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| Prologue | 3 | (6) | |||
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9 | (15) | |||
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24 | (20) | |||
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44 | (14) | |||
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58 | (13) | |||
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91 | (26) | |||
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117 | (18) | |||
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187 | (13) | |||
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216 | (18) | |||
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234 | (39) | |||
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273 | (18) | |||
| Acknowledgments | 291 | (4) | |||
| Notes | 295 | (20) | |||
| A Selected Bibliography | 315 | (2) | |||
| Web Sites | 317 | (2) | |||
| Index | 319 |
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Dr. Glenn Morris was growing very worried. His patient was not supposed to die.
The son of Southern Baptist missionaries, Morris had grown up in Bangkok, Thailand. There he had witnessed firsthand the magnitude of devastation that could be wrought by a bacterial plague. During the dreaded dry season after the monsoons had passed, waves of cholera would sweep through the canal-laced city, killing hundreds at a time. Morris would never forget the screams of ambulances racing through the streets. Cholera seemed to strike without warning: a man who'd sampled the food from a street vendor would be hideously sick just hours later, lying limp and helpless as his vital nutrients flowed out of him amid ceaseless diarrhea. Death would often follow. Was it the food? The water? Who knew? Morris had heard about the horrors of hell in church on Sunday. He didn't think it could be much worse than the dread permeating a city in the grip of a cholera epidemic.
Morris's parents had assured the shaken child that by staying away from street food, drinking boiled water, and, most important, taking fluids and antibiotics at the slightest cholera-like symptom, he would be safe. But as Morris now looked down at his suffering patient, he knew that such soothing assurances had no relevance here.
A year before, Ed Burke* had taken his good health for granted.
Forty years old, lean and fit, he was a recently divorced accountant living with his mother while he tried to put his life together again. But Burke had been feeling weak and tired when he went to the University of Maryland's Medical Center for a checkup. He told doctors he'd been having stomach pains and chronic colds. A routine blood test revealed that he was suffering from leukemia. Though Burke was shocked and frightened by the diagnosis of cancer, his physician explained that most forms of leukemia responded well to chemotherapy. In all likelihood, he'd be able to undergo the regimen and soon resume a normal life.
That was the beginning of the end.
Burke's physician initiated chemotherapy almost immediately. Though often effective against leukemia and other cancers, the drastic treatment-with its searing chemicals that course through the body like Drano-can have the undesired effect of suppressing the immune system as well, sometimes leading to bacterial infections that the weakened immune system cannot contain. Physicians use antibiotics to help eradicate these potentially life-threatening infections. Sometimes these bugs prove resistant to the initial antibiotic, in which case the physician simply switches to another one. For decades, there had always been plenty in reserve. But for this particular case, the reserve had been exhausted.
Burke's infection was caused by the bacterium known as Enterococcus faecium . One expert calls E. faecium the cockroach of microbial pathogens: proliferating freely in the gastrointestinal tract, it usually causes no more trouble than roaches colonizing a dark cupboard. But when breakdowns in the immune system allow the bugs to escape, they begin to cause serious infections, anywhere from the heart down to the urinary tract. After proving resistant to the initial antibiotics used, Burke's E. faecium also showed resistance to vancomycin, an older but still powerful antibiotic that represented the last-chance treatment for resistant enterococci when all else failed. This time vancomycin failed as well: vancomycin-resistant E. faecium , better known as VRE, had appeared in Burke's bloodstream, a dangerous escalation. That was when Morris had been called in.
With his stocky build and powerful arms and shoulders, the ruddyfaced Morris looked more like an ex-linebacker than a man of medicine, though his soft-spoken manner made him, at first glance, seem shy and retiring. But when he was stationed behind a microphone at a scientific conference and given a rapt audience for his impassioned calls to action about disturbing bacterial advances, the Southern preacher inside him very clearly emerged.
Awed by the bacterial devastation he had witnessed in Thailand, Morris had grown up determined to do what he could to prevent such suffering in the future. Through willpower, hard work, and a keen intellect, he had turned himself into a formidable microbe hunter: schooled in tropical medicine, public health, food safety, and genetics, he had a breadth of training possessed by few in his field. Now Head of Infectious Diseases at the University of Maryland's Baltimore Veterans Affairs Medical Center, Morris was one of the country's best-known experts in his field. And Maryland needed an expert. In the last few years, Morris had seen an explosive growth of VRE right in Baltimore.
