MRSA: The Boomerang Bacteria

If you go to the hospital and happen to catch MRSA, the assumption is you will be treated for it and that will be the end of the story. Unfortunately, we’re learning that catching MRSA in the hospital is often just the beginning of the story, and not a pretty one at that. Specifically, “successfully” treated MRSA patients are almost 50% more likely to die in the year after their release from hospital compared to similar patients who never had MRSA.

This was the conclusion of a recent US study that followed the progress of 3,592 MRSA patients after they were released from hospital. They were matched to a second group of 3,592 patients, the difference being that these patients never had MRSA. The results: Patients with MRSA hospital-acquired infections (HAIs) were 49% more likely to die within a year of their release from hospital compared to the non-MRSA patients.

The researchers offer two reasons for this: “First, the increased risk of death may be caused by recurrent infections, which are common in patients with MRSA infection. Second, recent evidence suggests that Staphylococcus aureus HAIs can lead to long-term disabilities (e.g., chronic ventilator dependence, dialysis-dependent end-stage renal disease), which may also increase the risk of death.”

Moreover, death after discharge isn’t the only consequence of a MRSA HAI. For example, other studies have found with patients surviving to discharge, 1 in 4 will require multiple re-admissions for complications due to their MRSA infection. And surgery within 30 days as well as admission to an ICU were also associated with MRSA infection.

The results of the US study alone, say researchers, “underscore the importance of [hospital] interventions designed to reduce the transmission of MRSA and the need to consider long-term outcomes when evaluating the economic impact of such interventions.”

Here’s the thing: we know how to intervene. Take the case of Canada’s Vancouver General Hospital, who were determined to cut down on the number of infections associated with major surgery. So they engaged in a year-long non-antibiotic project – thus not contributing to the rising plague of antibiotic resistance – involving more than 5,000 surgical patients. Using a combination of photodisinfection technology and chlorhexidine wipes they reduced surgical site infections by 39% and the number of readmissions due to SSIs from 4 to 1.25 cases per month. Their effort saved the hospital more than $1 million in costs.

For this work they were awarded the Innovation Award of Excellence by the International Consortium for Prevention & Infection Control which is endorsed by the World Health Organization. And from BC Minister of Health Terry Lake they earned this accolade: “Congratulations to the Vancouver General Hospital team on this significant recognition of your work as leaders in the area of infection control. This achievement is a great example of how we are turning to innovation throughout the health system as a way of enhancing patient care and safety, while reducing costs.”

So we can do it that way. Or we can continue to send the MRSA-affected patients home … and wait for them, like MRSA itself, to come back.

The choice is ours.

How we think: “the death of one person is a tragedy; the death of one million is a statistic.”

We protect our emotional selves just as we do our physical selves. The surprising part, though, is the kind of thing that triggers this emotional self-preservation.

For example, the big news story lately about infectious disease is that by the year 2050 more people will die from drug-resistant infections than from cancer. The number of deaths is estimated to be around 10 million – each year.

Logic suggests that this is a compelling storyline and so we would want to know more and perhaps see if there’s something we could do to help. But psychologists tell us that just the opposite happens: “when the numbers [of dead or injured] go up, the amount of sympathy people feel goes perversely down. And with it goes the willingness to donate money or time to help.”

Psychologists call this the “collapse of compassion.” It means that “when people see multiple victims, they turn the volume down on their emotions for fear of being overwhelmed.”

So let’s test the theory by comparing our response to two bits of similar information and see which scenario collapses – or triggers – our compassion:

(1) Each year in the US more than 23,000 people die and over 80,000 are seriously infected by MRSA. Serious infection means things like multiple surgeries, the loss of a limb, excruciating pain, and lifelong scarring.

(2) A video (from Oprah Winfrey) of just one person – not 23,000 – who fell victim to MRSA.

Just how aggressive are bacteria? Watch them in action

We often think of bacteria as idle creatures. But here’s this neat video that shows them to be more like a hard-charging cavalry. After you watch it imagine that MRSA bacteria have gotten into your blood. And imagine what happens as your circulatory system drops off the MRSA at your body’s vital organs like your heart and lungs. That’s what they call sepsis, and it’s described as an “aggressive” infection. The video shows you why.

Dangerous Popsicles: Does a California artist know more about science education than scientists?

We humans like to think that we’re rational beings. That before we make an important decision we gather all the relevant facts and assemble them in some logically cohesive fashion. Alas, that is not always us.

