Experts Weigh In On Continued Rise Of MRSA

   Methicillin resistant Staph aureus (MRSA) infections are on the rise around the world as infections pass between hospitals and the community. The infections are not only associated with morbidity and mortality but also pose a high financial cost to patients and the healthcare profession, according to experts. What is causing the rise in antibiotic resistance and what steps should DPMs take to prevent and combat infection?    The incidence of MRSA infection has increased 40 percent in five years and one-third of pneumonia among patients on ventilators is caused by MRSA, noted Richard Wunderink, MD, during a recent conference call on the subject. He notes the infection is common in hospitals as it can be spread between patients on the hands of caregivers. Dr. Wunderink says it can also be carried over into the community, partially due to the increasing treatment of outpatients.     “As the frequency in the hospitals increase, the spillover into the community becomes much more common,” says Dr. Wunderink, who practices pulmonology and critical care medicine at Northwestern Memorial Hospital in Chicago.    There are many costs resulting from antibiotic resistance since patients with resistance have longer hospital stays, according to Michael Niederman, MD, Chairman of the Department of Medicine at Winthrop University Hospital in Mineola, N.Y. He says MRSA also leads to higher costs for patients because hospital staff tends not to see infected patients as often as others. Dr. Niederman notes the efficacy of some drugs such as vancomycin and linezolid.    One recent study presented at the annual meeting of the Infectious Diseases Society of America (IDSA) found that linezolid had a higher cure rate and was more cost-effective than vancomycin in treating MRSA. According to the study of over 700 patients who were admitted to the hospital for proven or suspected MRSA, the average total cost for patients treated with linezolid was $4,187 whereas the average cost for patients treated with vancomycin was $5,058.    Dr. Niederman acknowledges some new drugs are in development but says their effectiveness remains to be seen.     “The patients we treat today are sicker than ever before. Antibiotic resistance is going to be here for a long time to come,” says Dr. Niederman.

Is The Main Cause Overuse Of Antibiotics?

   Warren Joseph, DPM, says part of the reason for the increased MRSA prevalence is the “incredible overuse” of antibiotics both inside and outside of hospitals. Many patients who present to doctors with minor ailments will receive prescriptions for antibiotics, and many of these are broad-spectrum drugs that may potentiate the development of resistant gram-positive organisms, according to Dr. Joseph, a Fellow of the Infectious Diseases Society of America. He adds that some patients also hang on to leftover antibiotics and take them when they think the drugs will help. Dr. Joseph points out that other patients may stop taking antibiotics too soon after viral symptoms decrease.    Patients also receive unnecessary antibiotics in hospitals, notes Dr. Joseph. He adds that lapses in infection control procedures, procedures sometimes as basic as doctors washing their hands in between patients, can contribute to the increased incidence of infection as well. However, Dr. Joseph points out that most strains of MRSA found in hospitals were actually community-acquired strains as opposed to nosocomial strains.    David G. Armstrong, DPM, MSc, PhD, concurs that inappropriate use of antibiotics among humans contributes to the increase in MRSA infections but also links the phenomenon to the natural evolution of microbes and a “dramatic increase” in utilizing antibiotics as promoters of growth in the livestock industry.

What Steps Can DPMs Take To Combat MRSA?

   Therefore, podiatrists should be aware of the potential for overusing antibiotics, cautions Dr. Joseph, an Attending Podiatrist at the Coatesville Veterans Affairs Medical Center in Coatesville, Pa. For example, he explains patients with diabetic foot ulcers do not require antibiotics unless they have clinically infected ulcers. This is one of the points made in the new IDSA guidelines on diagnosing and treating diabetic foot infections, which were recently published in Clinical Infectious Diseases and co-authored by Dr. Joseph. He also recalls the first two cases of vancomycin resistant Staph aureus (VRSA) occurred in diabetic foot wounds.    Dr. Armstrong, a Professor of Surgery, Chair of Research and Assistant Dean at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University Of Medicine, echoes the importance of choosing appropriate antibiotics. When podiatrists are prescribing antibiotics, Dr. Armstrong says they should ask themselves whether they are treating the patients or treating themselves. Dr. Armstrong, a member of the National Board of Directors of the American Diabetes Association, also advises using agents with as narrow spectrums as possible for the shortest time period possible.    The Centers for Disease Control and Prevention (CDC) advises many of the same precautions in its 12 steps to preventing antimicrobial resistance. When using antimicrobials, the CDC advises healthcare professionals to minimize using broad spectrum antibiotics and monitor antibiotic use. The CDC also recommends that one should: understand how to differentiate between infected wounds and wounds with contamination or colonization; reevaluate the use of empiric therapy after 48 to 72 hours; and avoid treating asymptomatic bacteria. The CDC says practitioners should discontinue antibiotic treatment when cultures are negative, when infection is not likely or when infection has resolved.    Overusing antibiotic prophylaxis in surgery is another cause of MRSA, according to Dr. Joseph, who cites a study by Manian and co-workers in an April 2003 edition of Clinical Infectious Diseases. Dr. Joseph says the study found that using antibiotic prophylaxis for more than 24 hours was associated with a statistically significant increase in the rate of MRSA infections at surgical sites. The CDC also emphasizes that practitioners avoid the use of long-term or chronic prophylaxis.     “When podiatrists used to ask me about how long to continue prophylaxis after surgery, I would tell them no more than 24 to 48 hours. If they told me they used a week, I would shrug it off as ‘treating yourself’ but not affecting the patient,” recalls Dr. Joseph. “I am no longer that cavalier. I feel that it actually may hurt the patient. While I am not saying that avoiding more than 24 to 48 hours of post-op prophylaxis constitutes ‘standard of care,’ it is certainly evidence-based.”

