Maryn McKenna

Journalist and Author

Ten tips for avoiding hospital infections

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ScientificAmerican.com (disclosure: I have written a story for them, and it is edited by a friend) has a great interview with a hospital epidemiologist about things to do to avoid hospital infections.

It’s a smart list, with some non-obvious things on it. For instance:

5. Make sure you’re kept warm
The air temperature in operating rooms typically hovers between 65 and 69 degrees Fahrenheit (18 and 20 degrees Celsius). That’s great for the doctors and nurses bundled head to toe in scrubs, but not necessarily for the person on the table. [Stephen Streed, an epidemiologist who oversees infection control at the Lee Memorial Health System in Fort Myers, Fla.] says that the body responds to chilly air by constricting vessels supplying blood to the skin and the tissues just below it; diverting blood away from the body’s surface and toward its core is the body’s strategy for conserving heat. With less blood supplying oxygen to the incision site, the immune cells there become oxygen-deprived and therefore less effective at battling invading germs. Ask the surgical team how they intend to keep you warm — if they will crank up the room temperature by a few degrees, cover you in blankets, or warm you with IV fluids, for instance.

6. Ask about presurgery antibiotics
For many operations, including those involving the heart and bone, doctors routinely give patients preventive antibiotics to nip infections in the bud. One dose is typically given via IV an hour before the surgeons make the first cut, and sometimes two more doses are given over the next 24 hours, Streed says. If you think there is any possibility that you have an infection before going into surgery, tell your doctor so that he or she can treat you first. (Having an existing infection in, say, the bladder or skin ups the risk of developing a second, surgery-related infection, Streed warns.)

The whole list is worth reading.

Resistant bacteria on health care workers’ phones

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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

MRSA reductions in ICUs – good news, but qualified

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Constant readers, you will no doubt have seen the overnight news about a paper by CDC authors in the Journal of the American Medical Association, reporting a significant decline in catheter-associated bloodstream infections (known by the uncatchy acronym CLABSIs, and yes, people pronounce it “klab-seez”) in intensive care units.

Our results show that the 6 most common adult ICU types reporting central line–associated BSIs to the CDC, which together account for 96% of all reported MRSA central line–associated BSIs among studied ICU types, have experienced declines of 50% or more in the incidence of MRSA central line–associated BSI since 2001. This means that the risk of primary MRSA bloodstream infections among patients with central lines in these ICUs has substantially decreased in recent years.

First, let’s stipulate that any reduction in healthcare-associated infections is good, good news.

Having said that, let’s drill down into the paper a bit. Because in some of the coverage last night and this morning, this paper is being represented as “Hooray, the MRSA problem is over,” and that’s an over-reaction. Here are some reasons why.

The data come from several overlapping CDC databases: the National Nosocomial Infections Surveillance system (NNIS) and the National Healthcare Safety Network (NHSN). The NNIS existed from 1970 to 2004; there was a data gap in 2005, and the NHSN sprang up in 2006. There were 300 hospitals in 37 states reporting to the NNIS when it shut down, and in 2007 there were 518 reporting to the NHSN, many of which joined that year as a result of new mandatory HAI reporting in New York, Colorado and South Carolina. Participation in either database was/is voluntary.

The CDC analysis abstracts data from the reports to those systems for the years 1997-2007. But, as you can guess from those numbers above, the data does not cover all 7,500 US hospitals; and because it is more weighted to certain states, it does not represent a nationally representative sample. In addition, hospitals came into the system(s) during the study, and also dropped out; an accompanying editorial estimates that only 6% of the 599 hospitals in the study reported data for all 11 years.

Second, it’s important to note that all CLABSIs went down: MRSA infections, drug-sensitive staph (MSSA) and other organisms. So something is going on — but it is not MRSA-specific. Optimistic interpretation: Enhanced infection control in hospitals is suppressing all HAIs. Pessimistic interpretation: Enhanced scrutiny, in the states that account for the most additional hospitals, is negatively affecting HAI reporting. Can we distinguish which? Probably not. On the one hand, CLABSIs started trending down in 2001, before the earliest mandatory reporting legislation became effective. On the other hand, the study doesn’t/can’t associate declines in CLABSIs with any specific interventions — so it is not possible to know from this study whether one particular strategy was responsible for this decline.