The latest reminder of the folly of our ways comes to us from a study about our decision-making when it comes to taking antibiotics. They don’t work for viruses, which includes most colds, the flu, earaches, and bronchitis. So if your doctor tells you your sickness is viral-based, you’re not going to ask for an antibiotic are you? Well, more than half the people in that situation will. More surprising yet, doctors will go ahead and write the prescription simply because you asked for it – yikes. In other words, the message isn’t getting through.

So how are we to educate the public – and doctors – about this? A San Francisco artist, Wei Li, thought it would be a good idea to turn a yucky subject – MRSA, HIV, influenza, etc. – into something fun and familiar. Thus all the better for discussion and sharing of information. Ms. Li has designed a line of so-called “Dangerous Popsicles” – yes, we actually get to eat them! – that give new life to the hazardous bacteria, which normally infect our bodies, not delight our taste buds. Have a look at what she has done:

Dangerous Popsicles from Bold or Italic on Vimeo.

If this kind of thing raises awareness about infectious disease then more power to Ms. Li. Because as a recent report tells us, drug-resistant infections will outstrip cancer as a cause of death by 2050. But just because this is serious business, it doesn’t mean that learning about it has to be all business

So let’s talk about this stuff … and pass the popsicles please.

We’re Already There

Tom Frieden, MD, Director of the Centers for Disease Control and Prevention, addressed a gathering of journalists this summer at the National Press Club in Washington, DC. His concern is the rising plague of antibiotic resistance. These were his heartfelt words:

I’m an infectious disease physician. I’ve treated patients for many infections and I’ve also treated patients for whom there are no antibiotics left. I felt like a time traveler going back to an era before antibiotics. We talk about the pre-antibiotic era and the antibiotic era. If we’re not careful we’ll soon be in a post-antibiotic era. And, in fact, for some patients and some pathogens, we’re already there.

We’re already there for people like 19-year-old Jessica Petzold of Indiana. Though healthy at the time of Frieden’s talk, about one month ago on November 20 – a week before Thanksgiving – Jessica noticed a pimple on her face. It progressed swiftly to fever and joint pains then to a full blown MRSA infection in her bloodstream, lungs, and hips. Ten days later Jessica was dead.

“We were all just so dumbfounded and shocked when the doctors came and said, ‘There’s nothing else we can do,’” said her mother Lisa.

Despite their pain, Lisa and her husband Joe are reaching out to share their story. They don’t want what happened to them to happen to us. Here they are:

Where’s the Outrage?

Courage comes to us in many forms. Here, it comes to us from Larry and Mary Stulen from Wilmar, Minnesota. They are speaking about their son, Troy, whose life was saved by a successful bone marrow transplant. Then, just one year later, Troy lay dying in hospital from an antibiotic-resistant bacteria.

A scene like that takes place more than 23,000 times every year in the United States. MRSA alone causes almost half of those deaths.

Perhaps even more extraordinary, 70% of these deaths could be avoided – if only hospitals would follow their own hygiene rules. But they don’t, in Canada or the US.

There was a recent “freakout” over Ebola that involved a total of about 6 people, 1 of whom died.

Yet for Troy Stulen and the tens of thousands like him we hear almost nothing.

The reasons: politically, there is no active constituency — no patient groups marching in the streets. We take antibiotics for a short period and then forget about them. And hospitals, which can be cauldrons for resistant bacteria, often remain silent about infections and outbreaks out of concern for adverse publicity and patient privacy.

Troy’s father, Larry, a 54 year old accountant is doing his part: “We don’t want any other parents to have to go through the experience of losing a child,” he told NBC News.“We hope that by telling Troy’s story, it will help to raise public awareness.”

We hope he’s right.

A Patient’s Story in Ireland is Universal

We don’t often think of it this way but a patient’s experience with disease is often the same, regardless of where they are. Consider, for example, the case of Tony Kavanagh in Ireland.

Tony Kavanagh today

Ten years ago at age 54 and with a management consultant career that saw him travel the globe, Tony developed a circulation problem that left him unable to walk any distance. After seeing his GP and a specialist he had “routine” surgery on the veins in his legs and was out of the hospital in just over a week, good as new … for 5 days.

Then the real trouble began: a burning sensation from head to toe that felt “like holding your hand over a naked flame.” His organs began to fail and he was rushed to emergency. Though he didn’t know it at the time, Tony was dying from an infection that was attacking all the vein grafts that were just put into his legs. And this caused his blood to stop circulating. The culprit was MRSA.

