Super Bug II

Registered Nurse

12-04-2007

Conn Hallinan & Carl Bloice

When a Brooklyn middle student died Oct.14 from an antibiotic resistant “super bug” he may have picked up at school, the media took notice. After a 17-year old high school football player from Virginia succumbed to the same pathogen and student deaths were reported in New Hampshire and Mississippi, the news went page one. Then the Center for Disease Control (CDC) released a study suggesting that methicillin-resistent Staphylococcus aureus (MRSA) kills almost 19,000 Americans a year—more than from AIDS—and it was the lead story on network news.

For a week, the combination of dead children and the alarming CDC report caught the press’s attention, before fading, a victim of the media’s short attention span and California’s monster fires. But while MRSA may have disappeared from prime time news, it continues to stalk the nation’s hospitals, nursing homes and, increasingly, locker rooms, gymnasiums and schools.

What caught the eye of the media in the October stories was that MRSA is no longer something you pick up in a hospital. You can get it from wearing someone else’s football pads, pumping iron in a weight room, or sharing a towel.

“The bad bugs are getting stronger and they’re getting stronger faster,” says Smithsonian Institution ethnobiologist Mark Plotkin.

In 1972, only 2 percent of Staphylococcus were methicillin-resistent. By 1995, 22 percent were classified MRSA. In 2005 it was 60 percent. The New England Journal of Medicine says MRSA is now the leading type of skin infection in the nation’s emergency rooms.

According to the Association for Professionals in Infection Control & Epidemiology (APIC), about 126,000 patients are infected with super bugs each year, ten times the previous estimates.

APIC has just completed a nationwide study of MRSA, the first to examine the prevalence of the bacteria beyond the confines of intensive care units (ICU) and operating theaters. “What we found was surprising,” says APIC CEO Kathy Warye, “67 percent of those (infected) patients were not in high risk areas, like ICUs, but in places like cardiology. It’s in all areas of hospitals.”

Besides being dangerous, super bugs cost an estimated $30.5 billion a year to fight. Warye says that the average cost of treating a MRSA patient is $35,000. “They are enormously expensive,” she says.

The CDC’s Dr. Scott Fridkin, co-author of the study, says the survey demonstrates “the need for better prevention measures” that include “curbing the overuse of antibiotics and improving hand-washing and other hygiene procedures among hospital workers,” which is thought to be a major source of the MRSA outbreak.

But while overuse of antibiotics and hygiene are clearly important, the role of staffing levels didn’t make it into recent coverage of the current outbreak.

The Harvard School of Public Health found a direct link between hospital-acquired infections and nursing staff levels. According to a study of 799 hospitals, inadequate staffing resulted in a greater number of urinary tract infections and hospital-acquired pneumonia.

Nurses may have upwards of 12 patients and hundreds of bedside contacts. That translates into at least one and a half hours of hand washing a shift, time that may be in short supply for overworked staff.

“The trend in health care is to cut staff, cut nurses, and cut cleaning staff,” says Lisa McGiffert of Consumer Union’s Stop Hospital Infection Project based in Austin, Texas.

It is a trend with deadly implications. According to Ohio nurse Michelle Mahon, RN, CLNC, the 2003 Institute of Medicine reports there were 98,000 preventable deaths attributed to insufficient staffing of nurses.

A 2002 study by the Chicago Tribune found that many hospital-cleaning staffs receive inadequate training, and there were 25 percent fewer cleaners than in 1995. McGiffert says, “We have had phone calls from cleaning staff saying, ‘It’s impossible to do this job on one shift.’”

One problem with cleaning, says Mahon, is that “some of these chemicals should be left to stand for awhile—say 10 minutes—and that doesn’t always happen.” She says cleaning crews are stretched thin, and hospitals use skeleton crews at night, “regardless of the patient load.”

Further, many hospital have contracted out their cleaning services to companies where turnover rates are almost twice as high as with in-house cleaning services, and training can be sketchy.

As a result, approximately 75 percent of patients’ rooms are infected with MRSA.