Third, to put the study focus in context, MRSA accounts for only about 7% of CLABSIs; according to the paper, it is not those infections’ most common causative organism. And CLABSIs do not account for the largest proportion of MRSA HAIs; according to a 2007 paper, they fall third on the list behind nosocomial pneumonia and septicemia.

Fourth, since it is abstracted from a hospitals data base, this study doesn’t address community MRSA infections — and there are some scientists in the family of MRSA researchers who would insist that it is the increasing prevalence of community infection that is the true driver of the MRSA epidemic.

So: Decreased MRSA HAIs, good news. Reasons, unfortunately unclear. Significance, possibly less than the headlines this morning maintain. But whatever it is that those hospitals were doing, let us hope they keep doing it.

The cite is: Burton, DC, Edwards, JR, Horan, TC et al. Methicillin-resistant Staphylococcus aureus Central Line-Associated Bloodstream Infections in US Intensive Care Units, 1997-2007. JAMA. 2009. 301(7): 727-36.
The accompanying editorial is: Climo, MW. Decreasing MRSA Infections: An End Met by Unclear Means. JAMA. 2009. 301(7)772-3.

An inside look at combating HAIs

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I’ve been moving my RSS feeds over to a new reader and so am behind in reading things. That’s my lame excuse for not noticing an excellent story in the Washington Post Tuesday, a first-person account tracing the “conversion” of one skeptical physician to the cause of reducing hospital infections.

The story was highlighted at the New Health Dialogue, a must-read health-reform blog, by my friend and former fellow Kaiser fellow, Joanne Kenen.

HAI money in the stimulus bill

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Constant readers, for those of you who are following the back-and-forth over the economic stimulus bill, I wanted to let you know that the Association of Professionals in Infection Control (APIC) is saying that the compromise may cut money for state programs to reduce hospital-associated infections.

Here is APIC’s alert:

ACT NOW TO PRESERVE HAI AND PUBLIC HEALTH FUNDING IN STIMULUS BILL

Your urgent action is needed now to preserve public health funding related to HAIs in the stimulus bill pending in Congress.
The stimulus bill passed by the House of Representatives includes $3 billion in funding for overall public health, prevention and wellness programs. Part of this funding includes $150 million for carrying out activities to implement a national action plan to prevent healthcare-associated infections, $50 million of which would be provided to states to implement HAI reduction strategies.
Because of the fast-moving action on this legislation, and the fact that an agreement has been reached to remove prevention and wellness from the Senate stimulus bill, your Members of Congress need to hear from you today as the House and Senate prepare to confer over a final version of the bill. We need them to support the House-passed provisions for public health, prevention and wellness and the HAI language in the stimulus bill (the American Recovery and Reinvestment Act of 2009).

I apologize that, being deep in book production, I don’t know the details of the HAI-reduction programs they are talking about, whether it means support for new mandatory reporting programs or some other thing. (I’ll ask some of the HAI-focused organizations to weigh in back-channel if they can.)

But if you are concerned about the recent new initiatives in various states to report, track and control HAIs, this is probably worth looking at.

Reducing errors: Worldwide proof that it’s not so hard

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There’s an encouraging joint announcement coming this afternoon from the World Health Organization and the New England Journal of Medicine. (I’ve set the timer on this post to publish when the embargo lifts.)

Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

The checklist study was sponsored by the WHO’s Safe Surgery Saves Lives campaign. It was headed by surgeon and author Atul Gawande, MD, who is lead author of the NEJM paper and has spoken passionately about checklists as a simple, reliable, reproducible, low-cost intervention that can return extraordinary improvements.

The checklist idea originates in medicine with Dr. Peter Provonost, Johns Hopkins University critical-care researcher and MacArthur “genius” fellow. Gawande wrote a profile of Provonost, and plea for checklist implementation, in the New Yorker in Dec. 2007, and followed that article two weeks later with a New York Times op-ed piece.

The checklist idea has been borrowed from other tech-intensive fields, notably aviation. As a licensed pilot, I can testify that no pilot or crew, no matter how experienced, would ever dare take off without running through a checklist. To believe that you can keep everything you need to do in your head without reference to an external reminder is, in aviation, simply not a credible position. It is considered an absurd display of ego that puts others at unnecessary risk. (For a taste of how aviation looks at medicine’s resistance to improvement, see Sir Richard Branson’s comments last month.)

