Wednesday, 27 February 2019

The symptoms and dangers of untreated sleep

In September 2016, a woman in her 70s died of septic shock in Reno, Nevada, from an infection which was fully resistant to 26 different antibiotics. She had spent much of the previous two years in India, where she was treated for a hip fracture. The hip became infected, and after several more hospital stays, she returned to her home in Nevada.

Within weeks, she was desperately ill, and back in a hospital in Reno. A sample from her hip wound revealed a strain of the bacteria Klebsiella pneumoniae which was not sensitive to any antibiotics. It was even resistant to a drug called colistin, an old-fashioned, somewhat toxic, and rarely used antibiotic that is considered the last line of defense against antibiotic-resistant bacteria. Before she died, the patient was isolated and kept in a private room. There is no indication that her resistant bacteria had spread to other patients in the hospital or in the Reno area.
How these bacteria outsmart antibiotics

The Klebsiella bacteria that killed her had a powerful enzyme that breaks down antibiotics, known as New Dehli metallo-beta-lactamase (NDM), because it was first found in a patient who had travelled to that Indian city. Indian politicians have disputed the link between their capital and a deadly superbug, and the local tourism board and chamber of commerce probably aren’t too thrilled about it either. In any case, it is probably unfair to focus too much on the Indian origin of this resistant bacteria. Klebsiella bacteria with a slightly different, but equally fearsome form of antibiotic resistance known as KPC have already become entrenched in the United States, as well as in Brazil, China, Israel, Colombia, and Italy.

The vast majority of cases of resistant Klebsiella infection in the United States involve patients who have been hospitalized. But alarmingly, highly resistant bacteria have started to percolate down into the community. A recent outbreak of NDM-positive Klebsiella in Colorado involved patients without health care exposures. A woman in Pennsylvania presented to a clinic in May 2016 with a urinary tract infection with bacteria resistant to colistin, which she had probably picked up during a recent hospital stay.
Is it the end of antibiotics as we know them?

Hand-wringing about antibiotic resistance has been around almost as long as antibiotics. Newsweek somewhat prematurely proclaimed “The End of Antibiotics” in 1994, and the New England Journal of Medicine bewailed the rising tide of antibiotic resistance as early as 1960. All the way back in 1945, scientists had discovered it was relatively easy to create antibiotic-resistant bacteria by exposing them to very small amounts of antibiotics, and then gradually increasing their degree of antibiotic exposure. In retrospect, this shouldn’t be so surprising. Penicillin and cephalosporin antibiotics are derived from molds, which used these compounds for millennia to suppress competition from bacteria. So bacteria, in turn, have developed ways to neutralize and break down antibiotics. Overuse of antibiotics has favored the spread of bacteria carrying these resistance mechanisms.

Another sobering development is that the antibiotic pipeline is drying up, with dim prospects of new drugs coming along to replace the old ones that are losing potency. The economics of antibiotic discovery are bad. Many pharmaceutical corporations have gotten out of the business of developing new antibiotics altogether. The cost of bringing new drugs to market can ratchet up into the billions. The anticipated payoffs are small, as infectious diseases practitioners only use new and powerful antibiotics when absolutely necessary, in an effort to have them retain their effectiveness for as long as possible.
Here’s what you can do

You can take a number of steps as a patient, a consumer, and a citizen to help keep the flood waters of antibiotic resistance from breaking through the levee.

Don’t press your doctor to prescribe antibiotics if they believe it is unnecessary. Taking antibiotics increases your risk of acquiring drug-resistant bacteria, kills off your beneficial gut bacteria, known as your “microbiome,” and exposes you to the potentially deadly bowel infection, Clostridium difficile colitis.

About 80% of the antibiotic use in the United States is in agriculture, not medicine. In particular, low doses of antibiotics are added to livestock feed in factory farms to prevent infections and promote growth. This constant, low-level antibiotic exposure is an excellent way to create drug-resistant bacteria. At least some of these bacteria probably work their way up the food chain to affect humans. You can support the responsible use of antibiotics in agriculture by only purchasing meat raised without antibiotics. And consider calling your congressperson to ask their support for greater public funding for new antibiotic discovery.

