A Tale of Two Infections

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In an attempt to broaden my eight-year-old daughters' video interests beyond Disney princesses, I recently rented the 1994 rendition of Little Women. It was delightful to introduce my girls to the Louisa May Alcott classic and we were all enjoying the adventures, joys and tribulations of the March family when about halfway through the movie, selfless and compassionate Beth contracts scarlet fever. The illness almost kills her and leaves her heart permanently weakened. My daughters were perplexed and frightened. Could they get scarlet fever? Could their friends get scarlet fever?

I paused the movie and began in my best doctor-mom way to explain that scarlet fever occurs when you have strep throat and the strep germs in your throat migrate to your skin. The girls were even more frightened. Each of them had had strep throat — could they have almost died? I reassured them that Beth March had nearly died because doctors in the 19th century, unlike today, didn't have medicine for strep throat and scarlet fever. They calmed down and we were able to return to the movie.

In Louisa May Alcott's era, a diagnosis of scarlet fever could only be made by clinical deduction; the distinctive rash accompanied by fever, nausea, vomiting and a sore throat. In my office practice, I swab throats daily looking for the dreaded strep bacteria and "rapid strep tests" allow concrete diagnoses to be made in a matter of minutes. Although the National Institute of Health estimates that more than 10 million mild infections caused by strep are diagnosed each year, the serious consequence of untreated strep infections are extremely rare in the U.S. Treatment for strep consists of oral antibiotics and the cure rate is practically 100%.

But there is a greater risk to patients: the inappropriate use of antibiotics for sore throats that, unlike strep, are caused by viruses, not bacteria. Antibiotics, used incorrectly, may be more harmful than the disease itself. Contrast strep's success story with the saga of staph. Staph is also a microscopic bacterium, one that lives on our skin and in our noses but can cause infections that vary from the inconsequential to severe. It causes superficial skin lesions such as boils and styes; more serious infections such as pneumonia, mastitis, and urinary tract infections. Even more serious infections can dwell deep in the heart muscle or bones. Staph is also the major cause of hospital-acquired infections of wounds and, like strep, of toxic shock syndrome. Any break in the skin, whether a surgical wound or a scratched mosquito bite, can allow staph to infect the layers below. For this reason, staphylococcal disease has been a constant problem in the hospital environment.

When antibiotics were introduced in the 1940s, infections caused by staph were easily fought. By the 1950s, however, the bacteria had developed defense mechanisms to antibiotics and today they are increasingly resistant. Until recently, these resistant bacteria were found exclusively in the hospital environment, but they have spread to the community — particularly in Georgia, Texas and California. I see children in my office every week with tender, warm boils of pus on their buttocks, legs, arms and even foreheads. Ten years ago these infections were rare and quickly treated with a shot of antibiotics in the office and a short course of oral medicine. But today's children return to the clinic day after day for incision and drainage of their abscesses while we wait for the first or perhaps second oral antibiotic to treat the infection.

When these patients develop recurrent boils, they undergo weeks of bleach baths and intranasal antibiotic creams to hopefully eradicate the resistant bacteria that have colonized their skin and nasal passages. Occasionally, oral antibiotics are ineffective and patients must be admitted to a hospital to receive intravenous therapy and sometimes surgical treatment of their abscesses. Unlike strep, staph is alive and getting stronger all the time, with few new effective antibiotics on the horizon.

Little Women and my thoroughly modern daughters have reminded me of how miraculous the antibiotic era has been. The advent of penicillin was hailed as miraculous and indeed it was. Mickey Mantle would have had his leg and future baseball career amputated if not for penicillin. Thousands of wounded soldiers would not have returned home from World War II. But the battlefields around us have changed. We have quietly entered a new era of antibiotic resistance, and the rules of germ warfare are changing as fast as military tactics. The next generation of patients, scientists, and drug therapy must be prepared to fight battles which will be waged microscopically as well as deep in our throats, skin, hearts and bones.