The Medical Use of Touchscreen Technology is a Magnet for Bad Bugs

New research tells us that all touchscreen devices like this one contain pathogens that increase the risk of infection in patients.

Virtually all smartphones and tablet computers used by doctors and nurses are contaminated by pathogens, and therefore the use of these devices increases the risk that patients will contract infections.

So says a study conducted by German researchers and presented last week at the 16th International Congress on Infectious Diseases. As reported in Medscape Medical News, it found that 100 of the 101 smartphones and 19 of the 20 tablets tested were positive for at least 1 pathogen.

Many of the pathogens were bacteria that cause serious infections, including our usual suspects MRSA, Methicillin-susceptible Staphylococcus aureus (MSSA), Salmonella, and E. Coli.

So you would think that the obvious solution would simply be to regularly clean the devices. In fact, that’s what one of the researchers said we should do: “It’s the same problem as hand hygiene. If you are going to use your phone or device while working, you have to clean it when you go home. Otherwise, it’s a source of infectious contamination.”

Yet this seemingly common sense advice is significantly contradicted by the study’s own data. Because it found that after intense cleaning the number of pathogens on smartphone screens was reduced by only 7.7%, and on tablet screens by 22.2%. No explanation was given for this unexpected result.

One more thing. The study only looked for bacterial pathogens, it did not look for that whole other universe of evil – the viruses.  As one physician put it, “I’m especially interested in influenza so I would be very interested in knowing the levels of influenza virus that might be contaminating these devices.”

So given that touchscreen technology is here to stay – in fact, it is on the rise – where does that leave us?

Bad Canada: The World Health Organization Says That in High-Income Countries, Canada Has the Second Highest Health Care-Associated Infection Rate in the World

Breaking Bad: Canada has over 200,000 hospital-acquired infections every year, of which 8,000 to 12,000 people will die.

As shocking as the headline may seem – remember, it compares only high-income countries – it’s actually worse than that. Because when you compare Canada to low- and middle-income countries you see that we have double the infection rate of Mongolia and Latvia, and a far higher rate than Iran, Lebanon, Thailand, Indonesia, and Cuba. In fact the average infection rate for these lower-income countries is 10.1%, while Canada’s rate is higher at 11.6% – basically even with Senegal.

The WHO report has 2 excellent maps with all the data. The map for high-income countries is on p.13 of the report, and the map for low- and middle-income countries is on p.17. They’re well worth looking at.

While the United States is not on the map because the researchers only had data for one year, its infection rate for 2002 was 4.5%.

For ease of reference here is a listing of the infection rates for high-income countries:

New Zealand    ………..       12.0%

Canada   …………………         11.6

Finland  …………………..           9.1

United Kingdom  ………..            9.0

Switzerland  ……………..            8.8

Spain ……………………..           8.1

Greece …………………..            7.9

Netherlands………………           7.2

Belgium…………………..            6.9

Italy ………………………             6.7

Norway  ………………….             5.1

Slovenia …………………             4.6

France    …………………             4.4

Germany …………………            3.6

On Any Given Day

Dr. Michael Bell sounds the alarm on hospital infections: 1 in 9 patients who have a hospital infection go on to die, he says.

On any given day in the U.S. about 1 in 25 hospital patients has at least one healthcare-associated infection. There were an estimated 722,000 HAIs in U.S acute care hospitals in 2011. About 75,000 hospital patients with HAIs died during their hospitalizations.

As troubling as these numbers are they do not include nursing homes and outpatient facilities. If they were included, the suspicion is that the numbers would be even higher.

These figures come to us from the first-ever nationally representative count of the overall problem of infections in U.S. hospitals. The study was conducted by the U.S. Centers for Disease Control and Prevention, and it was published last week in The New England Journal of Medicine.

