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


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?

The Case for Clean Hands

Infectious disease has been front page news all summer and it looks like it’s going to be that way for some time. People often feel helpless in the face of such things but as it turns out there’s actually something really effective that we can all do – wash our hands.

As it happens, today is Global Handwashing Day, an international effort based in the U.S., aimed at preventing infectious disease, especially in children. The graphic below was passed on to us by some good people over in Britain. It offers a number of interesting and downright surprising facts about how simple handwashing can ward off infectious disease; for example: Guess how many lives, especially kids under 5, that proper handwashing could save every year? Are we even close to washing our hands properly? What’s best, plain old soap and water or antimicrobial soaps? Who’s more guilty of not washing up, men or women? And what does the song ‘Happy Birthday’ have to do with it?

Have a look.

Side Effects

Antibiotics are no longer the darling drug we once thought they were.

Antibiotics are like people. A few times in life you may find yourself in trouble and really need them. Most of the time, though, antibiotics are like passersby and you won’t have much to do with them. But on occasion, whether by accident or by design, they will hurt you – and that’s the part we’re beginning to understand.

For example, date collected between 2004 and 2006 showed that more than 140,000 people per year in the United States visited emergency rooms due to adverse reactions from antibiotics. That accounts for 20% of ER visits for all prescription drug-related side effects. Because only 16% of all prescriptions were for antibiotics, that means antibiotics are not safer then the average drug. (Antibiotic Resistance, by Karl Drlica, PhD, and David Perlin, PhD.)

Just how unsafe antibiotics can be is seen with how they’re driving up the rates of Clostridium difficile-caused death and disease. C. diff is an intestinal diarrheal-causing bug that, in the U.S. alone, causes 250,000 infections a year requiring hospitalization. It also kills 14,000 people every year, more than 90% of whom are 65 and older. That’s why the U.S. Centers for Disease Control and Prevention list C. diff as “an immediate public health threat that requires urgent and aggressive action.”

To remedy the problem, the CDC is telling healthcare providers to “prescribe antibiotics carefully.” Here’s why: The human gut is full of microbes, the vast majority of which are good. Their presence literally leaves no room for the minority of bad microbes, like C. diff, to expand their numbers. But when you take an antibiotic like vancomycin, say, to knock out a MRSA infection, it also knocks out – kills – hundreds of millions of those good microbes. And that’s all the opportunity C. diff needs to get busy reproducing and move into those spaces formerly occupied by the good microbes. Once the C. diff load hits a threshold level, you get sick – or worse.

This graph shows you the relationship between taking the antibiotic vancomycin which is used to treat MRSA infections, and the rise of C. diff and its lethal consequence:

The Speed of Resistance

Just how fast can bad bugs become resistant to the antibiotics we use to treat them? The answer is in weeks, if not sooner; and, importantly, in the very patient who wasn’t resistant to the antibiotic when he began taking it. In other words, that’s how fast we can go from Step 1 to Step 3 in this diagram:

This is a recent phenomenon. Until about 10 years ago resistance was seen as a problem for populations of people but not for individual patients – either you were resistant or you weren’t, but you didn’t develop resistance during the course of antibiotic treatment.

But in the early 2000s clinicians saw a change. For example, in Antibiotic Resistance by Karl Drlica, PhD, and David Perlin, PhD, they tell us about a patient, JH, suffering from bacterial pneumonia caused by a Staphylococcus aureus infection. Initially, JH was resistant to 4 antibiotics including erythromycin, so they put him on oxacillin and vancomycin (the antibiotic usually given to treat MRSA). However, his illness continued; 2 months later they discovered he had developed resistance to oxacillin and so they discontinued it. Three weeks later JH also developed resistance to the vancomycin. One week later, he died.

Rule 1 in the use of antibiotics is that the more we use them, in people and in food animals, the more we encourage the emergence of antibiotic resistance. That means more and more people will be resistant to an antibiotic before they ever take it; and, like JH, more people will acquire their resistance after starting a course of antibiotics – and because of it.

So where does that leave us? In a word – Prevention.

Last month, the United States government rolled out its National Strategy to fight the growing crisis of antibiotic resistant bacteria. When the president’s science advisors tabled their report that became the basis of the National Strategy, Christine Cassel, MD, made these poignant remarks:

Dr. Christine Cassel. Member, President's Council of Advisors on Science and Technology.

