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"Cipromania" and "Superclean" Homes Are Now Increasing Antibiotic Resistance
Brian Vastag
JAMA. 2002;288:947-948.
Washington—Last year's anthrax-in-the-mail–induced "cipromania" and the ubiquity of germicidal household products are worsening community-based antibiotic resistance, warned Stuart Levy, MD, professor of medicine at Tufts University School of Medicine, at an annual press event sponsored by the National Foundation for Infectious Diseases (NFID). Whereas in the recent past, public health officials were most concerned about hospital-based drug resistance, the problem has spread into homes, schools, and workplaces, said Levy, rendering some strains of bacteria resistant to eight or nine classes of antibiotics.
He cited the case of an 11-month-old girl with a chronic ear infection that was refractory to treatment. She required hospitalization and intravenously administered antibiotics after six courses of various oral antibiotics proved futile. The Pneumococcus strain eventually identified from the girl "could have been deadly," said Levy. Several of the child's playmates at her Georgia day care center also harbored the bacteria. "Such strains don't just appear, they are formed," said Levy. "This is Darwinism at its best. We're helping the evolution [of bacteria] by giving antibiotics [indiscriminately]."
Dangerous community-based strains may originate in hospitals, said Levy, as rapid patient turnaround now renders each discharged patient a potential vector. At the same time, bacteria species have begun swapping resistance genes. Immunity to vancomycin, for instance, has apparently moved from Enterococcus faecalis into Staphylococcus aureus, many strains of which are already resistant to methicillin and other antibiotics.
The Centers for Disease Control and Prevention (CDC) isolated vancomycin-resistant S aureus (VRSA) in June 2002 from the catheter exit site of a dialysis patient in Michigan. The strain contained the same antibiotic-resistance genes as those found in samples of E faecalis collected from the same patient, leading to the jumping-gene theory (MMWR. 2002:51;565-567).
In an effort to combat the problem, the CDC has launched a monitoring program, asking all health care facilities to test S aureus isolated from patients for vancomycin resistance. Positive results should be reported to the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC, telephone (800) 893-0485.
A less exotic route to resistance also threatens: bathroom cabinets stocked with ciprofloxacin left over from last fall's anthrax panic. While the number of doses in circulation is difficult to estimate, Levy said that perhaps 2 million households maintain superfluous supplies.
Each bottle holds the lure of a quick cure for the uninformed. "It's not hard to see someone with a cold or the flu saying, ‘We already spent the money, let's just open the bottle'," Levy said while flashing a slide listing bacteria resistant to ciprofloxacin and other quinolones: S aureus, Escherichia coli, Klebsiella oxytoca, Neisseria gonorrhoeae, and Campylobacter and Pneumococcus species. "We're talking about true resistance here, not just reduced susceptibility," said Levy, adding that the list is guaranteed to lengthen. He considers these mutant strains the real threat from last year's anthrax mailings. The potential toll, in terms of health care costs and lives, could eventually dwarf the 22 cases and five deaths caused outright by Bacillus anthracis.
Antibiotics fed to livestock and antibacterial household products pose two other dangers that Levy and his group, the Alliance for Prudent Use of Antibiotics, are warning against. While veterinarians generally advise against feeding antibiotics to livestock, the market-determined desire for quicker, leaner growth keeps the easily obtained drugs in heavy demand by farmers, said Robert Whitney, DVM, a member of the NFID's board of directors. Sweden has eliminated agricultural antibiotics, he said, a model he wants the United States to follow.
No country has eliminated antibacterial household products, a recent marketing trend that has reached every room of the house. Levy elicited laughter when he described some of the more bizarre instances he's seen: mattresses, phone wipes, and, in a restaurant in Boston, chopsticks. "I assume that's to protect you from your oral flora."
While that proposition is ludicrous, the problem is real. As surface antimicrobials seep into sinks and toilets, they wash through sewage systems and into water supplies. Bacterial strains that carry genes for tiny internal pumps eliminate the antimicrobial compounds, recycling them back to the environment unchanged. "I wish more bacteria would destroy the antibiotics, but they just pump them out," said Levy. Consequently, bacteria are awash in the compounds, which weed out the susceptible strains. The remaining resistant strains flourish. "Somehow we've got to revive susceptible [bacteria]," said Levy. "We're in their world, and they were here before us. They aren't leaving."
AUTHOR INFORMATION
Public Health Expert Says False-Positives Are Avoidable
Last fall's media announcements of "positive" anthrax tests at post offices and other buildings in the Washington, DC, area likely exacerbated the run on ciprofloxacin. The vast majority of those results—excepting only the Hart Senate Office Building and Brentwood postal facility—proved false after more robust laboratory testing.
The reason? Law enforcement personnel, ignoring advice from public health experts, used rapid test kits designed to detect plumes of spores wafting across desert battlefields. For simplicity, the polymerase chain reaction kits were designed to respond to genetic sequences common to many Bacillus species, not just B anthracis.
This built-in bias would be immaterial during war, as experts say that no enemy would bother releasing any Bacillus species except B anthracis. But in cities, many sources of harmless Bacillus exist; B thuringiensis, for example, is a common biological insecticide.
Traces of these harmless bacteria triggered many of the false-positive test results last fall, said Michael Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy at the University of Minnesota School of Public Health and a special bioterrorism consultant to the US Department of Health and Human Services. Osterholm said the poor results could have been avoided by relying on more proven, although slower, tests advocated by the public health community.
However, the military test kits are favored by police and fire departments, which bought them by the case after the Persian Gulf War. T heir reliance on the kits last fall clearly bothered Osterholm, who related one instance from Minnesota. During the height of the anthrax scare, the National Guard investigated a suspected attack. "Their tests were giving such poor results," he said, "that they abandoned their field kits and began sending swabs to the state public health laboratory."—B.V.
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