The Struggle for Survival

This 4 ½ minute animated video is just too good to pass over.

Engaging and viewer-friendly, it explains the biological basis – Darwin’s theory of natural selection – of the global crisis of antibiotic resistance.

It will either shore up what you know or, better yet, answer a question you might have. The crux of it begins at the 1:35 mark. Here’s the verbatim:

Just like any other organism, individual bacteria can undergo random mutations [changes]. Many of these mutations are harmful or useless but every now and then one comes along that gives its organism an edge in survival. And for a bacterium, a mutation making it resistant to a certain antibiotic gives quite the edge.

As the non-resistant bacteria are killed off which happens especially quickly in antibiotic rich environments like hospital there is more room and resources for the resistant ones to thrive, passing along the mutated genes that help them do so.” (Emphasis mine.)

We humans are a biological “organism” too. The beauty of natural selection is that it explains not just how bacteria are engaged in – and will win – their struggle to survive against the onslaught of antibiotics; but how we humans, too, struggle to survive against such things as disease, famine, and war.

Enjoy:

The Resistance Movement

Here’s a neat graphic on how antibiotic resistance happens, courtesy of the US Centers for Disease Control and Prevention. It nicely illustrates how the use of an antibiotic – or any antimicrobial, such as soaps and cleaners – does something quite unintended and counter-intuitive: it drives resistance.

A few brief comments:

Step 1. Bad to the bone: How did those resistant bugs get there in the first place? Aside from being the product of modern medicine, bacteria are “born” resistant. From Antarctic ice to the bottom of the ocean to deep underground caves – places where man has not yet set foot – scientists are finding bacteria that are already resistant to our drugs: they’re simply an ancient part of nature.

Step 2. Thanks for telling us: If antibiotics kill good bacteria that protect our body from infection, does that mean antibiotics leave us more vulnerable to infection? Yes, according to New York University infectious disease specialist Martin Blaser, MD. As he candidly puts it:  “Has any health-care professional ever told you that taking antibiotics would increase your susceptibility to infection?”

Step 3. Fast and furious: Humans take 20 – 30 years to produce a new generation; bugs do it in 20 – 30 minutes. So for example, by reproducing every 20 minutes a single E. coli bacterium can create 69 billion progeny in just 12 hours of growth. Kill one, and as many as 69 billion more can pop up in 12 hours! (Brad Spellberg, MD, Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them. (New York: Prometheus Books, 2009))

Step 4. Clever critters: Not only will the bug fight off the antibiotic you’re taking, penicillin say, but at the same time the bug will develop the ability to fight off other antibiotics too; for example, methicillin, amoxicillin, and tetracycline. The bug will then transfer the resistances it developed to those 4 antibiotics, to all his little bug buddies. This transfer will take place not just within a single species, E. coli to E. coli for example, but also between species, say from E. coli to Salmonella to Shigella (a bug that causes dysentery). In other words, when you take an antibiotic a whole other world of bugs that become resistant to multiple antibiotics develop inside you.

The Leader of the Pack

MRSA - the yellow, round items - killing, and escaping from a human white cell.

When it comes to antibiotic-resistant infections, what’s the number one pathogen that’s killing Canadians and Americans? The answer is MRSA – and it’s not even close.

We know this because last fall the US Centers for Disease Control and Prevention issued its first-ever “Threat Report,” which ranks the 18 leading drug-resistant pathogens (germs) by how much damage they do. Altogether, these bugs sicken more than two million of us with antibiotic-resistant infections and kill over 23,000 – every year.

Of the 23,000 deaths, MRSA alone kills 11,285 – almost half of the entire total. Next in line is streptococcus pneumonia which kills about 7,000 people a year. But after that there’s a huge drop-off to the rest of the germs that typically kill in the hundreds.

Canada’s counterpart to the CDC, The Public Health Agency of Canada, doesn’t track drug-resistant infections by pathogen the way the CDC does. However, they report that more than 200,000 Canadians contract healthcare-associated infections (HAIs) every year, which kills over 8,000 people. MRSA was found to be “the most common cause of serious hospital-acquired infections,” and that it “increased [by] more than 1,000% from 1995 to 2009,” (the last year for which numbers were available).

To appreciate the seriousness of these infections and the deaths they cause, consider that HAIs cause more deaths in Canada each year than breast cancer, HIV/AIDS, traffic accidents, and homicide’s combined.