In the current study, one hospital in each of eight cities — Toronto, New Delhi, Amman, Auckland, Manila, London, Seattle and Ifakara, Tanzania — agreed to follow a pre-, during- and post-surgery checklist for every noncardiac surgery on patients older than 16. The study group collected data before implementation of the checklist on 3,733 consecutively enrolled patients, and during the checklist implementation, on 3,955 patients.

The checklist is on the WHO website (.pdf in English) along with toolkits for implementation. If you look, you’ll see it is very simple. For instance, before anesthesia:

  • Patient has confirmed: identity, site, procedure, consent
  • Site marked (or marking confirmed not applicable)
  • Anaesthesia safety check completed
  • Pulse oximeter on patient and functioning
  • Does patient have a known allergy? (No/Yes)
  • Does patient have a difficult airway/aspiration risk? (No/Yes, and equipment/assistance available)
  • Is there a risk of >500ml blood loss (7ml/kg in children)? (No/Yes, and adequate intravenous access and fluids planned)

There are similar short, thorough and noncomplex checklists for before skin incision and before patient leaves the operating room. Amazingly — or not, for those of you who follow the struggle against medical errors — these interventions, simple as they are, were new to most of the study hospitals.

Now, the research team is careful to point out the possible confounders to this study: It introduced changes in systems at the hospitals that may have created independent effects. It may suffer from the Hawthorne effect (“Observation changes the behavior of the observed.”) Given that it used consecutively enrolled patients, it may be affected by secular trends at the individual institutions. And it does not track complications post-discharge.

All that being said, I think we can take this as a very potent argument for the adoption of surgical checklists as a component of campaigns to reduce medical errors. And, as Gawande says in the press release that WHO put out this afternoon, a pointer to possible improvements in other specialties as well:

These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields… [I]n specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope.

The cite on the study is: Haynes, AB, Weiser, TG, Berry, WR et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Eng J Med 2009: 260: 491-9. Published ahead of print Jan. 14, 2009.

UPDATE: The full text has been placed online for free.

Seriously, a global problem

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Serendipitously, as I was preparing the previous post (an intro to GlobalPost.com, which will be featuring posts from SUPERBUG), an auto-push email from the National Library of Medicine‘s PubMed service landed in my inbox.

For those of you whose bedtime reading is not obscure medical journals (I know: This is what you have me for), PubMed is a search interface that allows you to pull articles for medical journals wordwide. It also offers a push option: Set a search term, fill in your email, and links to the latest articles on your term of choice are delivered. I have my search set to “MRSA” and have the results pushed once a week; there are never fewer than 25 new papers, which is a great gauge of how active an area of research — and how important a topic — MRSA is.

The latest push — 26 articles — vividly reminded me that, as NIAID Diretor Dr. Anthony Fauci said a few months ago, we are in the midst of “a global pandemic.”

Here is a sampling of those latest papers, from, again, a single week:

No question, constant readers: What we are talking about here is an international problem, a truly global bug.

Reducing healthcare infections – what it really takes

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Happy holidays, constant readers. Whatever you celebrate, I hope your days are full of security, calm and joy.

For those of you reading over the break, here’s a pointer to a post that takes us on the other side of the curtain, into the world of hospital administrators. Those of us who are concerned about nosocomial infections are often confused about why HAIs are so intractable. I mean really, how hard could it be?

This post and especially its associated comments suggests why it’s so hard. It comes from the marvelous blog Running a Hospital, which is written by Paul Levy, president and CEO of the Beth Israel-Deaconess Medical Center in Boston. As a thought experiment, he proposes getting all the hospitals in Boston (which is a LOT of hospitals: Harvard-associated, Tufts-associated, Partners, community hospitals — a huge, dense concentration) to commit to eliminating three categories of infections: central-line infections, ventilator-associated pneumonias and surgical infections, three categories for which there are well-recognized, well-tested interventions. He says:

The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

It’s a stirring and elegantly simple proposal — but as we all know, simple is seldom easy, and the commenters — whom I take to be health care workers and executives as well — light up how not-easy this might be. They say:

  • It isn’t simple enough for busy employees to put into real-world practice
  • It’s unreasonable to expect hospitals in competition to collaborate
  • It’s unthinkable that insurance companies would allow this much transparency

… and on.

The entire exchange, and Levy’s blog, is worth reading. It’s a consistently succinct, thoughtful, revealing look at the complexities of modern American health care, and at the unintended consequences — such as intractable infections — those complexities can provoke.

Brilliant entrepreneur asks: “So why CAN’T you fix this?”

