infectionNet - for people who manage infections

If your hands and wrists are not bare, if your nails aren't short and tidy, you can't wash your hands properly. We all learn this when we first go to the operating room and are introduced to the ritual of "scrubbing".

Well, it is time to bring the scrub to the wards. It's simple. We'll all take off our dirty white coats, roll up our sleeves, leave our rings and watches at home and scrub. Nothing fancy, no complicated rules about who has MRSA or VRE or C. difficile or ESBL, just good clean hands.

Here is a bit of foreshadowing of messaging for an upcoming campaign to encourage attention to simple measures to prevent infections.

We physicians have an obligation to be ecologists. Our collective actions are having measurable effects on the evolution of the microorganisms that live with us and occasionally infect us. Have a read of this paper I wrote with Dr. David Patrick of the BC CDC to see how you can be part of the solution to this ever-escalating problem.

Click here to check it out.

A recent article from The Lancet Infectious Diseases, July 2008, raises the issues of overcrowding and understaffing as key contributors to the rise in MRSA rates.

1. The drive towards greater efficiency by reducing the number of hospital beds and increasing patient throughput has led to highly stressed health-care systems with unwelcome side-effects
2. The economic benefits of downsizing health-care systems are likely to have been offset by the increased burden of adverse events, such as MRSA infection, leading to a false economy.
3. MRSA can compound problems of understaffing in hospitals through its effect on staff workloads and staff availability.
4. Large outbreaks of epidemic MRSA, or those that cannot be brought under control, might result in ward closure, the consequences of which can be seen as an extreme example of bed blocking.

Feel free to download, read and distribute the full pdf .

Abstract:

Recent decades have seen the global emergence of meticillin-resistant Staphylococcus aureus (MRSA), causing substantial health and economic burdens on patients and health-care systems. This epidemic has occurred at the same time that policies promoting higher patient throughput in hospitals have led to many services operating at, or near, full capacity. A result has been limited ability to scale services according to fluctuations in patient admissions and available staff, and hospital overcrowding and understaffing. Overcrowding and understaffing lead to failure of MRSA control programmes via decreased health-care worker hand-hygiene compliance, increased movement of patients and staff between hospital wards, decreased levels of cohorting, and overburdening of screening and isolation facilities. In turn, a high MRSA incidence leads to increased inpatient length of stay and bed blocking, exacerbating overcrowding and leading to a vicious cycle characterised by further infection control failure. Future decision making should use epidemiological and economic evidence to evaluate the effect of systems changes on the incidence of MRSA infection and other adverse events.

Other key points include:

1. In Australia, the requirement for hospital beds is predicted to increase by 70–130% by 2050.
2. fewer people in some high-income countries seem to be choosing nursing as a career, potentially contributing further to the ageing and diminishing size of the health-care workforce.
3. In the USA, these factors have led to an increase in the average age of registered nurses from 37.4 years in 1983 to 41.9 years in 1998 and 46.8 years in 2004.

From Lancet Infect Dis 2008; 8: 427–34

There has been a large amount of media attention afforded to infections caused by antibiotic-resistant “superbugs”. This is an opportunity to examine the consequences of the increasingly common practice of labeling people as colonized with superbugs for the purpose of applying special isolation precautions intended to minimize spread. By far, the most important of the current superbugs is methicillin-resistant Staphylococcus aureus or MRSA which is the focus of this opinion piece.

MRSA

Staphylococcus aureus (staph) is a normal human-associated bacteria (germ) that lives on the skin and, particularly, in the front part of the nose. All people are said to be “colonized” with staph – i.e. all people have staph in and on them. However, staph sometimes causes infections, most commonly in skin that has been damaged. It is the most common bacteria causing boils, abscesses, infected hangnails and infections in cuts and scrapes. Everyone has experienced at least a minor staph infection. More importantly, it is also responsible for many serious infections, in particular in hospital after surgical procedures.

In the 1950’s when antibiotics were first available most bacteria were easily killed by most antibiotics. The bacteria that commonly caused infections in people including Staphylococcus aureus were susceptible to the effects of early antibiotics like penicillin and tetracycline. However the miracle of antibiotics soon started to fade as bacteria became resistant to antibiotic effects and the race to find “new and improved” antibiotics began. The 1960’s through 1980’s were a time of heady optimism when the many new antibiotics that became available “solved” the problem of resistance. Methicillin (and related antibiotics) easily treated staph infections.

But the “bugs” continued to become more resistant to the effects of even new antibiotics. Particularly problematic was the development and spread of methicillin resistance in Staphylococcus aureus. The options for treating staph infections became very limited, often reduced to a single antibiotic – vancomycin that is only available in intravenous form. Methicillin-resistant types of Staphylococcus aureus (MRSA) became increasingly common particularly in hospitals and spread from patient to patient was well described.