“I just wanted to – and this is not really I think in the report yet … – add to the definition of stewardship [restricting antibiotic prescriptions and use] in two ways. One is we think of stewardship as not prescribing antibiotics unnecessarily. But there’s another kind of stewardship which is reducing the risk of infection so the person doesn’t need the antibiotic … if you think about American hospitals … Medicare & Medicaid, and in particular the innovation center programs have incentives in place … to reduce HAIs, which is where some of the more dangerous ones are.

And we learned just in the last year that’s down 10%. You may say 10% is not a lot, 10% is half a million adverse events and 15,000 lives. Not to mention lots of dollars, but also lots of avoided need for antibiotics in the first place, and for exposing those bacteria to more antibiotics. So I think there’s a way in which looking at prevention is an important thing.” (My emphasis.) (Webcast, Antibiotic Resistance Report Discussion, 39 minute mark.)

Here’s what’s at stake. Each and every year at least 2 million Americans are severely hurt and at least 23,000 die (almost half due to MRSA alone), because of infections that antibiotics can no longer cure. And as antibiotics continue to lose their usefulness, these numbers will grow.

However, people tend not to be persuaded by numbers. So here’s the thing: Imagine, for example, that the Ebola virus hadn’t just caused the hospitalization of one person in Dallas, but was knocking us off at the rate of 23,000 a year. Just imagine our response to it then.

So how is it that we pay so little attention to the deaths and infections caused by all these other untreatable bugs – and that we know will cause it all over again next year –  yet pay so much attention to the one bug that really hasn’t caused any local harm yet?

Vancouver General Hospital Trial Proves Safety, Efficacy and Work-Place Integration of MRSAid™ Photodisinfection Therapy

MRSAid ApplicationRecently published in the Journal of Hospital Infection, the Vancouver General Hospital’s inaugural deployment of Ondine Biomedical’s MRSAid™ Photodisinfection in a universal decolonization study concluded that it was successful in its ability to decolonize Staph aureus and MRSA from the noses of pre-surgical patients. Given the size of the treated patient population, the study was able to demonstrate both clinical and statistical significance.

In addition to proving MRSAid’s safety, the 3,068 patient trial involving elective cardiac, orthopaedic, spinal, vascular, thoracic, and neuro surgical patients demonstrated antimicrobial impact and a 40% reduction of the surgical site infection (SSI) rates. The SSI rate was reduced to 1.6% vs 2.7% (p=0.0004) for the preceding period of 4 years (historical comparison study). Most noteworthy were the 55% reduction in the surgical site infection rate of the spinal patient group, the 61% reduction in the orthopaedic group and the 80% reduction in the thoracic patient group.

From the untreated sub group, the study demonstrated that patients were 4 times as likely to contract a surgical site infection without MRSAid™ nasal decolonization as compared to having the Photodisinfection treatment. Excellent patient compliance (94% of patients) and ease of work-flow integration within the pre-operative ward were significant advantages that contributed to VGH’s adoption into standard infection control and patient safety practices.

Serious Infections Greatly Increase Your Risk of Becoming Depressed, Which in Turn Undermines Your Recovery From Disease or Surgery

Surgical site infections are the most common healthcare-associated infections accouting for almost 1/3 of all HAIs

The risk of developing a mental disorder, especially depression and even bipolar disorder, is 62 percent higher than in the general population if you have suffered a serious infection, according to a landmark study (3.56 million people tracked over 33 years ending 2010) published last year in the Journal of the American Medical Association.

According to the lead researcher Michael Benros, MD, the depression overlaps with the infection and will even pick up where the infection leaves off. ”We know that some of the symptoms that you get with infections are very similar to those you get when you’re depressed,” he says. “You get tired, lose your energy and your mood is affected. This [study] indicates that some of these symptoms remain after the infection has passed.”

The reason? It’s all in your head – literally. Infections affect the brain, says Benros, because infection causes inflammation which produces antibodies and other substances. They cross the blood-brain barrier and disrupt brain chemistry which results in the depression. In other words it’s “real,” in the sense that it has nothing to do with the patient’s character or willpower as is often thought: once your brain chemistry gets hijacked you’re forced to go along for the ride. Should the depression continue the person can slide into “health-damaging behaviors,” such as poor nutrition, hygiene, and sleep habits, and increased smoking and alcohol consumption.

And what effect does depression have on your surgery? It’s a double whammy: it slows healing of the surgical wound and at the same time it undermines your immune systems ability to control the infection itself. That’s why these patients suffer longer hospitalizations, more hospitalizations, more readmissions to the ICU, more reoperations, and more deaths.

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