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Biofilm-forming, multiply antibiotic resistant coagulase negative staphs, ones that make exotoxin A and exotoxin B, are incredibly common in Lyme patients who have a concomitant low level of alpha MSH. Biofilm is called "slime" by those few in the field who measure it. We culture the deep aerobic nasal spaces (about 3" back into the nasopharynx) and use an API-STAPH technique to prove the presence of these nasty little commensals.
These staphs make hemolysins that are 22 amino acids long that form a tetramer in blood, and in turn activate a huge pro-inflammatory response.
The coag neg staphs must be eradicated before any significant improvement will occur. Often there will be a die-off response when antibiotics are begun, but not one associated with a rise in MMP9 such as what we see in Herxheimers. The use of one antibiotic at a time for these organisms creates a driving force that selects for mutant, resistant species.

Methicillin resistance is found in over 60% of these organisms.

The not uncommon use of rifampin for Bartonella by some practitioners concerns me, as I am now seeing a bloom of rifampin resistant coag neg staphs in those patients who come here later. Rifampin is one of the few antibiotics that can penetrate slime.

Ritch Shoemaker MD
CRBAI
Pocomoke, MD