Fitness and youth are no guarantee of protection when an antibiotic-resistant form of infection takes hold, as two Kiwis recently found.
One night, as Mike lies awake in bed listening to the wild West Coast surf, he becomes aware of an irritating pimple on his knee, which by morning has become sore and the area around it a little angry. Over the next two days it worsens, and his leg stiffens. They are just about to drive to Wanaka to see a doctor when they hear there is a district nurse staying in Haast. She gives Kelly Flucloxacillin, an antibiotic that is active against most staphylococci and almost all streptococci, which are the usual causes of skin infections.
A day later, there’s no improvement. In fact, it’s much worse. The Kellys are getting worried, being so far from help. They decide to end their holiday early and book flights back to Auckland from Queenstown. By the time they get to Queenstown Airport, he can hardly walk.
Back in Auckland, they go immediately to an A&E clinic in Ponsonby. He is prescribed another lot of Flucloxacillin and told to report back if there’s no improvement overnight. His leg continues to throb and swell alarmingly. This time, the doctor sends Kelly straight to Auckland City Hospital, where he is admitted and the infection is cultured. After 48 hours, staff confirm it is a strain of Methicillin-resistant Staphylococcus aureus (MRSA) causing his cellulitis, and give him intravenous Vancomycin, appropriate to treat his particular strain. Kelly is put in a room on his own. In some countries, MRSA infections are commonly spread in hospitals, but in New Zealand, they’re usually spread in the community.
In fact, this country has one of the highest rates of invasive and non-invasive Staphylococcus aureus infections, including MRSA, in the developed world.
After 70 years of being fit and well, Kelly was shocked to find himself in hospital for the first time, and for two weeks. And it was the worst possible timing. It looked as though he wouldn’t make his youngest son’s wedding in London in four weeks’ time. His other three sons and their families were all going, too. It was to be the family occasion of a lifetime.
While Kelly was in hospital, he found out that a family friend, Paul Sullivan (33), was also in hospital, in Rotorua, with a serious MRSA infection. It seemed an amazing coincidence. Sullivan sent Kelly some photos of the crater-like hole in his arm. Kelly was worried when he heard Sullivan had been trying to treat the infection himself. “I was really concerned for him, knowing how quickly it had floored me,” he says.
The story of Sullivan, a law and commerce graduate with an MSc in environmental policy and regulation from the London School of Economics, began just after last Christmas, when he, partner Fliss Winstone and daughter Chloe were on holiday in Queenstown.
“I had a spill on my mountain bike on the Rude Rock Trail on Coronet Peak, but I had only superficial grazes on my elbow and left knee. Nothing major.” Having seen his share of serious illness during a spell working in poor communities in India, he thought little of his injuries.
“They were almost healed when we arrived in the Bay of Islands for some family time and I came into contact with my nieces and nephews and father-in-law, who all had staph infections. Overnight, a blister appeared over the almost-healed knee graze, which gradually came off the next day.
“Over the next few days, the graze became worse, getting redder and more tender. One day at the beach, while in the water, I decided to lightly squeeze the wound and got a squash ball-sized amount of pus out of it. I exposed the wound to the sun and regularly rinsed it in salt water from the sea during the day and put a potato poultice on it overnight. I was sceptical about how successful the potato would be – imagine getting into bed covered in potato – but it did a great job of pulling the infection to the surface, and I saw rapid improvement.”
Despite that, Sullivan decided to get a second opinion, given the severity of the infection. “I went to a doctor in Russell, who swabbed the wound and prescribed antibiotics. Because it was healing so fast, I decided to take them only if things got worse. I like to take a considered approach to antibiotics, given the effect they can have on your gut microbes and the emerging threat of antibiotic resistance to global health and food security. A few days later, the swab came back as positive for MRSA and the doctor called to say the antibiotics he’d prescribed were not right for that.
“Unfortunately, while this infection was healing, a number of other large pimple-like eruptions appeared on my left leg and then my right leg. These hung around for 2-3 weeks.
“At this stage, I was treating all the infections internally and externally. I was taking high doses of vitamin C, echinacea, goldenseal and olive leaf, and eating a healthy diet of organic vegetables, grains and fruit – no dairy or gluten.
“Externally, I was applying mānuka essential oil, propolis and a sesame-based wound-healing product called Mebo. I was also applying the potato poultices to each infection overnight and covering them during the day. This would draw the pus to the surface, and in the morning the pus would drain in the shower. Sorry about the graphic descriptions,” he says.
