Cases Of Flesh-Eating
Bacteria May Be On The Rise In Hawai‘i
The
dangerous and sometimes fatal bacteria with the apt acronym of
MARS has been evidenced with increasing frequency. One of the
ways to combat it is the proverbial “fighting fire with
fire.”
T.
O’Connor, Jr., M.D.
The
scenario goes something like this.
You unwittingly come in contact with some source of Staph Aureus,
either from another individual who is colonized, an animal with
a running sore, a body of contaminated standing water, a wet area
of your environment that has been contaminated (such as toilet,
garbage disposal, leaky pipes, hospital furniture, etc.) or an
object contaminated with a body fluid. The bacteria gets on your
skin. You then touch the inside of your nose or mouth and place
the bacteria in a warm, moist, dark environment where it can survive.
I have personally treated at least half a dozen patients who had
previously been treated for nasal “allergies” who
turned out to have been infected by Staph Aureus. It was living
off the nutrients provided by the mucous membranes.
Staph (Staphylococcus) Aureus is a virulent, flesh-eating, bacteria
that can spread so rapidly one can almost watch it advance up
an extremity. I have had patients say they can almost see the
line of red moving towards their trunk. If it gets within a tissue
space, it can create large areas of necrosis (rotten flesh) filling
the space with pus and clotted blood within an amazingly short
period of time. It is dangerous in and of itself whenever it gains
access to the body; however, its ferocity is magnified by virtue
of its ability to acquire resistance to antibiotics. Over the
last few years, it has become increasingly resistant to multiple
antibiotics. When it acquired resistance to the previously dependable
Methacillin (a synthetic penicillin) it began being referred to
as Methacillin Resistant Staph Aureus, MRSA. It also has taken
on the acronym that more aptly defines its dangerous nature, MultiAntibiotic
Resistant Staph, or MARS. The most dangerous are those that are
resistant to Methacillin. These so-called "super bugs"
– strains of Staphylococcus aureus unfazed by the entire
penicillin family and other first-line drugs – are worrying
infectious disease experts, who say the problem will only get
worse. It is not uncommon to see a single bacterial culture that
shows resistance to all the Penicillins, Cephalosporins, Quinolones,
and Macrolides. This becomes significant because if one of those
antibiotics are chosen to
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burning. Firefighters battle a brush fire that scorched
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treat
a patient, by the time the culture results are available the infection
can have spread so badly that it becomes unmanageable. The most
awesome form that these infections take is called Necrotizing
fascitis. It is a common consequence of MARS, MRSA, Staphlococcus
Aureus, Streptococcus Pyogenes, and other "flesh eating”
bacteria." Necrotizing fascitis occurs when the bacteria
enters tissue planes within the body, such as those fascial planes
(separations of structures by tough, membraneous, connective,
tissue that separates and defines structures such as muscles or
that separate skin from muscles) and digests the contained structure.
What happens is that when it gains access to these spaces in the
body, it can flourish where there is little blood flow. When the
bacteria get sequestered into areas away from blood supply, the
concentrations of the antibiotics are not as high as they need
to be to kill the bacteria. Consequently, it lives in that space
and continues to "eat" that "flesh." When
it does, the flesh becomes rotten or "necrotic." Hence
the name, necrotizing fascitis. It literally means "rotting
of inflamed connective tissue structures." In actuality,
it is rotting the structures between the fascia, for instance
muscles and fat. It tends to get messy rather fast and even intraveneous
antibiotics are not sufficient to arrest its progressive onslaught.
Therein is the first mistake that many physicians make when handling
these infections. They assume that it is sufficient to use IV
antibiotics. This can be a fatal mistake. These infections are
too rapidly progressive and distant from the blood supply to simply
rely upon IV antibiotics for a solution. If the area of necrosis
(abscess) is not immediately opened and drained, it continues
to advance under pressure between the fascial planes, and the
space or bodily structure is completely occupied with blood, pus,
and bacteria.
Contrary to media reports that characterize this condition as
“harmless,” MARS is potentially a very dangerous condition.
