Wash your hands or lose your job

We've been talking the past few days about hospital infection control: Is it as simple as Sir Richard Branson suggests? Or as complex as Paul Levy's commenters make it appear?

The National Health Service of Scotland comes down on the side of simple. It is poised to enact a new, no-tolerance policy: Wash your hands or lose your job.

It is important to add that the Scottish health service (a subset of the National Health Service of the entire UK) has actually done a good job of promoting hand hygiene in its hospitals. A year ago, an audit showed that Scottish hospitals were at 79% compliance, and so the service set a 12-month goal of 90% compliance.

(All of these numbers, by the way, are better than in the United States, where even intensive attention to hand-washing gets even caring hospitals only to about 70%. And yes, it is true that hand hygiene alone does not equal infection control — but it is the basic building block. If you can't establish hand hygiene, what are your odds of accomplishing more complex interventions?)

But now they've decided to go for 100%. In Scotland the move is being applauded. The Glasgow Evening Times editorialized:

If it takes the threat of the sack to make medical staff wash their hands then it is a justified action. It is scarcely credible that up to 10% of doctors, dentists and nurses do not practice this basic hygiene measure.

Anyone want to disagree?

Reducing healthcare infections - what it really takes

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?"

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.

Terribly sad story from Florida

Cody Shrout, a 12-year-old 6th-grader who lived in Daytona Beach, Fla., was found dead in bed a week ago today by his 8-year-old sister.

His death was initially put down to chickenpox, which was circulating in his school, but the Volusia County medical examiner determined Tuesday that his death was due to MRSA.

Two weeks ago, he scraped his knee skateboarding, subsequently spiked a 103+ degree fever, was treated at a local ER and sent home. The story describing his treatment quotes his grandfather in a way that suggests the scrape was treated as a sports injury, with ice and ibuprofen.

Cody lived with his mother, sister, 3-year-old brother and grandfather. His mother, who is single, could not afford a funeral. With extraordinary generosity, Heather and Jason Jenkins, who own a plumbing business in Apopka, Fla., have paid for the funeral. He will be buried Tuesday.

An odd tidbit in this very sad story: Ten months ago, according to the Daytona Beach News-Journal, he was treated at that same medical center for a staph infection. The story doesn't say whether he was an admitted patient or seen in the ER, and also doesn't say whether it was MRSA or drug-susceptible staph. Interesting, though.

MRSA and jails and public reaction

I have a GoogleNews Alert set to crawl for any new posts that mention MRSA. The Google crawler goes pretty deep and often finds things that I would not have known to look for; this week, it has produced a letter to the editor about conditions in a women's jail in South Florida.

The letter itself is interesting, but the public reaction to it, in the form of comments on the website where it was reproduced, is breathtaking.

Here's a quick recap: A woman named Susan M. Woods writes in the letters to the editor on TCPalm.com (which appears, after some drilling, to be a joint site for the Stuart, Fla. Treasure Coast News/Press-Tribune, the Vero Beach Press Journal, the Jupiter Courier, and the Sebastian Sun) about conditions at the Indian River County Jail, where she has been an inmate:

The absolute squalor women are forced to live in is similar to a Third World country. Backed-up toilets, black mold, roaches all around, and nothing to clean the common areas except diluted Windex — it’s frightening. It should be no surprise to hear that at least seven women have gotten MRSA — a staph infection — in as many months.

It will not surprise any of you who follow news about MRSA that jails and prisons are particularly vulnerable to outbreaks; the Los Angeles County Jail epidemic (first described in this MMWR article and further described in this one and covered in this book, which was written by, umm, me) has been going on for half a decade at this point and has affected thousands of prisoners. That there is an outbreak in a jail in Florida is exasperating and sad.

But that people in Indian River County think prisoners somehow deserve staph is just astounding. In the comments on Woods' letter, they say:

In my opinion, someone with Susan's alleged criminal record deserves far worse conditions in her cell than what she is describing in her letters.

You are supposed to not want to be there you idiot. That's why its like living in a third world county.

The conditions in jail are horrendous but people keep coming back. What should the taxpayers do then? Take money away from roads, schools, emergency services to make sure the jails are clean, bright and cheery? Or hope that the bad conditions convince just one moron to obey the law.