Thousands of deaths worldwide
“During this time, I was reading a lot of peer-reviewed medical-journal articles about natural healing methods for staph and MRSA, and the role certain bacteria strains, such as Bacillus [commonly found in over-the-counter probiotics], can play in targeting staph in the gut and nose. Several articles spoke to the power of applying mānuka essential oil to the infections – something we are lucky to have in abundance in New Zealand. I was also reading about antibiotic resistance, in particular taking a closer look at the World Health Organisation’s position and the effect on our health and agricultural sectors.
“I learnt that staphylococci infections cause tens of thousands of deaths worldwide every year, and that Staphylococcus aureus can live in the nose or gut of humans without causing harm. However, if the skin is broken or the immune system compromised – in my case, probably both – these bacteria can cause serious infections.
“I also read that to stop new infections growing, I had to decolonise my body of MRSA, a process that usually includes administering high doses of antibiotics, with mixed results, as well as controlling the spread of the bacteria on to surfaces. This meant washing the bed sheets in very hot water most days and cleaning our house thoroughly, as the bacteria can survive for quite a long time on surfaces, and I didn’t want to risk our daughter contracting it.
“These infections healed over to the point where I was clear of them for about two weeks, before two monsters popped up on my bottom. These were about 3cm in diameter, with a 10cm red surround – sore and nasty. From first appearing to fully healing took more than a month. I still have scars.
“As these infections healed, I then got a small graze on my left elbow and this contracted MRSA. This was the worst of all the infections I had. I visited my doctor, who was interested in getting to the root cause of the MRSA and provided support over the next few days as things progressed.
“I was also working in parallel with my naturopath to give my body the support it needed to fight the infection naturally. I know naturopathy is not for everyone, but I am a strong believer in the body’s ability to heal itself and that, alongside modern medicine, traditional and natural medicine have a role to play in helping our gut microbiome and wider immune system.
“I saw real progress over the next day or so, but then it started to slow and reverse. I was under a lot of pressure to abandon my self-treatment approach. Friends and family were getting worried. Fliss’ mother told me it was easily the worst thing she had ever seen in her 64 years and that another family friend had recently had part of his finger removed as a result of a staph infection. At this point, we left Auckland to spend Easter in Rotorua.
“On arrival in Rotorua, I went downhill fast. Fliss and Chloe took me to A&E because of the pain. I was starting to sweat. Things happened very quickly after that. I was septically unwell, so blood cultures were taken and I was moved from A&E to Rotorua Hospital to have surgery to wash and debride the infection – a polite term for cutting off the surface – which they did twice. The surgery was done by an orthopaedic team, as they were concerned about damage to the bone by the infection. Following surgery, I was given intravenous antibiotics for five days, which meant spending Easter in Rotorua Hospital, and an improvised Easter egg hunt around the hospital bedroom for Chloe.
“On my discharge from hospital, the Rotorua district nurse visited daily to dress the wound – an amazing service. On my return to Auckland, I visited the Greenlane Clinical Centre orthopaedic team weekly to check healing and had the district-nurse team dress the wound weekly as well. I was discharged from the service when it finally healed two months later. There is a large scar, to which I am applying a natural cream.
“To be deemed free of MRSA, I need to have three clear swabs. I have had one clear swab, but need to have another two. Unfortunately, my father-in-law and niece have had new infections, so I’m hoping I won’t see a recurrence.”
Responsible antibiotics use
Why did Sullivan hold out for so long, and why does he place so much faith in the body’s ability to heal itself? How justified was his fear about antibiotics killing his gut bacteria?
Dr Xochitl Morgan, director of the Microbiome Otago research team and an expert in the human-gut microbiome, says, “It’s true antibiotics affect our microbiomes and that it is important to use them responsibly. However, I would not hesitate to take them when medically necessary, especially with a serious infection. Our microbiomes are quite resilient and, in most cases, have almost entirely recovered from antibiotic use within a month or two.
“The best way to help your gut recover from antibiotic use is by feeding dietary fibre to your gut bacteria, which helps beneficial species grow. You can do this by eating a variety of fruits and vegetables. Probiotics can help to reduce some antibiotic side effects, such as diarrhoea, but most probiotics will not colonise the gut long term after you stop taking them.
