Stalking the Super Bugs
By Conn M. Hallinan and Carl Bloice
Royal Marine Richard Campbell-Smith, a buff 18-year old, was completing his basic training in Devon, England when he got a few scratches on his leg. Two days later he was dead.
Gloria Bonaffini checked into a Bridgeport, Ct. hospital for a routine bypass operation. Doctors told her husband she would be out in a week. She stayed 448 days, finally dying of an acute infection she caught during her surgery.
Three children—age 15 months, nine months, and 17 months—were admitted to a Chicago-area hospital with respiratory problems. They were all dead of toxic shock within a week.
In all three cases, the killer was the same: methicillin-resistant Staphylococcus aureus, or MRSA, a drug-resistant bacterium that first appeared in early ‘90s. Since then it has seared a lethal path through hospitals and rest homes and started appearing in day care centers, prisons, and gymnasiums. Several players for the St. Louis Rams caught it during training and passed it to opposing players.
MRSA is only one of several varieties of bacteria that have become resistant to medicine’s magic bullet—antibiotics. Formally ubiquitous or easily treatable germs like E. coli, Salmonella and Campylobacter have morphed into organisms that can be virtually immune to treatment.
“The bad bugs are getting stronger and they’re getter stronger faster,” says Smithsonian Institution ethnobiologist Mark Plotkin. “We feel like we’re looking at an almost hyper-evolutionary period.”
In 1974, only two percent of Staphylococcus was methicillin-resistant. By 1995, 22 percent were classified MRSA. Last year it was 60 percent.
Solving the problem will not be easy, because antibiotic resistant pathogens are generated by a constellation of conditions and practices, from poor hygiene in hospitals, to the widespread use of antibiotics in animal agriculture.
And to make matters worse, at the very time these super germs are on the rise, many pharmaceutical companies are abandoning the search for new antibiotics in favor of more lucrative drugs aimed at long-term, chronic conditions.
According to Dr. John Bartlett of John Hopkins, chair of a legislative taskforce for the Infectious Disease Society of America, there are virtually no new antibiotics “in the pipeline,” which means, “We’re in a bit of trouble now, and maybe a great deal of trouble in five years.”
Certainly the statistics are sobering:
According to the Chicago Tribune, 103,000 people in the U.S. die each year from these infections, making them the fourth leading cause of death after heart attacks, stroke, and cancer.
The Center for Disease Control (CDC)—which puts the fatalities at 90,000—found that hospital infections were up 36 percent over the past 20 years and, that out of 35 million admissions a year, some 2.1 million will acquire one.
While the problem is serious, and more than a little scary, getting a handle on it may not be that complex. For instance, the solution to hospital infections may have less to do with high tech labs and fancy biochemistry than old-fashioned remedies like proper cleaning procedures and keeping the patient-nurse ratio down.
The Harvard School of Public Health found there was a direct link between hospital-acquired infections and nursing staff levels. “The national study of 799 hospitals found that patients were more likely to contract urinary tract infections and hospital-acquired pneumonia if nurse staffing was inadequate.”
The other part of the hospital equation is housekeeping.
A survey by the Auditor General of Scotland found that cleaning services “play a key role in minimizing the risk of hospital acquired infections.”
However, the Tribune study found that many hospital cleaning staffs receive inadequate training, are overextended, and have fewer personnel than a decade ago. Cleaning staffs have been cut 25 percent since 1995.
One East Coast nurse, who requested anonymity, told Registered Nurse, “Hospitals are filthy. It is really incredible. The housekeeping staff at my hospital was cut by one-third several years ago.”
The nurse says that to reduce staff, many hospital workers are “cross trained.” But this means they may end up “touching the patient’s bed, and at times the patient, after doing housekeeping work.”
Many hospitals have contracted out cleaning services to workforces that may not be adequately trained, and where turnover rates are almost twice as high as in in-house cleaning services.
Pia Davis, president of the Chicago health care chapter of the Service Employees Union (SEIU), says “We have report after report showing that rooms are not cleaned every day,” she told the Tribune, “hospitals hire people and just say go in there and clean. They don’t show them what chemicals to use or not to use.”