Here is a chart showing the CDCs breakdown of infections in U.S. Hospitals:

Major Site of Infection Estimated No.
Pneumonia 157,500
Gastrointestinal Illness 123,100
Urinary Tract Infections 93,300
Primary Bloodstream Infections 71,900
Surgical site infections from any inpatient surgery 157,500
Other types of infections 118,500
Estimated total number of infections in hospitals 721,800

What role does MRSA play in these infections? According to the CDC report ANTIBIOTIC RESISTANT THREATS in the United States 2013, MRSA was responsible for 80,461 severe invasive infections and 11,285 related deaths in 2011 (the last year for which figures are available). An unknown but much higher number of less severe MRSA infections occurred in both the community and in other (non-hospital) healthcare settings.

The CDCs Dr. Michael Bell, in a powerful video address, warned the public this week that “The challenge that we see is that some of those bacteria, the nightmare bacteria, are now completely untreatable. That means that as a doctor I have nothing to offer a patient who has an infection like this in the hospital.”

Doing the Math on Hospital-Acquired Infections

To get a sense of the  disproportionate number of deaths caused by hospital-acquired infections (HAIs) in Canada each year, I drew up a list of some other well-known causes of death. The number shown represents deaths per year.

Breast cancer …………………..  5,000

HIV/AIDS ……………………….. 1,000

Motor vehicle accidents ……….  1,000

Homicide……………………………543

_____

TOTAL                                          7,543

Now compare the Total to the annual number of deaths caused by HAIs: 8,000 – 12,000.

In other words, HAIs cause more deaths in Canada each year than breast cancer, HIV/AIDS, traffic accidents, and homicides combined – and that’s using the lower figure of 8,000.

Here’s the thing. People I know – professional types – aren’t even sure what an HAI is. When you ask them they tend to answer with a question, such as, “Well, do you mean ….”  Sometimes they get it right and sometimes they don’t. But when you tell them how many lives it claims and how many people are infected each year – around 220,000 – they are positively stunned, verging on disbelief.

It’s this total lack of awareness that’s so inexplicable. That’s the part in all of this that just doesn’t add up.

On Canada’s Fourth Leading Cause of Death and the Secrecy that Surrounds It

This is the philosophy of health care policy that puts lives in jeopardy

Last year, CBC’s The Fifth Estate conducted a special 9 month investigation – “the longest in our 40 year history” – into Canada’s health care system. Surprisingly, the main topic of the report was what they called the “hidden enemy,” i.e. “the deadly bacteria that lurk in hospitals and kill thousands of Canadians every year.”

In fact there are so many deaths that “Hospital infections could be the 4th leading cause of death [in Canada] … and between cancer, heart disease, and stroke, it’s coming up as number 4,” said Dr. Dick Zoutman, Chief of Staff at Quinte Health Care in Belleville, Ontario.

Just how many such deaths are there? Dr. Zoutman puts it at 8,000 to 12,000 every year, that are “directly attributable” to hospital infection. These deaths are part and parcel of the 220,000 people who become infected while receiving hospital care – again, every year.

While the reflex might be to focus just on the hospitals as being responsible for these sky high numbers, The Fifth Estate says not so fast, you need to take a hard look at our government as well.

To begin with, they say, there’s no one in charge of Canadian health care delivery. Therefore, there are no national standards, no national surveillance system to track the spread of infectious disease, and no national plan of attack to combat infectious disease. Dr. Michael Rachlis, a Toronto-based health care consultant says “The federal government could have a strong role in health care if it wished. It’s not taking that role and I think overall that endangers Canadians’ health.” In other words, with a proper country-wide plan we could prevent a large number of deaths from happening – each and every year.

But The Fifth Estate stumbled across something else – government secrecy – that may help explain why most people would not put hospital-acquired infections in their top 10 list of causes of death, let alone at number 4.

They came across the secrecy quite by accident. For their report they needed data on such things as the number of hospital-acquired infection rates, the number of “foreign objects,” such as sponges, left in during surgery, and weekend mortality rates for several medical issues, a figure that would give patients an idea of whether they were at greater risk on Saturdays and Sundays.

