Bay Windows - July 8, 2004
Ethan Jacobs, ejacobs@baywindows.com.

City and state health officials say it is unclear whether, at the local level, this strain of drug resistant staph infections is confined solely to the gay male community, but they are working with health centers around the state to determine the nature and scope of the infections.

Previously the vast majority of staph infections, which can produce boils and sores, occurred among patients in hospital settings, and most of those infections were treatable with penicillin-like antibiotics. But in the recent years a strain of staph called methicillin-resistant Staphylococcus aureus, or MRSA, has appeared outside the hospital setting among gay men in a number of cities, including Los Angeles, San Fransisco, Atlanta, Washington, D.C., and New York City, as well as Boston. Cases of MRSA contracted outside the hospital setting are known as community associated MRSA, or CA-MRSA.

Jerry Feuer, a physician assistant at Fenway, said that patients with staph often have lesions on their buttocks, belly, armpits, and other parts of their body. Providers use a culture from the lesions to diagnose MRSA and test which antibiotics can be used for treatment. Thus far Feuer said all the cases have been treatable with Bactrim, a drug available in pill form, but the only other medications that can treat the infections are intravenous drugs.

Even with the antibiotics, Feuer said patients frequently require surgical intervention to drain the sores and some of the cases of MRSA were severe enough to require hospitalization. If left untreated, a staph infection could lead to a potentially fatal blood infection, although none of the cases among gay men in Boston have been fatal.

"This is not in any sense a panic state," said Feuer, noting that 40 cases in two years is a comparatively small number of infections. "It is certainly indicative of a trend and something people should be cognizant of."

CA-MRSA is often transmitted through skin-to-skin contact, and Feuer said it may be sexually transmitted among gay men and MSM. Because it can be spread through skin-to-skin contact, safer-sex devices like condoms may not prevent one partner from infecting another.

"You could be playing totally safe and get this disease," said Feuer. The infection can also be spread through sharing items such as towels, and some people can be carriers for the bacteria without developing symptoms.

Thus far about 70 percent of CA-MRSA cases that Fenway has seen are among HIV positive men. Feuer said for men whose HIV is under control through medication there have not been any additional difficulties in treating MRSA.

Fenway recently reported its findings to city health officials, and the city and the state are now working with Fenway to determine the nature of MRSA infections in the Boston area. Dr. Anita Barry, director of the Boston Public Health Commission's Communicable Disease Control Division, told Bay Windows that individual cases of CA-MRSA are often difficult to track.

"MRSA is not reportable in Massachusetts, but clusters or outbreaks are," said Barry. She said providers are not required to report MRSA unless they see enough cases to convince them that there might be a potential cluster or outbreak. The Boston Public Health Commission plans to conduct a survey of health care sites in the coming weeks to determine whether other health centers besides Fenway are seeing CA-MRSA cases and whether these cases are only occurring in MSM or whether other populations have been infected. At present Barry said there is too little data to say whether CA-MRSA infections in the Boston area are occurring primarily among gay men.

Dr. Alfred DeMaria, Jr., who heads the state Department of Public Health's Bureau of Communicable Disease Control, said that cases of CA-MRSA infections have been happening around the country, but he said many of the cases go unreported or undiagnosed.

"It's sometimes hard to pick up because many of the people with skin infections don't get cultured," said DeMaria. He said in many cases staph infections heal naturally or with antibiotics, so providers often do not think to take cultures of the sores. He said the state has been collecting MRSA cultures from health centers for the past couple of years, but most of the cultures they have are from hospital settings rather than from people with CA-MRSA infections. DeMaria advised providers to take a culture of any sores on patients that they suspect might be staph infections.

With such limited data DeMaria said the state is unable to tell whether CA-MRSA is occurring in other populations besides MSM.

"It's hard to tell. We aren't seeing clusters, we haven't seen clusters in other groups," he said.

The rise in CA-MRSA diagnoses around the country has prompted to Centers for Disease Control and Prevention (CDC) to begin studying the occurrence of infections. Officials from the CDC did not respond to Bay Windows' request for an interview by press time, but an August 2003 CDC fact sheet on CA-MRSA says that the CDC is working with state health departments to develop strategies for controlling MRSA infections.

The CDC is also working with states and local health centers to develop prevention efforts targeting different populations at risk for CA-MRSA. Nationally, CDC has noted outbreaks of MRSA among inmates in correctional facilities and athletes involved in team sports, as well as among MSM.

Until doctors know more about CA-MRSA Barry said the best way to avoid contracting it is through good hygiene. She said people with any sort of wounds should keep them covered with clean dressings. People should avoid sharing towels, make sure they have clean bed sheets, and wash hands frequently.

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