Supergerms! Bacteria that Antibiotics Cannot Kill!
Strains of bacteria that are resistant to the most powerful antibiotics have been found in Tokyo, Michigan and New York City!

Dr. Sarah Rawstron, an Infectious Disease Pediatrician from Downstate Medical Center, is an expert on antibiotic-resistant bacteria. On Friday, May 28, 1999 she spoke to the Pediatric Working Group. This issue of the PWG Newsletter summarizes the information she presented.

Bacteria that used to be treatable with antibiotics (also called antimicrobials) are now problematic because of resistance. As parents of HIV+ children we understand the idea of resistance to drug therapy. We are familiar with the human immunodeficiency virus' ability to mutate and become resistant to antiviral drugs. Antibiotic resistance is similar in its origin: misuse or overuse of antimicrobials results in bacteria which are resistant to those agents. If one sort of bacteria, such as enterococcus, becomes resistant to a specific antimicrobial drug, it is possible to transfer that resistance to related species of bacteria, such as pneumococcus and gonococcus, and then all of these organisms will be harder to kill.

Unfortunately, antibiotic resistance is a problem for the whole population. The resistant bacteria that your child's negative playmate contracts can be passed to your immuno-compromised child who may suffer from the "supergerm" much more than the playmate did.

Four things have contributed to the current state of antibiotic resistance:

1. Antibiotics are used unnecessarily and so bacteria become stronger. This is the case when antibiotics are used for viral infections such as a cold, some ear and eye infections and bronchitis, all of which antibiotics can do nothing to make better. Antibiotics only work on bacterial infections.
2. Antibiotics are not used correctly even when they are needed. This is typically something like not finishing all the pills in a prescription. Antibiotics usually work very quickly and within 24 hours the patient feels better. If s/he quits taking the medicine earlier than s/he should have, not finishing the whole prescribed course, the bacteria which caused the infection will not all be killed and the ones that survive will be stronger and more able to withstand the next dose of that antibiotic.
3. Antibiotics are used prophylactically for more and more diseases.
4. The modern hospital and nursing home environments have become breeding grounds for antimicrobial resistance.

HIV+ children are especially dependent on antibiotics to treat and prevent diseases that the rest of the population hasn't even heard of. If these antibiotics are no longer effective, what will happen to our children?

Earaches 1 and 2: Some of Them Require Medicine, Do They All?
In Scandinavian countries, there is very little antibiotic-resistant bacteria. For example, Finland reported 0% resistance to penicillin in 1989. In Scandinavian countries, when a parent brings in a child complaining of an earache, the doctor takes a look and then typically sends the child home with pain medication, asking the parent to return the next day only if the earache is no better.

Because 80-90% of all earaches resolve by themselves within 24 hours, Scandinavian doctors work on the idea that by waiting to see if the body can do the healing by itself, the 10-20% of earaches that actually need antibiotics will be the earaches that return for a second appointment the next day. Those "un-better" earaches are the ones which are treated with antibiotics. (This is when "Take two Tylenol and call me in the morning," really is great advice!)

Earaches 1: Is Waiting an Alternative to Antibiotics?
Interestingly to me, I had seen this exact outcome just weeks before Dr. Rawstron's talk. It was a heavy, muggy kind of week, every night was foggy and every day cloudy.

My HIV+ son complained of an earache three times that week. I usually run to the doctors and specialists at any sign of something wrong but I really hated to drag him in to clinic again. I thought there might be some atmospheric pressure from the strange, heavy weather that was pressing on his eardrum and making it hurt.

My son has had allergic reactions to three classes of antibiotics and for years I've been concerned about running into problems with the antibiotics he has left. I'm afraid we'll use them up now when he's only a little sick and then we won't have them when he gets something really bad.

So I didn't take him to the doctor and, really unusual for us, I didn't even call the doctor to check! (I'm not advising this kind of behavior, lucky for my son, it turned out right this one time. Next earache I may run to have the ENT see him.) But this time I didn't call the doctors because I knew they would send a prescription or ask me to bring him in. I didn't want him to miss any more school; I didn't want to use another antibiotic and chance him becoming allergic to it too.

Each day I expected the school to call and send him back home, but no one called. A couple evenings he said his ear hurt and had hurt during school. I hoped he was just exaggerating. Heck, for the first time in his life I hoped he was lying!

I didn't ignore his complaint, I was cautious and worried that it would get worse, but since the pain was intermittent and responded to ibuprofen, I felt we could wait. Pretty soon -- within four days -- he completely stopped complaining and the earache just wasn't there anymore. I was relieved but still worried that my non-action might have caused some irreparable harm to his hearing or maybe the infection was going to come roaring back, having only sulked away to a deeper area of his inner ear. But nothing bad happened. He seemed to be cured.

