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Watch Out For MRSA In Your Community

“Community acquired” (that is, not acquired in the hospital, which would be “hospital acquired”) methicillin-resistant Staphylococcus aureus (MRSA) infections have not likely come about because germs that have evolved bacterial resistance by residing within hospitals have spread into the community. Rather, this bacterial resistance to methicillin appears to have arisen independently. The “community” now absolutely needs to be considered to include the outdoor community. Hikers, kayakers, divers, climbers and all other outdoors persons who share equipment or mingle with the general population are susceptible. From a reference entitled “Diagnosis MRSA – The Clinical Challenge of Multidrug-Resistant Infections,” authored by Peter DeBlieux and colleagues and published as a supplement to ACEP NEWS, comes some useful observations.

Skin and soft tissue infections are among the most common infections caused by bacteria that can develop resistance to bacteria. Persons at particular risk for such infections include males, certain geographies, time of year (during warmer months), and affliction with diabetes. Many of the infections are abscesses, in which there is a pus pocket that can be drained by making an incision. Such treatment is in fact important to help control the spread of MRSA infections, presumably by helping to cure the abscess(es).

The current thinking is that in the setting of an “uncomplicated” skin and soft tissue infection (e.g., no involvement of deep tissues, minor clinically: simple abscess, impetigo, pimple, or superficial cellulitis), incision and drainage of small, localized abscesses can be curative. However, this is not an absolute, so many physicians are of the opinion that adding an effective antibiotic is useful. Until we have more information, it remains the clinical judgment of the treating physician about whether or not to prescribe an effective antibiotic, such as trimethoprim-sulfamethoxazole.

In complicated infections, which involve deeper skin structures (such as infected tissue ulcers, rapidly progressive infections, diabetic foot infections involving MRSA), antibiotics are deemed to be essential. The oral antibiotics that are felt to be effective against MRSA are clindamycin, trimethoprim-sulfamethoxazole, doxycycline, minocycline, linezolid, and rifampin. The injectable antibiotics that are felt to be effective against MRSA are vancomycin, clindamycin, daptomycin, tigecycline, linezolid, and quinupristin-dalfopristin. Notably, the fluroquinolone category of drugs, which includes ciprofloxacin, is not recommended as an effective treatment for community acquired MRSA infection. The same holds true for the macrolide category, which includes erythromycin, as well as cephalexin, penicillin, and dicloxacillin.

To prevent the spread of MRSA, wounds should be kept covered with clean, dry bandages; hands washed with soap and water or an effective hand sanitizer after each dressing change; close contacts instructed to bathe regularly; no sharing be allowed of bedding, towels, washcloths, bar soap, razors, and so forth.

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This post, Watch Out For MRSA In Your Community, was originally published on by Paul Auerbach, M.D..

Ciguatera Poisoning and Sex

Ciguatera fish poisoning involves a large number of tropical and semitropical bottom-feeding fish that dine on plants or smaller fish that have accumulated toxins from certain microscopic dinoflagellates. Therefore, the larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the barracuda, jack, grouper, and snapper. Symptoms, which usually begin 15 to 30 minutes after the victim eats the contaminated fish, include abdominal pain, nausea, vomiting, diarrhea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, incoordination, difficulty sleeping, and occasional difficulty in breathing. A classic sign of ciguatera intoxication is the reversal of hot and cold sensation (hot liquids seem cold and vice versa), which may reflect general hypersensitivity to temperature. Unfortunately, the symptoms persist in varying severity for weeks to months. Victims can become severely ill, with heart problems, low blood pressure, deficiencies of the central and peripheral nervous systems, and generalized collapse. Anyone who displays symptoms of ciguatera fish poisoning should be seen promptly by a physician.

It was reported this spring that ciguatera fish poisoning has been linked to pain during sexual intercourse. Despite the sensational coverage that this announcement received by the press, the phenomenon has been known for quite some time. It is indeed a fact that a person affected by ciguatera fish poisoning may suffer symptoms of pain during sex. These symptoms include painful ejaculation in men, and a burning sensation during and after (for up to 3 hours) intercourse. What was interesting about this most recent report, which was generated by observations made in North Carolina, was quantification of the duration of the uncomfortable symptoms. One male reported that his symptoms lasted a week, and two of the women said that they were affected for a month. The fish implicated in this particular cluster of cases was amberjack.

Treatment for ciguatera fish poisoning is for the most part supportive, although certain drugs are beginning to prove useful for aspects of the syndrome. An example is intravenous mannitol for abnormal nervous system behavior or abnormal heart rhythms. These therapies must be undertaken by a physician. Prochlorperazine may be useful for vomiting; hydroxyzine or cool showers may be useful for itching. There are chemical tests (such as Cigua-Check® Fish Poison Test Kit) to determine the presence of ciguatoxins in fish, but there is not yet a specific antidote.