So they contacted provincial and territorial health departments for the information and they also sent a survey to over 600 hospital CEOs across the country.

But nothing much happened. To their surprise over 75% of the CEOs wouldn’t respond and the governments wouldn’t release any data. And no one would tell them why.

So they made a freedom of information act request and discovered that provincial and territorial governments entered into a “national decision” to deny the requests. The provincial governments actually asked the relevant departments not to release the information, and they also contacted hospitals asking them not to respond to the survey.

But why on earth would they do that?

According to The Fifth Estate the government decision to circle the wagons was based entirely on self-interest. Dr. Rachlis explains: “One of the major barriers to finding out more about Canada’s health-care system and its quality of care is that it is a government-paid-for system, [and] governments tend to be secret about what they do. They are concerned about measurements and comparisons in case they look bad,” he said. In other words they’re scared, scared of not measuring up to the next guy.

David Musyj, CEO of Windsor Regional Hospital, and an attorney, is a leading advocate for transparency in health care.

Fortunately, not everyone holds those values. One such person is David Musyj (pronounced ‘Moo-shay’), CEO of the Windsor Regional Hospital. He’s guided, instead, by what he calls the principle of full disclosure – don’t bury the data, broadcast it, make it public, because that’s what makes us better.

And he walks the walk. For example, when he began his tenure as CEO he discovered that his hospital’s hand washing rates were a paltry 40%. So what did he do? He went public and told the Windsor community about the failing rates, adding this sobering thought: “If you don’t hand wash you kill people.” And with that, the rates improved to over 90% and he hopes to eventually achieve 100% compliance.

He’s driven by a very uncomfortable truth that he’s willing to talk about. Approximately 8 – 10% of people who walk through hospital doors are hurt by us, he says. And if you don’t recognize that you have no chance of fixing it.

Obama’s Budget for Bugs Takes the Fight to Them, and it’s About Time

"Just trying to get the bugs out."

First, some background. President Obama unveiled his fiscal 2015 Budget last week and we see that he proposes to double federal funding to fight the emerging problem of antibiotic resistant infectious disease in the United States

The numbers alone warrant the close attention of any budget-meister because antibiotic resistance germs continue to cause more than 2 million illnesses and 23,000 deaths in the United States every year. MRSA alone kills a minimum of over 11,000 people and causes over 80,000 severe infections – again, every year. (Canada, population adjusted, has a similar infection rate of about 200,000 a year, but 2 ½ times the death rate – about 8,000 every year.)

To appreciate the scope of the problem, consider that over the next 5 years there will be more deaths caused by antibiotic resistant germs than there weredeaths by combat in the Vietnam War and the American Revolutionary War, combined (115,000 deaths from resistant disease; 110,848 from the 2 wars).

Given these monstrous numbers, the president therefore proposes (p.82), to double the funding to the Centers for Disease Control and Prevention to $30 million annually for the next 5 years.

The CDC says that with this increased funding they could achieve a 30% yearly reduction in invasive MRSA infections alone, and reductions of anywhere between 25 and 50% for 4 other kinds of infections, for an overall harm reduction of 37%. That would save a lot of pain and a lot of lives.

So how, exactly, does the CDC plan to do all this?

Press reports like this one and the CDC website tell us there will be construction of a country-wide 5-area regional Lab Network that will allow for early detection of outbreaks and thus quicker and more effective treatment. And we’re told that hospitals will be part of this network and they will have new programs to reduce the spread of bacteria.

Now be honest, what does that really tell you?

Here’s the way to think about it, using a war analogy that compares bad bugs to an invading army.

