MARCoNS FAQ
12 Total Items
Question Volume 1
Does every patient with a positive culture get BEG spray plus Rifampin? Or do you start with BEG and add rifampin if no improvement seen? I have a patient who has a positive culture but would prefer to not use any antibiotics. PS. I notice that you do not talk much about the psychology of handling mold patients with anger and disinhibition. Do you have any hints?
Answer
We only treat those patients who have more than one class of antibiotic resistances. Commonly we will see penicillin resistance alone or macrolide resistance alone. Don’t treat them until we can prove they are actually making biofilm. For those intolerant of rifampin, and make sure you dose in AM with food, we use BEG spray two sprays each nare three times a day. Mood swings are common; these are the most difficult patients you and your staff will ever treat. They can drive you crazy if you let them. Follow their line of thinking, but cut it off when the logic starts to fail. Don’t let them get away with assumptions and wacko medicine, they will try. Caution giving them unlimited access to your phones and you. You can (and must) set boundaries just like you would with an untrained puppy. When their brains are getting back to normal, they will thank you. The MR spectroscopy really helps here to show reduced oxygen delivery with consequent suppression ratios of glutamate to glutamine. As far as disinhibition goes, the role of reduction in volume of dopaminergic pathways in the caudate nucleus is showing a tight correlation with such behavior. If you aren’t doing NeuroQuant on your brain MRIs (takes 10 minutes) you really should be.Question Volume 1
How are biofilms detected? So far every patient who has sent a nasal swab has received a positive culture, and only one has less than two resistant strains. I talked to the lab and they seemed to think everybody is positive for coagulase negative staph. But just to clarify everyone who has two resistant cultures is treated for at least two months with BEG spray and Rifampin 300mg po bid. Those who have less than two resistant strains are not treated unless biofilms are detected?
Answer
We treat all multiply antibiotic resistant coag neg staphs for one month. The DLM does not have the results on 9000 cultures (I do); their opinion is not going to change our data 23 base. Having said that, about 80% of cultures are positive and about 60% of those are methicillin resistant organisms, so the culture can’t be skipped. It is not the culture that is resistant; it is the antibiotic resistance pattern of the individual organism. The new lab that will do biofilms for me (it has been a while since we have had a biofilm assay) does them in lots of 96.Question Volume 1
Also, is it possible to use a topical anesthetic for the nasal swab or will that impact the culture?
Answer
I have never used the topicals. I don’t see anything about a topical that would affect biofilm-formers. We’ve been trying to eradicate them with just about everything else for years! With a small bit of patient preparation and some experience in doing the culture, it is over in 7 seconds.Question Volume 1
What to do for migraines that have become excruciating and for the first time include intense pain across the nasal bridge after starting Rifampin and BEG spray combination? Have held the BEG spray pending notification from you regarding possibility of modulating dosage or any other option to improve tolerability. There was a brief re-exposure to mold in the basement during start-up of remediation with placement of air scrubber.
Answer
Though not common, there can be die-off when MARCoNS are being eradicated. I would track the VCS scores in row E and then D, looking for a fall. Also, MMP9 will rise within two days of onset of symptoms. If that is the case, hold the BEG for a few days, beginning to pre-treat with omega 3 or Actos, with the no-amylose diet, for five days before returning to the BEG spray (without rifampin). Most really bad headaches in these patients are rarely migraine and much more commonly are volume depletion with high osmolality.Question Volume 1
Patient had large amount of coag neg. staph approximately two and a half months ago. She was treated with BEG spray 3 x per day and rifampin 2 x per day for 6 weeks. Retest of nasal culture shows continuing large amount of staph coag neg. Resistance now is penicillin and erythromycin. 2 1/2 months ago resistance was penicillin and clindamycin. What would be recommended protocol now and for how long?
Answer
I have used the BEG spray each nare TID and rifampin 600 once a day in AM with food for years. Now I just start with double dose of the BEG spray. I would say your organism was resistant to penicillin and macrolides and not believe it was a new one despite the listed differences in macrolide resistance. This is an organism that we should study with biofilm production assays as it is distinctly unusual to find resistance to BEG/rifampin. I would also look at the potential for carriage of a reservoir in the nose of a dog. The few times I have had such absence of clearance, there was a family pet that was welcomed into the patient’s bed. (I think I may have done more nose cultures in dogs that the average family doc.) The carriage is not in cats, a finding that surprised me. I would go to BEG two sprays TID in each nare, with a re-culture in about 2 weeks while on Rx. I don’t like to use orals for these organisms, but in the past I used Bactrim (one BID) and doxy (100 mg BID) with good success.Question Volume 1
When doing the nasal culture for MARCoNS, do you need to use a special culturette for the nose? Will an ordinary culture swab do? Do you just go in on one side, one nostril? Can I send my specimens from California to the lab that you use?
Answer
We use a standard red topped Copan swab for nasal cultures. Don’t use the alginate swabs. I do just one side. Yes, see the previous answer for contact info for DLM.Question Volume 1
Is there a CPT code that you have found which would be appropriate for obtaining the nasal culture swab? I need to charge patients something for doing this and mailing it off, but it would be good if they could get reimbursed by their insurance.
Answer
I have not billed though others use the procurement code. We usually send our cultures in batches. The sample is stable for a week or even more in the culturette, so my cost to mail is not large.Question Volume 1
I am not clear about what qualifies a nasal culture result as positive for MARCONS. One recent result was resistant to erythromycin and penicillin. Is that considered 2 different classes of antibiotics or one? What about resistant to cephalosporin, penicillin and methicillin? Another was resistant to penicillin and intermediate to Levaquin. Are all of these considered positive? Does the amount of growth enter into it?
Answer
Nasal cultures need to show presence of coagulate negative staph to be considered positive. A MARCoNS will have resistance of at least two separate antibiotic classes present. Simple resistance to penicillin alone or no antibiotic resistances aren’t to be considered as a positive MARCoNS culture. Resistances to penicillin and Levaquin (quinolones) both make the culture positive. The amount of growth is irrelevant in that this is a blind culture and there is no way to insure that this was a quantitative culture.Question Volume 2
Is it possible to become ill and stay ill without one of the HLA haplotypes associated with susceptibility?
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Question Volume 3
After being treated for positive nasal cultures my most recent nasal culture from DLM negative but they noted a small amount of mold-like fungi. Is there any significance to this finding?
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Question Volume 3
I have used xylitol with benefit. My culture is negative now and I no longer have crusts in my nose.
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Question Volume 3
Do CSM and Welchol bind the exotoxins of MARCoNS?
Answer
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