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Constant readers, you’ll note that posting has slowed down a bit: I am deep into a chapter that is giving me some difficulty. (And I seem to be playing holiday host to an unexpected bout of bronchitis. I’m sure I didn’t need both lungs…)

But here’s something that crossed my monitor this morning, and it’s worth looking at. Sir Richard Branson, founder of Virgin Air and many other extremely successful entrepreneurial efforts. has accepted a post as vice-president of the Patients Association, a nationwide nonprofit that advocates for hospital patients in the UK. Speaking up in his new position, Branson gave an interview to the BBC in which he talked about hospitals’ failure to curb MRSA:

It feels like they have tinkered with the problem rather than really got to the heart of the problem. The hospitals are there to cure people. They are not there to kill people.

It’s a marvelous interview — read the whole thing, it’s not long — because it’s such a breath of fresh air. Branson is an outsider to health care, but he knows how to make businesses work. And as the head of an airline, he’s extremely familiar with what we in the US call “never events”:

Sir Richard says the health service could learn a lot from the airline and rail industries on how to avoid mistakes.”In the airline industry if we had that kind of track record we would have been grounded years ago,” he said.”In the airline industry if there is an adverse event that information is sent out to every airline in the world. And every airline makes absolutely certain that that adverse event doesn’t happen twice.”

So his advice is brutally practical: Health care workers carry MRSA? Screen and swab them. Workers are positive for MRSA? Treat them, and take them out of direct patient contact for two weeks. That costs money? Spend the money: It’s less costly in the end than killing your patients.

File under Unintended Consequences, 2

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Via the BBC comes a report, from a conference hosted by the journal Lancet Infectious Diseases, that some healthcare-infection experts in the UK are publicly questioning efforts to reduce hospital-acquired MRSA.

The argument is that, by focusing so tightly on MRSA, hospitals neglect other drug-resistant HAIs to such an extent that the overall rate of illness in the hospital remains approximately the same. They argue instead for a broader focus on all resistant and nosocomial organisms:

“It’s not clear that overall things have got better,” … said [Dr Mark Millar, a medical microbiologist at St. Bartholomew’s Hospital and the London NHS Trust].
“Rates of E. coli are going up and it almost compensates for MRSA.
“All you’ve done is replaced one problem with another one,” he said. … “”There’s no evidence that overall we have fewer hospital infections or fewer people are dying.” (Byline: Emma Wilkinson)

This is a highly contentious debate in the US as well, with no resolution in sight. I’ve covered some aspects of it here, and there is a long point-counterpoint from Infection Control and Hospital Epidemiology here and here.

File under Unintended Consequences, 1

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My friend and colleague Helen Branswell of the Canadian Press reports (via the Toronto Sun) on the cruel and accidental irony behind an outbreak of healthcare-associated infections at Toronto General Hospital between Dec. 2004 and Mar. 2006. Based on a new paper in Infection Control and Hospital Epidemiology, it’s a fascinating and bizarre tale of the unpredictable hurdles that a hospital can face in attempting to eradicate HAIs.

It seems the hospital, in an attempt to reduce HAIs, installed hand hygiene stations in each room in its medical-surgical intensive care unit, in between the patient’s bed and a countertop that held patient-care materials. This would seem like good design: The sink was right in the middle of the “zone of action” in the room, so health care workers would be reminded to use it (unlike, for instance, retrofitted rooms I have seen where the sink is away from the bed or out of the path between the bed and the door, and where health care workers have to consciously think about using it rather than having it be automatic). And the sinks were of a particular design meant to reduce accidental contamination of health care workers’ hands: When the water was turned on, it flowed from a high gooseneck faucet straight down into the sink drain, without washing around the sink’s side.

But it turns out that design and location both had unanticipated flaws. Water flowing straight into the drain was more likely to splash from the drain back out of the bowl; when investigators marked the sinks with fluorescent dye, they found splashes up to a yard away. Because the sinks were so close to the patient beds, the water was able to contaminate the patients, and the countertops on the other side as well. And because the water was falling directly into the sink drains, without the reduction in velocity caused by allowing it to wash around the sides of the sink, it was able to dislodge biofilm colonies of drug-resistant Pseudomonas aeruginosa, a moisture-loving organism that was growing in the sink pipes — which then splashed out of the sinks in the water bouncing back from the drain.