As Nancy Foster, vice-president for Quality and Patient Care Policy for the American Hospital Association points out, “Cleaning in a hospital is a skill very different than cleaning an office building.”
As a result, according to the Tribune study, approximately 75 percent of patient’s rooms are infected with MRSA.
Hospitals and health care workers are at war with an ancient and recently invigorated enemy. Given the nature of bacteria, it is a war in which all victories are incremental.
The daily mutation rate for E. coli in human beings is 10 to the 12th power, a figure that is hard to grasp even using a computer. The phenomenal reproductive rate, coupled with bacteria’s ability to share genetic material, means that almost as fast as human beings invent something to kill them, bacteria become resistant.
The history of anti-bacterials is a history of stroke and counter stroke. Penicillin was isolated in 1939. By 1941 there were penicillin-resistant streptococci.
Human practices add to the problem. Sometimes patients don’t finish the prescribed course of antibiotics, which means it is easier for resistant germs to emerge since“what doesn’t kill bacteria makes them stronger.”
Sometimes the problem is picking the wrong drug. A U.S. Office of Technological Assessment found that up to 50 percent of antibiotics are prescribed inappropriately.
While the American Medical Association is deeply concerned about the global increase in resistance to antibiotics—a 1995 statement by the organization warns of a “public health problem of potentially crisis proportions”—it jealously guards the right of doctors to prescribe what they wish, and fiercely resists setting any national standards for the use of antibiotics.
But you don’t have to go to a doctor to get a dose of antibiotics, just chow down on some barbeque.
In a study for the CDC, L. Clifford McDonald found that supermarket chicken was riddled with vancomycin-resistant Salmonella. According to McDonald, “The widespread resistance to this drug now seen in meat-borne bacteria appears to stem from farm use since 1974 of a related antibiotic—virginamycin—as a growth promoter.”
An estimated 13.5 million pounds of antibiotics are used in animal agriculture for non-therapeutic purposes—the same kinds of antibiotics used in human medicine— according to Susan Prolman, the Washington Representative of the Food & Environment Program of the Union of Concerned Scientists (UCS).
About three million pounds of antibiotics in the U.S. are used to treat human beings annually.
The UCS says that 70 percent of all the antibiotics are used on healthy animals because they save farmers money. Thousands of animals are packed into sheds and pens which, according to Prolman, are rarely cleaned. “Chickens raised for meat live about 45 days, but their cages are only cleaned out every one or two years. They not only live in their own filth, but the filth of generations.”
Cows, pigs and fish are raised under similar conditions.
Such CAFOs (Communal Animal Feeding Operations) act as giant Petri dishes in which antibiotic resistant bacteria evolve and get passed on to workers in these establishments, as well as to consumers.
CAFOs also produce two trillion tons of antibiotic laden-waste that finds its way into “rivers and streams and water tables that affect downstream consumers,” says Prolman.
All of these antibiotic practices conspire to put resistant bacteria into the community. CAFO workers, their families, consumers, patients, and health care workers spread the pathogens to places like gymnasiums, sports facilities, and day care centers. You don’t have to check into a hospital to get a MRSA, you can go work out a your local gym.
Over the past decade there has been a dramatic increase in antibiotic resistant germs in the community. According to the Tribune study, such organisms have increased a thousand fold in Illinois.
New hospital procedures aimed at generating a rapid turnover of beds adds to the problem. In the 1970s, the average hospital stay was seven days, enough for doctors to identify and treat infections. Today the average stay is three days, which means that many patients go home before they can be properly diagnosed.
“If you spend five minutes in a room with someone with MRSA, you are going to get colonized,” says Dr. Neil Fishman, director of epidemiology and infection control at the University of Pennsylvania’s School of Medicine.
Jill Furillo, RN, and Southern Director for the California Nurses Association (CAN), points out that this is particularly important for healthcare workers, “because they are exposed and can potentially bring those germs home to their families.” From there, the bacteria can spread to the wider community.
As tough as some of these pathogens are—and many are meaner and deadlier than they were 10 years ago—most health care experts agree that MRSA is no match for hospital hygiene.
