Emerging CF Pathogen Is Transmissible

A bacterial species increasingly responsible for lung infections in cystic fibrosis patients can be transmitted from person to person, although probably not directly, researchers said.

Genomic analysis of Mycobacterium abscessus isolates taken from clusters of infected CF patients found almost no sequence differences -- in fact, less than is normally found in isolates taken from a single individual -- "strongly indicating between-patient transmission," according to Julian Parkhill, PhD, of the Wellcome Trust Sanger Institute in Hinxton, England, and colleagues.

"Comprehensive environmental sampling" in the hospitals where these patients were housed failed to identify a source for these nontuberculous mycobacteria, whereas the patients had "numerous opportunities for within-hospital transmission from other individuals," Parkhill and colleagues wrote online in The Lancet.

"Although the exact transmission route is yet to be established, our epidemiological analysis suggests that it could be indirect," they added.

M. abscessus has recently been identified as a major cause of illness in CF patients, whose sticky lung secretions create a favorable environment for bacteria to flourish. Parkhill and colleagues noted that M. abscessus is hard to eradicate, requiring long treatment with toxic antibiotic combinations that often ultimately fail.

Some 3% to 10% of CF patients in the U.S. and Europe are currently infected with the organism, which has also been linked to dermal infections from tattoo inks and equipment.

In the case of CF patients, reasons for the pathogen's rapid emergence have been unclear. Possible factors include greater infestation in shower heads and the unintended consequences of chronic antibiotic therapy in these patients. Eliminating other bacteria may provide a previously unavailable foothold for mycobacteria, and some antibiotics may impair normal host-defense mechanisms.

In addition, person-to-person transmission has been suspected but never proven, Parkhill and colleagues indicated. Their current study aimed to find evidence that it contributes to the organism's spread.

They obtained 168 M. abscessus isolates from 31 patients seen from 2007 to 2011 at a CF treatment clinic housed at Papworth Hospital in Cambridge, England, and performed whole-genome sequence analyses as well as antimicrobial susceptibility tests.

The genomic analyses indicated that some of the isolates were virtually identical, differing by only 10 base pairs or less. It appeared that these isolates had infected a total of 11 patients in two separate outbreaks.

As an example, Parkhill and colleagues cited the case of one patient, whose isolates had genetic diversity that "was entirely encompassed within that of [another patient], indicating immediate relatedness by direct descent."

These isolates were of the subspecies massiliense, one of the three major subspecies of M. abscessus previously identified.

The researchers also examined patterns of antimicrobial susceptibility as a clue to the organism's recent genetic evolution. They found that several patients whose records indicated no previous exposure to long-term macrolides or aminoglycosides nevertheless carried M. abscessus isolates that resisted amikacin and clarithromycin.

These findings, too, suggested transmission between individuals. Parkhill and colleagues suggested that it was likely that these mycobacterial strains had picked up resistance elements as a result of coinfection with resistant organisms in some individual.

Parkhill and colleagues sought to exclude the possibility that the outbreaks originated with environmental contamination either at Papworth Hospital or elsewhere in the community. They determined that patients within the outbreak clusters did not live near each other or share water supplies, and tests of the hospital's water supply and equipment (including shower heads, bronchoscopes, and dishwashers) were all negative.

On the other hand, they found that, prior to becoming infected, each of the outbreak patients had been at the clinic simultaneously with a patient who was infected at the time. The exceptions, of course, were the initial cases in each outbreak cluster, whose route of acquisition of M. abscessusremains a mystery.

Finally, the researchers estimated mutation rates for the isolates, which indicated that the outbreak strains shared a common ancestor during "the period when opportunities existed for hospital-associated transmission." Other isolates not associated with the outbreaks were likely to have been genetically distinct for several decades.

But Parkhill and colleagues argued that transmission from close patient-to-patient contact was unlikely because of strict patient segregation policies in place at the Papworth clinic. "Patients are advised not to meet socially and are cared for in individual rooms," they wrote.

They suggested that "fomite contamination" -- in which the organism moves from person to another via an inanimate object -- was a more probable route of transmission. M. abscessus can survive severe physical and chemical assaults as well as dessication, they noted.

Another possibility is that aerosol generation during physiotherapy and lung function testing and other procedures in CF patients produce contaminated aerosols that subsequent patients breathe in.

The researchers added that, as a result of their findings, infection control procedures have been strengthened at Papworth. Steps taken include continuous sputum screening of all patients for nontuberculous mycobacteria, treating infected outpatients in a dedicated clinic with single-use rooms, and negative air pressure in inpatient rooms.

They indicated that it was too early to say whether these measures had reduced mycobacterial infections.

From Medpage Today

MRSA and Cystic Fibrosis continued...

Last week I posted an exchange between myself and a fellow community member regarding her child and MRSA (which can be found here). Many of you were very interested in the post and requested that I share stuff like that more often. The community member and I continued our conversation a bit so I thought I'd share with you the rest of what we discussed. Hopefully you find it useful and/or interesting.