The full import of this trend was difficult for patients to absorb. Certain strains of E. faecium were resistant to nearly all of the more than one hundred antibiotics that modern science had produced. They were, quite simply, unstoppable.
Even harder to explain to patients was that E. faecium was a hospital bug. Almost certainly, it had infected Burke after he was in the care of his oncologists. It had infected him right there in his hospital bed. And how had it gotten there? Probably by alighting from the unwashed hands of a busy doctor, nurse, or other healthcare worker who had just had contact with another patient carrying the bug. Oncology wards and intensive care units of nearly all hospitals were notoriously rife with resistant bugs, though few institutions would admit as much. All too often, these drug-resistant bugs took weeks to develop into infections, so that the doctors and nurses who had inadvertently passed them to a patient might not ever learn what they had done.
For elderly patients with chronic illnesses and ravaged immune systems, VRE was proving lethal, the extra infection that nudged an already sick person over the edge. Younger patients were usually impervious to it -unless, that is, their own immune systems were compromised by chemotherapy, as Burke's was, or by drugs given to prevent rejection of a transplanted kidney, or by some life-threatening, out-of-the-blue calamity: a car accident, perhaps, or a thirddegree burn. Then they were as susceptible as patients twice their age. Given that well over one million Americans were diagnosed each year with some form of invasive cancer-15 million since 1990-the number of potential victims for VRE was surprisingly large.
When Morris entered Burke's hospital room the first time, the accountant had looked up at him with desperate hope. Gently, Morris had had to explain that he had no magic bullet for Burke's VRE-no cure at all. He could only hope that with the end of chemotherapy, Burke's white blood cell count would bounce back up quickly enough for his immune system to handle the infection itself.
As if in answer to the Burke family's prayers, that was what happened- at first. The leukemia disappeared-whether it was in remission or gone for good, the doctors could not yet tell-and chemotherapy was halted. Burke's immune system began to recover and started producing the white blood cells responsible for killing bacteria that invade the bloodstream. As the white blood cells attacked the infection, the patient's fever broke, and he felt stronger every day. Within a week, he was sent home.
Just ten months later, Burke was back in the hospital with a relapse of leukemia. Reluctantly, his doctors gave him more chemotherapy. When they did, VRE reappeared in his bloodstream. It had been lurking in his intestinal tract, a killer within. Twice more the man recovered enough for his immune system to fight the VRE to a standoff. But the superbug was not yet beaten.
A year later, another relapse of leukemia, and more chemotherapy, pushed Burke's white blood cell count down too far. The bug that had been his constant companion, as Morris grimly put it, once again infected his bloodstream. Back came the high fever, the chills, the irregular heartbeat, the shortage of breath. But this time there was no rebound, even when chemotherapy was halted. Burke began vomiting, and his blood pressure plunged. As the flow of blood to his brain slowed to a trickle, his vision dimmed and he became disoriented. At the same time, his ever weakening heartbeat pumped less and less blood to his other vital organs. One by one they began shutting down, like lights winking out during a power blackout. As the kidneys and liver ceased to operate and cleanse his body of waste materials, Burke essentially poisoned himself. Finally came full-blown septic shock. Burke went pale and delirious, cold and clammy to the touch. He suffered a series of small heart attacks, and began to suffocate as his lungs filled with fluid. Eight days after the VRE infected his bloodstream a final time, Burke succumbed.
That was in September 1995.
It doesn't get much worse than this , Morris thought at the time: a forty-year-old man with an infection no antibiotic can stop. But he would be wrong. Over the next six years, a grim new era of multiresistant bacteria would unfold in-and out of-hospitals around the globe, making Burke's case seem all too typical. Relentlessly, these newly hardy, invisible bugs would proliferate all around us, some festering on bedrails and seat cushions, telephones and thermometers, others passing through the air from one human host to the next. Silently, they would colonize even the healthiest of us, coating our skin, nestling in our noses, spreading in our throats, swimming through our stomachs and gastrointestinal tracts-until it could not be said that any of us was ever without at least a smattering of highly drug-resistant bugs, waiting for the chance to infect those among us who grew suddenly weak and sick.
The bugs were everywhere, exponentially multiplying. And each year now, fewer drugs seemed able to stop them.
* Some names, including this one, have been changed to protect the privacy of patients and their families.
Excerpted from The Killers Within by Michael Shnayerson and Mark J. Plotkin Copyright © 2002 by Michael Shnayerson and Mark J. Plotkin
Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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