The Tribune study found that out of 103, 000 fatal infections in the year 2,000, some 75,000 were “preventable.” According to a study by the CDC and the Society for Healthcare Epidemiology of America, 20,000 lives could be saved by health workers just cleaning their hands. Hand washing “is the single most effective way to prevent transmission of disease,” says the CDC, but fewer than 70 percent of health workers follow the proper guidelines.
Fishman says he has found that nurses are better at washing their hands than doctors, and nursing students are better than nurses. “It seems like when you get your degree you stop washing your hands,” he says.
But sometimes nurse-patient ratios simply overwhelm “technique.” Depending on the unit in the hospital, nurses may have upwards of 12 patients and more than a hundred bedside contacts. “Sometimes it is a matter of time,” says Hedy Dunpel, RN, JD, Chief Director of Nursing Practice and Patient Advocacy for the CNA. “Under conditions of speedup, which do exist, people will take shortcuts.”
Because of the presence of the CNA, California has the best nurse-patient ratios in the country, ranging from 1:1 in trauma units, to 1:5 in medical surgical units. But those figures are rare elsewhere in the U.S.
According to the CDC, proper hand washing translates into an average of 1.5 hours per shift, which is not only time consuming, but may also irritate the skin.
The introduction of alcohol rubs has improved the situation some—such gels save about 15 seconds off of traditional soap and water and are less irritating—but their use may run into fire code problems. Alcohol is flammable, and some states ban its use near carpets or in closed rooms.
Many nurses work over 60 hours a week, which leaves them exhausted. Study show that tired health care workers are less likely to follow proper hand care procedure.
But hands are not the only problem. Infections are passed by clothes, food and equipment as well.
“Once, when I was working as an intensive care nurse, we began to be alarmed by the number of infections occurring on our ward,” says Kay McVay, RN and former president of CNA. “We checked everything we were doing,” including hand washing and sterilizing instruments, but still couldn’t find the source.” McVay says an infection nurse came in, watched everything, and finally figured it out. “She noticed the doctors were not wiping down their stethoscopes as they moved from patient to patient. With that discovery we were able to deal effectively with the problem.”
But according to the Tribune study, infection-tracking units have been cut 20 percent since 1995. “One of the effects of the cutbacks in nursing carried out by hospitals in the ‘’90s,” says CNA’s Furillo, was a sidelining of procedures for infection detection and control. “Many facilities eliminated the position of infection nurse.”
Tracking hospital infection rates is difficult because there are only a few states that require health establishments to make such information public. According to the Tribune study, “The health-care industry’s penchant for secrecy and a lack of meaningful government oversight cloaks the problem. Hospitals are not legally required to disclose infection rates, and most don’t.”
When they do give out information, it may be undecipherable to the average consumer. For instance, the CDC allows hospitals to use the term “nosocomial infection,” which means “hospital acquired,” but unless you are a Latin scholar or Catholic bishop, you aren’t likely to know that.
A good deal of this is about money.
Dr. Victor Yu, professor of medicine at the University of Pittsburgh and an expert on infections, says there is, in fact, pressure for hospitals not to be particularly aggressive in ferreting out infections. “Repairs to equipment or extensive cleaning can means shutting down a department or a floor. Even a few hours is a significant loss of revenue.”
McVay says her experience is that many hospitals simply do not insist that proper sterile procedures are followed. “They have little incentive to do so. People seldom sue over hospital acquired infections, and it’s difficult to prove negligence, and, therefore, there is little liability to worry about.”
And unless a nurse is protected by a union, complaining about procedures may be risky. “There are numerous forms that intimidation can take to keep nurses quiet about the problem,” says CNA’s Furillo, “and without union representation the nurses have little protection against reprisal.”
When people do get infections, treating them is increasingly a problem, because many antibiotics are no longer effective. Fishman recalls one patient with an infection that resisted all the standard antibiotics. “I finally had to give him colistin, which is very toxic to the kidneys and doesn’t work very well, but that is what I had left.”
That problem is likely to get worse, because many drug companies are disinterested in producing more antibiotics. “There is unequivocal evidence that antimicrobial research is on a steep downward slope,” says John Edwards, the head of policy at the Infectious Diseases Society of America.
