Most antibiotics appear safe during pregnancy, study finds

Doctors assume antibiotics to be fairly safe during pregnancy -- and their use is quite common -- but data comparing classes of drugs are scant. Researchers at the Centers for Disease Control and Prevention decided to clarify the safety and the risks.

Using the National Birth Defects Prevention Study, they analyzed data on more than 13,000 women whose babies had birth defects, comparing their antibiotic use before and during pregnancy to that of almost 5,000 women whose babies didn't have birth defects.

Penicillins, erythromycins and cephalosporins didn't raise any red flags. Two cases of birth defects were associated with erythromycins; and penicillins and cephalosporins were associated with one case each.

The researchers wrote: "Determining the causes of birth defects is problematic. A single defect can have multiple causes, or multiple seemingly unrelated defects may have a common cause. This study could not determine the safety of drugs during pregnancy, but the lack of widespread increased risk associated with many classes of antibacterials used during pregnancy should be reassuring."

But sulfonamides, among the older antibiotics, and nitrofurantoins, often used to treat urinary tract infections, gave the researchers pause. These drugs were associated with "several" defects, they said.

The new research appears in the Archives of Pediatrics & Adolescent Medicine. Here's the abstract -- and more on pregnancy and birth defects from the CDC.

The data don't indicate cause and effect, but rather -- the researchers stress -- a reason for further inquiry.

They point out that participants might not have recalled exactly when they took the drugs or even the correct name of those drugs. Further, the authors wrote: "Another limitation is that it is not possible to determine whether the birth defect is associated with the antibacterials used or the underlying infection."

As they say, more inquiry is needed.  

-- Tami Dennis

Credit: Los Angeles Times

A prescription for tackling antibiotic resistance

Antibiotics are great for treating bacterial infections such as bronchitis and pneumonia. They are so great that many doctors prescribe them even when infections are caused by viruses, not bacteria.

But the overuse of antibiotics has helped spawn the development of antibiotic-resistant bacteria. One obvious solution is to prescribe fewer antibiotics. But that is easier said than done.

Patients with lower respiratory tract infections caused by bacteria have the same clinical symptoms as patients with lower respiratory tract infections caused by viruses. There are tests that can tell them apart, but it can take days to get the results. Sick patients – and the doctors who treat them – simply don’t want to wait.

Wouldn’t it be great if there were some kind of test that could tell you in a matter of minutes whether your infection was caused by a bacterium or a virus?

There is, according to a study published in Wednesday’s edition of the Journal of the American Medical Assn.

Procalcitonin, or PCT, is a substance that circulates in the blood when a patient is fighting a bacterial infection but is rarely released in response to a viral infection. Hospital laboratories can measure the amount of PCT in a blood sample in about 20 minutes.

A group of Swiss researchers wanted to know whether PCT levels could help them figure out when it was appropriate to prescribe antibiotics for lower respiratory tract infections. They recruited 1,359 patients from six hospitals and randomly assigned them to two groups. One group got antibiotics according to their PCT levels; the other group’s prescriptions were determined the old-fashioned way.

It turned out that patients in the PCT group took fewer antibiotics but were just as likely to get better as patients in the control group. Not only did fewer patients in the PCT group receive antibiotics, but those who did took them for fewer days, the study found.

How big was the difference? Overall, the antibiotic prescription rate was 87.7% in the control group and 75.4% in the PCT group, according to the study. Among patients with community-acquired pneumonia, the difference was 99.1% versus 90.7%; for patients with exacerbated chronic obstructive pulmonary disease, it was 69.9% versus 48.7%; and for patients with acute bronchitis, the difference was 50% versus 23.2%.

When patients took fewer antibiotics, they also had fewer adverse events related to antibiotic use, such as nausea, diarrhea and rash, the study found.