About the MRSA. I am still confused. The nurses, RT, pharmacist and Dr all told us that lots of people carry the bacteria and dont even realize it. If it wasnt that our son had CF we wouldnt know he had it either. If it were any of our others kids if somehow we found out they tested positive for it they would probably treat them w/ antibiotics but if they continued to test + they wouldnt treat any further and wouldnt worry about it unless it caused problems. He said it wouldnt be anything I would have to disclose to the school district when he started either. (if the antibiotics fail and he remains + that is) One of the nurses said they havent seen an effect CF wise in patients who carry it. But they would like him not to have it so he had more options when it comes to antibiotics seeing MRSA is resistant to the penicillin family. They also said there are different strains of MRSA, there is hospital acquired which seems to be more difficult to eradicate and community acquired which has a better chance. I asked about the bleach baths again and he said we do have staph on our skin. Although MRSA likes the nasal and sinuses more, it is present on the skin also. By taking the bleach baths it just helps reduce the amount of bacteria present and helps the drugs do their job.

So, in one breath they make me feel like "no worries, lots of us have it...we're exposed to it all the time. Less than 1% of people actually show symptoms and have the boils/lesions. He'll be fine." Then the next breath though they are all dressed in gowns wearing gloves talking about how he'll have to be on isolation from now on until/if his cultures are negative for 3 consecutive months.

The Dr himself said he understands our confusion and that he agrees the medical field is kind of hypocritical when it comes to treating. One breath, no big deal, the next VERY big deal.

I asked about the rest of us getting tested. He said he thought it would be a waste of time, as they probably wouldnt treat us anyway. He also said that very recently they've started testing everyone who is admitted to the hospital especially for surgery for MRSA. If they test + then they treat them w/ antibiotics prior to surgery but then that's it. They do no follow up w/ that patient regarding the MRSA.

I was kind of peeved though for the fact I found out yesterday that at his Feb 8 clinic he did test + for staph. Not MRSA but a staph and not only did they not let me know that but they didnt do anything about it either. I asked him why not? and he said they dont treat for a staph unless he was sick which he wasnt. Dont get that though...isnt any/all staph not good? Whatever, cant do anything about that now either.

So, he is on Clindamycin and Rifampin (which is a dark red color) The Clindamycin is the yucky one...3xs/day for 10 days. Not going well. I went to Walgreens today and had them flavor it thinking maybe that would help but nope. Put a little in pure grape juice (they flavored w/grape) but nope. So I have to pin him down and try my best to get him to swallow it. The Rifampin doesnt smell like it would taste bad but he wont take that one either. AND that one stains like mad! I feel bad, he gets so totally pissed at me he doesnt even want me to hold him when he gets done. He runs to his big sister and makes her hold him:( He also has some ointment that we have to put in his nose 2x/s day for 7 days. Once he's done w/ these two antibiotics he'll get another refill on the Rifampin and then start Bactrim. He'll be on something for a total of 28 days.

As far as other people that carry MRSA - it is estimated that about, depending on who you believe, 30 to 70% of nurses in a hospital setting carry MRSA in their nose or on their skin. I think the best way to really grasp how it is different is to think of all these bacterias as completely different for a CFer. Like the docs said, MRSA hasn't been shown to do a lot of damage so far, so a lot of clinics treat it, or don't, like your docs do. The biggest difference is for the CF community it can get into our lungs because we don't have the ability to naturally clear our mucus as the rest of the population does. As I said before that's the key difference when it comes to all of these bacterias. So although many healthcare workers will have MRSA it never makes its way to their lungs because they can “naturally” fight it off. Like your medical team is saying it's not something that you have to disclose to the school district because it's not something that can spread to the general population from your son.

The “he'll be fine” attitude is very common in the CF community towards MRSA. It is true that more likely than not MRSA will not have a major impact on his health anytime soon (as far as studies have shown and what the American healthcare community believes). They were wearing gloves and gowns because it is of course better not to spread MRSA to other patients if they can avoid it. Even though it may only be a 1% chance to develop into skin lesions, they certainly don't want to take that chance with passing it on to others.

Confusion is expected. Remember that medicine is comprised of educated guesses. It's often the doctors that make the most correct educated guesses that are considered the best doctors :)

I agree that getting the rest of the family tested would in fact be a waste of time. If you wanted to take it upon yourself to do some bleach baths and some nasal washes it certainly wouldn't hurt, but it also wouldn't necessarily take the chances down to 0% that you would carry MRSA. Also keep in mind that your son may very well of not have gotten MRSA from your family and picked it up in clinic or out in the community, which is probably more likely.

Each clinic has a different response to staph. Some will treat aggressively right away and some will do what your clinic did - not treat unless symptoms are present. I would venture to guess that most CF clinics take the stance that your clinic does and that is not to bombard the body with antibiotics unless it's absolutely necessary. Not saying that I agree, just saying how it is.