In 1775 the British launched attacks against a loosely organized band of American colonists at various points along the eastern seaboard from Lexington and Concord, Massuchesetts in the north to Chesapeake Bay, Virginia, some 560 miles south. At each point of attack the colonists would rally and do what they could to fight back, each colony operating on their own and largely unaware of what was happening at other outposts. Reports of the fighting would filter back to General George Washington after the event. From there, strategies, such as they were, were hastily cobbled together.

Now imagine, instead, that the colonists were an organized group of professional soldiers with a coordinated chain of command, a sophisticated communication system, and a network of spies. These things would allow them to know when the British were coming, where they were, what direction they were headed, how many there were, what kind of weapons they had, and so on. Such early detection and information immediately shared amongst the colonists would have permitted a coordinated rapid response, precisely tailored to meet each threat as it materialized along with the ability to constantly monitor the invaders. In other words, this enhanced capacity would have told Washington exactly where to attack, when, and with what force and weaponry. And thus a 37% reduction is American casualties would have been reasonable to expect – the same reduction the CDC is looking for based on the changes envisioned in the Budget.

The crucial change is  the proposed Lab Network that would be strung across the bug battleground that is the whole of the United States.  For the  CDC and its partners, now armed with the latest technology, it would mean the ability to engage in rapid diagnoses, a precision and coordinated response, early and more effective treatment, and a continued monitoring of any abnormal bug presence – and a 1/3 reduction in harm to Americans that would otherwise have been caused by bugs that antibiotics can’t touch.

The present system, however, can be described as every man – or hospital – for himself, and is in the sense described in the war analogy, an 18th century throwback..

Dr. Brad Spellberg, author of "Rising Plague: The Global Threat from Deadly Bacteria and Our Dwindling Arsenal to Fight Them," has been arguing for years to enact the measures proposed in the Budget.

Dr. Brad Spellberg is an infectious disease specialist and leader in the field of developing ways to combat drug resistant infections. In a wide-ranging interview with Frontline (in bold) last October he basically indicted the current system:

… Is the government doing enough? Is the kind of action that we see up to the nature of the crisis?

“When reporters like you ask me how many resistant E. coli infections do we have, it’s pretty sad that I have no idea what the answer to that question is. It’s not that the government agencies are not aware of the problem and are not doing anything. It’s that we have not had a comprehensive plan for how to deal with antibiotic resistance. We don’t have reporting mechanisms like they do in Europe to know where resistance is occurring. Who is using the antibiotics. Are we overusing them?

You’re telling me we don’t know the answers to the extent of the problem? We don’t have the data?

That is correct, that is correct. I do not know how many resistant infections are occurring right now. I don’t know what the frequency of resistance in different bacteria are. We do not have those data. They are not presented publicly. They are not gathered on a large scale.

There are pieces of data acquisition, but there is not a concerted, coordinated effort to gather the information and make it available. Nor is there a concerted effort to apply financial or regulatory constraints to overuse, either in humans or in animals.

… It is frankly embarrassing that we as a country do not know where resistance is occurring, how bad the problem is for various organisms, or who’s using what antibiotics when. Europe has taken great strides to solve this problem, and we haven’t.”

These, then, are exactly the problems that the proposed Budget aims to correct. It could be a game changer. Of course there is one obstacle that remains – our friend, the Congress – perhaps the greatest bastion of resistance that we have today.


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Guess What Your Doctor Has Up His Sleeve?

How about MRSA!

The height of professionalism or a hotbed for disease-causing bacteria?

So says Britain’s National Health Service who have therefore banned the traditional long-sleeved white lab coat that we are so used to seeing doctors wearing.

They instituted the ban in an effort to stamp out deadly infections plaguing British healthcare, especially those caused by bugs such as MRSA.

The traditional lab coat has been replaced by a short-sleeved blue tunic with pockets made of a quick-drying antimicrobial fabric, which actively repels bacteria.

But here’s the catch: the ban took place 6 years ago, back in 2008.

