Nosocomial listeriosis

The Sydney Morning Herald is reporting that 3 patients in 2 Sydney hospitals have developed listeriosis after consuming profiteroles served to patients at the hospitals. The infecting strain in all patients was identical. One of the patients has died from an apparently unrelated cause.

Nosocomial foodborne illnesses, particularly those of bacterial origin, are seemingly uncommon. I suspect this is likely due to a lack of appetite in many hospitalized patients, and the highly processed nature of hospital foods (sometimes I'm not sure it's actually food).

A few weeks ago, while making morning rounds on the inpatient infectious diseases consult service, I went to see an immunosuppressed patient with pneumonia. As I was about to leave his room, I noted a clear plastic container of macaroni salad on his overbed table that had been served the evening before. My paranoia of foodborne infections must have been palpable. He thought it was quite funny that I alarmingly said, "Don't eat that!" While laughing at me, he said, "that's old Doc, I'm not gonna eat that." Just to be sure, I threw it in the garbage, which made him laugh all the more.

Photo: Culinary Catastrophy

Loophole Found in FDA Antibiotic Restriction Rule

Last week, Dan posted on the new FDA rule requiring prescriptions for antibiotics in farm animals. This rule is potentially significant since 80% of antibiotics in the US are used in animals, as mentioned in the referenced NYT article. Now an astute reading by Tom Philpott at Mother Jones picks out a potential loophole in the new FDA rule. 

Here is the quote from the NYT's article as I read it: "Michael Taylor, the F.D.A.’s deputy commissioner for food, predicted that the new restrictions would save lives because farmers would have to convince a veterinarian that their animals were either sick or at risk of getting a specific illness."

and...

Here is the quote as Tom Philpott read it: "Michael Taylor, the F.D.A.’s deputy commissioner for food, predicted that the new restrictions would save lives because farmers would have to convince a veterinarian that their animals were either sick or at risk of getting a specific illness."

That does seem like a pretty big loophole.  If pediatricians used the "at risk" determination for prescribing antibiotics, I think my kids would have been on them 24-7. You can read his full interpretation over at Mother Jones. As Dan mentioned last week, only time will tell. Since Mike Taylor said "we’re confident that it will result in significant reductions in agricultural antibiotic use," we probably should wait a bit before all becoming vegetarians.

US District Court Judge Orders FDA to take Action on Antibiotics in Animal Feed

In a story Maryn McKenna broke last night, Judge Theodore Katz of the Southern District of New York (largely NYC) has ordered the FDA to take action on it's 1977 finding that antibiotics in animal feed impact resistance in human populations. For 35 years, various interests have blocked further efforts to limit 'growth promoting' antibiotics in feed. This lawsuit, brought by Natural Resources Defense Council with the Center for Science in the Public Interest, Food Animal Concerns Trust, Union of Concerned Scientists, and Public Citizen, sought to restart the evaluation process and move away from the current voluntary participation supported by FDA.

All right, nothing more here. Head on over to Maryn McKenna's SuperBug post to get the rest of the story. She's also provided links to her prior posts on the topic. Awesome!

Antibiotic-free pork ≠ #MRSA-free pork

Ashley O'Brien in Tara Smith's UI lab has a new study out in PLoS ONE looking at MSSA and MRSA in fresh retail pork samples.  Tara has a comprehensive blog post covering this study and their prior work leading up to this paper, so check it out if you want a lot of the details.

Briefly, they collected 395 samples from 36 stores in IA, MN and NJ. 300 samples were from "conventional" pork and 95 were from pork labeled "raised without antibiotics."  S. aureus was found in 67% of conventional samples and 57% of antibiotic-free samples, while 6.3% of conventional pork and 7.4% of antibiotic-free pork were contaminated with MRSA.

This is a relatively small study, so it likely should be repeated.  Also, as Tara mentioned in her post, in the states included in this study, very few USDA-certified organic products were available unfrozen, and they targeted sampling of fresh meats.  It is hard to speculate why MSSA and MRSA didn't differ significantly between the types of pork, but contamination during processing or at retail is certainly possible.  Could it be that conventional and antibiotic-free pigs are raised in close proximity?

