Nightmare bacteria

CNN today picked up on the CDC director calling antibiotic resistant strains of enterobacteria 'nightmare bacteria':

CDC: 'Nightmare bacteria' spreading

Hospitals need to take action against the spread of a deadly, antibiotic-resistant strain of bacteria, says the Centers for Disease Control and Prevention. The bacteria kill up to half of patients who are infected.

The bacteria, called carbapenem-resistant Enterobacteriaceae or CRE, have increased over the past decade and grown resistant to even the most powerful antibiotics, according to the CDC. In the first half of 2012, 200 health care facilities treated patients infected with CRE.

"CRE are nightmare bacteria," CDC director Dr. Tom Frieden said in a statement. "Our strongest antibiotics don't work and patients are left with potentially untreatable infections. Doctors, hospital leaders and public health must work together now to implement CDC's 'detect and protect' strategy and stop these infections from spreading."

Proximity patterns

Here's a neat idea:

To investigate transmission pathways, European researchers of the SocioPatterns collaboration fitted 119 people in a ward of the Bambino Gesù Children's Hospital with radio-frequency identification (RFID) badges. The tags registered face-to-face interactions—and the potential spreading of airborne pathogens.

The original 2011 research paper is here: Close Encounters in a Pediatric Ward: Measuring Face-to-Face Proximity and Mixing Patterns with Wearable Sensors

When Scientific American reported on this research they included a series of striking diagrams that may, or may not, help interpret the results!

Ask a lawyer

An interesting question in class today - can you sue the hospital if you get a hospital acquired infection?

Just googling any version of this query brings up a lot of similar questions and links suggesting this is a pretty popular question.

Lets ask a lawyer:

Can I sue a hospital if I contract MRSA while in the hospital?

Answer (from an Ohio 'MRSA lawyer' !):


In order to sue a medical provider in Ohio and in many other states, you have to show that the hospital or medical facility had a duty to keep you safe, was negligent in that their treatment standard of care fell below that of an ordinary hospital in the area, and that as a result of their negligent and careless acts, you contracted MRSA or did not get treated quickly or effectively with negative consequences.

As any competent MRSA lawyer / attorney will tell you, if you want to sue a hospital or medical provider after you contract MRSA, you have to basically show they did something wrong that led to you contracting MRSA or not get treated correctly for MRSA.  As you can see these cases depend on the specific facts of each case. This breaks down to basically several theories of negligence? I will discuss four of them here.

Negligence / Failure to protect you from danger of catching MRSA
Delay in diagnosing MRSA
Delay in treatment of MRSA
Using wrong drugs to treat MRSA

So the key issue is negligence which can be difficult, but not impossible, to prove. Getting an infection and proving it came from the hospital is not sufficient. You need to prove the hospital was, in some way, negligent. The fact that some individuals have won big settlements has attracted a swarm of lawyers who are eager for cases. (I found this on one site: 'hospital infections are said to be the next asbestos'. The good news is that this may lead hospitals to improve their practices. The bad news is that it will further drive up medical costs.

Speaking of fomites

Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens?

Short answer: Yes

Long answer: Significantly higher rates of pathogens (39.6% vs 20.6%, respectively; P = .02) were found in mobile phones of patients' (n = 48) versus the health care workers' (n = 12). There were also more multidrug pathogens in the patients' mobile phones including methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Escherichia coli, and Klebsiella spp, high-level aminoglycoside-resistant Enterococcus spp, and carabepenem-resistant Acinetobacter baumanii. Our findings suggest that mobile phones of patients, patients' companions, and visitors represent higher risk for nosocomial pathogen colonization than those of health care workers. Specific infection control measures may be required for this threat.

 

Seething cauldron

 
Restaurants are inspected for cleanliness but not hospitals. Not even operating rooms. You can go home and make your own dinner...

Hospital acquired infection from the PBS Second Opinion series.

Teaching hospital medical staff to handwash

Someone asked for the reference for the Australian handwashing study. The papers is called  Teaching hospital medical staff to handwash, and is from the Medical Journal of Australia in 1996.

The study contains several more elements than I mentioned in class including an initial covert observation (the low rates of ~10% I mentioned), an estimate by medical personnel of their compliance rate (the 73% figure I mentioned), a period of overt observation and finally a period of overt observation and performance feedback.