5 Ways to Protect Yourself from MRSA

Protect yourself at all times

As we discussed last week, Canada’s Chief Public Health Officer recently reported a 1,000% rise in Healthcare-Associated MRSA in Canada. And earlier in the year, researchers at Toronto’s Sunnybrook Hospital told us that 1 in 12 adults in Canadian hospitals are either colonized or infected with MRSA, VRE (vancomycin-resistant enterococci) , or C. difficile (Clostridium difficile) . MRSA was the major offender because 67% of the patients who tested positive were positive for it.

Infectious disease experts agree that the single most important thing healthcare workers can do to prevent the transmission of MRSA and other pathogens is to wash their hands before and after seeing patients. The problem, however, as we reported last month, is that healthcare workers aren’t doing that, with doctors being the biggest offenders with compliance somewhere between 0 and 50%.

So if healthcare workers won’t do what they should, then it falls on the patient to do what they can to protect themselves. A number of experts recently offered the following suggestions:

1. Know What to Look For

In general, fevers, if they’re accompanied by shaking chills, if they’re getting worse instead of better, that would suggest there’s a bacterial process. With community-acquired MRSA, many people first notice a skin infection or boil that becomes larger and more painful. But if you do suspect such an infection, don’t rush to the emergency room, where you might be exposed to other bugs or infect others. Call your primary-care doctor first for advice.

2. Get a Flu Shot

When people get influenza, they actually become at higher risk as they recover for complicating bacterial infections. This is because people with weakened immune systems are more vulnerable to other bugs.

3. Ask Whether You Need that Antibiotic

Don’t assume you need one — antibiotics don’t work on viral infections like colds or the flu. If your doctor does recommend one, ask whether you really need it. Using antibiotics does kill off non-resistant bacteria in your body and makes you likely to acquire antibiotic-resistant bacteria – like MRSA – in their place.

4. Ask Your Doctors to Wash Their Hands

It is every patient’s right to have every health-care provider entering the room to have clean hands.   They’re supposed to do it, they are mandated for 100 percent hand- hygiene compliance, but the reality is it doesn’t happen. And that’s where the burden falls on the patient to make sure they do.

5. Advocate for Loved Ones in the Hospital

One of the ways drug-resistant bacteria spreads in hospital is through tubes inserted in the body, such as catheters. If someone you care about is on such a device, don’t be afraid to ask doctors whether they still need it, and when the tubes can come out. Every day that decision needs to be made: Do these things need to stay in or do they need to come out?  The key, is empowering patients or their advocates to stand up for their health-care needs.

HOTEL MRSA

About two weeks ago CBC’s current affairs program Marketplace aired The Dirt on Hotelswhere it investigated the prevalence of germs in six of Canada’s largest hotel chains. They went on a bacteria hunt and discovered not just bacteria, but the more troublesome antibiotic resistant bacteria, in every hotel chain they went to. MRSA, in particular, was found growing on a faucet in Toronto’s upscale Royal York Hotel, and on telephones, counter-tops, and bed comforters in the other hotels.

Erica Johnson, the CBC reporter who investigated this, says she has  resorted to self-help when she travels. She brings alcohol wipes with her and uses them on hotel room surfaces where her investigation revealed superbugs are most commonly found: on door handles, light switches, taps, the phone, clock radio, and the toilet seat. She puts a towel down for her toiletries, brings her own cup instead of using a hotel glass, and for the biggest offender – the tv remote, she puts it in a plastic bag and uses it that way!

What this investigation uncovered is but one example of what the US Centers for Disease Control and Prevention just published in their report Antibiotic Resistant Threats in the United States, 2013.  This first-ever assessment of the threat the country faces from antibiotic-resistant organisms contained the following warnings about MRSA’s impact on human health:

  1. Of the 23,000 people who die each year as a direct result of antibiotic resistant infections, MRSA is responsible for almost half of the deaths (11,285  = 49% ).
  2. The CDC rates the threat level posed to us by MRSA as “serious.” They conclude “This bacteria is a serious concern and requires prompt and sustained action to ensure the problem does not grow.”
  3. During the past decade, rates of MRSA infections have increased rapidly among the general population.
  4. While antibiotic-resistant infections can happen anywhere, most deaths related to antibiotic resistance happen in healthcare settings such as hospitals and nursing homes.
  5. Staph bacteria, including MRSA, are one of the most common causes of healthcare-associated infections.

The CDC emphasized that their numbers of infection and death are purposefully conservative. So for example, by way of contrast, the Journal of the American Medical Association reported in 2007 that 18,650 deaths each year in the US are associated with 94,360 invasive MRSA infections.