“It’s commendable of Paul to try to be an educated patient, and to be aware of antimicrobial resistance, which is becoming a serious public-health problem. However, your microbiome gets what it needs to function properly when you eat a well-balanced diet. There is no strong evidence that healthy people need to take extra herbal supplements or vitamins to make their microbiomes work better.
“At the beginning of the 20th century, everyone had microbiomes unaffected by antibiotics, because they didn’t exist, but the average life expectancy at birth was 47 years, largely because rates of infectious disease were so high. Antibiotics have been a major contributor to raising our life expectancy to more than 80 years.”
Sullivan has a slightly different take on the research, and believes that, although the gut microbiota of healthy adults are resilient and able to recover after short-term exposure to antibiotics, broad-spectrum antibiotics may reduce the diversity of the intestinal bacterial ecosystem and that diversity can take years to recover.
“Supporting my immune system to fight the MRSA was my main focus for the three months I had the infection. I know some people will find it hard to rationalise the path I took, but I take comfort in the fact that my body was able to heal 12 infections on its own and I reached out for help when I thought the balance had tipped; the last one on my arm was a step too far for an already ‘maxed-out’ immune system.
“If there’s one thing I want people to take away from my story, it’s not to question the skill of our medical practitioners or the validity of modern medicine, but to be curious about what a more holistic approach to well-being and health could look like, including gaining a deeper understanding of the role stress – physical, relationship and environmental – devices, diet and sleep play. There’s a stress epidemic coming, if not already here, and I’m not convinced modern medicine is the right or only answer.
“That doesn’t mean I am not in awe of modern medicine and the miracles it performs on a daily basis. I am incredibly grateful for the care I received. We are fortunate in New Zealand to have access to world-class medical care.”
The big worry
University of Auckland associate professor Mark Thomas, a specialist in infectious diseases, says it is not unreasonable to treat yourself in the way Sullivan did – up to a point. He advises people to see their doctor if the diameter of a boil on the skin is more than 3cm, and the red area around it more than 7cm, and certainly if they are feeling feverish. The main thing about treating these boils is to drain the pus, which Sullivan did assiduously, and to cleanly dispose of it, along with any dressings, as they will be full of millions of bacteria looking for somewhere else to live.
Why did the bug have such a devastating effect on a fit young man? Sullivan thinks it was the stress of life in general at that point, made worse by the fact that he couldn’t run to relieve it, as he usually did. Sweating is ill-advised with such an infection, as it provides just the right conditions for bacteria to grow on the skin.
“Fitness and youth afford no special protection,” says Thomas. “Some immune systems cope better with particular bugs than others, and their capacity can change with time. Some bugs are just more aggressive than others.”
Where did Kelly’s infection come from in the complete isolation of the West Coast? “It was probably from his own body,” says Thomas. “A third of us have staph living in our noses, just a few millimetres inside the nostrils. About a tenth of the bacteria, on average, are Methicillin-resistant strains. In almost all cases, they’ll do no harm. The proportion of staph infections that are caused by MRSA has been increasing in New Zealand, though very slowly. In some countries, it is up to 30%. Most staph infections, whether MRSA or not, are still treatable with antibiotics, but the range of effective antibiotics is gradually getting smaller. That’s the big worry we all have.”
MRSA is more prevalent among Māori and Pacific peoples, probably because of poverty and more crowded living conditions. Children are generally more vulnerable because of their less-developed immune systems. Boils were a lot more common among baby boomer and earlier generations.
The problem has been growing since British pharmaceutical company Beecham developed the new beta-lactam antibiotic in 1959 – strains of MRSA were reported as early as 1961. UK economist and chair of the Review on Antimicrobial Resistance, Jim O’Neill, warned in a 2016 report that, without urgent action, antimicrobial resistance – not just antibiotic resistance – will kill 10 million people a year by 2050.
Sullivan was only just able to make it to Wellington at the end of May – five months after the initial infection – for the Government House reception for Dame Jane Goodall. He is a board member of the Jane Goodall Institute New Zealand, which is promoting the English primatologist and anthropologist’s message about the power of individuals to act on climate change and environmental issues. He managed to stay on his feet during the event. No one had any idea of what he’d just been through.
As for Kelly, he recovered just in time to travel with the family to see his son, Nick, get married at Stoke Newington Town Hall, London. He has no scars to remind him of his trauma, just a new appreciation of his mortality and our health service.