In this case handwashing rates covertly observed 7 weeks after the end of the study were ~50%, a huge improvement on the initial values of ~10%. The authors drew the conclusion that 'Performance feedback is moderately effective in training hospital medical staff to handwash'. I guess 50% is better than 10% but it takes the offer of a free cup of coffee to get it higher...

Starbucks and nosocomial infection

What does Starbucks have to do with nosocomial infection? Well if you read the second Freakonomics book, perhaps not surprisingly entitled 'Superfreakonomics', you'll have recognized part of today's lecture. The author's, economists Steven D. Levitt and Stephen J. Dubner, narrate the same story from Semmelweis's amazing conclusion to today's problem of poor handwashing compliance in hospitals. However because they are economists their main interest is in how this problem is best addressed - by punishing doctors who fail to wash their hands, by education and regular reminders, or by rewarding doctors who do.

Levitt and Dunbar cite a study at Cedar-Sinai hospital where they had identified low compliance with hand washing protocols as a problem. Initially the hospital tried gently cajoled the doctors with e-mail, faxes and posters. But that didn't work. They knew this because the  hospital had enlisted a crew of nurses to surreptitiously report on the doctor’s hand-washing.

They then started a Hand Hygiene Safety Posse that roamed the wards but rather than searching for doctors who weren’t compliant, they’d try to “catch” a doctor who was washing up, giving him a $10 Starbucks card as reward. You might think that the highest earners in a hospital wouldn’t much care about a $10 incentive but this simple startegy was very effective and compliance rose to about 80 percent as doctors competed for Starbucks cards! By utilising the screen saver I showed in class as a continual reminder to doctors they were able to raise it even further - apparently close to 100%

The antiotic resistance

Although we will generally proceed forward in this course at a steady pace, covering a new disease and topic each week, there are some topics that overlap. For example in week 6 we will discuss nosocomial, or hospital acquired, infections. As we will see then the problem is made much worse by the problem of antibiotic resistance. This cartoon is correct - the best place to find antibiotic resistant strains of bacteria is in hospitals.

He not busy being born is busy dying

Chris sent me a link to this movie, The Business of Being Born, that is very relevant to our discussion today. The website contains a trailer and some interesting information in the Press Notes. Looks like you can get it from Netflix.

Among 33 industrialized nations, the United States is tied with Hungary, Malta, Poland and Slovakia with a death rate of nearly 5 per 1,000 babies, according to a new report from Save the Children (April 2006). This is the second worst newborn death rate in the developed world. The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway – midwives were used as their main source of care for 70 percent of the birthing mothers. Cesarean section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years. (In 1970 the rate was 5.5%). A new report by the World Health Organization, published in the international medical journal, Lancet, identifies complications from cesarean surgery and anesthesia as the leading causes of maternal death in developed countries, including the United States.

Safe Patients, Smart Hospitals

This relates to the topic of nosocomial infections from a few weeks back but I thought this interview with Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, in the New York Times on Monday was interesting. Click the link for the full interview, I've just posted some snippets below. Even something as simple as making sure supplies are together and at hand can reduce infections:

At Hopkins, we tested the checklist idea in the surgical intensive care unit. It helped, though you still needed to do more to lower the infection rate. You needed to make sure that supplies — disinfectant, drapery, catheters — were near and handy. We observed that these items were stored in eight different places within the hospital, and that was why, in emergencies, people often skipped steps. So we gathered all the necessary materials and placed them together on an accessible cart. We assigned someone to be in charge of the cart and to always make sure it was stocked.

Q. WHAT CAN CONSUMERS DO TO PROTECT THEMSELVES AGAINST HOSPITAL ERRORS?

A. I’d say that a patient should ask, “What is the hospital’s infection rate?” And if that number is high or the hospital says they don’t know it, you should run. In any case, you should also ask if they use a checklist system.

Once you’re an in-patient, ask: “Do I really need this catheter? Am I getting enough benefit to exceed the risk?” With anyone who touches you, ask, “Did you wash your hands?” It sounds silly. But you have to be your own advocate.

Hospital Survival Guide

I said in class that there wasn't much you could do to prevent nosocomial infection in hospital but the Daily Mail, a British Newspaper, had an interesting article today that comes up with a variety of obvious, and not so obvious, ways you can help reduce the chances of infection if you do have to have an operation.
Your hospital survival guide: The ingenious tricks that can save you from superbugs and other hospital disasters

• Swallowing 300mg of aspirin daily for three days prior to surgery can halve your risk of developing a deadly infection, according to research from Dartmouth College in the U.S.