And while this sounds bleak, there are other things you can do as a consumer and as a patient to help. You can start by paying attention to the food you eat and by not pressing your doctor for unnecessary antibiotics. “Doesn’t it typically happen during the summer?” asked a worried lady that had walked into my clinic in November with a growing circular rash on her wrist. She was referring, of course, to Lyme disease, that scourge of outdoor enthusiasts. While the peak season for Lyme disease is indeed summer, the ticks that transmit it are active March through December. And, while this may be off-season for the ticks, it is a good time to catch up on how to stay safe in the not-so-distant spring.
What is Lyme disease, and how do you treat it?

Lyme disease is caused by a bacterium called Borrelia burgdorferi which is spread to people through the bite of infected black-legged ticks, also popularly known as “deer ticks.” Early symptoms include a typical enlarging red rash (“bullseye rash”) at the site of the tick bite. This is common, but not everyone with Lyme disease gets this rash. Other signs of Lyme include flu-like symptoms (fever, fatigue, and headache). If left untreated, over time the infection can lead to Bell’s palsy (paralysis or weakness of facial muscles on one side), meningitis (inflammation in the brain and spinal cord), heart rhythm problems, and joint pain and swelling. Additional symptoms can include headaches and stiff neck, tingling and numbness (often in the hands and feet), and rarely, inflammation of the eyes.

The diagnosis is usually based on a person’s symptoms, the presence of the typical rash, and a history of likely exposure to infected ticks. Lab tests for Lyme disease do not turn positive until three to four weeks after the infection. Usually doctors do not wait for the results of these tests during the early stage of the disease, to begin treatment.

Once diagnosed, Lyme disease can be successfully treated with a few weeks of oral antibiotics. Doxycycline is the antibiotic prescribed to all but pregnant women and children, who usually get the antibiotics amoxicillin or cefuroxime. For people with severe heart or neurological symptoms of Lyme, intravenous antibiotics are usually necessary.
Here’s what you can do to keep from getting Lyme disease

As always, prevention is superior to cure. Right now, there is no Lyme vaccine available for people. There is a Lyme vaccine available for dogs! However, it does not protect against other tick-borne diseases, hence preventive measures against ticks are still necessary. Most dogs exposed to Lyme disease do not have symptoms. Some develop fever, lack of appetite, lameness, and joint swelling. Therefore, staying safe requires preparation and vigilance. The ticks that transmit Lyme disease are tiny, and you can’t feel it when a tick attaches to you. They may even make their way into your home by attaching themselves to pets. Here are some steps to follow to remain safe.

    Avoid wooded and bushy areas with tall grass and stick to the center of trails when hiking.
    Wear light clothing to make ticks easier to detect.
    Wear long pants tucked into socks to keep ticks on the outside of clothes.
    Use DEET or a permethrin-based tick repellent on clothing and outdoor gear.
    Pesticides like permethrin, fipronil, or amitraz may be used on dogs. These are available in the form of powders, impregnated collars, sprays, or topical treatments.
    Do remember to never use tick repellents that are intended for dogs on a cat! Cats are extremely sensitive to a variety of chemicals.
    When back home, shower or bathe as soon as possible and carefully inspect the entire body to remove any attached ticks. It takes up to 36 hours for the bacterium to be transferred after the tick bite. Prompt removal of the tick will reduce the chance of infection.
    Tumble dry clothes on high heat for at least 10 minutes to kill ticks.
    Carefully examine children and pets after outdoor activity.

 If you find a tick along for the ride, here’s what you need to do

Use thin tipped tweezers to grasp the tick as close to the skin surface as possible. Pull the tick straight upward with steady even pressure to remove the tick with the mouthparts intact. Squeezing the tick will not increase the risk of infection. Adult ticks are a lot more difficult to remove intact. If the mouthparts break off, the chance of getting Lyme disease is the same as if you hadn’t removed the tick at all. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. Watch for signs and symptoms of Lyme disease for up to 30 days.

See your doctor within 72 hours of the tick removal and if the tick removed was swollen. You may benefit from preventive antibiotics. This is especially important if you live in (or have visited) an area where deer ticks are common.
Create a tick-free zone around your home

Need a little more motivation to mow the lawn or rake the yard? Remember that ticks lurk in tall grasses, brush, and weeds around homes and at the edge of lawns. Remove any old furniture, trash, or mattresses from the yard that may give the ticks a place to hide. Place a three-foot-wide barrier of wood chips or gravel between lawns and wooded areas and around patios and play equipment to restrict tick migration into recreational areas. Stack wood neatly in a dry area (this discourages rodents that carry the ticks). Keep playground equipment, decks, and patios away from yard edges and trees, and place them in a sunny location if possible.

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