The urgent search for new and effective antibiotics
Kristin Dyet and Dr Michael Addidle are responsible for MRSA surveillance at the Institute of Environmental Science and Research (ESR). Labs around the country used to send them every MRSA isolate from human infections to record and analyse. Now, however, there are so many cases – the number doubled between 2009 and 2017 – that they survey all cases from one month only every few years to get a picture of the rate of infection and which strains are involved. It takes them up to a year to process just one month’s worth.
Dr Pippa Scott, an infectious disease epidemiologist at the University of Otago, studies how the bacteria spread among people in the community, with a view to finding the best ways to limit transmission. She says, “Infections with Staphylococcus aureus can range from relatively minor to potentially life-threatening events. In the worst case, some people with Staph aureus infection may develop sepsis, where the immune system goes into overdrive in response to a spreading infection. The resulting widespread inflammation can damage organs and interfere with blood flow.”
MRSA appeared in New Zealand during the 1970s, and since then some unique strains have evolved here. As infections continue to increase, periodic surveillance is the only realistic way to monitor them. However, surveillance techniques have become more sophisticated and all the studied MRSA samples will be fully described using “whole genome sequencing” – which gives a complete blueprint of an organism’s DNA.
Nigel French, a professor of food safety and veterinary public health at Massey University, uses whole genome sequencing to track the evolution of, and relationship between, pathogens isolated from different sources. Staphylococcus aureus is one of about 40 species of staphylococcus, he says, and has many different strains.
“Quite a few of the staph species can be resistant. Examples are MRSA [Methicillin-resistant Staphylococcus aureus] and one that’s important in dogs, called MRSP [Methicillin-resistant Staphylococcus pseudintermedius]. Countries with higher use of antibiotics tend to have higher rates of antibiotic resistance.
“A lot of us are probably colonised with Staphylococcus aureus – on our skin, up our noses and in our lower genital tracts – and some of us with MRSA. It could be considered a normal part of our skin ‘microbiome’. It can be transmitted from person to person through direct contact and indirectly through things used by an infected person, such as towels and clothing, and in healthcare settings such as hospitals and nursing homes. Cows can get Staph aureus mastitis through the milking machine.
“Tracking the evolution of these diseases, and pinpointing the changes in their DNA that confer resistance, is now possible and precise, but finding new antibiotic medicines to kill resistant mutants can be hit and miss. The serendipitous discovery of penicillin was purely accidental. Researchers are testing hundreds, if not thousands, of natural and synthetic compounds in the hope that new, effective classes of antibiotic can be identified and trialled for both human and veterinary use.”
A life-changing near-death experience
On a hike in the Himalayas, Paul Sullivan woke to find his partner without a pulse.
There’s no telling when a medical affliction will strike. Paul Sullivan initially thought little of his staph infection compared with the illnesses and infections he and partner Fliss Winstone saw while in India in 2014 and 2015. And Winstone herself almost succumbed to altitude sickness.
After working in Hyderabad, Sullivan went travelling with Winstone in the Himalayas for three months. Near the end of an eight-day hike to the base of the world’s third highest mountain, Kangchenjunga in Sikkim, Sullivan awoke in their tent to hear Winstone gurgling.
He had done a first-aid course for his job, but “couldn’t find a pulse – maybe because of the inflammation in her face and neck – or sign of breathing. With a mixture of CPR and cold water, I managed to revive her to the point where she could communicate. Winstone says images of her family flashed before her eyes.
“Then began a painstaking 17-hour effort to carry her down from the Goecha La pass at 5000m to Yuksom at 1800m – a mammoth effort by the Sherpas. During the descent, Fliss was vomiting and had no vision, and although she was conscious, it didn’t seem as if she was on this planet. At that stage, I had no idea that it was altitude sickness, as she didn’t have the usual symptoms. So, I thought there would be long-term consequences.
“We were in a no-fly zone as a result of conflict on the Indian border, so a helicopter was not an option. On arrival in Yuksom, Fliss was cared for in a basic clinic. The police constable checked her pulse regularly – now a running family joke. The next day, we managed to convince a caring local to drive us five hours to Siliguri, where Fliss received further medical treatment. She was diagnosed with, and treated for, both pulmonary and cerebral oedema, and has since made a full recovery.
“As low-key as ever, Fliss to this day believes we overreacted. For me, the toughest thing to acknowledge has been that I almost lost her. In the moment, I found it incredibly difficult to compose myself to a point where I could administer CPR. It’s tough when the person you love is the patient and not breathing.”
This article was first published in the August 3, 2019 issue of the New Zealand Listener.