To get the blood to flow doctors constructed an artificial circulatory system. They opened him up from the top of his chest down to his feet. Plastic tubing was inserted just below his neck that came out both sides of his chest that carried the blood from his heart down the outside of his ribcage underneath the skin to his legs.

In Tony’s words, “The best way I could describe myself at that stage would be like a massive zipper – because I was opened from the top of the chest right down to my toes. I died at one point in the hospital, but they brought me back.”

And fortunately he is still with us. After 5 months in the hospital Tony was discharged – weighing all of 126 pounds and requiring a walker. However, his blood kept clotting which meant another operation and, as he puts it, “I spent the next two years of my life practically in the back of an ambulance. The last time I went up was New Year’s Eve 2005, and I honestly believed that time that I was going back to die.”

But he didn’t die, though in the early days of recovery he thought about taking his own life. He also had to learn how to walk again. Today his mobility isn’t great; after walking about 200 yards he has to stop, “So I’m back to being worse than I was in 2004, before I went into hospital.”

Tony had the kind of serious infection must of us never hear about. But each year in the United States there are over 80,000 such serious infections caused by MRSA alone, and each year over 11,000 of those people will die.

Arlene Wilgosh: “If these patients were our loved ones, would we still not wash our hands and take proper precautions?”

Tony Kavanagh has gone on to become an advocate for MRSA patients because, he says, national guidelines on infection control in the UK aren’t followed by hospitals and as a result people like him needlessly become very sick, changing their lives forever, or die. Unfortunately, the allegation of hospital negligence holds true here as well.

For example, at an infection control conference last month in Canada, Winnipeg Regional Health Authority CEO Arlene Wilgosh, to her credit, publicly admitted that hospitals have breached their duty of care to their patients because they don’t follow their own hygiene protocols.

She candidly asked the audience: “If these patients were our loved ones, would we still not wash our hands and take proper precautions?” Ms. Wilgosh also admits that the hospital infection issue “poses a … very significant risk to those we care for,” and therefore “Something new has to be done to address it.”

But until that something is done there will be over 80,000 Tony Kavanagh stories next year in the U.S. alone.

Smart Watch or Trojan Horse?

“It’s like going to war every day,” said Winnipeg Regional Health Authority CEO Arlene Wilgosh to a packed audience last month at the 18th annual Bug Day held at the Health Sciences Center. Arlene Wilgosh is referring to our battle against hospital bugs, those invisible creatures that kill more than 8,000 Canadians a year – every year – making Hospital-Acquired Infections Canada’s fourth leading cause of death. (Why not Hospital-Caused Infections?)

The good news is we know what to do about it: “Wash your damn hands,” says Wilgosh, since 80% of these infections are spread by healthcare workers, or patients and their visitors. The bad news, she says, is that we just aren’t doing it. Only 70% of nurses comply and an embarrassingly low 38% of doctors – if that. It’s been suggested that even these numbers are inflated because staff know when the hand washing police are watching and will thus “buckle up.”

Today's enemy, the bugs, are invisible to us, so they can hide on the watch - there's no need to take refuge in it.

Since healthcare worker noncompliance with hand hygiene rules is epidemic, a U.S. healthcare company has come out with a smart watch that shows whether nurses and doctors have washed their hands before they walk into patient rooms. The company describes how it works: “The watch detects motion and it knows when a wearer goes from room to room. As soon as I leave a room, I need to be aware that I should be washing my hands. So the watch has a color-based alarm that goes off as I change rooms. Now the watch instead of being green is red, and based on a period of time, we also change that to yellow to give clinicians the indication that they should be washing their hands for sepsis control.”

While the company claims to have “tracked a reduction in infection,” an insightful reader – a microbiologist – wonders if the technology might have the opposite effect: “You know what I never see is a comment about the watch itself (any watch). You can’t sterilize a watch, you can’t even clean most very well. You could clean and sterilize the watch band, if you want to take the time to remove the watch from it. That watch sees many patients a month. That watch can catch all types of particles [germs] …”

Britain’s National Health Service agrees. On the basis that bugs attach themselves to what healthcare workers wear, 8 years ago they enacted a “bare below the elbow” dress-code. Every doctor, nurse and therapist is banned from wearing watches, jewelry – such as rings and bracelets, and neckties. They also banned the traditional white lab coat and replaced it with a short-sleeved blue tunic with pockets made of a quick-drying antimicrobial fabric, which actively repels bacteria. Since the policy was instituted, instances of MRSA cited on death certificates has fallen by 77 per cent.

