Maryn McKenna

Journalist and Author

A good start?

By Leave a Comment

I happened to notice today that the WHO has posted an update to its campaign Save Lives: Clean Your Hands, which aims to get 10,000 hospitals around the world to sign on — by May 5, 2010, which is next week — to a global commitment to improved hand hygiene in hospitals.

As of last week, 8,173 hospitals had signed up (1899 in the United States, FYI).

If I sound skeptical, it’s because we all know that merely supporting hand-washing (or the gel equivalent) is an easy thing to do. If you asked any hospital in the US, you would hear 100% support for hand-washing — including in the hospitals where healthcare workers miss 50% of opportunities to wash their hands. It’s in the granular details of implementation — and the relentless laser-like focus on execution practiced, for instance, by Novant Health Care in North Carolina, whose story is told in SUPERBUG — that change really happens.

Whether this WHO campaign can bring that focus and create that change… we’ll just have to see.

The WHO campaign’s page includes videos, guidelines, and plans for a global survey to be executed on May 5.

Two good reports published elsewhere

By Leave a Comment

Some holiday reading:

MRSA news from Europe – Society for General Microbiology

By Leave a Comment

The annual meeting of the UK’s Society for General Microbiology is taking place this week, so here’s a quick roundup of MRSA-related news. As with these posts from a year ago, abstracts are not online; in a few cases there are press releases from the science-news service EurekAlert.

  • MRSA-colonized patients who have been identified in a hospital by active surveillance culturing may not need to be isolated to prevent their bacteria being transmitted to other patients by healthcare workers — provided hospital staff and visitors adhere to very vigorous handwashing. (P. Wilson, University College Hospital, London; press release)
  • An engineered coating made of titanium dioxide with added nitrogen could be employed as an antibacterial surface in hospitals; exposure to ordinary white light activates the compound to kill E. coli and may be useful against MRSA also. (Z. Aiken, UCL Eastman Dental Institute; press release)
  • The natural antiseptics tea tree oil and silver nitrate enhance bacterial killing when combined, which may also allow them to be used in lower doses – important for avoiding toxicity. It may also be possible to deliver them encapsulated in engineered sphere made of lipids called liposomes. (W.L. Low, University of Wolverhampton; press release)
  • Overuse of antibiotics in farming is not only breeding resistant bugs in animals, it is also changing soil ecology and depleting nitrogen-fixing bacteria that improve soil fertility. The antibiotics are affecting soil when manure from drug-using farms is spread as fertilizer. (H. Schmitt, University of Utrecht; press release)

Germs: All-singing, all-dancing, all urging you to wash your hands

By Leave a Comment

Because it is Friday, and we could all use a laugh… I’m currently writing about a hospital system that has had very good success with an institution-wide campaign to promote hand-washing.

The system is called Novant Health Care. They won a major award from the Joint Commission last year (months after I interviewed them, news-radar points to me). Their campaigns have worked so well that they have put their graphics (images for posters, computer wallpapers, wndow films and the like) free for download here.

But what was new to me is their hand-hygiene promoting video, which they have put on YouTube, featuring a singing, dancing E. coli channeling Barry Manilow. Ladies and gentlemen, I give you: Soapacabana.

(Wanders away, humming: My name is Germy, I like it dirty…)

MRSA research at Society for Healthcare Epidemiology of America meeting

By Leave a Comment

As promised, a round-up of some of the research presented at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA), held last weekend in San Diego. (Disclosure: I was on the faculty for the meeting; in exchange for co-hosting a session, SHEA will be reimbursing me for airfare and hotel. I wasn’t otherwise paid, though.) There were 143 presentations on MRSA; here are a few.

I’m going to put in links to the online abstracts — I have SHEA’s permission to do this — but I can’t guarantee how long they will stay up. For those outside the science world, what happens at these meetings is that research is presented, in slide/PowerPoint sessions or in a poster, as a preliminary step to getting it published in a journal. Once a journal expresses interest, a cone of silence descends, the researchers are asked not to discuss the research until the paper is printed, and the abstract will probably be taken offline.

So, efforts to control hospital MRSA are showing some success:

  • Invasive hospital-onset MRSA infections declined 16% from 2005 to 2007, and hospital-associated community-onset infections went down almost 9% — probably, though not provably, because of in-hospital prevention campaigns. (A. Kallen et al.)
  • MRSA control in a small ICU (22 beds) leads to MRSA reductions throughout a 270-bed Montana community hospital. (P.J. Chang et al.)

But those efforts face some complexities:

  • Swabbing the nose and culturing the swab, the classic test to check for MRSA colonization, misses 30% of positive patients because they are colonized in the groin or armpit. (C. Crnich et al.)
  • If a hospital does not use AST (active surveillance and testing, or “search and destroy”) it may seriously underestimate its MRSA incidence, though it may be able to detect general trends. (P.J. Chang et al.)
  • But medical centers of similar size and situation that did v. did not use AST achieved similar reductions in hospital infections. (K. Kirkland et al.)

