Maryn McKenna

Journalist and Author

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.

Much new news on hospital-acquired infections

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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!

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.

UK: Hospitals’ MRSA deaths could bring manslaughter charges

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Last Wednesday was the first day of the new federal fiscal year, and therefore the day on which HHS’s new “non-reimbursement for medical errors” rule went into effect. Under this new rule (blogged here and here and covered in this New York Times story), the Center for Medicare and Medicaid Services will no longer reimburse hospitals for the increased care that a patient needs after an extreme medical error has happened. While infecting a patient with MRSA is not specifically disavowed in the rule, it outlaws reimbursement as of this year for infections associated with vascular catheters and coronary artery bypass graft surgery, and next year (Oct. 1, 2009) for surgical site infections following orthopedic procedures. (Disappointingly, CMS rejected requests to define staph septicemia and nosocomial MRSA infection as “never events.”)

Now, however, it seems that the UK government is willing to go much further than our own. According to a story in The Independent (first flagged here by ace flu blogger Crawford Killian), “tough new manslaughter laws” will allow corporations — including healthcare institutions — to be held accountable for deaths in which corporate behavior plays a role:

Maria Eagle, the Justice minister, told a meeting of more than 100 chairs and non-executive directors of NHS trusts that where managers ignore warnings of health risks, prosecutions may follow. She said: “Putting the offence into context, imagine that a patient has died in a hospital infected by MRSA and the issue of corporate manslaughter has been raised. Could the organisation be prosecuted and convicted? The answer is ‘possibly’. (Byline: Robert Verkaik, law editor)

Public attitudes in the UK are ripe for this change. In July, there was significant protest after it emerged — via a government report — that 345 patients died of Clostridium difficile infection at three hospitals, after government warnings, with no punishment to the hospitals. In fact, according to The Independent, the chief executive of the trust that operated all three was allowed to resign with $150,000 in foregone pay, and is now suing for additional compensation.

So far, US protests and citizen action over nosocomial MRSA infections have been within individual states (see this recent post on the new Nile’s Law in California). But isn’t it interesting to see what coordinated national action — granted, in a smaller country — can do.

Not-reimbursing hospitals for MRSA: The reaction

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You’ll remember that early in the summer we talked about the proposal by the Center for Medicare and Medicaid Services to cease reimbursing hospitals for the additional care of a patient that is required when a hospital gives a patient a nosocomial infection. CMS has been debating whether to include several types of hospital-acquired infection in the 2009 iteration of its “never event” no-reimbursement list. (CMS has not announced its final choices.)

Healthcare’s reaction has been, hmmm, not positive. At The New Health Dialogue, Joanne Kenen captures the reactions, many of which run along the lines of “infections are inevitable because patients are so sick.” But she’s also found a marvelous (and appalling?) argument that goes, more or less, “Preventing infections will be more costly, not less, because hospitals will introduce additional procedures to protect themselves.”

This recalls the intriguing and dismaying suggestion in JAMA a few weeks ago that “search and destroy” active surveillance is driven less by wanting to halt in-hospital transmission and more by hospitals wanting to build a case that patients brought the infection with them.

Maybe we just build them better? (But who pays?)

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OK, campers, I know I’m tossing crumbs here, but I drove 6 hours today and am now, umm, well, not in any major metropolitan area, that’s for sure. But I’m visiting a very interesting hospital program tomorrow. And my chain motel is smack-dab between a Denny’s and a Waffle House. Just think of the breakfast options. (And imagine my arteries clogging. OK, don’t.)

Skittering back to the reason why we’re here: Via the LA Times, an intriguing article about the possibilities of reducing hospital-acquired infections by designing hospitals better: single rooms, improved airflow, more sinks, etc.

“Private rooms are the most important design element that reduces the spread of infection between patients,” says Richard Van Enk, director of infection control and epidemiology for Bronson Methodist Hospital in Kalamazoo, Mich. Bronson is a pioneer of evidence-based design and was among the first hospitals in the United States to build a facility with all private patient rooms.
The hospital’s new design also incorporates two sinks in each patient room, one of which is dedicated for the exclusive use of the healthcare worker. Many easily cleaned surface materials such as water-based low VOC (volatile organic chemical) paint, plastic counter coverings and linoleum floorings with antimicrobial properties were also used throughout the hospital. (Byline: Lisa Zamosky)

It sounds plausible to me. Superbug Spouse is an expert in human-factors design, and we both do photography and web design (he’s better), so issues like this – which way do your eyes go? what button do you naturally want to push? – get tossed about a lot in our house. And just yesterday I listened to an infection-control nurse describe the difficulty of getting healthcare workers to use sinks in older rooms in which the sinks are within the bathrooms; the HCWs perceived the bathrooms as the patients’ private space, not as accessible to all. So there may be something to this.