-- Karen Kaplan

Photo: Overuse of antibiotics has led to dangerous bugs like methicillin-resistant Staphylococcus aureus, better known as MRSA. Photo credit: Visuals Unlimited

Some antibiotics can cause double vision

Add one more side effect to the growing list of adverse events associated with the family of antibiotics known as fluoroquinolones: double vision. The powerful drugs are widely used to treat infections, including bacterial or chronic bronchitis, pneumonia, sinusitis, urinary infections and some skin infections. But they have been associated with a wide variety of side effects, including tendinitis (an inflammation of tendons) and tendon rupture, gastrointestinal problems, liver damage, central nervous system problems and skin phototoxicity.  Although most of the side effects have been mild and self-limiting, at least five of the drugs -- gatifloxacin, grepafloxacin, temafloxacin, trovafloxacin and alatrofloxacin -- have been removed from the market because of the problems.

Spurred by sporadic reports of eye problems associated with the drugs, Dr. Frederick W. Fraunfelder and Dr. Frederick T. Fraunfelder, ophthalmologists at the Casey Eye Institute at the Oregon Health and Science University in Portland, compiled all eye-related adverse event reports related to the drugs between 1986 and 2009. They reported in the September issue of the journal Ophthalmology that they found 171 case reports of double vision (diplopia) -- 76 in men, 91 in women and four for which no sex was reported. There were 75 cases linked to ciprofloxacin (Cipro), 9 linked to gatifloxacin (Tequin), 20 to levofloxacin (Levaquin), 16 to moxifloxacin (Avelox), 11 to norfloxacin (Noroxin) and 40 to ofloxacin (Floxin). The number of cases were roughly proportional to the number of prescriptions written for each drug, suggesting that the problem involves the class of drugs rather than a particular product. Although the overall numbers seem small, experts note that perhaps fewer than 10% of such complications are routinely reported to monitoring bodies.

There appeared to be no long-term effects on the eye. In the 53 reported cases in which the antibiotic was withdrawn, vision returned to normal quickly. In five of those cases where the patient was then given the drug again, the problem returned.

There is no clear reason why the problem occurred, the authors said. One good possibility is that the drug affected tendons controlling the eye, interfering with their ability to focus.

-- Thomas H. Maugh II

A strep infection may have felled Mozart, but we have antibiotics

Austrian composer Wolfgang Amadeus Mozart died in 1791 at age 35 -- young by even 18th century standards. Historians have long theorized about the cause of death, attributing it at times to various fevers, poisoning, kidney failure and trichinosis.

Nope, say researchers in Amsterdam, Vienna and London.

They got together, analyzed his symptoms -- including some pretty remarkable swelling -- and the illnesses of the time and decided that the great man died of ... streptococcal infection leading to an acute nephritic syndrome caused by poststreptococcal glomerulonephritis.

In other words, strep.

The article was published in the Annals of Internal Medicine. Here's a Bloomberg News story. And a bit more on glomerulonephritis from Merck.com. (Blood vessel structures in the kidneys become inflamed; the body swells.)

As causes of death go, strep may not seem as exciting as the sometimes-popular theory that a jealous rival offed him. But in 1791, a strep infection was more dangerous than a fellow composer with a complex.

Here are the basics on streptococcal infection, from the Centers for Disease Control and Prevention. And what MedicineNet says of strep throat treatment specifically: "Because of potential significant complications, if strep throat is detected, it must be treated adequately with antibiotics. ... Streptococcus is highly responsive to penicillin and the cephalosporin antibiotics. Penicillin has shown good effectiveness, and it is reliable and cheap."

The first of these, penicillin, was discovered in 1928.

-- Tami Dennis

Scared of antibiotic resistance? Here's how to get more scared

Much news and many public health warnings have stressed in recent years the rising rates of antibiotic-resistant bacteria -- and the fact that science is not coming up with new replacement antibiotics at anywhere near a fast enough clip.

People who want to learn more about the topic can go to two Southland events on Sunday at which UCLA infectious disease specialist Dr. Brad Spellberg will be talking about his book, "Rising Plague,"  which chronicles, among other things, the experiences that he and his colleagues have had treating patients with antibiotic-resistant infections and the issue of the dwindling supply of new drugs.

