing the problem here. We've already begun to put patients with MRSA in separate rooms from other patients. But we've got other things we need to do. In certain hospitals, there's a whole list of ways in which they have prevented, essentially, the passage, the transmission of the organism from one patient or one room to another. MARGARET WARNER: And I want to get back to more about what can be done, but first just a couple more questions about how someone knows if they have it. Let's take -- and we'll stick with the hospital, for a minute, Dr. Levy -- if you're either a patient who's aware, or you're the loved one of a patient, what's the visible signs that you or your loved one has contracted this -- the virulent strain? DR. STUART LEVY: Usually, it starts with a boil. Now, sometimes you can't see it, and you see a swelling or a warmth in the area of the skin. It could be an arm, a leg, a finger, whatever. And the community one, the one that is relatively new and actually more virulent, makes an enzyme, a protein, which is the toxin, and it can start destroying the tissues. So, this wound may grow very quickly, and that's a sure sign that you've got this kind of MRSA. MARGARET WARNER: Now, when you say "the community one," now you're talking about the type that could pop up in a student or in anybody -- DR. STUART LEVY: That's -- MARGARET WARNER: -- out in -- DR. STUART LEVY: -- correct. MARGARET WARNER: -- the community. DR. STUART LEVY: That is correct. And this is -- because it has just a little bit better way of sitting down on the skin, and a better way of entering, and, when it enters, of producing these toxic materials that make you very sick and can cause the spread and growth of the infection much quicker, interesting enough, than the hospital-associated one, which is bad enough, but this one is worse -- because, as Dr. Benjamin was saying, the hospital one, we can understand that, because patients in the hospital are very sick, and they're more susceptible to infections, so we have to protect them by putting MRSA patients in different rooms and avoiding that. But in the community we're talking about healthy, young, strapping males and females that we don't expect will come down with this kind of infection, except this is this bacterium. |
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Dr. Stuart Levy
Tufts University |
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| More importantly, and more, shall we say, striking to us, was that these same bacteria resistant to this soap ingredient were resistant to antibiotics.
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The importance of hand washing
MARGARET WARNER: And, Dr. Benjamin, if -- whether someone in a hospital or a strapping young student does come down with it, what are the drug treatments that do work? And I gather some of it can be -- some of the treatment could be pretty extreme.DR. GEORGES BENJAMIN: Well, they -- first of all, many of these create an abscess or, like, a big boil, and a first principle in managing those is usually draining, so usually they open them up and drain 'em and get rid of the puss. Secondly, there are antibiotics that can treat this. I mean, that's one of the -- that's the good news here. Unfortunately, it's often not the ones that are commonly used, the penicillins and some of the easier antibiotics on your system, and so that's just one of the big concerns, is that we have to use some of the more high-powered antibiotics on this particular type of infection. MARGARET WARNER: All right. Well, let's turn to some of the blizzard of questions we got on MRSA since our discussion on the program Monday night, the 21st. And, Dr. Levy, I'll go back to you. This comes from G. McNamara, from Grosse Pointe, Mich., and he basically asks, you know, "Can one get it from shaking hands with fellow parishioners during a church service?" He was particularly commenting on the fact that in -- at some services, it's almost part of the -- of the gathering, that you turn to the person on your left, and you turn to the person on your right. DR. STUART LEVY: It certainly can. And viral diseases can, too. I mean, it's very well known that the hand is often the vehicle, but it often goes to the mouth. So, you put hand-to-mouth transfer, how colds are transferred in other diseases. The way you handle it is, you wash your hands. But there is nothing particularly bad about shaking hands, and it's not going to mean that, if you do pick up a random MRSA, that it's going to cause an infection in you. It's not all that common. On the other hand, most people, I hope, are washing their hands, so they wouldn't be transferring these organisms. MARGARET WARNER: But how often should people wash their hands? DR. STUART LEVY: I recommend washing before you eat, and obviously after you use the bathroom facilities, if you're taking care of a young baby or changing diapers, if you're preparing food for other people, especially meats, which often carry bacteria, and often resistant bacteria. But I guess my biggest emphasis now is on lunch, because I think that most people are so busy -- they're in meetings, and then everybody says, "Let's go to lunch." Meanwhile, all during that period, they've been sharing -- shaking hands, coughing, sneezing, whatever, and then they go and have lunch, and they eat with their hands. And I somehow feel that every meeting should have a wash-hands break. MARGARET WARNER: Somebody asked -- now that you mention hands, and I'll ask you this, Dr. Benjamin -- the widespread use of both antibacterial soaps -- this was Margaret, in Alabama, asked about that -- is that actually contributing to the drug resistance of some bacteria, or is it, in