MRSA and MDROs

We devote this issue of San Diego Physician to infectious disease (ID), the medical topic we once thought we had conquered. As the first cases of HIV/AIDS emerged in the early 1980s, we soon realized that “bad bugs” were here to stay and that our coexistence with them remains precarious.

I went to medical school in the early 1970s and have a fascination with microbiology dating back to my pre-med years. I remember well the big ID topic of the early ’70s was penicillin-resistant Staphylococcus aureus. Each month we would see figures about how rapidly the drug-resistant Staph was sweeping first the hospitals and then the community. Beta-lactam drug resistance entered our vocabulary and called for a new generation of antibiotics.

The current story of methicillin-resistant Staphylococcus aureus (MRSA) parallels the penicillin resistance that started as early as the 1950s and swept society in the ’70s. Currently, we talk about HA-MRSA, hospital-acquired MRSA, and CA-MRSA, community-acquired MRSA, as if they are different. Already many in public health and ID realize that we must now consider all Staphylococcus aureus as MRSA and treat accordingly.

Robert Peters, in his article on “Bad Bugs and Fewer Drugs,” discusses the many multi-drug-resistant organisms (MDROs) that are emerging around us. Our unlucky patients with serious infections are having unprecedented numbers of antibiotics being used in hopes of combating the infections. Not long ago, a healthy child returning from camp died here in San Diego County of overwhelming MRSA sepsis being aided by the presence of influenza virus. Turns out when you have influenza A, your respiratory tract is left with little defense to deal with the MRSA that is living in your nose.

We need to help our patients put MRSA and other MDROs in perspective. There is no avoiding their presence. It is silly to shut down schools or training facilities just because MRSA has been detected. MRSA is all over exercise equipment and other objects. A recent study even showed that 68 out of 200 stethoscopes (38 percent) harbor MRSA (1). We physicians have been agents of infectious disease in the past, and without good awareness and hygiene, this iatrogenesis continues.

Where does this leave us? Back to the rules of good hygiene. A simple break in the skin, if left contaminated, can leave us powerless and kill us and our patients. Handwashing is as important today as in the days of Semmelweis. We must wear clean clothing and look at what that white coat we have been wearing for a week might be harboring. Cleaning the surface of our stethoscope and other objects and surfaces between patients should be commonplace. I believe that seeing patients at home, both virtually and in person if we are clean, will become common again.

Time will tell if the predictions of a “coming plague” will come true in our lifetime. The odds are not in our favor when it comes to humans versus micro-organisms. Every time a patient takes an antibiotic, a delicate balance is disrupted. We need to be sure the antibiotic is warranted. Most superficial skin infections can be effectively treated using local care. There is a risk and benefit to all our treatment decisions in ID. Most importantly, we must practice and teach good hygiene and avoid being agents of infectious disease.

Reference:

1) Sanders S. The stethoscope and cross-infection revisited. Br J Gen Pract. 2005 January 1; 55(510): 54–55.