“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 School of Medicine.

If patients do get colonized, current hospital policies help spread the bacteria to communities. During the 1970s, the average hospital stay was seven days. Today it is three, which means patients return to their communities before MRSA infections can be identified, thus spreading them to family and friends.

“The environment in which you work is a huge concern,” says Mahon. “You often ask yourself, “Am I bringing this home with me?’”

While many antibiotic resistant pathogens are hospital-generated— 2.1 million patients are infected each year—an increasing number of antibiotic resistant bacteria come from the widespread use of the drugs in farm animals.

“We estimate that 70 percent of the antibiotics are used in animal agriculture,” says Bris Tencer, Washington Representative of the Food and Environment Program for the Union of Concerned Scientists UCS). “This is the part of the equation that gets overlooked.”

According to the UCS, the use of antibiotics in giant feed lots pumps two trillion tons of antibiotic laden waste into rivers, streams and water tables that eventually end up ingested by consumers.

The UCS is currently supporting House Resolution 962, which would prevent the “non-therapeutic” use of antibiotics on animals if those antibiotics were similar to ones used to treat humans. The European Union instituted a similar policy and sharply reduced the number of antibiotic resistant germs in commercial meat.

Once MRSA pathogens get established in a community, they are difficult to dig out. British authorities found that using standard detergents sometimes makes the problem worse, because they end up killing all but the toughest bugs.

While community infections are a problem, they only make up about 15 percent of MRSA cases. Hospitals generate 27 percent of the infections, and health care facilities, like nursing homes and assisted living facilities, account for 58 percent of the rest.

Nursing homes and assisted living facilities are difficult to sanitize because most of them either contract out cleaning services, or use untrained and low paid staff. In many states, such institutions also don’t have to report infection rates and there is little government oversight of their operations.

This is true for hospitals as well. Only a few states require hospitals to make infection rates public. “Infection is a hot topic for patients, because there is no way to hold the hospital accountable here in Ohio,” says Mahon. As a legal consultant, Mahon says she receives up to 2,000 calls a year from patients, and a “significant portion” are from MRSA sufferers.

APIC’s Warye is strongly in favor of making infection rates public. “Transparency leads to improved outcome.” But she also points out that collecting data is not enough. “You need to use those figures to change things.”

McGiffert’s organization lobbies states to pass legislation requiring hospitals to publish infection rates. So far, she says, 19 states have such rules. Governor Arnold Schwarzenegger vetoed such a bill in California.

Controlling infections “does take an investment,” says McGiffert, “and for the people who hold the money, it hasn’t been on their radar.” But in the long run, she argues, “it saves money,” not to mention lives.

But the Tribune study found that infection-tracking units have been reduced 20 percent since 1995. According to Jill Furillo, RN, and Southern Director of the California Nurses Association, “Many facilities eliminated the position of infection nurse” during the 1990s cutbacks.

When hospitals do take an aggressive “active surveillance” approach, they have gotten results.

Presbyterian University in Pittsburgh screened staff and patients to see if they were MRSA carriers, and disinfected blood pressure cuffs and stethoscopes after each patient. They also used disposable gowns and gloves and rigorously enforced hand washing procedures.

The result was a 90 percent drop in MRSA infections. Similar results using the same procedures were registered in Pittsburgh’s Veterans Affairs health care system, and in hospitals in Boston and New Haven.

The CDC has yet to call for the mandatory screening of patients, though they urge the implementation of many of the other practices.

Warye is upbeat about defeating, or at least sharply curtailing, MRSA infections. “If every institution has a focus of zero tolerance, and implements procedures to prevent these infections, we can get on top of this.”

“This is a really nasty bug, and it’s becoming apparent that we don’t have to live with it. Now we have new techniques, and good studies to show they re effective,” says Dr. Harold Standiford, the University of Maryland Medical Center’s infection control chief.

Warye agrees: “We need to spread the success we have seen in some institutions to the rest of the nation. Infection prevention is everyone’s responsibility.”