This post, Ciguatera Poisoning and Sex, was originally published on by Paul Auerbach, M.D..

Snakebite: Global Public Health Menace

Snakebite continues to be a significant public health issue worldwide. In the current issue of Wilderness and Environmental Medicine (2009;20:43-56), Ian Simpson and Robert Norris have published an article entitled, “The Global Snakebite Crisis – A Public Health Issue Misunderstood, Not Neglected.” In this very well thought out concept paper, the authors introduce a marketing model to examine global snakebite and to identify if the current approach to treatment (specifically, with antivenom) is relevant and effective. They use a model to examine if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum.

By their reasoning, the authors present the case that perhaps the current approach to antivenom issues is not adequate, and compounded by a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols.

Multiple flaws in snake antivenom (ASV) production and distribution are revealed, including selection of venoms against which to create ASVs, unscrupulous behavior by certain manufacturers, assumptions about the epidemiology of snakebites, definition of envenomation syndromes, estimations of mortality, sustainability of the current economic model, and others. The authors do not merely sit back and take shots at what they perceive to be flaws. They offer a practical model for how it might be possible to achieve solutions for most of these issues.

This paper has already stimulated a great deal of discussion, and will undoubtedly be viewed by some readers as provocative. The topic of snake bite, and therefore ASV production, distribution, and use, is on the agenda of the World Health Organization. Anyone interested in venomous snakebite and the medical-economic-social-political issues related to antivenom and other medical interventions for envenomation, would be interested in reading this paper carefully, and considering how best to determine if there is a need to validate the contentions and suggestions.

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This post, Snakebite: Global Public Health Menace, was originally published on by Paul Auerbach, M.D..

Contaminated Beachwater May Be Hazardous To Your Health

Summer has arrived and so many of us are headed for the beaches that line the coasts of the United States as well as those of our inland waters, such as lakes and rivers. There are plentiful healthcare concerns for beachgoers. These include sunburn, drowning, jellyfish stings, sprains, strains, and cuts and bruises. What perhaps doesn’t receive as much attention as it deserves is ocean water quality – specifically, whether or not the water is contaminated by environmental toxins and/or harmful bacteria.

Nearly a year ago, reports circulated in the press that indicated that at least 7% of beach water samples in the U.S. exceeded acceptable (from a health perspective) levels of bacteria. A writer for the New York Times reported, “The number of beach closings and health warnings issued to swimmers as a result of pollution fell in 2007 from a record level in 2006,” according to the Natural Resources Defense Council (NRDC). But the writer continued that the NRDC noted “that American beaches ‘continue to suffer from serious water pollution that puts swimmers at risk.'” He cited that the NRDC analyzed “data obtained from the Environmental Protection Agency on more than 3,500 beaches,” revealing “that beaches across the country closed because of pollution or issued pollution-related health advisories for a total of more than 22,000 days in 2007, down from more than 25,000 days in 2006.”

A reporter for the Los Angeles Times wrote that the NRDC found that “Los Angeles County is home to the dirtiest beaches in the state (California), with repeat offenders Avalon on Santa Catalina Island and Santa Monica among those with the highest levels of fecal bacteria in ocean water.” Overall, the NRDC found that, “Illinois has the most coastal beaches in the country with water samples exceeding acceptable levels of (potentially harmful) bacteria, such as E. coli.”

The NRDC posts an informative page on beach pollution. The major takeaway is that the beachgoer should be well aware of the current situation with regard to pollution or contamination of any body of water for which human entry is contemplated.

Here is the status of the federal Beach Protection Act of 2008, as reported by OpenCongress:

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This post, Contaminated Beachwater May Be Hazardous To Your Health, was originally published on by Paul Auerbach, M.D..

Aqua Pencil

At Beneath the Sea I had the opportunity to walk the show floor and check out some new products intended for divers. One that immediately caught my eye was the Aqua Pencil, which is an innovative underwater pencil designed for divers, kayakers, boaters and researchers who will be underwater or wet. Because of its properties, it can be used when one needs to write in the rain, sleet or snow, such as out in the field or during a rescue. I tested it and it performs as advertised.

The Starter Kit includes an Aqua Pencil, Tether, Lead Pack (writing leads) and Eraser. The tethers are available in different colors, and the pencil is advertised to work well with any slate and to write well on waterproof paper.

According to the company, which is named Xit 404, it was formed to fulfill the need for specialized products and to develop ideas that are overlooked by other companies.

The Aqua Pencil Kit retails for $21.95.

This post, Aqua Pencil, was originally published on by Paul Auerbach, M.D..

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