After hearing Dr. Rawstron speak, I knew the reason my son's earache had cleared up: most earaches don't need antibiotics, they go away by themselves.

Earaches 2: What about when antibiotics are needed?
What about those 5-10% of the total number of earaches that do need antibiotics? The ones that are accompanied by fever, the ones that don't get better in a day or so, bad earaches with pus or fluid coming from the ear? With at least 3 common bacteria that cause ear infections all becoming resistant to antibiotics, what will a call to the doctor produce?

It is always best to use the narrowest spectrum antibiotics (that is the antibiotics that are active against the least number of types of bacteria). It is best of all to use the one exact antibiotic that kills the exact kind of bacteria causing the problem. With earaches this is usually a standard dose of Augmentin or amoxicillin (40 mg/kg) which still works for the majority (80%) of ear infections in New York City. Of the remaining 20%, about half (10% of total) have only partial resistance which respond to increased doses of the standard antibiotics: a doubled dose of amoxicillin (80 mg/kg) or a combination of Augmentin with amoxicillin at the regular doses (40 mg/kg each). This prescription for the stronger dosing of narrower-spectrum drugs completely destroys the bacteria while reserving some "big gun" broad-spectrum antibiotics for any more-resistant bacteria that your child may get later.

Only in ear infections that do not respond to the higher doses, approximately 10% of total, a broader spectrum antibiotic may be necessary.

This is good policy in a public health focus because it doesn't cause further antibiotic resistance and it's good for the patient because it "saves" the broader spectrum antibiotics for the worst situations.

There's No Such Thing as a Sterile Environment
One way we can protect our kids from "supergerms" and antibiotic-resistant bacteria is easy for everyone but difficult to enforce. When in the hospital or at the clinic, we have to insist that all doctors, nurses, orderlies and visitors WASH THEIR HANDS before touching our children. And we have to have seen them wash, not assumed that it has happened in another room.

How can you politely remind someone who is supposed to be really up on infection control to do something so basic as wash his/her hands before touching your child and before touching even the bed rails? You could put up a sign, something funny yet serious like: "Beware of the mother bear in this room! She bites (hard!) if you don't wash your hands before coming near her cub!" You'll still have to mention to every single nurse, every orderly, every doctor, intern, resident and social worker that you DO MEAN IT and that they MUST wash their hands in front of you , because signs are really ignored a lot. But a sign can make you seem concerned, yet self-deprecatingly cheerful, and maybe even when you're NOT in the room the sign will remind everyone to wash.

Washing hands with regular soap is a very simple and effective way to prevent transmission of resistant bacteria from one person to another, especially in hospitals and clinics.

Antibiotic prophylaxis can save lives
Most positive children are on one antibiotic or another to prophylax against deadly diseases that used to be the greatest causes of death for HIV-infected individuals.

The Pediatric Guidelines strongly recommend the following:

1. Bactrim (trimethoprim-sulfame-thoxazole) to prevent PCP in all infected infants; for children ages 1-5 years who have a CD4 (T-cell) count under 500 and in older children who have a CD4 count less than 200.
2. Clarythromycin or azithromycin to prevent MAC for all children older than 6 with a CD4 count of less than 50, 2-6 years with less than 75, 1-2 years with less than 500 and infants with less than 750.
3. Other antibiotics are recommended as T-cell counts decrease, or if the child tests positive for other pathogens like TB. A complete list of antibiotic guidelines for the prevention and treatment of opportunistic infections as well as vaccination guidelines have been issued by the US Department of Health and are available by calling Margit at the Pediatric Working Group at 212-255-0520.

Protect Our Families from Super-strong Germs
Dr. Rawstron did bring some good news.

The most important way to stay free of harmful bacteria is just what we tell our kids: Wash your hands!! Twelve, eighteen, twenty-nine times a day, wash your hands and make your children wash theirs.

This doesn't get rid of all bacteria, of course. There are bacteria crawling all over us, bacteria floating in the air, hanging around the house, outside in the soil. Bacteria are everywhere, but remember: as a group, bacteria are like people, some are good (the ones that aid in digestion) and some are bad. Your goal in washing is to keep your family healthy, not sterile; use regular soap and warm water (although cold water is better than nothing), rub hands thoroughly and scrape under the fingernails; wash for at least 20 seconds.

One of the most surprising things to hear from Dr. Rawstron was the role of antibacterial soaps in the evolution of antibiotic-resistant bacteria.

You and I buy the stuff because we think it will protect our families from germs. We use anything labeled "antibacterial" because we believe it will help keep our loved ones well . . . But in this case we're contributing to the very antibiotic-resistant bacteria that may make us sicker. Through constant exposure to low levels of antimicrobial action, the bacteria that are not killed are the stronger bacteria which produce new generations of bacteria that are better able to withstand the next onslaught of cleanser.