I know it's tough for a little guy to understand but there will be a light at the end of the tunnel if he sticks with it. It can be so frustrating taking all of those meds but you just have to do the best you can with making them understand that as it is in fact all worth it (may be impossible with a 1 year old). I know you yourself can get frustrated, angry, disappointed and sad but make sure you always show him strength and commitment because that's exactly what he needs modeled from his parents.

Another Tylenol Recall

I certainly wouldn't panic, but it's always good for those of us in the CF community to know these things:

Bacteria identified in Tylenol recall

NEW YORK (CNNMoney.com) -- The Food and Drug Administration confirmed Wednesday that the bacteria found at the Johnson & Johnson plant that produced the recalled children's medicines was Burkholderia cepacia, a bacteria often resistant to common antibiotics.

Johnson & Johnson first identified the bacteria to CNNMoney.com earlier in the day.

The company said that although the bacteria was found on some drums used by its vendor to transport the raw materials, those contaminated drums never reached the Fort-Washington, PA-plant that made the recalled drugs.

According to the Centers for Disease Control and Prevention (CDC), B. cepacia is the name for a group of bacteria that can be found in soil and water.

The CDC said B. cepacia poses little medical risk to healthy people. However, those with certain health problems like weakened immune systems or chronic lung diseases, particularly cystic fibrosis, may be more susceptible to infections with B. cepacia.

The CDC also said that transmission of B. cepacia from contaminated medicines and devices has been reported in the past and that the bacteria has caused infections in hospitalized patients.

Johnson & Johnson (JNJ, Fortune 500) said that B. cepacia was found by a supplier to the factory that is operated by its McNeil division.

"Remaining drums from that lot were sent to us, all of which tested negative for bacteria. Samples of finished product also tested negative," said Johnson & Johnson spokesman Marc Boston.

However, the Food and Drug Administration's (FDA) 17-page FDA inspection report of the McNeil plant released Tuesday, said its review of seven vendor lots found some drums at the Fort Washington facility contaminated with B. cepacia.

An FDA official said, "To the agency's knowledge, no bacterially contaminated components were used in the manufacture of any of the recently recalled McNeill products. Also, testing done to date has not found bacteria in finished products."

"Still, the FDA felt there was the potential for contamination and that a recall of all of these products was prudent to protect the public health. Once again we advise that consumers not use these McNeil products at this time."

Johnson & Johnson could not immediately be reached for a response.

McNeil recalled some 50 children's versions of the non-prescription drugs on Saturday for quality concerns, including "tiny particles" in some of the products that the company said may be solidified product ingredients or manufacturing residue such as tiny metal parts.

The FDA said the recall affects some 1,500 "lots" of the drugs which were distributed both in the United States and internationally.

Original article can be found at http://money.cnn.com/2010/05/05/news/companies/childrens_tylenol_recall_bacteria/

Interesting article about Bacteria

Deep Inside Bacteria, a Germ of Human Personality

Bacteria are the oldest living things on earth, and researchers have long felt that they must lead dull, unfussy lives. New discoveries are starting to show just how wrong that notion is.

For a simple, single-cell creature, a bacterium is surprisingly social. It can communicate in two languages. It can tell self from nonself, friend from foe. It thrives in the company of others. It spies on neighbors, spreads misinformation and even commits fratricide.

"Really, they're just stripped-down versions of us," says Bonnie Bassler, microbial geneticist at Princeton University, who has spent two decades peeking at the inner lives of bacteria. Dr. Bassler and other scientists are using this information to devise new ways to fight infections and reduce antibiotic resistance.

Bacterial society is based on a chemical language called quorum sensing. To detect how many of its own species, or members of another bacterial species, are in the immediate vicinity, each bacterium secretes a certain molecule into the environment. The greater the number of molecules it can sense, the more fellow bacteria it knows are out there.

This is often a trigger to act. Some bacteria will attack a person or any other host only after establishing that there is a quorum -- a large-enough army to overcome the host's immune defenses. The strategy helps explain the virulence of a number of human ailments, including cholera, pneumonia and food poisoning.

Dr. Bassler was the first to identify the molecule that bacteria use to communicate with members of other species. She hopes the finding will lead to a new kind of drug that won't succumb to antibiotic resistance.

Resistance is a serious and growing health risk across the world. It occurs because most antibiotics are designed to kill bacteria. But some bugs survive the attack and pass on their resistant genes to their progeny, strengthening future generations and making the antibiotic less effective.

Instead of killing bacteria, Dr. Bassler wants to simply jam their communication lines -- the quorum-sensing mechanism. She figures that if the bugs can't signal each other, they can't properly assess the size of their growing army and might never attack. Another benefit: Because bacteria aren't killed, the approach could delay the onset of resistance.

To continue reading the article click here

Original article can be found at http://online.wsj.com/article/SB125236107718690619.html?mod=googlenews_wsj