When the investigators found that, they had an explanation for why 36 transplant patients in that ICU had become colonized with MDR pseudomonas over 18 months. Twenty-four of the patients developed invasive infections, and 17 died; 12 of those deaths were either caused or closely related to pseudomonas infection.

The investigators tried multiple times to decontaminate the sink drains; in a few cases, they were successful, but the drains became recolonized and grew fresh biofilms. It was not practical to relocate the sinks. Nevertheless, they shut down the outbreak: They swapped out the faucets, decreased the water pressure, put a splash barrier on the sides of the sink, and moved patient care materials on the counter next to the sink elsewhere in the ICU rooms. Once those rearrangements were complete, the outbreak stopped.

This outbreak obviously was not MRSA, and in the strictest sense it is not relevant to MRSA, which is not an organism that lives in sink drains. But in a broader sense — as an illustration of the completely unpredictable hurdles that can stand in the way of excellent infection control — it is a useful and tragic cautionary tale.

The abstract is here. The cite is: Susy Hota, MD; Zahir Hirji, MHSc; Karen Stockton, MHSc; et al. Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design. Infection Control and Hospital Epidemiology 2009 30:1, 25-3.

More on MRSA pneumonia, flu and ER delays

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Folks, yesterday I posted the very sad story of 39-year-old Robert Sweitzer of Tucson, who died of MRSA pneumonia after being triaged to an 8-hour wait, in an overcrowded emergency room, during the height of flu season.

As a follow-up, I want to emphasize that while necrotizing pneumonia may seem an unusual circumstance, there is one thing in his story that is very, very common: The ER wait.

Emergency departments all over the country are suffering extraordinary stresses thanks to a confluence of factors: The unfunded mandate of mandatory ER care or at least treatment and stabilization, through the federal legislation known as EMTALA. The closure of large numbers of in-hospital beds, which make it more difficult to get patients admitted. The lack of adequate primary care, which drives people to seek ER care because they cannot get into a regular doctor’s office. The extraordinary percentage of Americans who have no health insurance — a percentage that is likely to increase as the economic meltdown continues.

How crowded are emergency departments? On average in the United States, an ambulance is diverted — denied admittance because an ER is too full to take new patients — once every minute.

To quote a bumper sticker that got a lot of use over the past few years: If you aren’t outraged, you’re not paying attention.

(Disclosure: I was a Henry J. Kaiser Family Foundation fellow in 2006-07, and spent an average of eight nights a month, for a year, as an ER observer. So ER overcrowding is something I both have witnessed up close, and feel passionately about.)

I mention all this in order to let you know that the American College of Emergency Physicians released today a state-by-state “report card” on the condition of ER care in the United States. Our average national grade? C-. (If you don’t have time for the full report, the New York Times sums it up here. If you want to do more research, three Institute of Medicine reports on the issues, from 2006, are here.)

So, again: While Robert Sweitzer’s death may seem end-of-the-curve extraordinary, the conditions that contributed to his death — a crushing overload in a community-hospital ER — are very, very common. And that should frighten all of us.

It’s flu season: Watch for MRSA pneumonia.

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Via the (Tucson) Arizona Daily Star, I’ve just caught up with the very sad story of Robert Sweitzer, a Tucson resident who died on his 39th birthday, of MRSA pneumonia.

Sweitzer died last Feb.10, but his name is in the news now because a lawsuit filed by his wife Rachel against the hospital where he died has just been scheduled for a Sept. 2009 trial.

The apparently undisputed facts of the case (according to news reports that I cannot usefully link to because they require registration) are:

  • Sweitzer was a healthy man, married three years, who worked a full-time job and devoted all his spare hours to animal rescue.
  • On Saturday, Feb. 9, he woke up feeling as though he were coming down with a cold, with a cough and low back pain. He and his wife went to a regular volunteer shift at a local cat shelter, but by evening, he was having trouble breathing. They arrived at St. Mary’s Hospital ER at 6:30 p.m.
  • Sweitzer was triaged within a half-hour, judged to be a low-acuity case, and sent to wait.
  • It was February, the height of a bad flu season, and the ER was slammed with 170 patients.
  • Sweitzer’s breathing and back pain got worse and his wife twice asked unsuccessfully for him to be re-evaluated.
  • When he was finally seen at 2:30 am, an X-ray showed his lungs filled up with fluid. He was put on 100% oxygen.
  • He arrested twice and was pronounced dead near 7 a.m.

