Updates

Nubian Beer: An Ancient Health Tonic?

By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates Section Editor, HIV, is Associate Editor for Infectious Disease Alert

Roach J. National Geographic News

Varying levels of the antibiotic tetracycline found in Nubian bones from around the 4th century prompted a lengthy search for the source. Researchers at Emory University in Atlanta discovered that the answer may lie in ancient Nubian beer.

Nubia was an ancient kingdom along the Nile River just south of Egypt. Present day Nubia is an arid desert, part of the South Arab Republic and the Sudan, just north of Khartoum. Age-old Nubian bones dating from 350 to 550 A.D., dug up in the Sudan, have been found to contain tetracycline. The antibiotic has been found in more than 90% of Nubian bones, including bones from a 2-year-old child.

It turns out that Nubian beer, which was more like a mushy fermented cereal, was a popular drink. It was brewed from grains, which were stored in bins in mud. The grain became contaminated with a soil bacterium called Streptomycedes, which is ubiquitous in the arid climate of the Sudan. Streptomycedes produces tetracycline. Hence, in addition to providing calories, vitamins, and a slight buzz, the beer was essentially a daily antibiotic tonic.

The health benefits of beer have been touted for centuries. But ancient Egyptian texts suggest using beer as a treatment for all kinds of health conditions, including gum disease, wound dressings, and for afflictions of the anus, possibly because of the antimicrobial effect. Researchers indicated that Nubian bones are quite strong and healthy for people of that time period. Not stated was whether Nubians at that time were taller or heavier than their African counterparts.

CA-MRSA—Beyond Emerging

ProMED-mail post, May 24, 2005; www.promedmail.org

An expert in staphylococcal infections, Dr. Mark Enright, at Bath University in England, has publicly urged the British government to step up measures to combat the emergence of methicillin-resistant Staphylococcal aureus (MRSA) and other resistant bacterial organisms. The statement was made following the death of a healthy 18-year-old Royal Marine trainee who was scratched on his leg with brambles during a training session and, subsequently, died of staph infection. The report states that traces of the leukocidin commonly found in MRSA, Panton-Valentine Leukocidin (PVL), were found in his system, consistent with a toxin-producing strain of S. aureus.

Community-acquired strains of MRSA (CA-MRSA) almost uniformly carry a large, mobile cassette of genes (SCCmec IV), which produce various leukocidins, most notably PVL, as well as hemolysins, enterotoxin, toxic shock toxin, and other toxins. As such, these organisms are like soft tissue liquifiers, with a predilection for causing folliculitis, furunculosis, and soft tissue abscesses, which may require incision and drainage, parenterally administered antibiotics, and hospitalization. While these organisms seldom result in more serious, invasive infections in healthy individuals, the lost time at school or work, and the resulting scars, leave an indelible impression.

Dr. Enright’s cautionary message may be too late. While physicians have been waiting for newer Infection Control guidelines for control of MRSA in hospitals, community-acquired strains of MRSA (CA-MRSA) have already established a bulkhead in our community, and are presenting a challenge for hospitals, where they outnumber cases of nosocomial MRSA. CA-MRSA has extended well beyond the gay community, sport teams, and jails, and is now affecting ordinary, healthy school aged children and young adults, with no apparent risk factors or known exposure. About 30% of outpatient specimens of S. aureus at Santa Clara Valley Medical Center in San Jose are now MRSA, and at least 50% of pediatric cases hospitalized with staph infection are MRSA. I’m getting multiple phone calls weekly from pediatricians and primary care doctors who are stunned at the rapid pace of some of these infections, their recalcitrant nature, and frequent rate of recurrence, wondering what to do. Should patients be decolonized, especially those with recurrent infection? Should family members be screened? And, how many people can you reasonably screen and treat? (Never mind that some potential contacts have differing insurance plans, making it difficult to directly intervene or supervise their care).