Solutions to the “MRSA Crisis”

With spread of MRSA occurring in many hospitals, experts in Infection Control were challenged to find rapid solutions. However, the root of the problem was a very basic one. Canadian hospitals were physically inadequate to control the spread of any kind of bacteria. Basic principles of hygiene had been eroded by many years of “belt tightening”. Reductions in bed capacity had left hospitals commonly operating at greater than 100% capacity. The smaller numbers of patients admitted to hospital were much sicker on average. Cleaning and maintenance staffing levels had dwindled.

With real solutions (investment in infrastructure and human resources) not imminent, approaches turned to identifying the people that had the problem bugs (MRSA in particular) to apply special precautions aimed at limiting spread to other patients. Measures include use of private rooms, physical barriers (gloves, gowns etc), and increased cleaning of the environment near patient. The general term used is “contact precautions” for this above-normal attention to hygiene and signs are used to identify the special rooms. In order to apply this different level of hygiene to only those with MRSA a system of “flagging” patients was necessary. In most Canadian hospitals anyone found to have MRSA is identified in the hospital computer system and contact precautions are initiated when they present for their next episode of care.

Screening for Colonization

In the beginning, patients with MRSA were only identified when they had an infection. Soon, however, a process of seeking out patients that may be colonized with MRSA was advocated. This involves sampling material from the nose and skin for MRSA. This “screening” process was first used to check for spread of MRSA to patients that were close to someone that had a proven infection with MRSA. Typically, the patients sharing the same room would be screened and if MRSA found in their nose or on their skin they, too, would be isolated and flagged in the computer system. These colonized people do not have an infection but still can potentially be the source of spread to more patients. It is not known how long an individual will remain colonized but it may be a very long time or even forever. (Remember that staph is a normal human-associated bug and lives in and on everyone. The only difference between MRSA and other kinds of staph is that MRSA is more resistant to antibiotics).

The advocates of screening encouraged more widespread application culminating in screening of all patients being admitted to hospital as practiced in several Ontario hospitals and reported in the Globe and Mail a few months ago. Millions of dollars are being spent on increased staff and infrastructure to accomplish the task of separating patients presenting to healthcare institutions as the “Clean” (without MRSA) and the “Unclean”(with MRSA) for differential application of precautions to limit spread.

At present in Canada many thousands of individuals are labeled as having MRSA and registered in various databases in hospitals. This has very large implications.

Discrimination Issues

In hospital
Patients on “contact precautions” often get inferior care. Several reports have described the problem access to services. Less Xrays, less physiotherapy, less timely surgery are examples. Because of fears on the part of healthcare workers there is a natural tendency to avoid contact with patients identified as potentially infectious. It does not help that the term “superbug” is commonly used.

Patients on “contact precautions” get fewer visitors. This can be devastating especially to patients needing long stays. Family member fears can be extreme and near impossible to assuage.

Outside of Hospital
Analogous to the initial irrational fears surrounding patients infected with HIV, systematic discrimination in many areas is possible.

Employment
This is particularly troublesome especially for those employed or seeking employment in health care.

Housing
Access to group homes and shelters may be adversely affected for example.

Public services
Access to public transportation may by affected. Limited disabled person transportation in a community may put “superbug” people to the bottom of the priority list for example.

Education
“Superbug” status may be considered in acceptance criteria for all types of training.

As an expert in Infection Control I feel very strongly that the current direction of identifying individuals for special attention as a primary approach to the complex issue of antibiotic resistance is immoral.

While I recognize that some institutions have had short-term success in limiting the spread of MRSA using a “screening and isolating” approach, it is discriminatory and fails to address root cause. What is needed is renewed infrastructure and investment in human resources so that all Canadians needing institutional healthcare receive it in a safe fashion at all times. If all patients were in private rooms there wouldn’t be need for different precautions for MRSA patients because EVERYONE would be appropriately accommodated. If all rooms were cleaned as we now clean rooms housing MRSA patients there would be no need to identify any room as special.

MRSA is not the last antibiotic-resistant bug that will be a problem for Canadians. It is certainly not the only bug that is spread in inadequate healthcare facilities. This complex and exceedingly important issue will not have a simple solution.

Until such time as we find sensible, sustainable, equitable approaches, we must recognize the large sacrifices made by the unfortunate persons identified with “superbugs”. All efforts to mitigate any negative consequences must be made. This may include identifying “superbug” status as prohibited grounds in human rights legislation.

Ontario auditor claims poor hand hygiene and housekeeping standards helped the spread of C. difficile in Ontario hospitals.

The report's findings include:

1. hospitals do not always properly sterilize surgical instruments
2. ensure that rooms occupied by patients with [c. difficile] are adequately cleaned
3. only 28% of physicians were complying with pilot hand hygiene program
4. hospitals do not have systems to monitor use of protective equipment (gloves, gowns, masks, etc)

The director of infection protection and control at Toronto's University Health Network, Dr. Michael Gardam, says,

"We've known for quite a while that we need good housekeeping standards and guidelines to help hospitals know how much they're supposed to be cleaning and how often," [...] "All these things are issues that have been on the radar for quite a while."