O'Brien AM et al. PLoS ONE January 2012

More bad news from pig country

It is kinda funny moving back to the Midwest after spending almost 20 years on the east coast. To be specific, I grew up in the East North Central region (Great Lakes States) and now find myself in the West North Central (Great Plains States); never mind that Iowa isn't actually in the Great Plains.  People are always asking why I would move back or what's it like there in flyover country or the heartland or Middle America - I just smile and say that "all the women are strong, all the men are good looking and all the children are above average." Most of the over-stressed, over-crowded coastal folk have at least heard of Garrison Keillor, so that usually changes the conversation...

The Atlanta Braves' new mascot?

OK, so Maryn McKenna has a nice post over on her Wired Superbug blog discussing two studies looking at MRSA in US retail meats. She first reviews a study by Blake Hanson in Tara Smith's U. Iowa lab that found MRSA in retail pork including spa type t034 (ST398). 

The second paper from University of Maryland College Park included testing of 694 samples of retail ground beef, ground pork and ground turkey in the DC area. The somewhat surprising finding was the 17% of turkey and 17% of pork samples were contaminated with MRSA.

The funny part of McKenna's post was that she said that Tara Smith's work was particularly important because "they probably know ST398 better than any other US team looking at the strain" (OK, that's good) "and unlike the other research groups, they are embedded in pig country." ???

We can all agree that Iowa produces a lot of pork, but what about Virginia which is #4 or #5 in turkey production.  I guess, we can refer to people in Alexandria as being from turkey country. Oh, and Georgia is #1 in broiler production, so people from Atlanta are now from chicken country.  I guess, this re-transplanted Midwesterner is becoming overly sensitive...

Addendum: Strictly speaking, PIGS countries are Portugal, Italy, Greece and Spain which are in the midst of an economic crisis. Iowa's unemployment rate sits at 6% and is operating in a close to balanced budget.

Were bean sprouts the vehicle for E. coli O104:H4?

Some new developments today in the enormous enterohemorrhagic E. coli (EHEC) outbreak in Germany, an outbreak that has sickened at least 1600, caused over 600 cases of hemolytic uremic syndrome (HUS), and killed 22 so far. Daily updates can be found at the European CDC site, here.

Eli has blogged several times about the FDA Food Safety Modernization Act, which was passed several months ago. That law will do little to protect U.S. consumers from foodborne illness, however, if the FDA is not provided sufficient funding to implement it. Perhaps they should serve a delicious bean sprout salad at the next House Appropriations subcommittee meeting--we'll find out if our representatives are confident enough in U.S. food safety systems to eat it.

Would you like Staph with that steak?

Photo: Friend of the Farmer

A new study in Clinical Infectious Diseases cultured meats from grocery stores in 5 US cities. Much of it was found to contaminated with Staph. aureus (77% of turkey samples, 42% of pork, 41% of chicken, and 37% of ground beef samples). Moreover, 52% of the isolates were multidrug resistant.

I am now beginning a campaign to have laws passed in all 50 states which will mandate that all human carnivores be immediately placed in contact precautions.

Don't eat this house!

Today’s holiday advice: avoid houses constructed of cake and frosting. Assuming you manage to avoid being eaten by a witch, you face the threat of staphylococcal food poisoning. The Illinois Department of Public Health reports that several outbreaks of food-borne illness have been linked to an Illinois bakery with the unfortunate name Rolf’s.

Only 48 million get food poisoning annually in the US

Good news (not really). Through an estimate derived through 'substantially improved methods', the number of people who are thought to get sick annually via food poisoning fell from 76 million to 48 million.  That's fantastic. Annual deaths fell from 5000 down to 3000.

The two reports on illness due to major recognized pathogens and unspecified agents along with an editorial by one of my Maryland mentors, Glenn Morris, have been published in expedited form in EID.

I hope the timing of the article doesn't impact the bill modernizing the FDA that recently passed  in the Senate but has yet to make it to President Obama. 48 million and 3000 are too many, especially in 2010.

