Tuesday, March 26, 2019

MRSA: The not-so-famous superbug

Thank goodness for pediatricians. No matter what time of night, they answer the calls of frantic parents who are worried about sick children. I’ve made a few of those 4 a.m. calls myself to our pediatrician (an angel named Katherine), who calmly directed us to go to the hospital on one occasion, or give the baby a tepid bath on another. It’s been a sort of triage that has guided us to making the right decision. And that’s how of I think of the new trend in medicine called virtual visits.

Now, thanks to video conferencing applications (apps) that download to a smartphone, tablet, or home computer, people of all ages can experience a “virtual” visit with a qualified physician at any time, day or night.
Not just a fad

The benefits go beyond triage. Virtual visits are part of the shift toward making health care more convenient, and they’re already popular. “We can conservatively estimate that there will be at least a million virtual doctor visits in 2016,” says Dr. Ateev Mehrotra, an internist and a Harvard Medical School researcher who studies new ways of delivering health care.

Cost is another big attraction: it’s $40 or $50 per visit, about half the cost of an in-person visit, and most insurance companies are now covering them. Some, such as certain Blue Cross policies, offer their own virtual doctor services free of charge. Medicare does not cover virtual visits. However, the cost of a virtual visit can be less than the out-of-pocket co-payment that Medicare requires for an in-person doctor visit.
Quality of care

Physicians who take part in virtual visits are vetted. They’re assigned to you based on where you live, they are licensed in your state, they’re board-certified, they carry malpractice insurance, and they can even order tests and prescriptions for you. But without seeing you in person, their ability to assess you is limited. “The physician can look at your rash, but can’t examine the back of your throat or listen to your lungs. If it’s a virtual visit for depression, it probably doesn’t make a difference. But if you’re having abdominal pain, you really need a doctor who can perform a physical examination,” says Dr. Mehrotra.

Studies on virtual visits have been mixed. “People who go to a virtual visit are just as likely to have a follow-up appointment in the next few weeks, a sign that the care is equal. And the antibiotic prescribing rate is similar between virtual and in-person visits. But doctors at virtual visits are more likely to prescribe a broad-spectrum antibiotic, not one specific to your condition. And it appears that physicians are much less likely to order a test you may need, which could be a problem if you have strep throat,” says Dr. Mehrotra.
How to do a virtual doctor visit

To try a virtual visit, you need a smartphone, a tablet, or a computer with a camera. If using a smartphone or tablet, download the app for the service you’d like to use. If using a computer, you can conduct visits at the website address. Two of the most widely used are Teladoc ( and Doctor On Demand (

You’ll have to create an account with a password, and enter your payment information, medical history, and current symptoms. You’ll also need to provide important details, such as recent test results or the types and amounts of medications you’re taking. A virtual doctor who doesn’t have this information can make the wrong decision.

After you request a consultation, a doctor in your state will review your information, then appear in a video box on your screen within 20 minutes. If you want the doctor to see something, such as a skin rash, you’ll need to hold it up to the camera. Visits last about 10 or 15 minutes. If the doctor prescribes a medication, it will be sent electronically to your pharmacy.
When to consider a virtual doctor visit

Virtual visits aren’t meant to replace every trip to the doctor’s office, but may be a good option for minor, temporary problems such as cold and flu, sinusitis, a sore throat, rashes, diarrhea and vomiting, or conjunctivitis ― particularly if you can’t reach your doctor. Ideally, your virtual doctor should let your regular doctor know what tests were ordered and what treatments were prescribed — in any case, it’s best to see your regular doctor as soon as possible. It’s reassuring to know that expert advice is now just a click away. Like those on-call pediatricians, virtual doctors can guide us, no matter what time of the day or night. A young woman* came into my office complaining of horrible pain and itching in her genital area. She had recently started dating, and her current boyfriend was her first sexual contact. He, however, had had other partners before her. She had telltale sores and tests confirmed that the cause was genital herpes.
(*This is not one specific person but actually a composite of many patients. When I say we see a lot of genital herpes in our practice, I really mean it.)

Genital herpes is far and away the most common sexually transmitted infection (STI) that we see in primary care. I find myself explaining the diagnosis to distressed patients far more often than I would like. That’s why I was thrilled to see an update on genital herpes in a recent issue of the New England Journal of Medicine.

There are two types of herpes, HSV-1 and HSV-2. Generally speaking, HSV-1 is responsible for those annoying cold sores (skin ulcers) that can pop up during times of stress or lack of sleep. HSV-2 usually causes genital sores. Many people don’t realize that HSV-1 can cause genital ulcers as well, though these tend to be less severe and less likely to recur.

