Vancomycin

Vancomycin, for many of the people who have fallen victim to Methicillin-resistant Staphylococcus aureus (MRSA), it is a final solution. Vancomycin is a glycopeptide antibiotic. It is the solution of last resort but highly effective.

Vancomycin is used to treat bacterial infections by stopping or killing the bacteria responsible. When treatment using other antibiotics has failed, Vancomycin is the strongest option available. The antibiotic is available in capsule and injection form, although oral Vancomycin is not effective against MRSA.

The advantage of capsules is that generally they are not absorbed into the blood stream. It is argued that because of this Vancomycin in capsule form is unlikely to cause any severe side effects. However, this is precisely where the problem lies. Should the side-effects occur, they have the potential to become quite severe.

Problems Associated With Vancomycin

Nausea, dizziness, feeling cold, flushing, pain, muscle spasms, bruising, the development of a rash, ringing in the ears, hearing difficulties, or breathing problems are all potential risks.

The severity of these side-effects can be variable and immediate medical attention should be sought if any one of the above become apparent whilst taking Vancomycin.

In addition to the above side-effects, Vancomycin is also criticised for being practically and economically troublesome.

The Practical Problem Of Vancomycin

Non-serious MRSA infections, which may include urinary-tract infections (UTI’s), wounds and skin problems, are difficult to treat with Vancomycin. Slow cure rates and even failure cloud the Vanconycin success story.

The Financial Problem Of Vancomycin

Financially, Vancomycin and its course of treatment are somewhat expensive. Particularly in recent years, increasing incidence of MRSA is adding to the National Health Services budgetary commitments. Contributing to the argument against Vancomycin is the toxic issue.

Vancomycin – The Toxic Problem

A particularly significant issue for patients receiving Vancomycin treatment is that the therapy is more toxic than other methicillin-type drugs. Consequently, a patient’s blood levels must be continually monitored.

The Replacement Case – Vancomycin and Linezolid

Rarely does a credible article draw upon the successes and failings of Vancomycin without making some kind of reference to the drug Linezolid. This is because with the emergence of Vancomycin-resistant organisms, increasingly Linezolid has displaced Vancomycin as the drug of last resort. It has always been a concern amongst healthcare leaders and professionals that increasing use of Vancomycin would result in the energence of resistant organisms and this danger has become a reality.

The Case for Linezolid Explained

Linezolid is part of the Oxazolidone antibiotics. It is highly active in vitro against MRSA and additionally it can be taken orally. It is this oral dosing that may permit an earlier discharge of hospitalised patients and what is more Linezolid and Vancomycin have similar clinical efficacy for MRSA infections. So what are the issues surrounding Linezolid?

Problems Associated With Linezolid

With the use of Linezolid comes the risk of haematological abnormalities, including Myelosuppression and Thrombocytopenia. To compound the problem Linezolid is extremely expensive, sometimes more so the Vancomycin.

The prevailing argument appears to be that Linezolid should not be used routinely. That is, to avoid the emergence of Linezolid-resistant Vancomycin-resistant enterococcus (VRE).

The Way Forward for Vancomycin

Vancomycin is a successful drug but with side-effects and associated problems. The spreading of MRSA and the increasing usage of Vancomycin make the drug more susceptible to failure from Vancomycin-resistant organisms. Furthermore, we cannot rely on Linezolid to completely fill the role of Vancomycin. Ultimately, a return to the idea that prevention is better than cure must be encouraged. MRSA prevention programmes are rolling out across the country with the expectation that this will, in time, reduce our dependence on Vancomycin. It is the drug of last resort and should remain so if its effectiveness is to be maintained.

The Prevention of Methicillin-resistant Staphylococcus aureus
(MRSA)

Touch a person who carries the MRSA bacteria or touch something that an infected person has touched and MRSA may spread. That is how easy it is. To understand how to prevent MRSA we must first focus on how it is spread.

Spreading MRSA

The spread of MRSA can be linked to openings in the skin such as cuts or abrasions, contact with contaminated items and surfaces and close skin-to-skin contact, crowded living conditions, for example hospitals and poor hygiene. Of course some people are more at risk than others. In conjunction with understanding how MRSA is spread, we must know who is most at risk before we can attempt to role out prevention strategies.

People At Risk From MRSA

Those people at particular risk are hospitalised patients, people over the age of 65 and premature/newborn babies. It is important to note that for a nursing mother who has MRSA, some antibiotics can enter breast milk. The spread of MRSA is not however, inevitable. Efforts to prevent the spread can work at a number of levels. The strongest emphasis should be placed on individual responsibility.