This is why, for example, the American Academy of Orthopedic Surgeons describe  MRSA as a “silent epidemic.”

How does Photodisinfection Work?

Photodisinfection is a topical, non-antibiotic antimicrobial therapy that destroys a broad spectrum of pathogens including fungi, bacteria and virus without damaging human tissue. Unlike antibiotics, Photodisinfection selectively kills virulence factors such as the endotoxins and exotoxins produced by pathogens, leading to a clinically observable anti-inflammatory effect. The treatment process takes only minutes, making it over 1,000 times more effective at biofilm killing than antibiotics.

Photodisinfection is a minimally invasive non-thermal therapy involving the light activation of a photosensitizer to eliminate topical infections in a highly targeted approach. Photodisinfection has been proven to be safe and effective in other applications such as for the dental, sinusitis and hospital acquired infection prevention markets. In dentistry, Photodisinfection has been proven to be highly effective for the treatment of caries, endodontics, restorative dentistry, periodontitis, peri-implantitis and halitosis. Many new applications of Photodisinfection are now under development.

The Photodisinfection Process: Instant Antimicrobial Therapy

Apply Photosensitizer to Infection Site & Illuminate with Appropriate Wavelength for Several Minutes

A photosensitizing solution is applied to the treatment site where the photosensitizer molecules preferentially bind to the targeted microbes.  The photosensitizer molecules are inactive at this stage.  A light of a specific wavelength and intensity illuminates the treatment site and a photocatalytic reaction occurs.  The wavelength is carefully chosen to maximize absorption of light energy by the photosensitizer.

This 2 step procedure results in the destruction of the targeted microbes and their virulence factors without damaging host cells.  This reaction involves the formation of short-lived, highly reactive free-radical oxygen species.  These radicals cause a physical disruption of the microbial cell membrane through oxidative reactions, resulting in immediate rupture and destruction of the cell.  This process occurs in seconds with total kills completed in minutes.

The Photodisinfection process has also been shown to eliminate a multitude of virulence factors, unlike antibiotics. When the light isremoved, the photocatalytic reaction ceases along with all antimicrobial action. Photodisinfection does not promote the development of resistance.

The Photodisinfection process is both pain-free and stress-free due to lack of side-effects or damage to human tissue.

Source: Eastman Dental Institute, UK

Soap vs. Hand sanitizer: Which is Better?

The Centre for Disease Control and Prevention’s (CDC) position is that hand sanitizer is a good alternative when soap and running water is not available. This implies a preference for good old fashioned hand washing. The CDC also states that hand sanitizers are not as effective when hands are visibly dirty and that do not they kill all germs.

If soap, followed by intense abrasion/scrubbing, is better than hand sanitizer use, the next question is what kind of soap is better, bars or liquid soap? It seems like it may be liquid soap but the jury is still out. Bar soap has been found to harbour some microorganisms but these organisms are not transferred from the bar to our skin’s surface. That is good to know, because don’t we all avoid someone else’s used bar of soap?

As a medical student, we had a whole class on the importance of hand washing and how to do a better job of it. I am not lying. At first, it seemed a waste of time, but before long, we all came to understand why this topic warranted an entire class. Hand washing is one of the easiest infection prevention procedures. It is simple to do but despite all of the well-known benefits to hand washing for the prevention of infection, the noncompliance rate is still too high in hospital settings and contributes, in turn, to the current levels of Hospital Acquired Infections. Common infections are transferred from person to person by hand-to-hand contact or via fomites which are inanimate objects on which bacteria or other microorganisms can survive. The trick to adequate hand washing is time and effort in scrubbing. I was taught to wash my hands for 20 seconds, the amount of time to sing “Happy Birthday” twice.

So from an infection control perspective, soap (either bar or liquid) and water is the way to go. Remember, you can help stop the spread of infection by simply doing a good job of washing your hands. So scrub away with either bar or gel soap and you can do your part in infection control!

1) http://www.cdc.gov/handwashing/
2) http://www.ncbi.nlm.nih.gov/pubmed/3402545

Nelson Mandela- In Critical Condition Suffering from Lung Infection

Our heart goes out to the family of Nelson Mandela and to the people of South Africa.  While prayers and well wishes flood in from around the world, we would like to add our own in the hopes that good intentions and earnest positive thoughts can make a difference to this special man in such critical condition.

http://bclc.uschamber.com/sites/default/files/Nelson_Mandela,_2000_(5).jpg

At a time like this, we are reminded that Nelson Mandela was an inspirational leader and remains a true international treasure.  His guiding principals were way ahead of his time.  I cannot of think of the Mandela legacy without immediately thinking of the backdrop of the severe human rights abuses currently raging in the Middle East and around the world. The world needs more Mandela’s, not one less. I will pray hard tonight.