In the hospital setting, it seems that surveillance should be stepped up, with improved identification of colonized cases at entry to hospital (it is estimated that 70-90% of cases are not recognized), with prompt isolation of suspected cases, even in advance of identification of the organism. Strict contact isolation precautions should be adhered to, and attempts to improve hand washing are vital. Pre-operative screening of elective surgical cases should be considered, especially cardiac cases and those requiring hardware (eg, valves, hips, spine stabilization cases).

However, short of trying to decolonize the world, the cat may be already out of the bag with regard to the spread of CA-MRSA in the community, unless we act now. This will require a concerted effort on the part of the public health service and community physicians, enhanced surveillance and reporting, more research into the acquisition, pathogenesis and optimal management of this infection, and lots more designated public health dollars.

MRSA: Not Just a Human Pathogen

Weese JS, et al. Methicillin-Rresistant Staphylococcus aureus in Horses and Horse Personnel. Emerg Infect Dis. 2005;11:430-435.

Mrsa may not be just an emerging human infection—check out your family pet, or even the family horse (see Kemper C. IDA, January 2005). Prompted by the occurrence of MRSA infection in 2 horses hospitalized at the Ontario Veterinary College Veterinary Teaching Hospital (OVC-VTH) in 2000, these investigators performed a cross-sectional analysis of the prevalence of MRSA in horses and horse personnel from 2000 to 2002. The Large Animal Clinic at OVC, which is a tertiary referral center, sees ~2000 horses per year, many of which are inpatients with prolonged stays. The personnel caring for these horses vary from senior clinicians, surgeons, and specialists to assistants and students.

Nasal swab specimens for culture were obtained from a convenience sample of horses at OVC before, during, and at the end of hospitalization, and from a select group of breeding farms in Ontario. The prevalence of MRSA colonization varied in the horses at OVC from 4-8%, and from 0-13% at the farms. A total of 79 equine cases were identified, including 27 (34%) horses hospitalized at OVC, 41 (52%) at one thoroughbred farm, and 11 (14%) at other farms. While the majority of horses had nares colonization, 13 (16%) had clinical infection at one or more sites, including line sepsis, septic arthritis, bacteremia (often a consequence of indwelling central lines), abscesses, and osteomyelitis. One horse died as a complication of MRSA infection. Ten of the 13% of infected horses had a history of contact with colonized personnel or other colonized/infected horses.

Twenty-seven horse personnel were colonized with MRSA. About two-thirds of these worked at OVC, and the remainder worked at the thoroughbred farm. One veterinarian had infection at a tattoo site; the same strain was isolated from 2 horses under the care of that individual about one week earlier.

More than 90% of the isolates possessed SCCmec IV genes, commonly associated with CA-MRSA strains, although they did not produce PVL. All of these Canadian isolates were sensitive to clindamycin and quinolones, as well as vancomycin, synercid, and linezolid, but they were frequently resistant to tetracycline (96%), erythromycin (86%), trimethroprim-sulfamethoxazole (79%), and rifampin (71%). (These results are quite different from those CA-MRSA isolates we’re seeing in California, which are frequently resistant to quinolones, but susceptible to rifampin and trimethoprin-sulfamethoxazole).

MRSA may be an emerging infection in veterinary care centers, where MRSA appears to be readily transmitted between horses and horse personnel.

Pelifermin for Mucositis Approved

Medical Letter April 25, 2005

Palifermin (Kepivance, Amgen) has been approved by the FDA for the prevention of oral mucositis in patients with hematologic cancers receiving myelotoxic chemotherapy or stem cell transplantion. Palifermin is a unique recombinant human keratinocyte growth factor, which significantly reduced the risk of oral mucositis, as well as the duration and severity of disease in 2 randomized, placebo-controlled clinical trials. In an assessment of 212 patients randomized to receive palifermin vs placebo, the incidence of grade 4 mucositis was reduced from 62% to 20%, and the median duration of severe mucositis was reduced from 9 to 6 days. Drug is parenterally administered 3 days before and 3 days following chemotherapy.