But retrofitting is expensive. And the bill will be paid by… ??

Of course we would never have thought of that.

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A new paper in the Annals of Internal Medicine suggests an astounding technique for figuring out whether patients experienced an adverse event while in the hospital:

Asking them.

No, really.

The study by Massachusetts researchers (from University of Massachusetts, Brown, Harvard, Massachusetts Department of Public Health and Massachusetts Hospital Association) looked back at the experience of more than 2,600 patients in 16 Massachusetts hospitals during 6 months in 2003. The researchers started from the assumption that the medical-records review done by many hospitals to spot adverse events was not capturing enough information — and that the interviews that some hospitals do with patients after discharge were asking the wrong questions because they focus only on satisfaction.

So the team did a 20-minute phone interview 6 to 12 months after discharge for 2,600 patients, asking about “negative effects, complications or injuries,” and also reviewed the medical records of 1,000 patients who agreed to their charts’ being released for review. For each arm of the study, two physician-reviewers checked results to be sure what was scored as an adverse event actually qualified as one.

And they found: That twice as many adverse events were uncovered when patients were asked about their experience. Among the interviewees, 23 percent reported an adverse event; when records were reviewed, only 11 percent of patients were judged to have experienced one.

Now, let’s be clear: I’m very glad these researchers had the courage to do this study. Anything that supports better care, more transparency in care and more responsiveness to the patient’s experience is a good thing and I support it.

But when I think of the dozens of hospital patients and family members who have told me about their experiences with poor infection control — lack of hand-washing, lack of housekeeping, bloody gauze on floors — and with being completely unable to get anyone in those hospitals to pay attention, it just makes me want to beat my head against a wall. Coming up with the idea of asking the patients about their experience… this is so hard?

As one of the co-authors, Saul Weingart of Dana-Farber Cancer Institute in Boston, said in an accompanying press release: “It’s pretty clear that they can teach us important things about improving patient safety, if only we ask them.”

The cite is: Weissman, JS et al. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med 2008; 100-108.

MRSA colonization – the long-term risk

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One of the ongoing puzzles of MRSA’s behavior is the significance of colonization, that situation of MRSA living on the skin — or in the nostrils or other locations close to the body’s external surface — without causing illness. It’s not known how frequently MRSA colonization occurs, for one thing: The long-standing estimate of 1% of the population has been challenged by a number of recent studies.

Another persistent question has been whether the risk of illness and death changes as colonization continues. It has been established that up to one-third of newly colonized carriers will become seriously ill within a year of their acquiring the bug (Huang, SS. et al., Society for Healthcare Epidemiology of America Annual Meeting 2006, abstract 157 – not online that I can find)— but what happens beyond that? Does the risk of illness persist or decrease?

In Clinical Infectious Diseases, the same team that defined the risks of recent colonization report that there are significant risks to long-term carriage as well: 27% of invasive illness in the second year and 16% thereafter, based on a review of 281 patients who were followed for at least one and up to four years at Brigham & Women’s Hospital, a Harvard Medical School teaching hospital. These patients become very ill, and in addition use a significant amount of health-care resources:

At our hospital, there are 2–3 times as many hospital admissions involving patients previously known to harbor MRSA than there are hospital admissions of individuals who are newly detected as MRSA carriers each year.

What is the precipitating event that tips MRSA carriage over into MRSA illness? It may be health care. In other words, the long-term carriers do not become ill with MRSA disease and then come to the hospital. Instead, they come to the hospital for some other reason, and the surgery, IV placement, dialysis etc. they receive allows their MRSA strain to slip past the protective barrier of their skin and begin an invasive infection.

We submit that these high risks of MRSA infection among culture-positive prevalent carriers are not only preferentially detected because of hospitalization but may, in fact, be incurred because of the device-related, wound-related, and immunologic declines associated with a current illness.