Ominously, Glenn Morris points out in the editorial that "if one looks simply at rates of overall gastrointestinal illness in the United States, based on FoodNet Population Surveys, one might infer that overall rates of acute gastrointestinal illness have increased during this period, from 0.49 episodes per person per year in 2000–2001, to 0.54 in 2002–2003, and to 0.73 in 2006–2007."  On the plus side. Morris suggests that using FoodNet data "the overall trends show an initial drop in incidence of infection with the major bacterial foodborne pathogens after implementation of the 1995 USDA regulations, followed by a leveling off of incidence in subsequent years."

Well, there is some good news.  We now have more accurate estimates of infections due to foodborne pathogens in the US. When you have better data, you can have a a more modern, risk-based food safety system.  This is why Dan and I argued in our recent JAMA editorial that we need a continued expansion of the existing but somewhat limited hospital-infection and MDRO surveillance system in the US.

see also: William Neuman NY Times article

Weekend Links or WeekeLinks?

Jackie Robinson Rotunda - Citi Field

Pretty busy around here.  I just gave a talk on seasonal variation in hospital pathogens at the ID research conference this morning.  I saw Dan there.  He is alive, but on service. I think he had 12 consults one afternoon.

We're moving to a new research building next week here at the Iowa City VA, so I'm busy packing up the stuff that I unpacked only 5 months ago when I arrived.  The building is called "Building 42."   42 is Jackie Robinson's uniform number.  Those of you that have seen my old office will remember the Jackie Robinson poster that I had hanging next to the Jim Henson-Kermit poster.  I think I will call the building the 'Robinson Building' or maybe just 'Jackie'.

Here are some interesting posts for your weekend reading pleasure:

1) Pig-Borne ST-398 S. aureus infection (France) - Clin Infect Dis

2) FDA and the 29-million pounds of livestock antibiotics - Maryn McKenna Superbug blog

3) First 2 cases of NDM-1 in S. Korea

4) Clinical outcomes in HAIs and antibiotic resistance in European ICUs (Lancet ID)

Woo woo! Senate passes FDA Food Safety Modernization Act

Thanks Senator Harkin

Not too much to say, that I haven't said before. Today the Senate passed the FSMA bill 73-25-2. This bill was actually introduced in March 2009 and would cover 80% of the food supply excluding meats. This seems like a nice example of bipartisanship. The NY Times mentioned that Republican and Democratic Senate staffers met for the first time in ages and 'broke bread' with Starbursts and jelly beans. Let's hope this gets out of committee in time or is simply passed by the House as is. Would be sad to see this die when the clock runs out.

Final quote: “This legislation means that parents who tell their kids to eat their spinach can be assured that it won’t make them sick,” - Senator Tom Harkin (D-Iowa)  Of course, anyone who needs to figure out how to get their kids to EAT their spinach, should check out my friends Laura and Jennifer's book from the American Academy of Pediatrics: Food Fights: Winning the Nutritional Challenges of Parenthood Armed with Insight, Humor, and a Bottle of Ketchup

NY Times article 11/30/2010

Listeria: Safety-based date labels, cheese and the FDA

As I've written before, I spent several years on the USDA's National Advisory Committee on Microbiological Criteria For Foods (NACMCF).  We spent several years writing scientific briefs on a variety of topics. During 2002-2004, I worked on a subcommittee looking at "Criteria for Refrigerated Shelf-life Based on Safety."  For someone who didn't spend 100% of my time on food-safety issues, I was initially surprised that the dates on foods were not at all related to safety.  Dates on that yogurt you are about to eat are based on palatability, FYI.

The document we produced and then published in 2005 in the Journal of Food Protection was predominately a Listeria control document even though we considered four psychrotrophic pathogens: L. monocytogenes, nonproteolytic C. botulinum, Y. enterocolitica, and B. cereus. The hope was that a safety-date on refrigerated foods, when combined with education about proper storage and handling of these foods, could reduce the health risk in the very young, very old, immunocompromised and pregnant women, who are at increased risk for miscarriages and stillbirths after Listeria infection.  Of course, any safety-based date label would have little impact if the food is highly contaminated during production. 