Community strains are moving into hospitals:

  • Most of the cases of MRSA colonization identified in a Delaware healthcare system were found so soon after admission that they must have begun out in the community and were not due to hospital transmission. (K. Riches et al.)
  • The proportion of MRSA bloodstream infections caused by community strains (proven microbioogically) doubled at Chicago’s main public hospital between 2000 and 2007. (K. Popovich et al.)
  • One out of every 7 ICU cases of MRSA in Atlanta’s major public hospital involved a community strain. (H. Blumberg et al.)
  • The number of MRSA infections brought to a Chicago-area ER increased 566% between 2002 and 2007, and was seasonally clustered (D. Buchapalli et al.)

And at the same time, hospital strains are moving out into the community:

  • Hospital-associated community-onset cases accounted for 58% of all invasive MRSA in the US between 2005 and 2007, with patients undergoing dialysis or those who have been in long-term care the most vulnerable. (J. Duffy et al.)

Resistant bacteria on health care workers’ phones

By Leave a Comment

Here’s some of the news that I mentioned Friday – no, I’m not hoarding, I’m just desperately behind on some writing (and falling further down the curve all the time, but thanks for the concern).

A team from Ondokuz Mayis University in Turkey, publishing in the open-access journal Annals of Clinical Microbiology and Antimicrobials, looked beyond the concern over health care workers’ hands being clean, and decided to interrogate what those workers hold in their possibly-not-clean hands. They swabbed and tested the hands of 200 health care workers (“15 senior, 79 assistant doctors, 38 nurses and 68 healthcare staff “), and 200 phones. Their results:

  • 94.5% of phones colonized with bacteria
  • 49% of the phones grew one bacteria
  • 34% grew two species, 11.5% three or more

The language in the paper is a bit difficult, but if I’m reading it right, the colonization rates look like this:

  • 50 of the phone and 53 health care workes carried S. aureus (approximately 25%)
  • 52% of the S. aureus strains on phones were MRSA
  • 37.7% of the S. aureus strains on hands were MRSA.

Other organisms on the phones and the hands were other staph species, coliform, enterococci, moulds and yeasts.

The health care workers were certainly not infection-control outlaws: They washed their hands regularly. But only 10% of them had ever thought to clean their phones — which are held by the mouth and nose, a prime site for staph colonization, and go with them everywhere in the hospital, including to the OR and the ICU. (The paper doesn’t make clear whether the phones in question are hospital-supplied, with potentially many users, or personal, with one user, but going from hospital to home and back again.)

So: We’ve talked in the past about the many challenges of infection control in hospitals — all the many, tiny details in multi-person, highly technological health care that can trip up even well-intended infection control. (Remember the sinks?) Here’s just one more example of the unfathomable complexity of the journey of attempting to get to zero in healthcare-associated infections — a place, of course, where we all want to be.

The cite is: Ulger, F., Esen, S., Dilek, A. et al. Are we aware how contaminated our mobile phones are with nosocomial pathogens? Annals of Clinical Microbiology and Antimicrobials 2009, 8:7doi:10.1186/1476-0711-8-7

This is what hand hygiene looks like

By Leave a Comment


Contant reader Robyn pointed out an amazing image in the New England Journal of Medicine issue I discussed below. I missed it (thanks, Robyn!), so I went back and retrieved it. Here’s what you’re looking at:

The Cleveland Veterans Affairs Medical Center discovered via a routine nasal swab that a quadriplegic patient was colonized with MRSA; the patient had not had any signs that would have indicated an infection. To satisfy their curiosity over how much MRSA a healthcare worker might pick up from a patient whom they did not know was colonized, they had a health care worker do an abdominal exam of the patient — let’s underline that: abdominal; nowhere near his nose. Then they pressed the worker’s hand onto a growth medium that had been tuned with antibiotics so that it would allow MRSA to grow but suppress other bacteria.

That’s what you’re looking at above. All of that red is MRSA. The image on the right is what grew after the same worker did hand-sanitizing with alcohol foam and then pressed the same hand onto an identical culture plate. What’s growing? Nothing at all.

Here’s the back story, quoted from NEJM (re-paragraphed):

A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA) colonization of his anterior nares. He had no history of MRSA infection or colonization.
To assess the potential implications of the patient’s MRSA carriage for infection control, an imprint of a health care worker’s ungloved hand was obtained for culture after the worker had performed an abdominal examination of the patient. The MRSA colonies grown from this handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the worker’s fingers and thumb (Panel A).
With the use of a polymerase-chain-reaction assay, the mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates. After the worker’s hand had been cleaned with alcohol foam, another hand imprint was obtained, and the resulting culture was negative for MRSA (Panel B).
These images illustrate the critical importance of hand hygiene in caring for patients, including those not known to carry antibiotic-resistant pathogens.

