By DemFromCT, cross-posted from Daily Kos

Superbug: The Fatal Menace of MRSA
Maryn McKenna
Free Press (Simon & Schuster)
Hardcover, 288 pages, $26.00 list
Kindle Edition $12.99
March, 2010

Money quote:

To his bewildered mother and grandmother, the swirl of controlled chaos around Tony was as inexplicable as his sudden collapse; the ICU seemed to be trying everything, hoping it would bring him back from the brink. No diagnosis was possible yet. They had been in the hospital barely an hour, not long enough for test results to make it down to the lab and back. But the medical staff had a strong suspicion of what could bring a healthy boy down so quickly, and the clue lay in one of the drugs they ordered pushed into his veins. it was called vancomycin, and it was famous in hospitals as a drug of last resort. They had used it against a bacterium that had learned to protect itself against most of the other drugs thrown at it, a particularly dangerous variety of staph called methicillin-resistant Staphylococcus aureus – MRSA for short.

Basic Premise: A medical journalist, steeped in the ways of the CDC from covering them as a beat reporter, follows the threat of MRSA from the earliest reports in the 80’s of hospital nursery spread to reports of modern outbreaks of MRSA (at first rejected by medical journals) to the farms where it incubates and the prisons where it spreads. There were missed opportunities to control spread, and we are still missing opportunities (see the food chain) to do a better job of detection and control before things get even worse than they are now.

Author: Maryn McKenna is a journalist and author specializing in public health, medicine and health policy. She previously published Beating Back the Devil: On the Front Lines With the Disease Detectives of the Epidemic Intelligence Service. An award winning seven part series on flu vaccine was written for CIDRAP (University of Minnesota). Future projects include “a multi-year research project on emergency room overcrowding and stress”.

Readability/quality: This is an excellent read, with well researched science but written at a level any news magazine reader could follow. The author has the experience to write about the topic with authority, without hectoring or lecturing the reader.

Who should read it: Anyone interested in learning more about the well-publicized MRSA bacteria; anyone interested in epidemiology; understanding the relationship between animals, the food chain and human disease; and anyone who likes a good detective story. Well, medical detective story, anyway.

Bonus blog: Superbug: Research, strategies and stories from the struggle against methicillin-resistant Staph aureus (MRSA) maintained by the author.

Interview with the author:

Daily Kos: You’re a journalist that followed CDC for many years at the Atlanta Journal-Constitution and covered many different topics; what got you interested in MRSA?

Maryn McKenna: The first time I really aware became aware of MRSA was during a year that I spent embedded with the CDC’s Epidemic Intelligence Service (a story that’s told in my 2004 book Beating Back the Devil, the first book about the EIS). One month I was following an EIS officer, as they’re called, who was posted to the Los Angeles public health department; I happened to get there just as he was assigned to an investigation of skin infections among gay men who frequented sex clubs. The question facing the investigators was whether these infections, which were very serious abscesses and fasciitis that required IV antibiotics and surgical repair, were sex-related, or merely an artifact of the conditions inside the clubs. Those clubs combine some aspects of what you would expect with some aspects that are more like a gym: workout equipment, benches. The snag was that men who go to sex clubs generally don’t wear clothes inside them but rather a towel around their waists — so the same portion of skin that might bump up against the skin of a partner during sex were also the same portions that were exposed to the bench when they sat down naked.

I’ve concentrated on outbreaks and epidemics for most of my career, because what’s interesting to me about diseases is the nexus of their biological intricacy and the complex social conditions that give rise to them. This LA outbreak had all kinds of complexity. There was the delicate position of the clubs within LA society: championed by the gay community, in a town with a very large gay community, as icons of sexual freedom; respected somewhat uneasily by the public health community because the clubs offered access to a hard-to-reach population; viewed with discomfort by others. Then there was the behavior of the bacterium itself: This outbreak took place in June 2003, just when the community MRSA epidemic was starting to curve upward, and many people just didn’t believe that MRSA could do this kind of damage to otherwise healthy men.

Eventually the investigation concluded (verdict: the conditions were analogous to gyms and were not specifically related to gay, or any, sex). I wrote the outbreak up as a chapter in my book and and went on to the next one. But three years later, I was doing another embedded assignment, this time observing overnight shifts in ERs for a year, and I realized that I was seeing lots and lots of similar infections. The ER physicians I was shadowing were not impressed by them, because they had become so used to them, but I found the prevalence dramatic. That experience really sparked this book.

Daily Kos: Do you see new drugs against MRSA as part of the solution to the problem? Is that ever really a solution?

Maryn McKenna: By one estimate — almost certainly an underestimate, I think — invasive MRSA infections kill almost 19,000 Americans a year, and by another estimate, cause 369,000 to be hospitalized. Those numbers are evidence that MRSA — all strains of MRSA, hospital, community and livestock-associated — causes serious infections that require significant treatment. So we’ll always need drugs. And since all of those strains are increasingly drug-resistant. we’re always going to need new drugs; any infectious-disease physician at this point can tell tales of MRSA cases for which they have to try several big-gun drugs before they find a compound or combination that ameliorates the infection, doesn’t cross-react with what else the patient is taking, and is not overly toxic.

The challenges are, first, making sure that firms deliver new drugs, because as SUPERBUG explains, pharma companies are increasingly backing away from antibiotic research as not cost-effective; and second, conserving the usefulness of any new drugs as well as the ones we still have. That requires concerted effort throughout medicine, from hospitals down to primary care, to make sure that drugs are used thoughtfully, so that we slow down the endless game of leapfrog between bug and drug that the bacteria will always win. It probably requires additional funding for research to characterize resistance factors. We need to know more, for instance, about how specific resistance factors are packaged in bacteria’s genetic codes, so that we know in advance that a segment conferring resistance to drug A, if it moves among bacteria, might port along with it resistance to unrelated drug F. And it definitely requires taking the ecological approach of understanding that antibiotics are a limited, shared resource that should be conserved. There will not be an endless supply of new drugs, no matter how clever new small biotech firms are in their design.

Daily Kos: What role does USDA play in prevention of future superbugs?

Maryn McKenna: One of the reasons the international epidemic of antibiotic resistance has gotten so bad is because we’ve done such a good job, collectively, of ignoring the interplay between human health and animal health. MRSA is a perfect example of this, because what I consider the “third epidemic” of MRSA — MRSA ST398, or livestock-associated MRSA — began in pigs, spread to farmworkers and their social networks, and then spread beyond them to cause very serious illnesses in humans who have no connection to farming. The evolution of ST398 was clearly driven by agricultural use of antibiotics; if you look at the susceptibility profiles of the first cases, you can see that the bug is resistant to drugs that were given to pigs.

ST398 emerged in Europe in 2004 and was first spotted in North America in 2007, yet we are still not testing for it, in animals or in humans. It is not a test that the USDA requires. Moreover, the antibiotic-resistance tracking system for food, NARMS (for National Antimicrobial Resistance Monitoring System) doesn’t track MRSA. And as several GAO reports have pointed out, the USDA has an imperfect grasp of how many antimicrobials are administered to food animals and under what conditions. The best estimate of antimicrobial use in animals — 70% of all antibiotics used in the US each year — is now about a decade old and has not been updated because USDA and industry hold the necessary data so tightly.

Possible federal action around animal antibiotic use takes in FDA as well, because it is the FDA, not the USDA, that licenses the drugs for use in animals (as humans). FDA has co-ownership of NARMS as well, with USDA and CDC. There is legislation in Congress now that would ask the FDA to restrict the use of certain classes of veterinary antibiotics that are identical to/important in human medicine.

Thank you, Ms. McKenna.