And it goes further than just the long-sleeved lab coat. Under a “bare below the elbow” dress-code, every doctor, nurse and therapist will also be banned from wearing watches, jewelry such as rings and bracelets, and neckties.

So has the policy had any effect? According to this report the infection control measures of 2007 have so far been successful. Instances of MRSA cited on death certificates has fallen by 77 per cent:

In 2007 – a total of 1,593 cases of MRSA were recorded on death certificates.

By 2011 – only 364 cases of MRSA were recorded on death certificates.

The American Medical Association proposed a similar ban at their  2009 annual meeting. However, the recommendation was voted down on the basis that “the matter needed further study.”

Canada, however, hasn’t taken it  that far. In speaking with a high-ranking infection control specialist about the importance of hospital worker hand hygiene, she mentioned to me that she heard “something about” Britain’s NHS banning the use of the lab-coat  because the sleeves too easily pick up bacteria and spread them to patients. She did imply, however, that it’s something for Canadian infection control people to look into.

Apparently the young "Dr. Ben Casey" had it about right (as opposed to his mentor) - some 50 years ago.

And with good reason. In Canada, there are more than 200,000 hospital-acquired infections annually, and as many as 8,000 deaths as a result, according to a 2013 report by our Chief Public Health Officer.

One more thing. On Tuesday we wrote about the need for doctors to wash their stethoscopes after every patient contact because research shows that stethoscopes carry more MRSA and other bacteria than all other areas of the physician’s hand except the fingertips.

So let’s put ourselves in the position of a hospital patient. Early in the morning your doctor and perhaps a few colleagues come into your room, As glad as you are to see them you can’t help but notice that they’re wearing long-sleeved lab coats, ties, watches, and carry their own stethoscopes. Your doctor offers you a friendly hello and asks  how you’re doing today.

Given everything you now know, will you say anything about what you see, or will you just let it go and simply answer her question?

Doctor, Have You Cleaned Your Stethoscope Today?

Oh boy.

Not so fast, doctor!

Just when we thought we had a handle on how to control the spread of infections acquired at the hospital – healthcare workers should wash their hands before every patient contact – along comes a study that tells us that we’re only seeing part of the picture.

Research just published in the Mayo Clinic Proceedings tells us that stethoscopes carry more methicillin-resistant Staphylococcus aureus (MRSA) and other bacteria after a physical exam than all other areas of the physician’s hand except the fingertips.

Here are the numbers that the study reports: fingertips were by far the dirtiest, with an average of 467 bacterial colony forming units/25 cm2, followed by the diaphragm of the stethoscope (the part that touches you) which averaged 89 colony forming units, then the base of the thumb at 37, the base of the pinkie finger at 34, and in last place, the back of the hand, with 8.

The lesson? Doctors can wash their hands all they want but if they don’t clean their stethoscope they are essentially transmitting MRSA to each patient they touch with their hands (because they’ll touch the stethoscope after they wash their hands) or examine with their stethoscope.

The researchers put it this way: “From infection control and patient safety perspectives, the stethoscope should be regarded as an extension of the physician’s hands and be disinfected after every patient contact.”

And what are the chances of that happening? “Most stethoscopes don’t get cleaned even once a month,” the study says.

Oh boy.

Patients Beware! It matters a lot if your nose is colonized with MRSA

Most people are oblivious to the risks from bacteria that sit on the surface of the skin.  One of the most dangerous of the superbugs, a bacteria called Methicillin-resistant Staphylococcus aureus or ‘MRSA’, can reside in the anterior aspect of the nares (the bottom half of the nose) protected by hair follicles and lack of mechanical debridement or cleansing. Depending where you live, your chance of carrying these highly antibiotic resistant bacteria in your nose can be as low as 1% or as high as 80%. (1)