Ondine CEO to Represent Photodisinfection at the World Congress of the IPA in Seoul, Korea

The World Congress of the International Photodynamic Association (IPA) is a biannual conference highlighting the advances in scientific and clinical research around the world. This year’s Congress is being held May 28th to May 31st, 2013 at the Ritz-Carlton Hotel, Seoul, Republic of Korea.  All of the leaders in the field of PDT and their work will be represented during this event. Clinicians, scientists, researchers, hospital administrators, and students are welcome to participate at this year’s conference. Registration details are available here.

About the International Photodynamic Association

The IPA was founded in 1986 and its membership consists of the most prominent international clinicians and scientists involved in performing and researching photodynamic therapy (PDT) and photodiagnosis (PD). The purpose of the IPA is to promote the study of diagnosis and treatment using light and photosensitisers, to disseminate such information to the members of the IPA, the medical community and to the general public.

The IPA organizes an International Congress every two years which is a unique opportunity to sum up research activities in the clinical and basic research aspects of PDT. The IPA Secretary General is Dr Alison Curnow, Peninsula Medical School. Inquiries, comments and contributions can be sent to ipa@pms.ac.uk. To become a member, visit our webpage here to register.

Ondine Biomedical CEO Carolyn Cross has been selected to be a Plenary Speaker at this conference. She has been noted for translating research from the labs into usable products for patients. There are twelve Plenary Speakers representing countries and research facilities from across the world, Carolyn being one of the two Canadian plenary speakers. We look forward to hearing what she and the other speakers have to say about the latest advances in photodynamics!

Ventilator Acquired Pneumonia: A Large Problem for Hospitals

Although hospitals are centers of refuge for those who need care, an unfortunate reality is that the number of people coming in and leaving these facilities inevitably results with the spread of disease and infections between patients, doctors, and other health care workers. These unintentionally transmitted diseases, born in hospital settings, are collectively known as Hospital Acquired Infections (nosocomial infections in medical literature). This class of disease results in over  99,000 deaths each year in the United States alone.

One significant form of nosocomial infection is Ventilator Acquired Pneumonia (VAP) which, as the name suggests, is pneumonia (an inflammatory condition of the lung) transmitted to patients while they are on mechanical ventilator breathing support. The incidence of this disease is between 8% and 20%, and mortality rates are between 20% and 50%. As a result, VAP has a critical impact on morbidity, length of stay, and cost of ICU care.

A significant contributor to such high rates of incidence and morbidity is the fact that patients on mechanical ventilation systems are often sedated and are rarely able to communicate or cough up the biofilm that grows in the tubes and drains down into the lungs. Typical symptoms of pneumonia may be absent or unobservable, leading to delays in detection and therefore treatment.  Under these conditions, the medical signs that a patient has acquired pneumonia are increased number of white blood cells on blood testing and new shadows (infiltrates) on chest x-rays. Other important signs are fever, low body temperature, purulent sputum, and hypoxemia (decreasing amount of oxygen in the blood).

If any of these symptoms are suspected by care takers, two conventional methods of diagnosis are deployed. The first is to collect cultures from the trachea while also scanning the chest with an x-ray to detect new or enlarging infiltrates. The other method is more invasive and involves a bronchoalveolar (where fluid is squired out small areas of the lung and recollected for examination), as well as a chest x ray.

Treatment regimens depend on the specific bacteria causing the inflammation, although a widely used first step is the prescription of empiric therapy (broad spectrum antibiotics) until the particular bacterium and its sensitivities are determined. Once the specific microorganisms implicated in generating pneumonia are known, more antibiotics are prescribed. The use of antibiotics raises the issue of resistance from the bacteria, and the related decrease of efficacy of the antibiotic in the years to come.

Photodisinfection is a non antibiotic approach under development by the research and development teams at Ondine Biomedical Inc., for the decolonization of the tubes of long term intubated patients. Pre-clinical studies have demonstrated proven effects of Photodisinfection directed toward the inner surface of the endotracheal tubes. The Exelume™ Photodisinfection system is currently being tested in NIH funded clinical trials in the US. Other Photodisinfection applications under development by Ondine include:  periodontitis, chronic sinusitis, burns & wounds, UTI, vertical transmission of HIV, nasal decolonization to reduce SSI, GI infection protection, etc.

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