Are Women More Prone To Hallux Valgus Deformities?

By Brian McCurdy, Associate Editor    Differences in the size of women’s foot bones may underlie a higher incidence of hallux valgus deformity in women, according to a recent study in the Journal of the American Podiatric Medical Association.    Using a three-dimensional laser scan, study researchers scanned the talus, naviculars, medial cuneiforms and first metatarsals of 107 skeletons of people who lived between 1685 and 1885. According to the study, linear measurements revealed that male bones were larger than female bones and measurements of articular surfaces suggested more potential movement toward adduction among women. Accordingly, with first metatarsals being more predisposed to adduction among women, the authors say women may be more predisposed to hallux valgus.    In addition to anatomical differences between the sexes, one must also take into account shoegear and other variations, explains Michael Cohen, DPM, a Fellow of the American College of Foot and Ankle Surgeons. Dr. Cohen says women are more likely to complain about hallux valgus deformity than men due to their shoes, which are more confining, and a greater likeliness of being concerned with the appearance of their feet. Neal Blitz, DPM, concurs that women are more likely to seek treatment for hallux valgus.    However, Dr. Cohen cautions against reading too much into the results of the study, specifically the conclusion that facet configurations among women were more compatible with adduction of the ray. He says the authors “did not prove that the configuration did, in fact, cause the deformity itself, or that males with the same anatomical characteristics had or were more likely predisposed to the deformity.     “An initial study investigating the structural differences in both sexes with and without hallux valgus (predetermined) would have better validated this study,” emphasizes Dr. Cohen, Chief of the Podiatry Section and Director of the Podiatric Primary Medicine and Surgical Residency Programs at the Veterans Affairs Medical Center in Miami.    In examining hallux valgus, Dr. Cohen also advocates looking at a number of variables such as: variations in gait, angular and torsional differences in the femur and tibia; ligamentous differences and their responses to hormonal changes; hypermobiltiy as one would see in inflammatory arthritic disease such as rheumatoid arthritis; and musculotendinous differences. He says it is also appropriate to consider external factors such as shoe gear.     “Given that the authors’ conclusions were in fact true, it would be very difficult because of these multiple variables to evaluate just how much of a role the anatomical differences play in the development of hallux valgus,” says Dr. Cohen.

A Closer Look At Trends In Surgical Correction

   In his work with the VA system, Dr. Cohen performs “far more” hallux valgus surgery on men due to a large number of male patients. However, in private practice, Dr. Cohen notes he performs the surgery more frequently on women, most of whom have trouble finding shoes that are fashionable and comfortable.    Females undergo surgical correction of bunions three to four times more often than males, points out Dr. Blitz, an Attending Podiatric Surgeon within the Department of Orthopaedics at Kaiser Permanente Medical Center in Santa Rosa, Ca. He says women’s bunions tend to be more severe and associated with first ray insufficiency (hypermobility) and sub-second metatarsal pathology while men usually present with isolated complaints.     “I suspect the cause of this is both genetic and acquired by shoe gear,” posits Dr. Blitz, a Fellow of the American College of Foot and Ankle Surgeons.

Midwestern University Offers Promising Curriculum And Research Opportunities

By Brian McCurdy, Associate Editor    Among the country’s nine podiatry schools, the new kid on the block is the Midwestern University Arizona Podiatric Medical Program, which opened this fall. Two faculty members say the state-of-the-art technology, as well as the program’s connection to an academic health science center and strong curriculum, set it apart.     “Hopefully, we will be the premier program in the future,” says Denise Freeman, DPM, Associate Director and Professor. “We’re looking to create podiatric physicians that are lifelong learners and problem solvers.”    Dr. Freeman touts the school’s “exceptional” basic science program and says the plethora of research at the Glendale, Ariz.-based school makes it unique. Students receive a “well-rounded education at Midwestern. Early in the curriculum, students are introduced to scientific methodology as well as principles of clinical practice,” says Dr. Freeman. She believes that will prepare students for the school’s five biomechanics courses as well as courses in sports medicine, pediatrics and dermatology. Dr. Freeman says the faculty is working to make the classroom curriculum practical and emphasizes that students will do hands-on work in small groups as opposed to just attending lectures.    Since the school is so new, Dr. Freeman says it is difficult to foresee its impact on the profession but hopes its research will be innovative and have an impact.    The fact that the podiatry program is associated with the larger Midwestern University medicine program “brings resources to DPMs that they may not have in an isolated program,” says Associate Professor Stephen Barrett, DPM. Since the Southwest does not have a podiatry school, he feels Midwestern University’s program and its resources will benefit the podiatry profession once the school becomes more established.    Like Dr. Freeman, Dr. Barrett touts the school’s strong curriculum and research facets. One of his particular research interests is the use of growth factors in the treatment of musculoskeletal disorders, in which there is the possibility of research grants.     “They have virtually anything you would want from a research program,” notes Dr. Barrett.

In Brief

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Clarifications

   In regard to the News and Trends article, “DPMs Mourn Two Podiatric Pioneers,” in the November issue, Justin Wernick, DPM, co-founded Langer Acrylic Laboratory with Sheldon Langer, DPM.    In regard to the August cover story, “Unveiling The Top Ten Innovations,” an earlier version of the Kiddythotic was created by Keith L. Gurnick, DPM, and Arnold S. Ross, DPM, in 1982, and was originally manufactured by Los Angeles Orthotic Lab. It is currently being manufactured and marketed by KLM Orthotic Laboratories. For more information, see www.klm-lab.com.