One thing I noticed serving on NACMCF was the hard work and honest efforts of the others on the committee. Even though some members worked for industry, some worked for the government and some had worked for both, they all tried hard to produce a good document. There was no evidence of some conspiracy to harm the public.  Outbreaks of foodborne illness are bad for everybody. Producers looked to government to set standards and then helped determine the best ways to meet those standards.

With that background, I was shocked to read recently in the NY Times about an artisanal cheese producer from Washington state who was defying a recall order from the FDA. Her cheeses were found to be contaminated with Listeria.  She and others are claiming that the FDA is going after the little producers - a David vs Goliath story.  Senators and others are rallying to modify the food safety bill in the Senate that I blogged about last week, in an effort to exempt these types of small producers.  They suggest that the real risk is in the big producers since they make the most foods, but I think they are making a very poor decision.  If you had the choice to buy cheese that was subject to regulation and unlikely to be contaminated or some cheese that wasn't tested for safety, which would you buy?  I agree with William Marler, a Seattle food safety lawyer, who said he just doesn't "know how they make the leap from the government trying to do the right thing for public health to ‘they’re food Nazis in the pocket of big agribusiness.’ ”

What if we had that situation in HAI prevention? What if big hospitals had to publicly report CLABSIs and follow Joint Commission standards and small hospitals got a free pass? Wouldn't that be the quickest path for bankruptcy for small hospitals? It would be hard to imagine small hospitals claiming that they only take care of a few patients so a few excess deaths don't matter, but that is exactly what the small food producers are claiming in the NY Times article.

Falsum in uno, falsum in omnibus
It seems that we currently live under a logical fallacy, where the government is evil and people claim that the government is bad at everything. Sure, government has its faults and could improve its efficiency, but when we get to a point where we are saying that small food producers shouldn't have to be regulated and thus produce safe food, we have gone too far. I would love to support local producers and serve fresh produce in my home, but I won't do it if they get a free pass on safety.  I hope they can work out a compromise where the FDA and small producers can work together.

NY Times article: Small Cheesemaker Defies F.D.A. Over Recall - November 19, 2010

Food Safety Modernization Act

Senator Durbin (D IL)

Not hospital infection prevention, but still infection prevention.  I won't go into too much detail, but the Senate may "pass" the FSMA - S. 510 tonight - this would change how the FDA regulates what it regulates, which is to say, not all foods.  You can read Michael Pollen's take on the bill here.  From what I gather, this won't impact USDA, CDC, and NOAA's NMFS etc.  Will be interesting to see what happens and also how the 'spinmeisters' treat this.  There has been surprisingly little mentioned about this given how important food safety is.

Cowboy hats always win? FDA nudges towards limiting antibiotics in animal feed

According to an article in today's NY Times, the FDA has just released a new policy limiting agricultural antibiotic uses to settings protecting animal health, and stating that veterinarians should be involved in the drugs’ uses. Various estimates suggest that between 13% and 70% of total antibiotic use occurs in agricultural settings solely to promote animal growth. These new changes may reduce slightly the amount of penicillins and tetracyclines used in animals. However, it is not clear that limiting "old" antibiotics such as these will have a large impact on MDR-bacteria in humans since it represents marginal use of antibiotics with resistance genes/mechanisms already circulating.

This quote from the article seems accurate: "In the battle between public health and agriculture, the guys with the cowboy hats generally win."

NY Times article (here)

Program Alert: Food, Inc. on PBS Wed 4/21

Last year, Mike recommended the movie Food, Inc. I just received an email from Barb Kowalcyk, a friend and one of the stars of the documentary, announcing that it will be on your local PBS station this Wednesday, April 21. Barb and I worked together for years on the USDA Food Safety Inspection Service's National Advisory Committee on Microbiological Criteria for Foods (NACMCF). She is the co-founder of the non-profit, Center for Foodborne Illness Research & Prevention (CFI). Her story and her son Kevin's story are featured in the movie.

