From Bedside to Public Square

By Lee Anna Sherman

Most of Portland is still punching the snooze button when morning rounds begin on Pill Hill. By 6 o’clock, teams of doctors, residents and medical students have draped their stethoscopes around their necks, collected their clipboards and greeted their first patients at OHSU’s teaching hospital. Joining one of the white-coated clusters, the family-medicine team, is OSU pharmacy researcher and clinician Ravina Kullar. “I’m the main drug person onboard,” she explains. “I have a great role, educating residents on infectious disease, antibiotics, dosing of medication. It all comes together at the patient’s bedside.”

After growing up in London and then Pittsburgh, Kullar earned her infectious-disease credentials at ground zero, Detroit Medical Center. “Detroit is the mecca of infectious disease,” she says. “It’s where resistance developed.”

A big worry facing the health-care system is a bug called MRSA (methicillin-resistant Staphylococcus aureus). A common bacterium that lives on the skin, S. aureus is usually harmless. When it does cause infection, the cure used to be simple: prescribe a penicillin-type antibiotic. But staph infections are getting tougher to treat as the bacteria dodge drug after drug.

So far, Oregon has seen less MRSA than many other states, according to OSU pharmacy researchers at OHSU. But even in Oregon, MRSA is mounting. At OHSU, Kullar estimates, at least 75 percent of the patients she sees have some kind of resistant staph infection. “Almost everyone turns up with a positive culture for MRSA in their skin or bloodstream,” she says. “ It’s the top organism for skin and soft-tissue infection in hospitals.”

But it’s not just health-care settings where MRSA thrives these days, according to the Oregon Health Authority. Resistant infections such as boils, abscesses and cellulitis are gaining ground in the general community, too — so-called “community-associated” MRSA, as opposed to “health-care- associated” MRSA.

This new strain, warns Portland physician Mark Crislip in his online Infectious Disease Compendium, “is sweeping the world,” causing “plagues of boils, necrotizing soft-tissue infections and hemorrhagic pneumonia.”

Kullar has seen MRSA patients from all walks of life, from IV drug users to teenage athletes. “There was even an outbreak in a football team,” she reports.

One drug user in his 30s was suffering from endocarditis, an infection of the heart valve. He had been given vanco- mycin, but failed to get well. Based on her work in Detroit, Kullar switched him to daptomycin. “There was a lot of IV drug use in Detroit,” she says. “I knew vanco wasn’t going to work, so we went to a second-line agent.” So far, the patient is doing well.

True to their nature, the resistant bacteria continue to evolve. It wasn’t long ago that vancomycin was a reliable second line of defense against resistant staph infections. But vancomycin-resistant germs already have turned up in Detroit. It’s just a matter of time before the new superbug, VRSA, shows up at Oregon’s door. Kullar is ready. The wilier the bacterial adversary, the more she relishes the hunt. “Infectious disease is like a puzzle or a mystery,” she says. “It makes me feel like a detective.”