• Keep visitors off your bed. If they truly wish you a speedy recovery, your visitors should take a seat in a chair, not on your sheets. In a study published in the British Medical Journal, researchers found that a combination of infection-control strategies that included eliminating visitor contact with a patient's bed was able to stop the spread of MRSA and reduce the number of infections by 70 per cent.

and of course:

• Don't touch the toys!. Any children coming to visit need to be kept away from toys littering the waiting room. When University of Nottingham researchers swabbed the surfaces of 12 toys in an intensive-care unit, they found half of them swarming with various strains of bacteria, including Staphylococcus aureus.

Nosocomial Related Deaths

Despite the efforts of Florence Nightingale, Holmes, and Semmelweis to help prevent the spread of deadly infections, 100,000 people in the US die from nosocomial infections annually. Although the rate of acquiring a nosocomial infection has remained stagnant for the past few decades, the rate of nosocomial infections per 1,000 patients has increased over 2% due to shorter inpatient stays. To decrease nosocomial infection rates by 1/3, hospitals and health care facilities would only need to have an effective hospital epidemiologist, one infection control practitioner for every 250 beds, active surveillance mechanisms, and ongoing control efforts. That’s it. To read the rest of the CDC’s findings, visit http://www.cdc.gov/ncidod/eid/vol4no3/weinstein.htm.

The Nosocomial Colonization of T. Bear

The Nosocomial Colonization of T. Bear
Walter T. Hughes, Bonnie Williams, Bobby Williams and Ted Pearson Infection Control, Vol. 7, No. 10 (Oct., 1986), pp. 95-500

It's worth a quick read. The bear's (and yes, technically they are known as T.Bear) were already being used in a program in the hospital to encourage handwashing!

In view of the potential hazard, we suggest that this item not be used in hospitals or day care centers as recommended by the NIH and T. Bear Foundation. It must be emphasized that our criticism is not of the T. Bear Handwashing program, but rather of this one item utilized by the program. Nevertheless, although extensive development and promotion of the T. Bear Program are well under way at the national level, we are not aware of any objective experimental studies that have been reported. The program caused excitement at our hospital. Patients, parents, nurses, doctors, housekeepers, and technicians begged for a lovable T. Bear and the colorful lapel badge. But the objective is not fun with teddy bears, but rather washing hands to prevent infection. Will the T. Bear concept influence the busy surgeon, pediatrician, nurse, anxious parent, or sick child to perceive hand- washing to be "kid stuff' or an effective modality for preventive medicine? It would seem that objective motivational studies are warranted.

Summer re-runs - part 6

The Daily Show With Jon StewartM - Th 11p / 10c

Bubonic Plague

Daily Show Full Episodes
Important Things With Demetri Martin

Funny Political News
Joke of the Day

Some nosocomial infection and antibiotic resistance favorites:

• Almost inevitable
• Patients flee, drawing attention to quarantine dilemma
• Meet the Clostridiums
• XDR-Tb in California

"Old" Blood - Higher Infection Rate

A study presented at CHEST 2008 (a gathering of the American College of Chest Physicians - read about it by clicking the link) stated that patients who receive transfusions with blood stored for 29 days or more were twice as likely to suffer from nosocomial infections. Federal regulations currently allow blood to be stored up to 42 days - almost two weeks after the 29-day mark.

Cooper University Hospital researchers studied the relationship between the age of the red blood cells and the development of nosocomial infections, testing 422 patients receiving blood transfusions. They found:

• A higher portion of blood is "old": “Previous data indicate that the average age of transfused blood is around 17 days old...[but in] our study, the average age of blood was 26 days, and 70% of all the blood transfused was older than 21 days."
• Not only did over 10% of patients die, but some had multiple nosocomial infections: "The analysis showed that 11 percent of patients died, while 57 patients (13.5 percent) developed NOSO: 32 patients developed one, 21 developed two, and 4 developed three."
• Those who did develop nosocomial infections had older blood: "Patients who developed NOSO had a significantly higher age of the “oldest” unit of blood (28.5 days vs. 32 days)."
• And the final conclusion: "Patients who received transfusions with blood that was 29 days or older were twice as likely to develop NOSO as those receiving transfusions with blood stored for 28 days or less."

Some fear that strict regulations regarding blood donation and storage will result in a dangerous shortage. More research is what is necessary for an answer to this problem.