Following an autopsy, the Pima County Medical Examiner and the Arizona Department of Health Services asked the Centers for Disease Control and Prevention to evaluate Sweitzer’s case; based on the extensive lung destruction, they feared he died of hantavirus. Tissue samples were sent to the CDC, which reported in August that Sweitzer actually died of necrotizing pneumonia caused by MRSA.

We have talked before (here, here, here, here and here) about the particular danger of MRSA infection during flu season, when (it is theorized) micro-trauma to the lungs by flu infection allows MRSA to gain a foothold. Once it begins, MRSA pneumonia proceeds with incredible speed — I have spoken to parents whose children went literally from apparently healthy to dead or close to it, within 24 hours — and it is commonly mistaken either for flu or for community-acquired pneumonia, the usual drugs for which have no impact on MRSA.

So, constant readers: It is flu season. Please get a flu shot. The observations and research on this are still limited, but it does appear that if you prevent flu, MRSA will have a more difficult time gaining a foothold in the lungs. (And if you nevertheless find yourself in a situation similar to Robert Sweitzer’s, and you truly believe it is life-threatening for yourself or your loved one, do whatever is necessary to direct clinical attention to you in time.)

Because I cannot link through to the Arizona Star stories, here are the dates and headlines:

  • 20 February 2008, “His pet projects: rescuing dogs, cats,” byline Kimberly Matas
  • 16 March 2008, “39-year-old’s ER death leaves a lot of unanswered questions,” byline Carla McClain
  • 27 August 2008, “Feb. death of Tucson man, 39, tied to staph,” byline Stephanie Innes
  • 1 December 2008, “Suit over death at St. Mary’s ER set for trial in September” (no byline).

MRSA in newborns on Prince Edward Island: HA? CA? Matters?

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There’s been a running story for several weeks now about the Queen Elizabeth Hospital on Prince Edward Island (home to mussels and Anne of Green Gables). The hospital struggled earlier this year with an outbreak of MRSA and a second outbreak of VRE among adult patients. It got those under control, but since earlier this month has been dealing with a new outbreak of MRSA in its newborn nursery, according to the PEI Guardian:

Nine newborns and one mother have now tested positive for MRSA. Five of those nine cases can be connected to the same source. (Byline: Wayne Thibodeau)

The stories are detailed, for a small paper — they go into depth about the cleaning measures the hospital is taking — and yet they don’t answer the questions that we here want to know. Does “tested positive” mean colonized or infected? Does “connected to the same source” mean they all have the same strain, or does it mean there is an epidemiologic link?

In the latest news (Tuesday’s paper and online edition), the hospital reports that it is doing nasal swabs on more than 300 staff, with the intention to do a 7-day decolonization regimen on anyone who turns up positive. They won’t however, disclose the source when they find it — though, again, it’s not clear whether that means not identifying the staffer (appropriate) or not admitting that it is a nosocomial outbreak (inappropriate and at this stage lacking in credibility):

Rick Adams, CEO of the Queen Elizabeth Hospital, said about 290 staffers have already been screened.
“In terms of the test results, we’re not going to be making anything public,’’ Adams told The Guardian.
“We want to make sure the environment here is supportive of staff and create a climate where they can feel comfortable and open to come forward and be screened knowing that any results will be kept strictly confidential.’’
Adams said he realizes a solid argument can be made that the public should be informed if the source is found and that source is a staff member.
But he said the public should also realize the hospital is doing everything it can to prevent a further spread of the superbug.
“The staff are under enormous pressure. They feel like they are under a microscope.’’ (Byline: Wayne Thibodeau)

Some readers may know that it is outbreaks among newborns that have demonstrated that the designations “community-associated” and “hospital-acquired” are passing out of usefulness. There have been several MRSA outbreaks in newborns and their mothers in the US (in New York City, Houston, Chicago, Los Angeles and Houston again because Baylor College of Medicine has been particularly alert to this) that were clearly nosocomial, and yet when the microbiology was done, were found to be caused by community strains.

Why does this matter? Well, for the PEI hospital, it may not: They have an outbreak, it appears to be nosocomial in nature, and whether it is HA left over from their earlier outbreak, or CA that came in via a health care worker or a pregnant woman, mostly affects what drugs they give the children and mothers if those patients do in fact have infections. And for those of us who are primarily concerned with nosocomial infections, the distinction may also feel not-relevant: Failures of infection control are failures of infection control and should not happen period full stop.