Drug giants Roche and Eli Lilly recently announced they will give up making antibiotics. “Pharmaceutical companies are saying this is not a priority. They do a lot better making Lipitor,” says John Hopkins’s Bartlett.
Health activists, unions and environmentalists are moving on a host of fronts to tackle the problem, from improving sanitary procedures to sponsoring legislation on antibiotic use and hospital transparency.
One front is rigorous attention to cleaning, which seems to pay off.
Bridgeport hospital, where Gloria Bonaffini died, instituted a major overhaul in sanitation procedures, and the hospital’s 22 percent infection rate for heart surgeries dropped to almost zero. A similar program in a veteran’s hospital in Pittsburgh reduced MRSA by 85 percent, and eliminated it at the University of Virginia Medical Center.
A 36-bed surgical war in Dorchester, England was plagued by MRSA until authorities doubled the cleaning hours from 66.5 hours to 123.5 hours per week. A government study concluded, “In the long term, cost cutting on cleaning services is neither cost effective or common sense.”
The U.S. Society for Health Care Epidemiologists (SHCE) is pushing “active surveillance,” a variation of the European “search and destroy” model. This advocates that all patients be checked for infection, and isolated if they are infected, as well as increased attention to cleaning procedures.
The CDC, however, only supports using “active surveillance” in case of epidemics, rather than as standard practice.
The American Hospital Association is lobbying for the adoption of a Surgical Care Infection Policy (SCIP), which promotes standardizing antiseptic and behavior practices in all surgical situations. These include:
- Administrating antibiotics 30 to 60 minutes before surgery, and removing patients from the drugs after 24 hours if there is not sign of infections.
- Keeping surgical patients’ temperature stabilized.
- Aggressive antiseptic procedures including the regular cleaning of ventilators and filters.
According to Foster, when SCIP is implemented, “We have seen a decrease in infection rates and, for ventilator-associated pneumonia, some hospital rates have dropped to zero.”
Dunpel of the CNA argues “the causes of hospital infections and super bugs are multiple, so there is no single solution, but the starting point has to be adherence to the recognized precautionary principles.”
A number of organizations are working to keep the drug companies in the business of making magic bullets.
Bartlett’s taskforce is focusing on developing legislation that will encourage “drug companies to stay engaged,” he says. Proposals include tax incentives and giving companies exclusivity rights for a certain period of time.
The Union of Concerned Scientists is pushing the Preservation of Antibiotics for Medical Treatment Act (S-742 and HR-2562) that would halt the use of antibiotics on animals for non-therapeutic reasons, and require the government to keep records on where, and how much, antibiotics are used.
In 1997, the European Commission banned the non-therapeutic use of vancomycin-related antibiotics in animals, and a Danish follow-up study found a dramatic drop off in antibiotic resistant bacteria in meats sold to consumers. The European Union has since extended the ban to all antibiotic use in healthy animals.
But Prolman warns that the Preservation Act is “up against a powerful lobby of veterinarians, agribusiness, and the pharmaceutical companies.”
Organizations are also demanding that hospitals track infection cases and make their findings public. The American Federation of Teachers successfully lobbied the Connecticut legislature to require hospitals to publicly disclose infections; Connecticut is now one of seven states that require hospitals to release infection numbers to the public.
On yet another front there is a push to develop a vaccine for Streptococcus aureus. One vaccine currently in trials is showing promise.
Some doctors are experimenting with reducing the length of antibiotic regimes from 7 or 10 days, to just three. Medical researchers in the Netherlands have found that the shorter courses are just as effective and less likely to generate resistant bacteria.
As Dr. Wendel Brunner, director of the Contra Costa Public Health Department in California warns, “We have to do more than engage in an arms race with mother nature,” a sentiment with whichBartlett strongly agrees with, “Absolutely, we need to be working all sides of the equation.”
Fishman uses the analogy of a machine in making the point about all the different levels people need to work on in order to solve the problem: “It is only when you have all the parts of the machine coming together that the machine works,” says Fishman.