Super Bugs

Superinfections or “superbugs” occur when cells previously infected by one organism become re-infected by another at a later time. These secondary infections are often caused by drug-resistant strains of organisms that have evolved in response to the use of antibiotics in treatment.

A Need for Super Attention and Super Meds

By Charlotte Boatwright, R.N., PH.D.

What Makes These Bugs “Super”?

Superinfections are not a new problem. In the 1300s, bubonic plague killed about one third of Europe’s population. More recently, this deadly affliction has been controlled by the use of drugs such as streptomycin, gentamicin, and chloramphenical. But in 1955, a 16-year-old boy developed an infection that would not respond to usual antibiotics, the first recorded case of a drug-resistant form of plague. It was eventually controlled by another antibiotic as reported in the New England Journal of Medicine in 1997.

Superinfections surfaced almost immediately after penicillin was discovered over 70 years ago. Dr. David Bell with the Centers for Disease Control (CDC) maintains that virtually all human pathogens have developed resistant strains that can outmaneuver antibiotics. This problem continues to grow and has captured the interest of the medical world. Experts all over are in search of new methods to prolong the life of existing antibiotics and to develop new ones.

How Serious are Superinfections?

As far as infectious diseases go, superbugs are one of the most serious problems we have today. Of those superbugs that have developed immunity to many antibiotics, the best known is MRSA (methicillin-resistant Staphylococcus aureus). Panton-Valentine leukocidin, the deadly toxin produced by MRSA, is believed to destroy the white blood cell membranes, eliminating the body’s first line of defense against the organism. It is noted that in 2006, 19,000 deaths and 105,000 infections from MRSA were reported by the Centers for Disease Control and Prevention.

Today, organisms that cause infections like meningitis, pneumonia, ear infections, and tuberculosis can outsmart common antibiotics and synthetic antimicrobials. Mayo Clinic reports that the 58 percent rise in deaths from infectious diseases between 1980 and 1992 could largely be attributed to drug-resistant organisms.

“The three big ones are MRSA, the gram negative rods, and one of the other consequences of using antibiotics, C. Diffcile, where you treat the infection, but also kill the good bacteria that live in your colon,” says Dr. Jay Sizemore of the Infectious Disease Group of Chattanooga. The bacterium Clostridium difficile, often called C. diff, is everywhere, including soil, air, water, and most surfaces. The bacteria do not cause problems until they grow in large numbers in the intestinal tract of someone on antibiotics or antimicrobial drugs. Symptoms range from diarrhea to life-threatening infections of the colon.

“We have overused antibiotics, and that has largely driven these bugs to become resistant,” says Sizemore. “Then, none of the pharmaceutical companies are interested in developing antibiotics anymore, so that is pretty scary. If these bugs are resistant to all our current antibiotics and no new ones are being developed, we will essentially be where we were 70 years ago before antibiotics were developed. The reason drug companies don’t want to develop antibiotics is because they want to create drugs that patients take every day for 30 years rather than occasionally for 10 days. That is their business. Congress is currently developing legislation that will provide incentives to drug companies who will develop antibiotics,” he comments.

“The biggest outpatient superbug I see in children is MRSA,” says Dr. Janara Huff, Pediatric Infectious Disease Specialist. “For the past 5 years or so, we have seen it, and it seems to be different than the old Staph. It can be very aggressive, most commonly in skin and soft tissue infections. We have had several children with life-threatening infections that showed up initially as pain or a small boil, and then disseminate to become pneumonia, heart infections, bone or joint infections, or bacteremia,” she remarks.

