infectionNet - for people who manage infections

Antibiotic resistance is rapidly escalating and is a threat to us all. It is the "global warming" of medicine and just as energy consumption will necessarily continue, so will consumption of antibiotics. Resistance to antibiotics can't be completely "fixed" but must be actively managed - forever. As antibiotic consumption cannot be optimized by market distribution active regulatory control is the only option.

At present there are many uncoordinated levels of regulation of drug distribution in Canada. Federally, a new drug must be approved for sale by Therapeutic Products Directorate (TPD). Once approved (given a "notice of compliance" with regulations) a manufacturer can market the drug to prescribers. However, the central marketing effort is directed toward large governmental and third party payers as the vast majority of human drugs in Canada are payed for by these institutional drug plans. Each province and territory has their own drug plan and their are several large private plans that provide coverage to employees of private companies, unions members, government employees, and some individuals. The provincial drug plans vary widely in structure, eligibility, coverage, administration and means and levels of cost sharing.

The current infection control mantra advocating actively seeking out the humans harboring antibiotic resistant bacteria and "decolonizing" them with antibiotics is fabulously flawed and shortsighted. More antibiotics will certainly not be a fix for the complex problem of antibiotic resistance.

There will always be bacteria circulating in human populations. Staphylococcus aureus, Streptococcus pyogenes and Streptococcus pneumoniae have been living in and on humans since the inception of humanity. When a new or "re-circulated" type (strain) enters a population, as is happening now with so-called community-associated MRSA (USA type 300 or Canadian type CMRSA 10), some people will become ill with relatively minor illness. An unfortunate few will have serious illness. Many more will become immune without illness. The strain will spread widely and over time will appear to be less virulent (able to cause disease) as the immunity of the population increases. It will be transmitted less efficiently as there will be fewer people with overt disease and fewer susceptible individuals. Another strain will emerge that has an advantage and the complex story will write its next chapter.

It is simply not possible to fundamentally change this circumstance by focussing on the individual "bad" organism and killing it with more antibiotics. While "decolonizing" has a well-defined benefit in particular circumstances (the use of antiseptics and antibiotics prior to surgery is the best example), it certainly can't be viewed as a rational public-health response to a continuously changing world-wide ecologic problem. The extreme efforts focussing on individual organisms are stifling the debate on fundamental solutions for managing (not eliminating) antibiotic resistance and infections caused by antibiotic resistant microorganisms. Firstly, we need much more attention to antibiotics at all levels. Programmatic approaches to optimizing their distribution are essential. Secondly, we need a major renewal of healthcare infrastructure engineered to limit the spread of microorganisms. There is absolutely no reason why Canadians can't address these issues and become world leaders.

The antibiotic resistance file must be elevated on all agendas.

Everybody pees. Urinals are poorly designed. Pee ends up on shoes and pants and floors.

Someone in the Netherlands tackled this problem and designed a urinal that efficiently catches pee and uses a clever bit of psychology to help the boys leave the maximum amount of pee in the urinal. A fake fly is etched on the porcelain in precisely the right spot.

By the time it is realized that the fly doesn't move the pee is collected - simply brilliant.

One patient, one room, one bed, one sink goes the infection control rhyme. That was until a Pseudomonas aeruginosa outbreak between December 2004 and March 2006 at Toronto General Hospital killed 12 transplant patients.

The issue: tall, high pressure 'gooseneck' sinks drove water straight into the drain hole of the sink without getting water into the basin.

The problem: sludge in the bottom of the sink containing Pseudomonas aeruginosa was splashed out of the drain when the high pressure water hit it and transported around the room when people washed their hands.

The solution: Who knows best on this one? The doctor? The Infection Control Practitioner? The epidemiologist? The engineer?

The answer is likely all of the above.

First things first

Design is important and needs to be first. Before cost, before space, before time, before everything else, things need to be designed and evaluated. Things seem to get designed these days to fill a space, or fit along a wall, or to be this tall by this wide, and once the right ratio of tall-ness to wide-ness is achieved, the evaluation is over.

Design is how it works, not how it looks.

Since the 1980s Clostridium difficile colitis had been recognized as a, generally manageable, adverse consequence of antibiotic therapy. Not surprisingly, outbreaks in hospital were associated with shared bathrooms. Patients usually responded well to therapy and infection control efforts focused on cleaning and providing a private room and bathroom to those affected. Most often outbreaks were relatively easily managed. It was a regularly recurring nuisance type of problem for infection control practitioners.

However, the evolution and spread of an extremely virulent strain of C. difficile (referred to as NAP1 in Canada) has changed the landscape. The likelihood of severe disease ending with colectomy or death has markedly increased. Overall incidence has increased and outbreaks sustained. Canadians are truly dying for the lack of a toilet. Primary prevention is essential.

Canadian hospitals are aging and a cycle of renewal is beginning. We must make sure that acute care hospitals are constructed with a one patient: one toilet ratio. The added capital costs will be recovered many fold in infection avoidance. We need standards that explicitly state the requirement for a toilet for each patient and a maximum of 2 patients per room - Provincial standards and National standards. Lets make it the law.