But for those of us who are are also interested in the natural history of this perplexing bug, the answer to what is going on at the Queen Elizabeth will be an important piece of information, because it could underline that the distinction between HA and CA is becoming increasingly artificial. The epidemics are converging.

British infection control: Epic fail

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Via the Guardian comes news that British hospitals are failing miserably at hygiene and infection-control targets set by the Healthcare Commission, a government-funded but independent watchdog agency somewhat analogous to the United States’ Joint Commission (formerly called JCAHO).

While community-associated MRSA is still a somewhat new story in the the UK, hospital or nosocomial MRSA is a major epidemic, with resistant Clostridium difficile (“C.diff”) coming close behind. So there has been significant attention paid in the UK to improving infection control programs in hospitals, through the vehicle of benchmarks set for the National Health Service trusts (essentially, regional organizational groupings of hospitals).

And the results, according to unannounced spot-checks made by the UK commission, are appalling. Only 5 of 51 trusts ( 51 = 30% of all acute-care hospitals in the UK) that were checked hit the mark. For those slow at math, that means 3% of UK hospitals are doing what they should to protect patients from infections they cause. (UPDATE: To be fair, if we assume the “5 out of 51” holds true across the NHS, then 10% are doing what they should. That’s still appalling.)

“At nearly all trusts we have found gaps that need closing,” said Anna Walker, the commission’s chief executive. “It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems.” (Byline: Sarah Boseley)

How weak? This weak, according to the commission’s own report:

  • 27 of the 51 trusts inspected were failing to keep all areas of their premises clean and well maintained. These lapses covered issues ranging from basic cleanliness, to clutter which makes cleaning difficult, to poorly maintained hospital interiors.
  • One in five trusts in this sample did not comply with all requirements for the decontamination of instruments and other equipment used in the care of patients. Trusts that breached this duty tended to have no clear strategy for decontamination or to lack an effective process to assure compliance.
  • In one in eight trusts, the provision of isolation facilities was not adequate. The containment of infections is extremely important to managing outbreaks. Hospitals without adequate facilities must ensure they have contingency plans so that the risk of infections spreading between patients is minimised.
  • For over one in five trusts there were issues related to staff training, information and supervision. While training on preventing and controlling infection was often in place, boards could not always ensure that training days were well attended or that staff used their knowledge in practice.

UK hospitals have until next April to learn to hit these benchmarks or be held accountable under a new Care Quality Commission.

For infection-control geeks, the full text of the “hygiene code” which the hospitals must abide by is here. Details of inspections at individual trusts are here.

New newspaper series on HA-MRSA

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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.

Despite stewardship efforts, antibiotic use increasing

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Well, this is bad news.

I hope we can all agree that antibiotic use creates antibiotic resistance. (Proof, if any were needed, that the universe has a captious sense of humor; but then it has had millennia to practice. OK, sorry for the anthropomorphizing.) The more pressure bacteria are placed under, the more resistant mutants emerge and survive. So the challenge in using antibiotics is to use them sufficiently and not too much: enough to quell infection and save lives, but not so much that the benefit of successful treatment is outweighed by the cost of increased resistance.

That’s the theory, anyway. In practice, according to a paper published today in the Archives of Internal Medicine, we’re not living up to the plan.

Amy L. Pakyz, Pharm.D. and colleagues at Virginia Commonwealth University surveyed antibiotic use at 22 academic medical centers — tertiary care teaching hospitals, ones that would be most likely to have high awareness of the dangers of resistance and good antibiotic stewardship programs — between 2002 and 2006. And found: Despite all that awareness, antibiotic use is going up, and the use of broad-spectrum agents and vancomycin, MRSA’s drug of last resort, is going up most of all.

The third significant observation is the marked increase in vancomycin use during the 5-year period such that it became the single most commonly used antibacterial in this sample of hospitals from 2004 to 2006. …
The reasons for the continued increase in vancomycin use are likely multifactorial, including the increasing numbers of hospital-acquired infections caused by MRSA and the emergence of community-associated MRSA, all of which encourage greater empirical use of vancomycin.

With only a few new drugs of comparative effectiveness on the market, and none that are significantly better, this is bad news, the authors underline:

Vancomycin use is a risk factor for emergence of vancomycin-intermediate S aureus and vancomycin-resistant S aureus, although these strains are rare in the United States. Of greater concern may be the emergence of low-level resistance in MRSA to vancomycin, referred to as minimum inhibitory concentration (MIC) “creep,” and this is far more common. Strains of MRSA having vancomycin MICs of 2.0 μg/mL are associated with longer median times to clearance of bacteremia compared with strains having MICs of 1.0 μg/mL or less, as well as frank treatment failures.