In Hollywood:

11 a.m. Sunday
Center for Inquiry, Los Angeles
4773 Hollywood Blvd., Los Angeles

In Costa Mesa:

4:30 p.m. Sunday
Costa Mesa Neighborhood Center
1845 Park St., Costa Mesa

The drug-resistance story is a frightening one, though it's not new. Shortly after WWII, penicillin broke onto the medical scene as a miracle drug that could drag sick patients out of the jaws of death. It didn't take many years for the first cases of penicillin-resistant Staphylococcus aureus bacteria to show up. Even Alexander Fleming (who discovered the drug after noticing bacteria didn't grow near a mold that had contaminated a petri dish) noted this happening, according this account. In his 1945 Nobel speech he said: "It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body."

When penicillin started to fail, other drugs replaced it, many garnered from molds or by chemically altering already known drugs gleaned from natural sources. 

This time, though, we're running out of drugs.

Take a peek at Spellberg's book, to be published in September. Its full name is "Rising Plague: The Global Threat from Deadly Bacteria and our Dwindling Arsenal to Fight Them."

Read more about the problem at the website for the Infectious Diseases Society of America, in a 2004 report "Bad Bugs, No Drugs."

-- Rosie Mestel

Photo: Visuals Unlimited

Start looking for another way to treat those pimples

Our love affair with antibiotics just keeps taking its toll.

A recent MSNBC piece, "Super acne? Drug-resistant zits on the rise," quotes several dermatologists as saying that Propionibacterium acnes is not as easily cowed by the drugs tetracycline and erythromycin as it once was.

The story states: "As antibiotic-resistant acne becomes a growing concern, dermatologists are moving away from using antibiotics as a primary weapon against acne, fearing that the long-held go-to treatments may be contributing to communal antibiotic resistance. If they do prescribe antibiotics, it may be for only a limited time, usually a few months, and it's often combined with another medication that can lessen the drug resistance. Previously, patients might have continued on antibiotics for years."

The piece goes on to point out that the bigger, more serious issue is one of antibiotic resistance in general.

Here's an earlier warning from WebMD: "Drug-resistant acne: All in the family; antibiotic-resistant acne germ can spread within families."

Another one from NPR: "Doubts raised over antibiotic use for acne."

And still an earlier one from the British Journal of Dermatology: "Antibiotic-resistant acne: lessons from Europe."

-- Tami Dennis

Photo: Take care of your skin. Antibiotics may become less useful in that respect. Credit: Al Seib / Los Angeles Times

Antibiotic-resistant salmonella? Not this time

There was one lucky break in the ongoing salmonella outbreak that has so far led to 637 confirmed illnesses in 44 states and may be linked to nine deaths:

The strain of salmonella involved responds to antibiotics.

Like the nasty bugs highlighted in a story in today's paper, salmonella belongs to a large category of bacteria called "gram-negative," referring to how they respond to a lab test called a Gram stain. These bacteria are especially hard to fight because they are wrapped in a double membrane and harbor enzymes that chew up many antibiotics.

Already somewhat resistant to antibiotics naturally, some of these microbes -- including Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii -- have mutated to become resistant to almost every known treatment.

Salmonella infections usually resolve in five to seven days without antibiotics. Often they require little treatment besides liquids to replace fluids lost in diarrhea. Severe cases may require intravenous fluids.

In the rare cases in which salmonella infections spread beyond the intestines, however, antibiotics are necessary. And some salmonella strains have become resistant, according to the national Centers for Disease Control and Prevention.

Four years ago, the Infectious Diseases Society of America sounded the alarm about the dearth of new wonder drugs to treat antibiotic superbugs. The report called on Congress to provide incentives to drug companies, who find it more profitable instead to focus on therapies for high cholesterol and other chronic conditions.

Fortunately -- if anything that involves so many illnesses can be called fortunate -- there are still antibiotics that work to treat the strain of Salmonella Typhimurium involved in the ongoing outbreak, should drugs be needed. If that were not the case, public health officials say, the outbreak could be even worse than it is.

-- Mary Engel

Photo credit: AP / The Indianapolis Star, Michelle Pemberton

A new MRSA threat: children's ear, nose and neck infections

The community strain of methicillin-resistant Staphylococcus aureus behind an explosion in nasty skin infections across the country is now causing ear and sinus infections and neck abscesses in children nationwide, a new study has found.