If I understand the trolls commenters correctly, they believe that prisoners forgo human rights to such an extent that it is an appropriate part of their punishment to subject them to infectious diseases. So, OK: If they are unmoved to care for their fellow humans, we will leave them to their karma.

But really: Don't they want to take care of themselves? It is well-established by now that MRSA in jails does not stay in jails: It moves out into the community when inmates who acquire it in jail are released and return to the outside. So unless you're going to argue that people in jail should remain there indefinitely — which seems impractical given the rate at which we put people away — to be concerned about MRSA in jails is self-protection if nothing else.

File under Unintended Consequences, 2

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

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.

Even more bad news on new drugs

Via Forbes.com comes news that the Food and Drug Administration has turned back Targanta Therapeutics' application for its new antibiotic oritavancin, which was designed specifically to target drug-resistant staph, and has asked for additional trials. This is a follow-on to a decision by an FDA advisory panel last month that also expressed doubt about the drug.

This comes on the heels of last month's withdrawal of dalbavancin and delay in approval of ceftobiprole.

The long, thin pipeline of new drugs for MRSA just got longer and thinner.

More on MRSA pneumonia, flu and ER delays

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.

In excellent company

Constant readers, I'm pleased to report that SUPERBUG has been listed among 100 Global Health Blogs That Will Open Your Eyes by US PharmD+, an online info source for pharmacy education and the pharmacy profession.

We are in excellent company: Also listed are Effect Measure, Pump Handle, H5N1, Aetiology, Pharmalot and the indefatigable and indispensable crew at ProMED-Mail.

There are a number of intriguing-looking blogs on the list that I did not know about. I urge you to take a look. And much appreciation to Kelly Sonora and USPharmD+ for highlighting these resources and including this blog among them.

It's flu season: Watch for MRSA pneumonia.

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).

More bad news on new drugs

The Infectious Diseases Society of America (IDSA) has published a new report that fills in the background on last week's news below, and confirms: The landscape for new drugs against MRSA and other multi-drug resistant organisms is bleak. (The organisms, summarized in the acronym ESKAPE, are: E. faecium, MRSA, Klebsiella, Acinetobacter, Pseudomonas aeruginosa and Enterobacter.)

The report, published in the journal Clinical Infectious Diseases, is both an update of surveys of the new-drug landscape done in 2004 and 2006, and also a call to action that asks for broad federal effort to encourage pharma companies to produce new drugs.

Here are the highlights:

• Since the last iteration of the survey in 2006, only one new antimicrobial, doripenem — a very broad-spectrum injectable that is most active against the Gram-negative bacterium P. aeruginosa — has been approved.
• Only three new compounds — ceftobiprole, dalbavancin and Paratek Pharmaceutical's PTK-0796 — are in their final rounds of trials. (The report was obviously written before the latest news about ceftobiprole and dalbavancin.)
• Four of seven efforts to achieve a staph vaccine have been terminated.
  
• Though the pharma industry, through its lobbying arm PhRMA, claims "388 infectious diseases medicines and vaccines and 83 antibacterial drugs in development", that number is misleading:

Careful review of these data reveals that most are preclinical and phase 1 compounds. Also included are topical and nonabsorbable antimicrobials, which we do not consider here, and several compounds for which development has been terminated. Finally, ... many of the listed drugs are previously approved agents that are being studied for new indications.

Just to make sure no one misses the big picture, the authors emphasize:

...The number of new antibacterials that make it through the complete development process and ultimately receive FDA approval has precipitously decreased over the past 25 years. Indeed, we found a 75% decrease in systemic antibacterials approved by the FDA from 1983 through 2007, with evidence of continued decrease in approvals, even during the most recent 5-year period.

What are the answers? IDSA is candid, as in its earlier reports, that it believes incentives for drug companies are the only way to improve the situation: financial boosts, patent extensions and changes in trial requirements. Two things are critical, the group says:

• Novel intravenous and oral drugs to treat both hospitalized and community-based patients are needed, as opposed to “me too” drugs that provide minimal improvement over existing therapies.
• Priority should be given to antimicrobials with the potential to treat serious infections that are resistant to current antibacterial agents.