A painful skin infection not treatable with most common antibiotics is spreading through the Los Angeles County jail system, affecting more than 1,000 inmates in the last year and causing at least 57 hospitalizations.
Federal health officials believe that the outbreak of drug-resistant Staphylococcus aureus, commonly called staph, is the largest of its kind in any of the nation's correctional systems. By comparison, a similar outbreak in Mississippi prisons in 1999-2000 infected 59 inmates.
For months, the Los Angeles infections were misdiagnosed as spider bites and jail officials brought in exterminators. Now sure of the staph cluster, jail doctors are using more powerful drugs to treat all skin lesions and stepping up hygiene measures.
"The problem at the jail is not under control yet," said Dr. Jonathan Fielding, the county's public health director. More than 100 infections have been reported this month.
Staph infections are believed to be spread by skin-to-skin contact or shared personal items in the county's jails, officials said Thursday. The infection causes grotesque boils, deep skin abscesses and widespread surrounding inflammation.
Similar outbreaks of the same strain have been found elsewhere in the Los Angeles area since the summer -- among gay men, members of a sports team and newborns in a hospital's nursery. Some inmates are entering the jails with infections picked up in the community and are spreading the staph behind bars, doctors said.
The problem is believed to be more widespread and difficult to control in jails because hygiene is poor, inmates are in close contact, and laundry is not cleaned often enough, health officials said. Those same factors also explain why jails are incubators for other diseases.
Most of the 57 inmates hospitalized in the first eight months of 2002 had aggressive skin infections that required intravenous antibiotics or the surgical removal of tissue. Some of the infections spread into bones and blood, but no one is believed to have died, said Dr. Elizabeth A. Bancroft, a medical epidemiologist with the Los Angeles County Department of Health Services.
Since inmates and officials first blamed spider bites, jail doctors didn't contact the county health department until June, five months after they started tracking the outbreak.
"We spent a considerable amount of time screening all of our facilities, making sure that pest control measures were in place and actually trying to capture a specimen so we would have some idea what we were dealing with," said Dr. John H. Clark, the Sheriff's Department's chief medical officer.
The jail sent four or five spiders to the county entomologist, or bug specialist. "As it turns out, they were non-biting spiders," Clark said.
Clark said the confirmed staph cases represent a small fraction of the 165,000 people who spent time in the county jail facilities last year. About 20,000 stay there at any given time.
Although 928 inmates tested positive for drug-resistant staph in 2002, more may have been infected because jail staff did not routinely culture skin sores until after the health department got involved in June.
The American Civil Liberties Union of Southern California has received dozens of calls recently from inmates who complained about having "spider bites." Ben Wizner, a staff attorney with the group, attributed the staph outbreak to "too many inmates, not enough doctors."
Because the men's central jail is chronically overcrowded, he said, many inmates stay in cramped dormitories with their mattresses touching.
In addition, he said, inmates are sometimes forced to wait days or weeks for medical attention. Clark acknowledged that medical staffing has not kept pace with increases in inmate numbers.
To control the outbreak, federal and county health authorities recommend improved access to showers and clean laundry for inmates, and jail officials said they are taking such steps. In addition, medical staff are draining abscesses and administering two powerful antibiotics in tandem. Inmates are being told to seek help if they develop skin sores.
But that may not be enough. According to data from the jail, 9% of infected inmates reported sores within five days of booking, meaning that they probably came in contact with the bacteria before they were incarcerated.
"Control is not as easy as saying, 'We'll take care of everyone today and give them antibiotics,' " said Bancroft, who is leading the health investigation. "Every day, you have people coming in from the outside."
Health officials said they don't have the luxury of closing the jails in the way that cruise ships were taken out of operation recently to disinfect them of a gastrointestinal virus. "When you have 20,000 people who sleep in your jails ... it would be very, very difficult to do something like that," Bancroft said.
Staph is a common skin organism -- many people carry it without ill effect -- and it typically causes infection when it enters a skin opening. But the resistant strain seen in and out of jail in Los Angeles County may break through intact skin, health officials said.
Like other methicillin-resistant staph outbreaks, it doesn't respond to the cheapest and most frequently used antibiotics, such as penicillin and erythromycin. The only drugs that work against it are Bactrim, rifampin, clindamycin, the new and very expensive antibiotic Zyvox, and intravenous vancomycin for the worst cases.
Authorities said they are uncertain whether inmates with other chronic illnesses are more likely to contract the staph infections. The jail outbreak is affecting men and women, and their average age is 35.
Dr. Matthew Kuehnert, a medical epidemiologist with the U.S. Centers for Disease Control and Prevention, said his agency has limited knowledge of resistant staph outbreaks outside of hospital settings because there is no requirement that they be reported.
In addition to helping with the Mississippi outbreak, the CDC also has assisted authorities in Georgia, Texas and now California in dealing with resistant staph in prisons and jails, which he said is particularly difficult to control.
Some hygienic precautions that are routine in a hospital can't be followed in jails. Replacing bar soap with plastic soap dispensers poses a security risk, and jails won't use paper towels instead of cloth towels because inmates could use them to stuff toilets.