Of 21,000 pediatric staphylococcus infections from 2001 to 2006, 22% were the aggressive community MRSA strain known to scientists as USA300.

Moreover, the six-year review of data from more than 300 hospitals revealed an "alarming nationwide increase" in these infections, from just under 12% of in 2001 to 28% in 2006, according to the study published Monday in Archives of Otolaryngology -- Head and Neck Surgery. 

"Because of the proximity of the head and neck to important areas like the brain, the eyes and the chest, [these infections] need to be taken very seriously and treated aggressively," said Dr. Steven E. Sobol, a pediatric otolaryngologist at Emory University School of Medicine and one of the authors of the study.

As with the skin infections, some children seem to be more at risk than others for the ear, nose and neck infections. Living in crowded conditions, often because of poverty, is one risk factor. (Skin infections also have plagued football teams, wrestlers, gym rats and others who engage in sweaty, skin-contact sports.)

But Sobol said that he has seen ear, sinus and neck infections caused by USA300 in children who didn't appear to live in crowded conditions or have other risk factors.

The average patient infected was between 6 and 7 years old, an age at which immune systems aren't fully developed and children tend to catch infections easily, he added.

Infectious disease experts say that the increase in USA300-caused infections is not surprising. About one in three of us harbor staph on our skin or in our noses as part of our normal bacterial flora. Since the USA300 strain first appeared in the 1990s, it has been spreading across the nation and the world, pushing out other strains to become the dominant one.

Which is not to say that the spread isn't alarming. As long as staph stays where it's supposed to stay --on the outside -- it does little harm. But when it becomes invasive, slipping into a part of the body where it shouldn't be, any strain can cause severe infections of bones, joints, blood and lungs. And USA300 is particularly virulent, or capable of causing disease.

Sobol and co-authors Dr. Iman Naseri of Emory and Dr. Robert C. Jerris of Children's Healthcare of Atlanta at Egleston are completing a series of studies that look at how children who contracted these infections fared, how the germs spread and what makes USA300 infections so severe.

Sobol stressed in a phone conversation that parents shouldn't panic, but they and their pediatricians should be aware of the seriousness of these infections. For prevention, he recommended hand washing and avoiding overuse of antibiotics, which can both encourage further resistance and create a niche for bad bugs by destroying other ones.

-- Mary Engel

Cipro joins the 'black box' club

The club may not be as elite as it once was -- or perhaps, in an ideal world, should be -- but the Food and Drug Administration has decided Cipro and its ilk deserve to be members.

As such, the class of antibiotics known as fluoroquinolones will now bear a boxed warning, also known as a "black box," because of reports that the drugs increase the risk of tendinitis and tendon rupture. The FDA has told the manufacturers that the label, the agency's most serious warning, is necessary to ensure that the drugs' benefits outweigh the risks. Always a good thing. It's also told them, while they're at it, to throw in a medication guide to inform patients of potential side effects.

Most people may remember the drugs from their heady days as simply-must-have protection against a potential anthrax attack. But we've all grown older and wiser and less panicked and are now more worried about simply being able to move about the house without hurting something. Says the FDA's release: "The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in people older than 60, in those taking corticosteroid drugs, and in kidney, heart and lung transplant recipients."

The prescribing information already includes warnings about the potential problem, but sifting through that material isn't easy even for professionals. They're busy, you understand. And besides, there's just something about that black box label that tends to give prescribers -- and prescribees -- pause.

If you've had problems with the drugs (or any drugs), you can offer your two cents at MedWatch, a more user-friendly way of referring to the FDA Safety Information and Adverse Event Reporting Program.  Otherwise, how will anyone know?

For an easy-to-read list of other drugs with black box warnings, go to FormWeb. The information is easier to find than on the government site.

-- Tami Dennis

Photo: When anthrax was discovered at a New York mail processing facility in 2001, workers there were given Cipro as a precautionary measure. Other Americans soon wanted it too.

Credit: Gary Friedman / Los Angeles Times