fact, a good idea to use antibacterial soap? And also, though she didn't mention this, you know, these antibacterial gels that people sometimes use on their hands when they can't get to a place where there's soap and water, is that a good idea or is that contributing to the problem? DR. GEORGES BENJAMIN: Well, the alcohol-based hand sanitizers are pretty good, and probably pretty safe, and are probably not a problem. I think the issue -- and the jury is still out about the antibacterial soaps. Let me just say that what cleans your hands best, particularly if your hands are soiled, is soap and scrubbing and water. And so, whether you use the antibacterial soaps or simply soap without that, the emulsification of -- and the stuff that's in the soap that -- the detergent that's in the soap that helps clean your hands, and the action of scrubbing your hands to get the dirt off, is what really works; and, of course, of doing that under water. We are very -- we are concerned, increasingly, about the use of antibiotics that you take, in terms of drugs. I think there may be -- there is -- there's growing concern about some of the antibacterial products that have antibiotics in them. I think Dr. Levy probably has a perspective on that, as well. MARGARET WARNER: Dr. Levy, weigh in on this. DR. STUART LEVY: We actually studied that. And, I think, the laboratory found, actually, the target, the protein that one of the ingredients, triclosan, attacks when it hits the bacterium. It's a wonderful drug when it's used appropriately. It is not something you would take orally or put into the blood of a -- of a patient, but it's used to scrub down before surgery. But the casual use in the home -- that is, the 5- to 6-second estimated washing of your hands -- doesn't use that antibacterial -- it has to stay on there for minutes at a time, which never occurs. But, in our laboratory, we've been able to isolate all different kinds of bacteria with mutations to resistance to this product, so that means that it can't be used, let's say, if you want to -- you have someone sick at home, and you need it, someone whose host defenses are down. And, more importantly, and more, shall we say, striking to us, was that these same bacteria resistant to this soap ingredient were resistant to antibiotics. So, in fact, it's almost like spreading antibiotics around the home. And, unless you need it, the use of these products in healthy households is really not an advantage. As Dr. Benjamin was saying, washing is the advantage. That's what you do. It's the removing of the materials from your homes and down the drain that works, and the antibacterial-containing products should be reserved for those patients who are very vulnerable, and then they have to be used correctly -- that is, minutes at a time. |
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Dr. Georges Benjamin
American Public Health Association |
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| Any type of conjugate setting - daycares, schools, dormitories, where you have lots of people crowded together - that's a higher-risk environment. |
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Bacteria on surfaces
MARGARET WARNER: So, for instance, in offices, many people now have them in their -- in their bathrooms in the offices. You would recommend against that.DR. STUART LEVY: That -- in my own -- here at Tufts University, at project pharmaceuticals where I'm also associated, we removed all that. But, in the hospitals, when I'm making rounds and all at -- here at New England Medical Center, we have the alcohol-based foams that we use, which are great. And, in fact, the FDA had a session in looking at what is the best for hand washing, and it came down exactly as we've been stating here on your program, hand washing with soap and water is the first line; and, if you don't have it, then alcohol sanitizers is a good line if you can't access soap and water. MARGARET WARNER: Dr. Benjamin, let's -- and go back to more precautions and advice people are seeking here about what they can do. Kate, from Bend, Ore., wrote -- and we are not using people's last names here, because they often seem to be speaking of their own personal situations -- she said, "We have a 20-month-old son in daycare. How worried do we need to be about him contracting this? How do you know if your child's at risk? What percentage of the children who contract the skin infections actually die? How do we know if there are cases in our area? And, if there are, would it be advisable to remove our child from daycare?" DR. GEORGES BENJAMIN: That -- those are all very important questions. First of all, any type of conjugate setting -- daycares, schools, dormitories, where you have lots of people crowded together -- one -- you know, certainly they're -- that's a higher-risk environment. I think the best thing to do is talk to the daycare provider, find out what they are doing, in terms of infection control, making sure that the employees there are washing their hands between kids, make sure they have a protocol to handle infections in the daycare center. And they're all -- usually required by law, under regulation, to have those kind of protocols. Certainly, if the child gets a boil or a red lesion, or there's another child in the center that has a boil or red lesion, or they get the -- you know, usually, notification that someone there has that kind of lesion, then you need to be asking the provider what they're doing about that. Usually, they will let all the parents know, they will enhance their infection-control procedures, they will clean any area in which they think they may have had that problem. Sometimes they do have to, maybe, close the room