Breaking News

Just hitting the news today

Michael Jackson has a severe antibiotic resistant staph infection that he contracted during work to reconstruct his nose. The infection has spread and is inflaming his hands and face, or possibly his entire body, depending which news report you believe

He is currently receiving antibiotics via an IV drip at a Beverly Hills clinic, to treat the severe "staph" infection, similar to MRSA (which may actually be MRSA).

Nosocomial infection in Canada

Clumps of methicillin-resistant Staphylococcus aureus bacteria, magnified nearly 10,000 times.

A similar story in Canada.

Every year, 250,000 Canadians pick up infections while they are in hospitals being treated for something else. That's a staggering one out of every nine Canadians who are admitted to hospital. Every year, those infections kill more than 8,000 people.

That's more than will die of breast cancer, AIDS and car accidents combined. Many of those deaths can be prevented - by simple hand washing.

I'm not sure exactly why this was in the news today but I thought this article on 'The War against Superbugs' from CBCNews was quite nice.

Previous posts of relevance:

• Meet the Clostridiums
• Patients flee, drawing attention to quarantine dilemma
• MRSA infection

The Fight Against Nosocomial Infection

Scientists at The University of Nottingham are leading a major 3 million euro, 3 year study to unravel the genetic code of one of the most lethal strains of hospital acquired infections, Clostridium difficile.

They hope to use gene knock-out technology study the function of genes in this bacteria and hopefully get some answers, like why C.difficile is harder to eradicate and more resistant to antibiotics.

One scientist stated that “worryingly,” there are only two antibiotics still effective against these hypervirulent organisms. The fact that there is a “very real danger that total resistance may arise” is extremely serious.

The scientists hope the studies will point out genome differences between this strain and its less virulent cousins; this way, they can understand its spread and the way it causes disease. If you are interested in reading more about how the study will work, click here.

Hospital Acquired Infections

If you go into an intensive care unit in a major Sydney hospital it is almost inevitable that you will get MRSA if you stay long enough."
Richard West, chair of the Royal Australasian College of Surgeons infection control advisory committee.

I doubt that many of you read a Sunday paper any more. I can't say I blame you, most of them are pretty dire. Amongst the worst parts is the awful 'Parade' magazine that is a supplement carried by a large number of papers throughout the country. However it is so bad that it is usually worth reading and it always contains at least one splendidly awful advertisement - many of them from the Franklin mint where parody is indistinguishable from their usual tastelessness. But anyhow I digress, this week's parade (I only read it for the ads) contains a feature article 'Avoiding Hospital Mistakes' with a section on Hospital Acquired Infections:

Hospital-Acquired Infections
The Risk: The Centers for Disease Control and Prevention report that 99,000 patients a year die from hospital-borne infections. Germs are everywhere: on surfaces, doorknobs—even your doctor’s necktie.

What You Can Do:

• Ask anyone who examines you to wash his hands.
• Ask your doctor or nurse to clean her stethoscope before it comes in contact with your skin.
• If you need a urinary catheter, make sure it is kept in for the shortest possible time.
• If you need a “central line” (an IV tube going into a major blood vessel), ask if they have tubes that are coated with antibiotics.
• If you have an IV, make sure it doesn’t stay in place for more than a week. Let the nurses know if it becomes loose.
• Every time a line or regular IV needs to be inserted, ask whether the hospital staff follows sterile procedures before inserting the tube or needle.

Whilst this might all be sound advice my memory of hospitals is that acting like a demanding jerk might incur some risks of its own.

Hospital infection rates

State health regulators approved a sweeping crackdown designed to stem the spread of infections inside hospitals, a crisis blamed for thousands of patient deaths and millions of dollars in unnecessary medical expenses. The Public Health Council voted unanimously to dispatch state inspectors regularly to hospitals to make sure they are following rules on preventing infections and reporting them promptly when they happen. The panel also approved a plan to issue report cards on infection rates for each hospital and to post that information on a state government website. A hospital that failed to comply with the rules or continued to have an excessive number of infections could potentially forfeit its license.

A state report last summer found that potentially lethal infections contracted during hospital stays could be responsible for up to $473 million in medical costs annually in Massachusetts, a reflection of extended hospital stays and medication and surgical costs. National studies estimate that up to 90,000 patients a year die because of infections they catch while in medical facilities, with deadly germs gaining entry through surgical incisions and catheters and sometimes transmitted by doctors and nurses who fail to wash their hands. Here is the link to this article by the Boston globe.