U.S. support for the idea that bugs hitch rides on what we wear comes from research published this year in the Mayo Clinic Proceedings. It tells us that stethoscopes carry more MRSA and other bacteria after a physical exam than all other areas of the physician’s hand except the fingertips.

If Arlene Wilgosh is right to use a war metaphor to deal with infection, then we need to think about being smart soldiers. The Greeks tricked the Trojans – infiltrated their ranks – with a daring, ingenious plot using the best technology of the day, a wooden horse big enough to hide its soldiers. So we forgive the Trojans for being duped, even sympathize with their misfortune. But what would we think of them if we discovered, instead, that they were the ones who built the Horse?

The Antibiotic Timeline

Here’s an interesting 2 minute video from Harvard Magazine on antibiotics and how bugs inevitably develop resistance to them.

Staphylococcus aureus illustrates the principle: When we first introduced the antibiotic penicillin into a bacterial population of s. aureus, the bug developed resistance to it in 5 years (which turned into a global pandemic). With penicillin no longer effective against staph we developed methicillin in 1960. Just two years later we noticed the first strains of staph resistance to it. We’re now on Plan C – vancomycin – the so-called last line of defense against MRSA. And sure enough, staph are developing resistance to that too.

So why the cat and mouse game between us and the bugs and why do the bugs always seem to win? In a word – history.

Bacteria have been around for about 3.8 billion years and to have survived that long in a constant war against other micro-organisms they had to develop weaponry of their own – what we call “resistance.” Then along came us, maybe 150,000 years ago – not quite the critters we are today. In the ensuing confrontation, bacteria kicked the life out of us for the longest time as evidenced by things like the Black Death (where they wiped out almost half of us) and the Spanish Flu. Then a mere 80 years ago we came up with “antibiotics” which are really just re-packaged soil organisms that the bacteria have been fighting – and beating — forever.

So back to the antibiotic timeline and the question of who will win, us or the bugs. The answer is that while we don’t know for sure, the problem is that every major health organization on the planet is saying some version of this: Antimicrobial resistance … [is] a problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century: The World Health Organization, 2014.

Given all of that, the more realistic view of Mr. Bug, courtesy of The New York Times, may be something more like the following graphic. It may not be how we think of them but it is who they are – warriors of almost 4 billion years experience.

Power to the Patients

Uh-oh.

It seems that we, too – Canadian hospital patients – are spreading infections throughout the wards.

That’s not what we’re used to hearing. The focus has always been on hospital staff – doctors, nurses, orderly’s, and cleaning personnel; hence the rule: “The critical thing that all of us as healthcare providers can do is clean our hands between patient contact: and that is the number one, two, and three action to keep our patient safe,” says Dr. John Embil, Director of Infection Prevention and Control at Winnipeg’s Health Sciences Center.

But this month a research team at Hamilton Health Sciences in Ontario, published a study that says hospitalized patients who don’t wash their hands are contributing to the spread of hospital-acquired infections – Canada’s fourth leading cause of death.

The researchers tracked hundreds of patients for a year and found they washed their hands about 30% of the time during bathroom visits, 40% of the time during mealtimes, 3% of the time while using kitchens on the wards, 3% of the time when entering their own rooms and 7% when exiting their room.

This matters because other research has found that requiring hospital patients to disinfect their hands 4 times a day significantly reduced the number of respiratory and gastrointestinal disease outbreaks.

The study’s lead author, Dr. Jocelyn Srigley, says hospitals should encourage patients to wash their hands, but she is not sure how to get them to do it.

Possibilities include “putting up posters, having someone talk to patients about hand washing, providing hand sanitizer or alcohol wipes at the bedside, etc.,” she said.

Turning the policed into the police - are we the answer to making staff follow hospital hygiene rules?

But there might be another way – a good way – to look at this.

Given that hospital staff are notoriously non-compliant with following their own hygiene rules, might it be the case that requiring patients to regularly wash their hands would make staff more likely to follow the rules? Put another way, wouldn’t they look rather foolish preaching, on the one hand, the need for proper hand hygiene yet, on the other, not practicing it themselves?

Moreover, if patients were educated in the importance of hand hygiene, would they not feel more like a collective force, thus empowered, and therefore be more willing to speak up when they saw staff breaking the hand hygiene rules?

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