in which the children were in. You know, sometimes these daycare centers have multiple rooms for kids of multiple ages, so they will clean that room while they're -- close that room while they're sanitizing that room. MARGARET WARNER: Uh-huh. DR. GEORGES BENJAMIN: It -- you can never know for sure. You obviously can't see these microbes. But, of course, I think, you know, the best thing for any parent is to watch their child very closely for any kind of infection. MARGARET WARNER: Well, and that raises the question -- we got this from a lot of online viewers, but Mary Catherine, from Woodbridge, Va., for instance, asked, "How long does the MRSA bacteria live on a non-skin surface, a dry surface, whether it's a doctor's stethoscope or a towel in a gym or a -- the floor in a daycare center?" DR. GEORGES BENJAMIN: I don't know that. Dr. Levy, do you know? DR. STUART LEVY: I -- you know, I know it's more than hours. In terms of more than 24 hours, I'm not sure. But the fact that we can pick it up so readily in environments -- or, shall we say, on clothing in areas where there is not an MRSA patient that would be rapidly transferring it, it's -- it's fairly stable, certainly in surfaces that have a little moisture. If they're completely dry -- all bacteria, studies that we've done before have demonstrated that they survive best on wooden surfaces than metal and things like that. MARGARET WARNER: Wait, I'm not sure I quite understood you, that they survive longer if the surface has any moisture? DR. STUART LEVY: Has the moisture, is -- DR. GEORGES BENJAMIN: Yeah. DR. STUART LEVY: -- correct. DR. GEORGES BENJAMIN: That's why you -- that's why the concerns about towels and razors and -- MARGARET WARNER: Showers -- DR. GEORGES BENJAMIN: -- on showers and -- DR. STUART LEVY: Yeah. I mean -- DR. GEORGES BENJAMIN: -- and things like that. DR. STUART LEVY: -- in fact, it's been picked up on soap, which is very interesting to me, and -- but I do think it's the -- it's been shown by CDC studies that towels -- and, as I said, in Australia, sheets -- can transfer. MARGARET WARNER: But that -- the soap was very -- very peculiar and counterintuitive. They're saying wash your hands with soap, and yet -- DR. STUART LEVY: Exactly. MARGARET WARNER: -- they've found it on commonly -- on shared soap in high-school showers. DR. STUART LEVY: Yes. And I -- and I think it's the residual -- you know, if you have one or two bacterium, that's not going to make the problem. We're talking about many more than that. And I would say that no one has looked -- to my knowledge, the time this particular organism remains on soap, on a towel, on a surface. |
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Dr. Stuart Levy
Tufts University |
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| I think one of the most important features of what's come up last week is this awareness that bacteria out there can be harmful, and we should be vigilant and be aware of it, and avoid the use of antibiotics. |
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Using antibiotics when necessary
MARGARET WARNER: Now, we had a letter -- I'll -- Dr. Benjamin, I'll come back to you -- Richard, from Falmouth, Maine, asked -- he said he's planning to get back to the gym -- a lot of us say that, but he really says he is -- and, "What's the best way to avoid getting and giving MRSA?"DR. GEORGES BENJAMIN: Well, certainly, again, the hand washing before and after exercise. To the extent you can put a towel down on shared equipment so you're laying on a clean towel and not just right on the platform itself, may be helpful; encouraging your gym to clean down their equipment every day after everyone's used it is certainly important; and taking a shower and washing up as soon as you're done exercising; and, of course, using a clean shower, not sharing any of the personal equipment, like towels or shaving equipment or anything like that. MARGARET WARNER: So, back to the antibiotic resistance, Dr. Levy, your particular expertise. We've been hearing about this now for decades, it seems -- DR. STUART LEVY: Yes. MARGARET WARNER: -- the over-prescription of antibiotics, that doctors shouldn't prescribe them so much, the patient shouldn't demand them so much. Has any progress been made on that? What can really be done? What can an individual physician do? DR. STUART LEVY: Well, I'm happy to say there is some progress, mostly in the pediatric area, where I think pediatricians and the American Society of Pediatrics have taken a very good stand on not overprescribing antibiotics, for instance, for earaches, which often are over on their own, because it's viral, in 24 hours. But we have a long way to go. We have the problem of antibiotic use in animals. We have the problem of over-prescription. We have the problem of stockpiling, that patients will get a prescription, they may not need it, they may use it for 2 or 3 days, find that they've got another 7 days left, they put it in the medicine cabinet, and they take it one at a time, whenever they feel a tickle in their throat, misunderstanding that antibiotics, although they're miracle drugs, have a downfall, and that is that they are the very ones that select bacteria that, through mutation or getting it from some other bacterium, learn to resist the antibiotic. And if you get to a stage, as the MRSA strain is, where you're resistant to more than one antibiotic, you really make a bacterium harder and harder to treat. And in an age when new antibiotics are coming through very, very slowly, this problem just makes the infection problem even worse, if we don't have the available antibiotics to treat it. Fortunately, for the MRSA, we have some new ones. But, for