MRSA Prevention and Individual Responsibility

• Wash hands thoroughly for at least 15 seconds and ideally, dry them with a disposable towel. Family and close contacts should be advised to wash their hands frequently.
• Carry a small bottle of hand sanitizer containing at least 60% alcohol and use it regularly.
• Cuts, abrasions and any other kind of wound should be cleaned and covered with sterile and dry bandages until they completely heal. Never touch other peoples’ wounds or bandages. We can prevent MRSA bacteria from spreading by covering infected sores (from which the pus may contain MRSA).
• Antibiotics should be taken exactly as prescribed by a doctor.
• Linens should be sanitized. Towels, bed linens, clothes and so forth, should be subjected to a hot water setting. A hot dryer is preferable to air-drying. This helps to kill bacteria.
• At the very beginning, if a skin infection requires treatment, the request should be made for MRSA testing. The quicker MRSA can be identified, the stronger our efforts to prevent it spreading.

There exists a common argument that only healthcare professionals need to know about an individual’s MRSA infection. This logic should be firmly re-examined. Perhaps the spread of MRSA could be in part, attributed to this thinking. A more open approach, informing school staff and any other individual who might come into contact and therefore be at risk, might prove more pragmatic if MRSA is to be prevented.

Preventing MRSA in Hospitals

The introduction of surveillance systems that track bacterial outbreaks and products such as antibiotic-coated catheters and gloves that release disinfectants may certainly help. Additionally, patients infected or colonised with MRSA should be placed in isolation. However, without the complete and absolute compliance of healthcare staff with procedures preventing the spread of MRSA, prevention efforts will be undermined.

Preventing MRSA – Healthcare Staff

The very highest standards of hygiene must be enforced.

• Healthcare workers must wash and dry their hands frequently and thoroughly.
• Healthcare workers must use the antiseptic solutions like alcohol rubs or gels provided.
• When changing dressings, handling needles, inserting an intravenous drip, or when having any kind of physical contact with open wounds, healthcare staff should be wearing disposable gloves.
• Healthcare staff have a responsibility to ensure that hospital surfaces are properly disinfected and any kind of non-compliance should be reported.
• We should consider the impact of continuous educational and training programmes (additional to that already in place) specifically on the prevention of MRSA. Furthermore, reintroducing hospital matrons might impact positively, preventing any slip in hygiene and cleanliness standards.

Preventing MRSA – Hospital Visiting

When visiting a patient in hospital, hands must be washed before and after visitation. Alcohol gels must be used regularly. No physical contact with a patient known to be infected with MRSA should be made (nor is it allowed). Furthermore, avoid wherever possible, physical contact with any of the objects inside the isolated room or a patient with MRSA.

Preventing MRSA – The Role of The Patient

Ideally, before a patient goes into hospital, the individual can be screened for MRSA, particularly if falling into a high risk group. A hospitalised patient can make the following efforts to prevent the spread of MRSA:

• Hands and body should always be clean and products, such as towels, never shared;
• Hands should be washed after using the toilet;
• Hands should be washed before eating a meal;
• Report any failure to maintain complete cleanliness and the highest standards of hygiene to hospital staff;
• Open wounds or damaged skin should never be touched;
• Never walk on hospital floors in bare feet.

MRSA can be prevented and does not have to spread at the rate we have recently witnessed. MRSA prevention measures should be taken at all levels if prevention strategies are to be successful and a reduction in infections realised.

David Fritzgerald used to work as a maintenance man at a North Dallas apartment complex. In 2003 he developed a stomach ulcer that required surgery. After being admitted to RHD Memorial Medical Center in Farmers Branch, however, he contracted MRSA and within a month he was a quadruple amputee.

Linda Turley, Fritzgerald’s attorney, said on behalf of her client

This has been a life changing event. There is nothing about his life that will ever be the same

Turley reports that a mere three days after undergoing surgery on his ulcer, Fitzgerald was feeling unwell. She goes into more detail:

He was coughing up green stuff, and had a high fever, and his chest x-ray was not normal. During the day, he developed sepsis, and then that evening, went into septic shock.

The septic shock caused irreparable damage to his limbs. By the time the infection was diagnosed and treated, gangrene had set in, requiring the removal of both arms below his elbows and both legs below his knees.

Turley maintains that Fritzgerald’s physician, Doctor Meenakshi Prabhakar, did not treat her client with the proper medicine. Just a month after his initial minor surgery, MRSA had infected Fritzgerald’s limbs so badly that he had to undergo major surgery to amputate his legs. Sadly, the ordeal was far from over when Fritzgerald had to undergo surgery for a third time to remove his arms.