If you were to get a bad cold that turned into pneumonia, and
Staph Aureus gets into your lung, it will eat the lung tissue
rapidly. Or, if you have it in your nose, every time you touch
your nose, your fingers become contaminated. So much as a mosquito
bite can then become infected if you scratch it.
What appears at first to be just a small red bug bite rapidly
gets worse as the bacteria enters deeper pores, taking the bacteria
down into the deeper area of the dermis (skin) where it rapidly
forms an abscess that digests the skin and breaks into the area
of fat and space beneath it. This then builds as an abscess under
the skin. The skin traps the abscess and causes it to be forced
along the space beneath the skin. It also invades the skin directly,
creating a “cellulitis.” This is an actual infection
that spreads through the skin.
The Center for Disease Control (CDC) has reported numerous outbreaks
of MARS across the nation. The bacteria has been reported in Colorado
fencing club members, football players in Pennsylvania and Los
Angeles colleges, and Indiana high school wrestlers. Many patients
were hospitalized, including most of the athletes. At least two
outbreaks have occurred among native Alaskans since 1996, many
cases were linked to steam baths.
To gain an appreciation of how exponentially the problem has grown,
doctors at Driscoll Children's Hospital in Corpus Christi, Tex.
saw fewer than ten cases per year of community-acquired resistant
staph infections in the 1990s. That number increased to 459 by
2003. Ninety percent were healthy children. Fifty percent of those
diagnosed with MARS were admitted to the hospital to receive intravenous
antibiotics. A few developed life-threatening lung and heart infections
or toxic shock syndrome.
In Great Britain, medical officials are considering closing some
hospitals due to an alarmingly high rate of general (non-MARS
related) patient admissions becoming infected while in the hospital.
People being admitted for minor surgery end up dying. In Hawai‘i,
health officials say, the incidence of drug-resistant Staph aureus
appears to be higher than elsewhere. However, there are no statewide
or national statistics to prove their suspicions. Another area
of concern is Seattle, Wa., where an otherwise healthy 19-year-old
died from a MARS infection. It would seem that the places having
the worst problems are those in which the environment is damp.
Doctors in Hawai‘i and across the nation say they are alarmed
by an increase in cases of the drug-resistant MRSA that has caused
fatal pneumonia or life-threatening heart infections. If that
isn’t bad enough, Staphlococcus Aureus food poisoning is
often caused when a food handler carrying the bacteria contaminates
edibles such as desserts, salads, or baked goods (especially custards,
mayonnaise, and cream-filled or topped desserts) that are served
or stored at room or refrigerator temperature. The bacteria multiplies
rapidly in food, and a large colony of bacteria may be present
without evidence of food spoilage. You can acquire the food poisoning,
colonization, or infection by ingestion of food prepared by a
person with a skin infection, ingestion of food kept too long
at room temperature, or ingestion of improperly prepared food.
This is a very dangerous bacteria because of its ability to develop
resistance to antibiotics, tendency to colonize the body, and
rapidly spread throughout the body during infections, resulting
in amputation or death. It has been called a “flesh eating”
bacteria because of its ability to develop necrotizing fascitis
(rotting soft-tissues of the body). It is important to make every
attempt possible to eradicate it from your body and environment
if you are found to have an infection or colonization. It can
be acquired from touching an infected person, animal, object,
or water/food source. If you do not identify the source of the
infection and eradicate the colonization, it is capable of recurring
after even a successful treatment.
Some authorities claim that “These bacteria are not inherently
pathogenic.... Staph aureus often resides in people noses or on
their skin without causing any problems.” I tend to disagree.
I have treated many people with chronic nose irritation whose
doctors have attributed it to allergies only to learn that they
were infected with Staph Aureus. The problem with leaving the
bacteria on the skin is if you get a break in your skin, a puncture
wound, or a burn, and it causes an infection, you could easily
die.
Combating MARS: What To Do If You Become Infected
If you become infected, the following steps can be taken to insure
that you have done everything you can do to eliminate it from
your body. If you accomplish all of them, you have done everything
I can think of to eradicate it. The more things you do, the better
chance you have of being successful.