Kikuchi Disease Causative Agent?

I know this is a stretch beyond infection prevention, but I am fascinated by diseases with unknown causes and perhaps biased to think many have infectious etiologies. I spent 6 years on the USDA's National Advisory Committee on Microbiological Criteria for Foods (NACMCF). During the last several years on the Committee I was on a subcommittee charged with the "Assessment of the Food Safety Importance of Mycobacterium avium subspecies paratuberculosis (MAP)." MAP is associated with Johne's Disease in livestock and we looked at whether MAP could be transmitted to humans via food and what methods are available to eliminate MAP from the food supply. We were not specifically charged with looking at MAP as a human pathogen, although Johne's in cattle is clinically similar to inflammatory bowel disease in humans. In fact MAP has been linked to Crohn's disease in humans. So I guess this post is turning into an infection prevention one, just not hospital infection prevention...

Anyway, Kikuchi disease is a rare disease with clinical features of diffuse lymphadenopathy and fever and 4:1 female predominance. It is often confused with lymphoma. The etiology is unknown but has been linked to EBV, HHV-6, HHV-8, Yersinia and toxoplasma. In a new case report in Pediatrics, authors in the UK discuss a case in a 15-year old boy associated with Pasteurella multocida bacteremia. I found it fascinating. The patient did well on antibiotics, especially considering that P. multocida bacteremia carries a 30% mortality rate.

cfr-mediated, linezolid-resistant MRSA outbreak

Investigators from Madrid report in CID a 15-patient outbreak during April to June 2008 caused by linezolid-resistant MRSA. As if the outbreak wasn't scary enough, they report that it's mediated through a new mechanism, the cfr gene. Since linezolid is a synthetic antibiotic with no analog in nature, linezolid resistance was thought to be rare and only result when a point mutation occurred at the drug target site. These investigators report that all strains in this outbreak lacked the point mutation but rather each had the cfr gene.

The cfr gene is naturally occurring in bovine staphylococci and mediates resistance to chloramphenicol, florfenicol and clindamycin. It has also been found in porcine isolates. In animals the gene is found on plasmids and is thought to be transferable between staphylococci; there is a suggestion that in human strains, while it is chromosomal it is likely on an integrated plasmid capable of excision/mobilization/transmission to other pathogens and could spread quickly.

It's possible that this type of resistance will be more difficult to control since the gene can hop aboard non-pathogenic species that we don't screen for, like coagulase-negative Staph, evade our detection and spread resistance to otherwise linezolid-sensitive strains, be they MSSA or MRSA. In addition, this type of transmission, of genes not bacteria, may be the Achilles' heal for antimicrobial use in livestock. If you are going to argue that pig strains are different from human strains as a reason to allow antimicrobials in animals, this argument doesn't seem to hold water if it's the genes that spread and lead to resistance. I take that back. It may not be an Achilles heal but rather a Trojan Horse.

Water

After Mike's recent posts on food safety, he asked, "What's next?" As if on cue, the NY Times has a scary front pager on the safety of our water supply. About 20% of U.S. water treatment systems have violated the Safe Drinking Water Act in the last 5 years, but only a fraction were ever fined or punished. One of the more common violations? Elevated bacterial levels.

It's worrying that one of the more developed nations in the world is having trouble supplying safe water to its citizens. The availability of safe potable water is already a global crisis that will only grow more urgent with time.

On a lighter note, learn more about the importance of safe drinking water from General Ripper.

Slimmer faster

As if yesterday's posting on contaminated chickens wasn't bad enough, today the Wall Street Journal reports that Unilever is recalling 10 million cans of Slim-Fast due to potential contamination with Bacillus cereus. What's next?

Carnivores beware!

Consumer Reports has released a study evaluating contamination of store-bought chickens. They tested 382 chickens from 100 grocery stores in 22 states. The results were appalling--62% of the chickens were contaminated with Campylobacter, 14% were contaminated with Salmonella, and 9% were contaminated with both organisms. So if you're gonna eat it, you better cook it well!