This raises the question of whether any admitted patient found to be colonized should undergo the routine known as decolonization before any other procedures are performed — and whether institutions and insurance companies will be open to the additional hospital days and drug costs that will represent.

The cite is: Datta, R. and Huang, SS. Risk of Infection and Death due to Methicillin-Resistant Staphylococcus aureus in Long-Term Carriers. Clinical Infectious Diseases. 2008 47:176-81.

Isolation: Doesn’t work if healthcare workers contaminate themselves afterward

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In the new Emerging Infectious Diseases, there is a small but very smart study that ought to get wider play. It was done by a PhD candidate at University of North Carolina, Chapel Hill named Lisa Casanova, with the help of faculty and the local health department.

Background: In certain highly infectious environments — including in-hospital isolation — healthcare workers wear what is usually known as “personal protective equipment” or PPE. PPE generally includes gloves, gown and an eye shield, goggles or face-splash guard (also called “barrier precautions”) as well as a mask or a respirator (“respiratory protection”). PPE protects the healthcare worker while he or she is in the patient’s presence, but it poses a problem when the worker leaves that environment, because the PPE is likely to be carrying the disease organism on its surface. If the worker doesn’t doff the PPE very carefully, he or she might contaminate himself/herself and become infected or colonized, or spread the organism further in the healthcare environment.

This accidental contamination was a significant problem in the 2003 SARS epidemic — so after SARS was over, the Centers for Disease Control and Prevention came up with a recommended procedure for taking off PPE (on this page, half-way down). Casanova decided to test how well the protocol actually works.

Answer: Not so much. She had 10 volunteers (men and women, left- and right-handed) dress in PPE, contaminated the equipment in certain spots (“front shoulder of gown, back shoulder of gown, right side of N95 respirator, upper right front of goggles, and palm of dominant hand”) with a benign virus, had the volunteers take off their PPE, and then tested them for the virus’s presence. Results:

Transfer of virus to both hands, the initially uncontaminated glove on the nondominant hand, and the scrub shirt and pants worn underneath the PPE was observed in most volunteers.

Casanova recommends changes: additional PPE; different PPE and doffing protocols, such as are used in surgical suites; or PPE impregnated with antimicrobials. (#1 and #3 of course would be more costly; #2 would require procedural change but not necessarily additional garments).

She also raises a vital ongoing issue for MRSA infection control: that healthcare workers may not be punctilious about hand hygiene because they believe that gloves are adequate protection. Only, as this study demonstrates, they are not:

This study also indicates the need for continued emphasis on hand hygiene. A barrier to improving hand hygiene compliance rates is the belief that gloves make hand hygiene unnecessary (14). This is contradicted by our study and others showing that organisms can spread from gloves to hands after glove removal (15). Even if double gloving is incorporated into protocols for PPE use, it is not a substitute for proper hand hygiene.

The cite is: Casanova L, Alfano-Sobsey E, Rutala WA, Weber DJ, Sobsey M. Virus transfer from personal protective equipment to healthcare employees’ skin and clothing. Emerg Infect Dis. 2008 Aug; [Epub ahead of print]

Closing the loop: meat, meat-eaters, health-care workers

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A posting on the international disease-alert mailing list ProMED led me to a scientific abstract presented at a European meeting this spring on the ST 398 MRSA strain. It adds another, quite unnerving piece to the emerging interplay of MRSA in pigs, humans who have close contact with pigs, humans who have contact only with pig meat, and health-care workers who treat those humans.

Brief precis: About a year ago, Dutch health authorities discovered that a patient who had come in for surgical debridement of a diabetic foot ulcer had an unrecognized MRSA strain in that ulcer. Subsequently, they discovered that four other patients and five health-care workers in the same institution were carrying the same strain. None of the patients reported any contacts with pigs (or calves, which have also been found to carry the strain). One of the health-care workers lived on a farm that raised pigs, but said that she had no contact with the animals in her daily life; nor did her partner.

The authors conclude:

While the source is not fully established it could be the HCW living on a pig farm. This outbreak makes clear that transmission on a larger scale can occur, even with NT-MRSA.

(Hat-tip to Helen Branswell of the Canadian Press for telling me about the ProMED report. And a note to loyal readers: The “MRSA in meat” story is being picked up by some US newspapers. Doesn’t it feel good to know you’ve been reading about the issue here for months? And if you’re a reader of Helen’s work, months more? Of course it does.)