It can take as little as a few days and up to a week after a person has been exposed before any symptoms appear. First, there will be redness and tingling, followed by painful bumps that progress to fluid-filled “blisters.” Eventually these burst to form ulcers which then crust over, healing over several weeks. HSV-2 infections can be more severe, causing terrible pain, as well as flu-like symptoms, and even inflammation of the membrane that covers the brain (meningitis).
You can only get genital herpes if your partner has an active infection with sores, right? Wrong

A person can be exposed to the virus and pass it to someone else without ever having symptoms. It happens more often than you’d think. That’s because the virus can exist in genital fluids even without any ulcers. This is called “asymptomatic shedding of virus.” Although there is a lot more active virus when there are sores, asymptomatic shedding is probably how most people get herpes. What’s more, only one out of four people who tests positive for genital herpes actually knows that they have the virus. That’s a lot of people. Combine the two and you have many people unknowingly infecting others.

As with the couple above, many people who learn they have genital herpes are shocked. They tell me that they didn’t see any sores on their partner (“And I really looked!”) or that their partner had never ever had any ulcers, ever (“And I believe them!”). This is common and true, because people can have genital herpes and not know it.
Got Ulcers? Get Tested

A person with genital ulcers should see his or her doctor. It’s important to confirm whether or not it is herpes and if so, what type. Genital herpes outbreaks are treated with antiviral medications. These medications can help to reduce the number of days of discomfort and have few side effects. They are most effective when taken early in an outbreak. Some people take these drugs daily to prevent outbreaks.

Once someone has had a test that confirms either type of genital herpes, future partners can have a blood test which tells them if they already have been exposed to the same strain of virus. If the person tests negative, the partner with the infection would be advised to take antiviral therapy daily, in order to help prevent infecting his or her partner. Although daily antiviral therapy decreases the chances of spreading the virus, there is no guarantee, so it’s best to have a frank conversation with a new sexual partner.
No ulcers doesn’t equal no herpes, so then what?

If you’ve never had genital ulcers and as far as you know, have never been exposed, is it worth getting tested? That’s a controversial point and in fact, the widely followed official guidelines discourage screening.

Why? Many reasons: Let’s say the test comes back positive for HSV-2. This means that the patient may have been exposed to HSV-2 at some point in their lives, somehow, somewhere. Research tells us that these folks may be periodically shedding virus particles in their genital fluids. These patients would then be diagnosed with genital herpes, encouraged to share their status with future partners, and offered daily antiviral medication to prevent possibly spreading the virus.

All of this can be a tough pill to swallow, so to speak. There is significant social stigma and shame associated with herpes. In addition, there are occasionally false-positive tests. Labeling someone with the diagnosis can be devastating to their future relationships, and asking someone to take a pill for a condition they may or may not have and may or may not spread seems unreasonable.

However, many experts disagree with the official guidelines. I wrote to Dr. John Gnann, professor of infectious disease at the Medical University of South Carolina and co-author of the New England Journal of Medicine article. He has suggested the below guidelines, and outlines the rationale:

“For herpes viruses, there is no ‘past exposure only’ scenario. If a person is HSV-2 seropositive, then that person is HSV-2 infected and will carry the virus forever. That means one of three things:

    The person has had herpes with symptoms.
    The person has had herpes with symptoms but didn’t realize the cause.
    The person has the herpes virus that from time to time can appear in genital fluids. The only way to know if a person is shedding the virus is with daily tests. That’s just not practical.

A lot of people fall into the second and third categories — again, that’s why so many people still get the virus. Dr. Gnann suggests herpes testing for

    people with any other sexually transmitted infection including chlamydia, human papilloma virus (HPV), etc.
    people in a relationship with a herpes-positive partner
    any person who asks to be tested.

He adds: “Anyone who has a positive blood test for HSV-2 (whether or not they have episodes with symptoms) should be told that she or he can potentially give HSV-2 infection to a partner. They should also be told about daily preventive antiviral therapy.”

As a primary care doctor, I found Dr. Gnann’s testing guidelines and rationale to be quite sound, and, I might add, different from my usual practice. To date, I have been following the official guidelines and steering away from the HSV blood test. After researching and writing this piece, I think that what he is suggesting makes a lot of sense. I personally plan on having a more in-depth discussion about the option for HSV blood testing with all of my patients who have been diagnosed with any sexually transmitted infection, as well as anyone who requests testing for such infections, in addition to those with partners with HSV. In a study just published in the journal Pediatrics, 85% of 2,110 parents made at least one dosing error in nine trials. Yes, that’s right: 85%. The majority of the errors (68%) were overdoses, with 21% giving more than twice the recommended dose of the medication.

Truly scary. People mess up in two ways: either literally measuring it wrong, or misunderstanding the instructions. Which is completely understandable, but the consequences can be dangerous.

Here are two simple ways to be sure that your child gets the right dose of a liquid medication:

Use a medication syringe. In the study, the researchers found that when parents used a dosing cup, they were four times more likely to make a mistake than if they used a syringe. Unfortunately, many medications come with a cup, which would seem to suggest that you should use it to measure out the liquid. The mistakes were more likely when the dose was small, but the cups can be confusing no matter what the dose.

Using spoons from the kitchen drawer isn’t the best idea either. You should definitely not use regular spoons, the kind you eat with; they literally come in all sorts of different sizes and it’s almost impossible to know how much you are giving. Measuring spoons are better, but you need to be very careful to fill them exactly — and then be sure that your child drinks the whole amount. Measuring spoons aren’t really designed for the mouths of children.