The cite is: Donskey, Curtis J., Eckstein, Brittany C. IMAGES IN CLINICAL MEDICINE: The Hands Give It Away. N Engl J Med 2009 360: e3

UPDATE: The tireless and too-seldom-thanked crew at ZoneGrippeAviare, who provide pandemic news for the Francophone community, have translated this post into French. Mes mercis respectueuses!

New newspaper series on HA-MRSA

By Leave a Comment

The Seattle Times this morning launched an three-day investigative project on incidence of HA-MRSA in Washington State that is worth reading.

As readers here already know, MRSA is not a reportable disease, and there are no diagnosis codes that directly correspond to MSRA that make infection or death easily trackable through hospital records or death certificates. The Times’ team came up with some innovative data-drilling techniques and apparently did a massive amount of number-crunching to come up with the incidence estimates that underpin their reporting. They use those to challenge hospitals’ reluctance to undertake surveillance and treatment that would wipe out MRSA on colonized patients and thus reduce the likelihood of MRSA infecting those patients or spreading to others via healthcare workers who neglect infection control. (NB, Michael Berens, the series’ co-author, did a huge project on nosocomial infections when he was at the Chicago Tribune a number of years ago.)

I am puzzled by one thing I am seeing on the story’s web page — one of the items in the break-out box that sums the story up very quickly to attract eyeballs to it. It says: “About 85 percent of people infected with MRSA get the germ at a hospital or other health-care facility. ” That figure doesn’t make sense to me; it sounds as though it is a mis-translation of the CDC finding a year ago (in the Klevens JAMA paper) that approximately 85% of invasive cases of MRSA have hospital-associated risk factors. Constant readers will remember that estimate has been challenged by researchers on community MRSA, who believe that CA-MRSA accounts for a much larger proportion of the current epidemic than has been acknowledged, and think that the wide spread of the community strain is the actual driver of the overall epidemic. I can’t see where in the text the Times team has done the math to support that assertion, so if anyone else spots it, or knows the reference it comes from, please let me know.

Outbreak of Zyvox-resistant staph (breaking news from ICAAC 2)

By Leave a Comment

Physicians from Madrid reported today on what’s believed to be the first outbreak of MRSA caused by a strain that was resistant to linezolid, usually known as Zyvox, a relatively new and costly drug that is used for complicated MRSA infections and when older drugs fail.

Linezolid resistance in single cases has been recorded before — the first isolate I can see in a quick scan of the literature dates to 2002 — but this appears to be the first outbreak.

Dr. Miguel Sanchez of the Hospital Clinico San Carlos said the outbreak was discovered April 13, 2008 in an ICU patient and subsequently spread to 11 other patients in the ICU and two elsewhere in the hospital. The patients, 8 men and 4 women, had been in the unit for at least three weeks for a variety of reasons; they were intubated, had central venous catheters, and had been receiving broad-spectrum antibiotics. None of them were colonized with MRSA on admission. The outbreak went on for 12 weeks, until June 27.

It was eventually shut down by a combination of strategies: taking the patients off linezolid in favor of other anti-staph drugs (vancomycin and tigecycline); drastically restricting linezolid use, a policy that is already followed by many US hospitals; checking the patients very frequently for colonization; and cohorting them, which means grouping them together physically, away from uninfected patients, and putting them under isolation.

In a quick briefing with reporters, Sanchez seemed to suggest that the hospital does not believe its infection control failed. The hospital swabbed 91 environmental surfaces (such as bed rails and room furniture) and the hands of 47 health-care personnel and found only one sample that grew the linezolid-resistant strain on a culture. A case-control study to find the cause is being conducted, he said.

Half of the patients died, he said, but not as a result of the linezolid-resistant strain.

Sanchez’ data slides were not available to reporters this evening. (More precisely, they were delivered to the press room, but in a format that wasn’t readable). I’ll update with more details if/when we get access to them. Meanwhile, the cite is: M. De la Torre, M. Sanchez, G. Morales et al. “Outbreak of Linezolid-Resistant Staphylococcus aureus in Intensive Care.” Abstract C2-1835a.

Much new news on hospital-acquired infections

By Leave a Comment

There’s a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on “search and destroy,” the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. “Search and destroy” has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:

  • the design and implementation of state HAI public reporting systems,
  • the initiatives hospitals have undertaken to reduce MRSA infections, and
  • the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)

The report is too thick to summarize here, but here are some key points:

  • No two places are doing this the same way — which means that data still does not match state to state
  • Experts are still divided about how much MRSA control is necessary
  • Hospitals that have undertaken MRSA-reduction programs have taken different paths
  • But MRSA control does work: It does reduce in-hospital infections, but at a cost.

This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don’t really know how much MRSA – in hospitals or in the community – we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!