The cite is: Pakyz, AL et al. Trends in Antibacterial Use in US Academic Health Centers 2002 to 2006. Arch Intern Med. 2008;168(20):2254-2260.

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

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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.

Breaking MRSA news from the ICAAC meeting 1

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There are 15,000+ people at the 48th Interscience Conference on Antimicrobial Agents and Chemistry (known as ICAAC – yes, “Ick-ack”) and 46th Infectious Diseases Society of America Annual Meeting, and at least half of them seem interested in MRSA. At the keynote address last night, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at NIH, referred to MRSA as a “global pandemic.”

Here are some highlights — a few of very, very many — from the first two days:

  • MRSA is truly a global phenomenon: Researchers here are reporting on local epidemics in Argentina, Australia, Botswana, Canada, Colombia, Ecuador, Greece, Japan, Nigeria, Peru, South Korea, Sweden and Taiwan.
  • In the United States, USA300 — the virulent community strain that is crowding out all other community strains — continues its dominance. It first appeared in the San Francisco jail in 2001 and now is the only cause of community MRSA infections there. (Tattevin, P. et al. “What Happened After the Introduction of USA300 in Correctional Facilities?” Poster C2-225.)
  • And MRSA continues to demonstrate its protean ability to cause unexpected forms of illness: The number of cases of sinusitis caused by MRSA seen at Georgetown University tripled between 2001-03 and 2004-06. (I. Brook and J. Hausfeld. “Increase in the Frequency of Recovery of Methicillin-Resistant Staphylococcus aureus in Acute and Chronic Maxillary Sinusitis.” Poster C2-228.)
  • Meanwhile, treatment options are shrinking. Hospitalization for vancomycin-resistant pathogens (that is, resistant to vancomycin, the drug of last resort for MRSA) doubled between 2003 and 2005 according to national healthcare utilization databases. (A.M. Ramsey et al. “The Growing Burden of Vancomycin Resistance in US Hospitals, 2000-2005.” Poster K-560.)
  • But, new drugs are beginning to emerge from the pipeline. Early results from a privately held company called Paratek Pharmaceuticals (co-founded by resistance guru Dr. Stuart Levy) showed that their new tetracycline relative PTK 0796 scored as well or slightly better than linezolid (Zyvox) in safety, tolerability and adverse events, and is advancing to a full Phase 3 trial. (R.D. Arbeit et al. “Safety and Efficacy of PTK 0796.” Poster L-1515.)

More as the meeting goes on.

Sign of the times: Taking your own cleaning materials to the hospital

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There are several new and important reports out on hospital-acquired infections (HAIs) that I hope to get to this week, but I spotted something today that I just had to highlight first:

Constant readers may know that I’ve done a lot of reporting in the developing world. In parts of Asia and Africa, it is assumed that patients or their families bring food to the hospital. People do not trust the hospitals to feed them, with good reason: Hospitals can’t afford it. Provision of food in the hospital, which we take for granted, is not part of the health-care culture. (In particularly poor countries, the family may feed not only the patient, but the health care workers taking care of the patient as well.)

Here now is an industrialized-world version of that developing-world practice. A company in England (which, as we’ve discussed, has ferocious rates of hospital MRSA and C. difficile) has begun marketing the PatientPak, the “world’s first personal anti-superbug kit.” It’s a $28 sample-sized collection of antimicrobial hair and body wash, hand wipes, hand sanitizer and a germ-killing spray for sheets and cubicle curtains, along with lip balm, bar soap, and a disposable nail brush and pen.

It’s entirely possible that using products like this might protect a patient from some hospital-acquired infections; the company suggests that a patient use the wipes and the hand spray when going to and from the bathroom or after touching any surfaces. But the difficult reality, of course, is that most hospital-acquired infections are not the patient’s fault: They are due to infection-control breaches by hospital staff, something over which a patient — with antimicrobial wipes or without — has little control.

This company will probably sell quite a few of these kits — and I don’t know that I can criticize them for doing so. If one of my family members was being admitted to hospital, I might well send something like this with them. But what a sad commentary on our own health-care culture that any of us would consider this necessary.