1. Take the prescribed antibiotic for the entire time it is prescribed
at the dosing schedule given as best as you can. The ideal time
required with treatment to eradicate an infection or a colonization
differs from one person to the next, and also depends on the body
site(s) involved. I generally recommend a two-week course of antibiotics.
The choice of antibiotics is determined best by the sensitivities
(resistance patterns) of the particular bacteria that has infected
or colonized you. These are determined by a culture, which tests
the particular antibiotics to determine which ones will work against
the bacteria. If the culture results are unavailable and an infection
is present, it is often necessary to make an educated guess as
to the antimicrobial susceptibility of the bacteria and treat
it with the most probably effective drug.
Sometimes, if the infection is severe or potentially life-threatening,
it is prudent to start two antibiotics and wait for the culture
results to determine which antibiotic to continue. It usually
takes about 3-4 days to obtain culture results. If nothing is
done in that time period, the infection can advance. There is
never any guarantee that the bacteria you have will respond to
any given antibiotic(s) chosen, especially because MARS can have
resistances to many drugs. Until a culture is done, no one can
tell what the best antibiotic would be to treat empirically. This
is where the “art of medicine” becomes important –
when there is not enough “science” to guide a decision.
If it is evident that you are not getting better within 24 hours
of being treated, inform your healthcare provider and insist upon
being re-evaluated. Once antibiotics are started, if they are
effective, the redness or pain should not advance. If it is advancing,
you probably need a change in antibiotics or an additional antibiotic.
2. You must use topical antibiotics on any wet areas of the body.
The nose especially serves as a source of colonization. It is
necessary to use an ointment or cream in the nose during the time
that the antibiotic is being used. This is best applied with a
cotton-tipped applicator to insure that the ointment gets high
into the nasal passages. Applying it three times a day is best.
The easiest choice is Neosporin (triple antibiotic) ointment.
For those allergic to Neosporin, Bacitracin with Polysporin can
be used. Yet another choice is Bactroban, but it is very expensive.
Other areas of the body that are of concern are the ears, eyelids,
the genitals, rectum, and under the fingernails. The eyelids present
a problem because you can’t put regular skin ointments or
creams in the eyes. Carefully using the cream or ointment by lightly
rubbing a small amount on the lids before sleep while keeping
the eyes closed may offer some successful eradication if there
is any crusting or irritation to evidence infection/colonization.
3. The mouth can serve as a site of colonization as well. It is
important during the treatment to keep your mouth and teeth clean.
By performing a thorough dental flossing and brushing with hydrogen
peroxide, you may be able to sterilize your mouth.
Another method is to use a tooth-whitening product. The type that
uses a gel applied to a tooth-fitting tray is probably the best.
It is a little messy, because you have to keep it in place for
about 30 minutes (according to the directions), but it can be
relied upon to sterilize the mouth.
I have seen this bacteria cause a chronic gum infection (gingivitis)
that caused the gums to recede away from the teeth exposing the
roots. I don’t think dentists are focusing upon this with
cultures and the awareness necessary to identify it; however,
it can be easily harbored in the teeth and mouth.
4. Try to determine the environmental source of the infection
and eliminate it. It could be a household member with a sore or
colonization, an animal (turtle, dog, cat, etc.) or any site of
standing water or dampness (frog pond, leaking plumbing, garbage
disposal, drain traps, roof leaks, etc.). Cleaning contaminated
surfaces with a one-to-ten dilution of Clorox in water is accepted
as a satisfactory disinfectant.
5. You must also clear the skin of any colonization. This can
be done by washing daily with Betadine liquid (providone iodine
solution). Betadine can be purchased from any pharmacy. By simply
pouring it onto your soapy washcloth while washing can turn any
soap into an antibacterial soap. Also, once at the beginning of
treatment and once at the end, it is good to paint your entire
body with Betadine after washing and then let it dry. Once it
is dry, rinse it off.
Some people have allergic reactions to iodine. If there is any
doubt as to whether or not you may have an allergic reaction,
apply a small amount on your skin as a test before using it on
your entire body.
In addition, a half-hour soak in a full tub with half a cup of
Clorox bleach is recommended. Again, this could cause an allergic
skin reaction or an asthmatic reaction if the vapor is breathed;
however, this is a recommendation I have seen in the medical literature.