Fritzgerald settled out of court with RHD Memorial Hospital for $900,000. Last week, a Dallas County jury awarded Fritzgerald $17.5 million in damages.

Judge Jim Jordan of 160th District Court awarded $9 million for Fitzgerald’s pain, mental anguish and physical impairment, but Texas state law caps non-economic damages at $250,000. This limit was established in 2003 by the Texas Legislature and applied to all medical malpractice cases. Lost earnings and medical costs, however, can be collected for life.

Turley responded

That is unfair. The jury awarded Mr. Fritzgerald the $9 million, and he’s entitled to his award

Fitzgerald, who lives with his brother in East Texas, has had to rely on family members for daily living over the last six years.

He can’t bathe by himself, can’t get out of the house by himself and will need assistance for the rest of his life

Turley said.

Doctor Meenakshi Prabhakar, a Bedford infectious-disease specialist, is appealing the decision with the help of attorney William Chamblee.

Chamblee:

I think it’s erroneous and it’s a travesty. In my opinion, the jury based their verdict on sympathy, and the judge told them not to

Chamblee went on to say that his client administered eight antibiotics to Fitzgerald but not the one drug that would have treated MRSA, methicillin-resistant Staphylococcus aureus.

Chamblee said of Fitzgerald’s infection:

There were no less than seven doctors from seven specialties, all board-certified, who saw this guy over the crucial time period, and nobody knew what it was

Nevertheless, the jury found Prabhaker to be 100 percent responsible for what happened to Fitzgerald, though it agreed the doctor was not guilty of “gross negligence.”

In recent years, MRSA infections have become more common in Texas and throughout the country. Many more are being acquired in community settings, including schools and locker rooms.

Hospital-Acquired MRSA

Recent research in the UK has found that mobile phones could be encouraging the spread of MRSA in hospitals. Mobile phones do not fall within the scope of hygiene restrictions in NHS hospitals and it is estimated that up to a quarter of phones carry infections such as MRSA. This unsettling discovery was made by scientists at Edinburgh hospital.

The use of devices such as mobile phones and PDAs by doctors on wards improves the communication and compilation of patient records – and is on the increase.  This use, however, helps MRSA and other bacteria spread between patients and doctors alike.

Richard Brady, co author of the report that the research produced, said

Our concern is that many individuals may not be aware of the potential of these devices to spread bacteria or how to clean their phones.

Brady is a research fellow at the Medical Research Council’s human genetics unit at the Western General.

The report appeared in the Journal of Hospital Infection and went on to state that the situation

allows the likelihood that healthcare workers touch mobiles during patient care without performing hand hygiene

US researchers in South Carolina have made a startling discovery in their fight against superbugs like MRSA. Their research has found that a compound from a sea sponge was able to reverse antibiotic resistance in several strains of bacteria. Erstwhile resistant strains became once again sensitive to readily available antibiotics

Resensitising Resistant Bacteria To Antibiotics

Peter Moeller of the National Oceanic and Atmospheric Administration’s Hollings Marine Laboratory in Charleston, South Carolina, reported that

We can resensitise these pathogenic bacteria to standard, current-generation antibiotics

Moeller works with researchers at the Medical University of South Carolina and North Carolina State University. His team noticed a sponge thriving in an otherwise dead coral reef and they started asking themselves how the sponge could survive when everything else was dying. The team then endeavoured to isolate the properties that helped the sponge thrive in hostile marine conditions.

The researchers found that pieces of sponge were able to repel bacterial biofilms – a slimy substance bacteria form to help stick to surfaces.

Moeller went on to say

What we found is these (sponge) derivatives actually dispersed existing bacterial biofilms as well as inhibited production of subsequent bacterial biofilms

As 65 to 80% of all human pathogenic infections are based on biofilms, this is a significant discovery.

Moeller’s team tested the substance on some of the toughest pathogens, including MRSA.

Mixing Sea Sponge With Antibiotics

The researchers found that several once-resistant bacteria were sensitive to antibiotics that were mixed with the sponge material. Moeller and his team are now working with a number of medical device companies to incorporate their discovery into the plastic materials used to make devices like stents (used to prop open diseased arteries or in intravenous lines used in critically ill patients).

Moeller envisages a new class of “helper drugs” that restore the potency of antibiotics that had previously lost the war to superbugs.

Overuse And Misuse Of Antibiotics

Overuse and misuse of antibiotics has led to drug resistance in some strains of bacteria, and this has become a serious problem in hospitals worldwide. This problem is highligted by the prevalence of  the superbug MRSA in our hospitals. In the US, infections such as MRSA kill a staggering 19,000 people every year.