Consider using only regular soaps to wash skin, scrub dishes and scour the bathroom. Regular soaps and detergents will do the job and will not add to the antibiotic resistance of household bacteria.

Wash and Cook, That's What We Do
Wash fresh vegetables well and cook meat thoroughly. This is advice we've heard our whole lives.

To wash vegetables and fruit some people use a drop or so of unscented detergent in a bowl of warm water or even a weak-bleach wash of one part household chlorine bleach mixed with 20 parts plain water, both techniques are followed by lots of rinsing with water. (Filtered water has the advantage of not containing tap water's possibilities for trouble.) These cleaning methods will certainly cut down the chances of any infection coming from whole pieces of fruit or raw vegetables.

The peel of fruit is where bacteria are located but juice is often made by crushing the whole fruit (as in apple cider) so bacteria from the fruit's peel will end up in the juice. Pasteurization, that is, exposing liquid to a high temperature for a period of time, kills microorganisms, parasites and viruses as well as bacteria. All products that have undergone this safety procedure will clearly be labeled "Pasteurized." Milk or juice labeled "Raw" has not been pasteurized. Additionally, some dairy foods, like soft cheeses (Brie, goat cheese, etc.) may not have been made from pasteurized milk. Always check before you buy!

Our Infectious Disease specialist pointed to HAMBURGER as a primary carrier of food-borne bacteria. The outside of any piece of meat can be contaminated by fecal material from the intestines of the slaughtered animal. Because pieces of meat from many different animals are ground together to make hamburger, one piece of contaminated beef with some intestinal bacteria on the outside of it can contaminate batches of ground meat. The Department of Agriculture's "Safe Food Project" gives 165° as a safe temperature for ground meat of any kind. If a thermometer is not available, such as when you're at a restaurant, do not eat hamburger that is still pink inside.

Basically, any food-borne bacteria can be killed by heat, so cook food thoroughly - even leftovers should be reheated to at least 165,° soups and gravies should have come to a boil - and carefully wash whatever is not going to be cooked.

PWG has twice-monthly meetings for parents! Join us! PWA Health Group 150 W. 26th Street, #201 (Between 6th and 7th Aves) New York, NY 10001 Phone: 212-255-0520, 718-882-0514 Fax: 212-255-2080 Email: pwahg@freewwweb.com

Meat Temperatures: Kill Those Wicked Germs
The suggested interior temperatures for beef, chicken and pork are 165,° 180° and 170,° respectively; use a meat thermometer to check.

However, if you just despise well-done beef, it is probable (although not absolutely certain) that completely searing the outside of a steak or roast and then continuing to cook the meat until it is at least medium (interior temperature of 150°) would make a safe dinner.

Antibiotic-Resistant Bacteria Cause Unhappy Events
A few years ago, the son of a Pediatric Working Group member was admitted to the hospital for an infection of the skin around his eye (otic cellulitis) caused by the bacteria staphylococcus aureus. In the hospital the little boy was given IV antibiotics for three days and the skin infection went away without hurting the eye. Everything seemed fine.

Eighteen days later the otic cellulitis came back, caused this time by a different bacteria: pseudomonas aeruginosa. This is an all-purpose infecting agent, it can attack many areas of the body, causing infections of the lungs, blood, skin and skin-structure, urinary tract, bones, joints and the central nervous system. This bacteria is one of those that don't bother the general population much but which can be pretty troublesome for the immunocompromised.

Again, the cellulitis was treated with a few days of IV antibiotics and voila! another apparent success. Unfortunately, the bacteria was antibiotic-resistant and the stronger organisms lived on in the child's body even though the second cellulitis looked to be as cured as the first had been.

Several weeks passed. The little boy began to complain about his throat, a fever started. The resistant bacteria had lodged in the soft tissue of the little boy's throat. His immune system was too weak to contain the infection so the bacteria's effect spread all around his neck. The infection caused his throat to swell so greatly that his airway started to close. He ended up in the ICU on a respirator for 8 days. He nearly died.

The last course of treatment required that two of the strongest antimicrobials be given intravenously for six weeks in order to be sure that all the antibiotic-resistant pseudomonas was finally killed.

The little boy has recovered, but the tissue of his throat was badly damaged. It took a very long time for him to be able to swallow properly or speak clearly.

Did the antibiotics used to treat the original staph infection change the balance of the normal bacteria in the boy's throat (killing those sensitive to the antibiotics but leaving resistant bacteria behind), or was the resistant pseudomonas picked up in the hospital? We can't know the answer, but we can try to minimize the chance of such a thing happening again:

1. Wash your hands, make the kids wash hands, be sure healthcare workers wash hands;
2. Do not use or ask doctors for unnecessary antibiotics;
3. Finish every bit of a prescription for any antibiotic.