After you have sterilized your body and figuratively cleaned the
slate, you could be re-colonized by the same bacteria unless you
introduce a different bacteria that will compete with the staph
aureus. Swimming in a fresh water source or pouring a volume of
it over your body immediately after the treatment(s) may be successful
in introducing “good old fashioned” bacteria that
are not disease causing, letting them establish a foot hold to
prevent competing bacteria from colonizing. One could also go
to the health food store, buy one of the pro-biotic products (my
favorite is Jerro-Dophilis) and break a couple capsules into a
can of chicken broth with a few teaspoons of sugar. Let that incubate
for a couple hours at room temperature, then put it in a bath
tub full of water. Immerse yourself in in this solution immediately
following the above cleansing. I can’t attest to the safety
of that; however, the bacteria are safe enough to eat, and I have
personally gargled such a solution and allowed it to flush out
my nasal passages when I was colonized by a “bad”
bacteria. I suffered no ill effects that I can tell, and I use
the product frequently whenever I have to use an antibiotic that
kills off my normal intestinal bacteria. I’ve been doing
it for years without any untoward consequences; however, the risk
of using these products must be assumed by the person using them.
I cannot make a solid, evidence-based, recommendation regarding
the above products, however I have seen what happens to people
who are colonized by staph aureus and the huge abcesses they acquire
just by receiving an insect bite, and this is evidence enough
for me to conclude that being creative has its merits in this
new era of “super-bugs.”
6. Any lesions, ulcers, scabs, or wounds on the skin should be
kept covered with a dressing and Neosporin, or some type of antibiotic
product. The wounds or open sores should be handled carefully
and the dressings disposed of properly to prevent contamination
of other people or surfaces. Any small pimples with trapped pus
should be opened and scrubbed with hydrogen peroxide and re-covered
with an antibiotic product until they no longer are staining the
dressing with the body fluid.
7. If you have been ever treated for Staph Aureus, there is a
good probability that you could still be colonized. In that event,
you have to be very careful to treat even a small, apparently
harmless scratch or cut with a great deal of concern. Clean any
cuts or abrasions with Betadine and hydrogen peroxide, and then
cover with a bandage and antibiotic ointment. If it the condition
worsens or the redness advances, then consult a knowledgeable
physician.
I say “knowledgeable” because Kaiser physicians do
not accept Staph Aureus colonization of their patients as something
needing management. I have been informed by patients that Kaiser
doesn’t even culture for it; nor treat the colonized state.
8. Since MARS colonizes the respiratory tract, should you acquire
a cold, or the flu, it could be the source of a secondary bacterial
infection such as otitis media, bronchitis, or sinusitis. If the
germ gets trapped in any of the body’s spaces (middle ear,
sinuses, or lungs) it could rapidly cause a fatal illness.
It would be wise to keep a personal copy of the culture results
with the sensitivities to show which antibiotics will be effective.
In the event you get an infection, the first choice of an antibiotic
should be one appropriate for the infection site and will kill
the Staph Aureus in case it is still colonizing your body. I have
seen too many people who have re-acquired Staph Aureus to not
make this recommendation.
There may even be people who, due to their body chemistry, provide
an ideal environment for Staph Aureus in preference to other bacteria.
Some of the people I have seen re-infected were re-infected with
Staph Aureus showing different sensitivities, leading me to believe
they were not infected by the previously treated germ.
9. Anyone in your family, persons sharing your environment, or
close contacts should be observed for any sores, difficult to
heal pimples, scabs, or infections. You may have gotten the infection
from them or given it to them. They should follow the same precautions
elaborated above, and should have their nose cultured to see if
they are colonized, even if they don’t have symptoms. A
lot of people have died because their healthcare providers didn’t
take this infection seriously enough.
No one whom I have had as a patient has needed hospitalization,
as I have been on the alert for this organism since its identification
as a threat years ago. In my own practice, I am seeing an explosion
of cases over the last few years, and I am meeting it with all
the vigor and creativity I can muster so that none of my patients
become one of the statistics cited above.
I encourage you to take this as seriously as I do.
