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?

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.

The Need for Universal Pre-Surgical Decolonization: Overcoming the Disadvantages of Antibiotics

Up to 30% of patients are carriers of Staph aureus. Colonization rates of the serious antibiotic resistant version of Staph aureus, known as MRSAid (one of the 3 major superbugs), range from 2% in Canada to 80% in Shanghai Ordinarily, these pathogens do not impact patients until they are weakened by illness or surgery. Post-surgical infection is a risk for patients colonized with this pathogens and therefore has led to the need for removing or reducing the bacterial load carried around by these patients just prior to surgery.

MRSAid ApplicationDisinfecting the skin prior to surgery has long been a standard of care. Whether with iodine, chlorhexidine washes or other antiseptic surfactants, reducing the bacterial load on the skin surface has been established as an important mechanism to control the rate of post-surgical infection. The nose, which is a warm, moist environment ideal for bacterial growth, however had been difficult to decolonize.

In several studies, the nose has been identified as the key reservoir of Staph aureus and MRSA, representing 40% of the bacteria load in one small area. Because the nose is not washed on a regular basis, unlike other body parts, Staph aureus can easily flourish in the nose and become a source of contamination for other body parts. Because of delicate mucosal tissue and the presence of cilia in the nose, the antiseptic washes used for hardier skin surfaces are not appropriate for use in the nose. Instead, nasal decolonization has been done by topical antibiotics such as mupirocin.

Topical antibiotics have 3 significant disadvantages that have resulted in many infection control experts rejecting pre-surgical nasal decolonization protocols. With sub-optimal patient compliance, infection control experts fear the resulting antibiotic resistance formation brought about by sub-optimal doses of antibiotics that occur when patients stop mid-way through their antibiotic treatments. Poor patient compliance, despite advisories about the severity of MRSA and Staph aureus infections, is the leading disadvantage of antibiotics.

The problem is the inconvenience and unpleasantness of antibiotic creams in the nose. Patients are known to dislike the thick viscosity of mupirocin and often do not comply with the 3 times a day for 5 days treatment protocol. Incomplete doses of antibiotics leads then to antibiotic resistance which in turn adds to, not subtracts from, the risks already present with patients colonized with Staph. This is the primary reason why many hospitals have not opted for nasal decolonization protocols despite the 30-40% reductions in surgical site infection rates demonstrated in clinical trials.

The second disadvantage of antibiotics is the time required to decolonize. On average, decolonization using topical antibiotics requires about 5 days which implies that patients need to be screened and identified early enough for the efficacy of antibiotics to kick in.

The third disadvantage of antibiotics, however, is the inconvenience to patients and the costs to the health care system to culture for and identify Staph aureus and MRSA carriers.  Because of antibiotic resistance concerns, only carriers of Staph and MRSA are given nasal decolonization therapy. New rapid diagnosis technologies have emerged, but prior to Photodisinfection, there was little acceptance of these rapid diagnostics because antibiotics, the decolonization remedy, still required 5 days treatment for effect. The saving of 2-3 days prior to a 5 day treatment protocol did not justify, to many, the additional cost of same-day rapid diagnosis.

Photodisinfection eliminates the disadvantage of antibiotics thereby allowing for universal nasal decolonization. Because there is no resistance formation, it is safe for all surgical patients, even if they are not carriers of Staph aureus or MRSA. Not having to spend the time or cost to identify carriers of Staph is an enormous benefit to work flow integration and patient compliance rates. Because the Photodisinfection process is instant, decolonization can occur at the hospital in the minutes before a surgery. Because it is painless and effective and only lasts 5 minutes, the treatment is well tolerated by patients and compliance can exceed the 90% range as was the case in the Vancouver General Hospital study (94%)7.

Photodisinfection is the disruptive new technology that finally enables health care providers to universally protect their surgical patients. Universal pre-operative decolonization protocols can materially impact patient safety outcomes and should therefore, in my view, be integrated into standard of care.

Universal Decolonization Protocols: Treating Everyone Before Surgery to Avoid Infections Now Possible

MRSAid

MRSAid Nasal Decolinization at Work

The Journal of Hospital Infections recently published the results of a year-long study conducted at the Vancouver General Hospital in which a 40% reduction in the rate of surgical site infections was demonstrated using a universal decolonization protocol to remove the potentially harmful bacteria in the nose and on the skin.  This is a significant clinical outcome that will influence the future of infection control in health care facilities. This is not the first time that decolonization of the nose and skin was deployed; in fact, there are many such studies that have demonstrated a 30-40% reduction in surgical site infection rates. What makes this study unique, is that this is the first time that all pre-operative patients, and not just those identified as having been MRSA, or even Staph aureus (MSSA) carriers, were decolonized whether they were carriers or not.

The unique feature of this nose/skin decolonization trial was the Photodisinfection treatment in the nose. Photodisinfection is a simple 2 step light based treatment that destroys potentially threatening bacteria in 5 minutes just prior to surgery. Because Photodisinfection is not an antibiotic and does not generate resistance, all patients are candidates for nasal decolonization treatment instead of only those screened and identified as Staph aureus carriers. Because Photodisinfection is so effective and destroys bacteria so rapidly, patients can be treated just prior to surgery by a health care professional instead of relying on patient compliance days before the operation. Lack of resistance concerns and lack of patient compliance requirements finally provide the health care provider with stress free surgical site infection prevention that can be universally applied to their patients.

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