STRONGER BACTERIA STIR FEARS DRUG-RESISTANT GERMS ALARM HEALTH OFFICIALS.

Byline: Robert Monroe Staff Writer

BURBANK - The 67-year-old man came to St. Joseph's Medical Center suffering from an ear infection that just wouldn't go away.

It nearly killed him.

First-line antibiotics didn't stop the bug that caused his earache, allowing it to race through his bloodstream and attack his heart. Now, after surgery and four weeks of treatment with one of the most toxic and expensive antibiotics, doctors say they believe the Glendale-area man will live.

``I've been in practice for 20 years - and this is something definitely different,'' said Dr. Milton Louie, an infectious disease specialist who advises epidemiologists at St. Joseph's and two other area hospitals. For reasons of privacy, he declined to identify his patient.

What attacked this man so viciously was a strain of drug-resistant Streptococcus pneumoniae, among a growing number of super-bacteria that doctors said have baffled them by appearing across Los Angeles County in seemingly otherwise healthy people.

``The majority of the cases of the resistant bacteria, we have a really good reason why they're resistant,'' said Dr. Arleen Rockoff, chief of infectious diseases at Kaiser Permanente Medical Center in Woodland Hills. ``The thing that's different about these ones is that these are ones that are basic healthy folks.''

Public health officials blame overuse and inappropriate use of antibiotics for the steady increase in bacterial imperviousness, but they also note that germs naturally develop resistance over time.

A handful of new antibiotics await approval by the Food and Drug Administration and a pneumonia vaccine for infants just approved Thursday promises help in the battle against bacteria. Physicians, wonder, though how much progress once easily treatable strains will make in the meantime.

< Tale of the numbers

In Los Angeles County, the percentage of pneumonia patients stricken with drug-resistant Streptococcus pneumoniae has crept slowly upward since 1996, the year the county began tracking cases in response to the threat.

In 1998, 24 percent of the 659 pneumonia cases reported to the county Department of Health Services involved bacteria resistant to penicillin. In the first six months of 1999, that rose to 28.9 percent. Streptococcus resistance to another common class of drugs, cephalosporins, rose similarly, from 10 percent of reported cases in 1998 to 14.9 percent in the first six months of 1999.

Area hospitals also reported increases in drug resistance among samples of different bacteria. Glendale Memorial Medical Center reported a 10 percent increase in the number of cases of Staphylococcus aureus resistant to methicillin, the class of antibiotics that includes penicillin, between 1998 and 1999.

The local percentages match what is seen nationally: Methicillin-resistant Staphylococcus aureus cases accounted for 2 percent of all staph samples tested in 1974, but had risen to 50 percent by 1997.

Subtle sign of trouble

No one could have predicted what lay ahead for the Glendale man when he came in with a pesky earache from Streptococcus pneumoniae, the most common cause of bacterial infections.

In the early 1980s, that germ could could always be killed by antibiotics. Now, in one out of every four cases, invasive strep can survive penicillin, according to the federal Centers for Disease Control and Prevention. And 7 percent of the time, it is resistant to three or more antibiotics, the CDC reports.

``By their definitions, these organisms are harder to treat,'' said Dr. David Dassey, deputy chief of Acute Communicable Disease Control at the county Health Department. ``The infection continues to do its thing during initial treatment so more damage can happen.''

What troubles doctors most, health officials said, is that these drug-resistant infections now are beginning to appear in the general population.

Drug-resistant bacteria strains like the one acquired by the 67-year-old are usually confined to people who have taken antibiotics before, allowing germs to build up resistance. Typically, they are found among patients in hospitals and nursing homes, places where infections can spread from bed to bed borne on invasive medical equipment.

But the 67-year-old man had no previous hospitalizations in his record and had taken no antibiotics before being prescribed two common drugs to treat his ear infection, which had also spread to his mastoid sinus. He took his medication properly, Louie said.

``He prided himself on not having to see doctors,'' Louie said. ``There was no known risk factor.''

At Kaiser, Rockoff said she has seen cases of another bacteria, enterococcus, immune even to vancomycin - the drug of last resort for many infections - among patients with no easy explanation for how they could have become infected.

Last line of defense

Vancomycin proved to be the last resort for the 67-year-old. It also is the last hope for patients with drug-resistant staphylococcus, but the germ gains a bit more of a foothold against vancomycin every time it is prescribed.

``After vancomycin, you're going to see people dead,'' said Dr. Brian Johnston, an emergency room physician at White Memorial Medical Center and a member of the county Department of Health Services Health Advisory Committee.

At St. Joseph's, the man with the out-of-control ear infection was given vancomycin before and after his heart valve surgery. Louie said the drug's effectiveness became most crucial because the new valve is especially vulnerable to infection.

``The consequence of this is pretty substantial,'' Louie said. ``You cannot ensure the clean heart valve will remain clean.''

After being treated for the earache, the man came back the hospital, but only reluctantly, Louie said. His desire to tough it out could have killed him.

For children, the risk of a raging infection resistant to first-line drugs is greater than in adults.

Dr. Paul Horowitz, a Santa Clarita pediatrician, said physicians now bypass conventional antibiotics and immediately treat a child who might have meningitis with vancomycin, despite side effects that can include hearing loss, severe rashes and phlebitis.

``Now we're using elephant guns just in case we're dealing with elephants,'' he said.

When to worry

Doctors offer a few guidelines for when to tough out an infection and when to seek medical attention:

Get your child immunized against pneumonia - A new vaccine booster series given to children at 2, 4, 6 and 15 months could prevent one of the most common ailments of infants and toddlers - the ear infection. It could also reduce unnecessary antibiotic prescriptions.

< Take your child to the doctor if ... - Sometimes what seems to be an ear infection isn't one at all but simple accumulations of fluid in the middle ear. Generally, three days is the amount of time to wait for infections to clear up, but a trip to the doctor is warranted earlier if a few accompanying symptoms appear. Pediatricians recommend bringing a young child to them if the child has a prolonged fever, difficulty breathing, dehydration that prevents him or her from urinating or making tears, or unusual rashes.

< Give your doctor a break - Public health officials say over-prescription of antibiotics creates most drug-resistant bacteria. Physicians have been known to cave in to demands for treatment and write inappropriate prescriptions. Health officials say viruses often create symptoms similar to those of bacterial infections, but treating a virus with antibiotics can do more harm than good. Trust your doctor if he refuses to give you an antibiotic. Parents should keep their children out of day care, and sick adults should stay home from work. But call the doctor again if symptoms don't go away after a few days.

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SOURCES: Centers for Disease Control and Prevention, Dr. Paul Horowitz