Medication syringes, on the other hand, are designed for giving medications. You can measure exactly, and you can be sure that all of it gets into your child’s mouth. While they are especially good for giving medicines to babies, they come in all sorts of sizes and work with older children too. You can usually get one from the pharmacist if your child is prescribed a liquid medication, and widely available to buy along with over-the-counter liquid medicines.

Make sure you understand the instructions. As obvious as this sounds, it’s easy to mess up — especially because different medications use different units of measurement. You might see “mL,” “milliliters,” “cc,” “teaspoon,” “tsp,” “tablespoon,” or “tbsp.” Many people get confused. So read it carefully, be sure you know how much you are supposed to give, and be sure that you know how to use whatever you are using to give the medication (hopefully a medication syringe). If you aren’t 100% sure, either ask the pharmacist (they can help with all medications, not just prescription ones) or call your doctor.

The most important point of this study is that the majority of parents make mistakes. We all like to think that we are smarter and will do things right, but 85% is a big number. So pick up some medication syringes, take the extra time to read and think, and ask questions. They are simple steps that can make all the difference. Last year Daniel Fells, a tight end for the New York Giants, was hospitalized with a bad infection in his foot known as MRSA, which stands for methicillin-resistant Staphylococcus aureus. It is a drug-resistant form of staph. The infection didn’t respond to antibiotics, and at one point there was talk of needing to amputate the affected foot. After multiple surgeries, doctors were finally able to clear out the infection, but it is unlikely Fells will ever play football again.

Although it rarely gets headlines, MRSA is perhaps the most well-known superbug –– a type of bacteria that is resistant to most, if not all, antibiotics. These infections may have once seemed like an exotic problem, but with each football season they are becoming more common, affecting high school, college, and professional athletes indiscriminately. But the problem isn’t limited to athletes, as these bacteria also infect healthy people in the general community.

MRSA proves to be especially adept at evading the grasp of antibiotics, becoming a truly dangerous superbug. But this shouldn’t be a huge surprise, because as long as we’ve had antibiotics, staph bacteria have been figuring out ways to become resistant to them.
What exactly is MRSA… and why is it so dangerous?

According to the National Institute of Allergy and Infectious Diseases, Staphylococcus aureus, or staph, causes skin infections. These can include boils, impetigo, skin abscesses, and other painful conditions. If the infection goes unchecked, staph bacteria can cause pneumonia, blood poisoning, toxic shock syndrome, and sepsis (a life threatening immune response to an infection).

Penicillin was successfully used to treat these staph infections after the antibiotic’s discovery in 1940, but its effectiveness began to wane as the S. aureus bacteria began to develop a resistance to the drug. So, scientists turned to the drug methicillin, but by 1961 they discovered that the first strains of S. aureus were beginning to show resistance to this antibiotic as well. Over time, MRSA has become resistant to numerous antibiotics, making it increasingly dangerous and difficult to treat.
Who can get MRSA?

According to the Centers for Disease Control and Prevention, about one in three people carry the staph bacteria in their nose, and two out of 100 people carry MRSA. There are more than 80,000 cases of MRSA each year, and more than 11,000 people die from these infections. Although most of these cases occur in the hospital setting, MRSA infection is becoming a more widespread problem in the general community.

“I actually think of [MRSA] as a pathogen that I have a tremendous amount of respect for, in the sense that it’s one of the very few bacteria that is very good at causing infections in healthy people and also very good at causing infections in sick people in the hospital,” says Dr. John Ross, an infectious disease specialist and professor of medicine at Harvard Medical School. “There aren’t a lot of bacteria that do that.”

Although MRSA infection used to be primarily a “hospital problem,” it’s clear that MRSA is becoming a problem in the general population, usually in the form of skin infections. People can become infected with MRSA after being in contact with an infected wound, or by sharing personal items like razors, toothbrushes, or towels that have touched infected skin. The chances of getting MRSA increase in situations that have what doctors call the five Cs: crowding, skin to skin contact, compromised skin from cuts or abrasions, lack of cleanliness, and contaminated items and surfaces. Examples of people commonly in these situations include athletes, military personnel who live in close quarters, and daycare and school children, as they all involve crowding, skin-to-skin contact, and the sharing of equipment, supplies, and toys.
How you can lower your chances of getting MRSA

It’s important to recognize the signs of an infection early on. According to the CDC, MRSA skin infections can occur anywhere on the body, and they usually appear as a red bump or an area that is red, swollen, painful to the touch, abnormally warm, or full of pus. If you develop any of these symptoms, it’s important to call your doctor right away.

According to the CDC, maintaining good health and basic hygiene can help decrease the risk of bacterial infection. Promptly cleaning and bandaging any cuts or wounds until they are healed also helps keep cuts from becoming infected. Since MRSA can spread through personal items, it’s important not to share things like razors or towels, especially if people have cuts or scrapes.

“Basic general hygiene and hand washing are important,” says Ross. “If there is someone in your house with a staph or MRSA infection that can be spread to other people in the household it’s important that they be treated.”

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