some other bacteria that are multidrug-resistant, we do not. MARGARET WARNER: So, let me be clear, that I understand this, here. Is there something an individual can do to make himself or herself less antibiotic resistant, or is this something that is a systemic problem, communitywide? And so, you could decline antibiotics most of the time, but, still, if you got an antibiotic-resistant strain somewhere, you'd be just as vulnerable as the person who stockpiles their antibiotics -- DR. STUART LEVY: Unfortunately, the latter is true. And this is why I call these drugs "societal drugs," the only kind that I think are out there, because your misuse, and your use, creates this environment around you of resistant strains. If you're treating an infection, that cost is well worth it, there is a real benefit. But the overuse for viral illnesses, the overuse by misuse, the overuse in animals, this is wasting good products and creating this resistance, which comes back to everyone in society, those that take the antibiotics and those that don't. MARGARET WARNER: So, Dr. Benjamin, what do you think an individual can do -- DR. GEORGES BENJAMIN: Well -- MARGARET WARNER: -- to safeguard oneself from developing -- one, developing MRSA, we know, just to wash and so on, but, on this larger problem of antibiotic resistance? DR. GEORGES BENJAMIN: I think contributing to the collective good by not using antibiotics and not requesting antibiotics from their physician when they don't need them; if your doctor says, "I think it's a virus, I don't think you need an antibiotic," don't insist on it. Encouraging various industries not to overuse antibiotics in animals is a -- is a -- is a big issue, and one that, certainly, the American Public Health Association has been greatly concerned about. Making sure that -- through some personal protection -- again, frequent hand washing covering up cuts and keeping them Band-Aid-covered until healed. If you're taking care of someone who has a staff infection, whether it's a MRSA bacteria staph or a regular staph infection, making sure that you're washing the sheets and the towels, not sharing equipment -- that's a very important message for our teenage population -- MARGARET WARNER: Uh-huh. DR. GEORGES BENJAMIN: -- and our school-aged population. And being vigilant; if you get a sore that doesn't look like it's healing, looks like it's advancing, has red streaks going up your arm, if you get a fever, see your doctor right away. MARGARET WARNER: And, Dr. Levy -- a question here came from Roger, of Lexington, Massachusetts, "What risks," he said, "do I face," or what precautions should he -- "I pursue," he said, "and discuss with my surgeon if I'm scheduled for surgery?" DR. STUART LEVY: I think you should definitely discuss the issue of who's doing the surgery, what is the infection rate in the hospital, how has that surgeon fared, and then, what precautions they're taking, because all surgeons do -- and all operating rooms do -- to prevent an infection in the site of the surgery. And most hospitals do very well. I think that we can do better, and I think it's also true about visitors to the patients' rooms, but largely the house staff and those who are managing the patients should wash their hands, as we've been saying repeatedly, and be on the alert. I think one of the most important features of what's come up last week is this awareness that bacteria out there can be harmful, and we should be vigilant and be aware of it, and avoid the use of antibiotics, which can help them multiply. MARGARET WARNER: Uh-huh. And a final question that came from many of our listeners, and from us, as well, is, Is there a bit of an over-reaction here? In other words, is all those coverage creating a climate of fear about the bacteria and leaving the public with the impression that MRSA infections, all of them are alike and they're equally rampant, and that it's just spreading like wildfire through society? DR. GEORGES BENJAMIN: Yeah, I'm always concerned about that when we have this kind of press coverage. But I think what we're achieve -- we're hoping to achieve is awareness, but not panic -- DR. STUART LEVY: Uh-huh. DR. GEORGES BENJAMIN: -- and for people to recognize that there's a multitude of diseases out there. Every year 400,000 people die of tobacco-related diseases, and many more people die of other diseases, automobile accidents, HIV/AIDS, and this is just another in the collection of things that we have to be concerned about, and we need to keep ourselves focused on the things that really kill people. We need to do the things that we can do, in terms of preventing some of these things from hurting us. But we not -- are not -- we should be aware, informed, and not panic. MARGARET WARNER: Dr. Levy? DR. STUART LEVY: I totally agree. I think that's one of the things that has concerned me, is, How much panic is this going to generate? And it should generate, first, interest and understanding. And I think programs such as this, if they can occur more often in -- throughout the country, will help to alleviate the fear, but to stimulate the understanding and awareness. MARGARET WARNER: Well, I want to thank you both, Dr. Stuart Levy, of Tufts University School of Medicine, and Dr. Georges Benjamin, of the American Public Health Association. You've both really done a lot to help clear up the confusion and panic, I think, out there over MRSA. And also, thanks to everyone who sent in questions for this week's edition of the Insider Forum. I'm Margaret Warner. Thanks. DR. GEORGES BENJAMIN: Thank you. DR. STUART LEVY: Thank you.
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Shields and Brooks Gauge 9/11 Trials, Afghan Troop Decision