Though hospitals in major cities such as New York report more cases, Chattanooga and Erlanger, in particular, are sort of in the middle of hospitals with the variety and numbers of cases, according to Sizemore. “Smaller hospitals do not have a huge problem yet,” he notes. “All the attention is paid to MRSA, and it is a problem, but we have plenty of drugs to treat it. But for the whole class of gram negative bacteria, such as Klebsiella or Pseudomonas, there have been no new antibiotic classes to treat them in 20 years, and there are no new ones on the horizon for the next 20 years. We could potentially go for 40 years without new treatment options, and when they become resistant, we have nothing to offer the patient. We have to make the public realize, and I have the responsibility to make my colleagues realize, that we have to be careful about the ways we use antibiotics if we are going to stop this problem,” he says.

Managing the Problem

Hospitals are implementing policies to slow the unnecessary use of antibiotics in order to reduce the likelihood of superinfections. “At Erlanger, we have a program called ‘Antimicrobial Stewardship,’” says Sizemore. “Memorial and Parkridge are looking at starting similar programs. Starting this year, the pharmacy and I monitor the use of antibiotics throughout the hospital. I get a list every day of patients on those antibiotics which we are targeting to reduce usage or those prescribed without a good reason. We go to the charts of these patients and provide passive feedback to the provider through comments such as, ‘We have reviewed your chart. It does not appear that your patient requires this antibiotic. Please consider discontinuing it,’” he explains.

“Antibiotics are very easy to give in an environment where physicians feel that they must practice defensively. Patient demand can be another factor in inappropriate prescribing. I think the pediatricians are further ahead in the outpatient arena than other physician groups in limiting antibiotic usage, probably because of many studies that are being done to show that even in middle ear infections, antibiotics aren’t that effective. We are way behind, and we are already in trouble,” Sizemore states. “Most people do not realize that. When you are in the hospital with an infection, the expectation is that it will be treatable. If you get a report from the laboratory with an ‘R’ for resistant beside every listed antibiotic, you have no options.”

“In the hospital, infection control, paired with antimicrobial stewardship, is necessary. Out of the hospital, we must teach the new generation of physicians about the judicious use of antibiotics and reeducate the physicians already out there. And we must provide incentives to pharmaceutical companies to develop new medications,” Sizemore emphasizes.

What Can You Do to Prevent Superbugs?

In order to prevent these infections in children, Dr. Huff suggests that parents encourage children to wash their hands or use hand disinfectant. “Any minor skin opening such as mosquito bites or abrasions should be kept clean and covered, perhaps using antibiotic cream. Pay attention if the injury starts to enlarge or hurt. That may be the first sign of infection. If it doesn’t heal pretty quickly, they need to see someone. These organisms are very common; they spread from person to person easily and can get out of control very quickly if not attended. We see these cases frequently in the emergency room and almost always have cases in the hospital,” she notes. “We need to use antibiotics judiciously. Most minor respiratory illnesses in children do not need antibiotics. Otitis usually will self-resolve. Only the more serious infections really need antibiotics. Overuse has led us to have to use more potent antibiotics in higher doses,” Huff cautions.

Avoiding Infections and Preventing Misuse of Antibiotics

• Do not take antibiotics intended for bacterial infection for viral infections such as colds or flu.

• If your provider determines that you do not have a bacterial infection, ask for suggestions to relieve your symptoms rather than antibiotics.

• Take medication as prescribed by your provider and take the full course of medication even though you are feeling better.

• Do not save medication for later or share with others.

• Store, handle, and prepare foods safely.

• Ask your doctor which immunizations you and your children should receive and take them.

• Wash your hands frequently and thoroughly, using soap and water for 30 seconds.

• Visit these websites for additional information to prevent spread of infectious diseases: www.cdc.gov/ncidod/op/antibiotics.htm – “Ounce of Prevention” tells how to keep germs away. www.fightbac.org/ – Information on safe food handling.

Charlotte Boatwright is a native Chattanoogan. She has a doctorate in health care administration and is a registered nurse and licensed professional counselor. Charlotte has been involved with health care for 35+ years and is the founding member and president of The Coalition Against Domestic & Community Violence of Greater Chattanooga, Inc./ Chattanooga Family Justice Alliance. She can be reached at cboatwright@comcast.net

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