April 7, 2005
By MIKE TONER
The Atlanta Journal-Constitution
An old bug with some deadly new tricks is showing up in Atlanta and other communities around the country with alarming frequency, health authorities reported Wednesday.
Staphylococcus aureus, a common germ that infects countless scrapes and scratches a year, is fast becoming an uncommon public health threat. Drug-resistant strains of staph known as MRSA, once confined to hospitals and nursing homes, have been turning up among pro football players in St. Louis, Marine recruits in North Carolina, inmates in Georgia prisons, gay men in Los Angeles, Native Americans in Minnesota and pediatric wards in Atlanta.
"Close to one-fifth of what used to be a hospital-specific problem is now a community problem, and that's a large number," said Dr. Scott Fridkin of the Centers for Disease Control and Prevention. "We didn't think it would be anywhere near that high when we started the study."
The CDC said a survey of reported cases in Atlanta, Baltimore and Minnesota, published Wednesday in the New England Journal of Medicine, show that community-acquired MRSA is now "a common and serious problem" that, unlike older strains of staph, often requires hospitalization, especially in children.
More than three-quarters of the cases in the CDC study were skin infections, but 23 percent of all cases were serious enough to require hospitalization. Researchers found that about 20 percent of the cases studied in Atlanta were community-acquired staph, compared with 12 percent in Minnesota and 8 percent in Baltimore.
A second study in the journal reports that the new strain, unlike previously known strains of staph, secretes a tissue-destroying toxin called PVL whose so-called "flesh-eating" characteristics are associated primarily with strep bacteria. At least 14 cases of rare staph-related necrotizing fasciitis have been reported in the Los Angeles area.
"Necrotizing fasciitis is a life-threatening infection requiring urgent surgical and medical therapy," warned Dr. Loren G. Miller of the Harbor-UCLA Medical Center. "We have recently noted an alarming number of these infections caused by community associated MRSA."
"We are seeing the emergence of a new strain of the bacteria that is the most common cause of skin infections in the country," said Dr. Daniel Jernigan, a medical epidemiologist at the CDC. "It has developed resistance to standard antibiotic therapy and it appears to be spreading rapidly."
Escape from hospitals
Until a few years ago, reports of MRSA were so rare outside of hospitals that many doctors may have unwittingly aided its spread by treating it with antibiotics that didn't work.
In the last few years, outbreaks of several new staph strains have been reported in dozens of states, as well as in England, France, Switzerland, Saudi Arabia, India, Australia and New Zealand. In the United States, at least two dozen people have died of MRSA pneumonia during the last two flu seasons.
Overall, health authorities have only a piecemeal picture of MRSA's prevalence — much of it based on isolated outbreaks and limited surveillance of a few communities.
A 2002 survey by the Georgia Division of Public Health, for instance, found that nearly 600 people seeking treatment for staph infections at hospitals and clinics in eight metro Atlanta counties were infected by MRSA. The rate doubled in just a year, but the study was discontinued for budgetary reasons.
The Georgia survey found that 70 percent of people treated for such infections were getting antibiotics to which the microbe was already resistant — an error that gave otherwise mild infections an opportunity to fester and spread.
Because it is passed by direct contact, staph is especially troublesome in confined settings. The Georgia Department of Corrections, which initially attributed a wave of staph-caused skin lesions in its prisoners to "spider bites," reports that 1,200 of the state's 55,000 inmates developed resistant staph infections last year. Although only a few inmates were hospitalized, staph-infected pimples, boils, and other skin lesions were reported in 71 of the state's 75 correctional institutions.
Prisons keep tabs
In all, Georgia, California and Texas prisons, where outbreaks are well monitored, have reported 13,000 MRSA cases since 2001.
The U.S. Bureau of Prisons is urging measures that include isolating infected prisoners and reducing the use of antibiotics that are no longer effective.
"Staph doesn't fly," says Dr. Louis Tripoli of the Johns Hopkins University Correctional Medicine Institute. "Staphylococcal organisms are transferred from one person to another by contaminated hands or surfaces."
Anti-staph measures — including advice on hand washing — have been in force at all Georgia prisons since 2003, but officials say there are limits to what can be accomplished.
"It is not possible to eradicate Staph aureus from Georgia Department of Corrections prisons or any other locality," said department medical director Dr. Joseph Paris. "Staph is everywhere and the world cannot be made sterile."
Facing a wave of MRSA outbreaks among athletes, the National Collegiate Athletic Association and the National Federation of State High School Associations warned coaches, trainers, athletes and parents to be on the lookout for "small, red, tender, pimple-like lesions" that can quickly progress to more serious infections.
Wrestlers, football players and participants in other contact sports are especially vulnerable, especially if they have an open wound.
MRSA struck the St. Louis Rams in September 2003, when five linebackers who did not cover their artificial turf abrasions were infected. Investigators suspect players passed the bug to each other by sharing towels, using a whirlpool without showering, and by only sporadic hand washing. They also passed the bacteria — through contact on the field — to three San Francisco 49ers during a game in St. Louis on Sept. 14.
CDC epidemiologist Dr. Sophia Kazakova, who headed the Rams study, said the reasons for the outbreak were unclear, but the team's heavy use of antibiotics may have been a contributing factor.
"The players in our investigation were receiving 10 times the number of anti-microbial prescriptions dispensed to the public," she said.
Many harbor staph
Roughly one-third of the population carries staph germs without ill effects. Commonly found in nasal passages, under fingernails and on the skin, staph invades only when given an opportunity — a surgical incision, a needle stick or a scraped knee. Although it can be transferred from person to person on doorknobs, countertops, locker room floors or even by a handshake, the bacteria can be controlled by simple hygiene.
In the 1940s, when modern medicine first used antibiotics, no one realized that was the beginning of an arms race between man and microbe that would rage across the medical landscape for the next 60 years.
Penicillin, introduced during World War II, greatly reduced staph as a threat in hospitals and operating rooms. But within two years, a strain of penicillin-resistant staphylococcus had emerged. By the 1950s, the germ was universally present in hospitals. And by the 1970s, it had spread to the community at large. Today, 95 percent of all staph strains in the world are resistant to penicillin.
Modern medicine fought back. And so did staph. A new class of antibiotics, led by methicillin, was introduced in the early 1950s. And within a few years, methicillin-resistant staph had emerged in hospitals and nursing homes, where the new antibiotics were most heavily used.
Today, staph is one of the leading causes of the estimated 2 million infections and 88,000 deaths among people who get infected in a hospital. At least 55 percent of all hospital staph infections, 60 percent of infections in intensive care units and 71 percent in nursing homes are now caused by MRSA.
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