MRSA Colonization, had been thought to be non-threatening given the body’s defense mechanisms. This is not the case, however, for those about to have surgeries. It has long been understood that patients who are carriers of MRSA, are at a higher risk for a MRSA infection following a surgery. This risk of a serious surgical site infection (SSI) rises when bacteria residing on the patient are able to breach the body’s defences once the body is opened up during the surgical procedures or once access is made available due to various medical devices (e.g. blood stream/central line catheters). Patients colonized with MRSA can become infected by MRSA. Infections can set in superficially at the surface or manifest deep within the body, far from visibility and access. Both infections however, are extremely dangerous to patients are represent an enormous cost to the health care system and to society. Surgical site infections result in up to 5 times the risk of in-hospital death and 5 times the re-admissions rate. (2)

A recent Singapore based study (http://www.biomedcentral.com/1471-2334/13/491 ) by Michelle ND Balm12, Andrew A Lover3, Sharon Salmon1, Paul A Tambyah45 and Dale A Fisher145 , draws attention to the major risks of MRSA colonization on patients in hospitals. The study, entitled Progression From New Methicillin-resistant Staphylococcus aureus Colonisation to Infection, which answers the question “Does it matter if you’re colonized (not infected) with MRSA?” The answer is: yes, it does matter. In fact, it matters a great deal.

The study shows the following worrisome outcomes:

  1. Approximately 15% of patients that had newly acquired MRSA colonization developed a subsequent MRSA infection. (A large study in the US reported 33% of patients developed MRSA infections over the next year, with the majority of infection occurring post discharge) (3)
  2. The highest risk for MRSA infection occurs shortly after patients become colonized (40% within the first 2 weeks of colonization; 72% within 60 days of colonization), once discharged from hospital.
  3. A significant proportion of patients who pick up MRSA colonization in hospitals will present with infection in a different admission
  4. There is a strong association between developing MRSA infection and death within six months; about 30% of patients with MRSA infections died within 6 months and 26% required multiple admissions due to complications of MRSA infections.

The study concludes that “prevention of MRSA acquisition in hospitals should be an important goal of programmes to reduce MRSA infections” and that decolonization strategies combined with enhanced efforts to prevent device-associated infection and vaccines should also play key roles in the future if MRSA infection rates are to be minimized.

New technologies, such as the MRSAid™ Photodisinfection, can play a significant role in eliminating MRSA colonization and therefore should be part of standard of care within hospitals to reduce the risk of MRSA infections. Given the enormous mortality rates and costs associated with MRSA infections, greater prevention measures are warranted. We, at Ondine Biomedical, will continue to advocate for introducing more effective MRSA infection prevention measures in our health care systems.

References:
1.    http://www.medscape.org/viewarticle/544583 Alpesh Amin, MD, MBA,FACP ; Donald Batts, MD
2.    Noskin et al. (2005) and Kuehnert et al. (2006)
3.    Huang SS, Hinrichsen VL, Datta R, Spurchise L, Miroshnik I, Nelson K, Platt R: Methicillin-resistant Staphylococcus aureus infection and hospitalization in high risk patients in the year following infection. PLoS One 2011, 6:24340. doi:10.1371/journal.pone.0024340

The Noncompliance Epidemic: Patients Are Not Taking Their Meds

In 2011, Consumer Reports published a survey of 660 primary care physicians, “What Doctors Wish Their Patients Knew.” The number-one complaint by far: Patients didn’t take the doctors’ advice or otherwise follow treatment recommendations.

Specifically, patients don’t follow through on their medication regimes: up to 75% of adults don’t take their medications as intended, a problem that is now among the most pressing in healthcare and described as “epidemic.”  When you consider that in the U.S. some 3.8 billion prescriptions are written every year, that involves a lot of people.

Surprisingly, the noncompliance problem even involves patients who are chronically ill and those that have suffered a life-threatening event – in both cases the compliance rate is only 50%.

The follow-through on antibiotics is interesting. Even though you have to take them for a very short time, 5 – 15 days, the compliance rate is still far from perfect. One study showed a compliance rate of 84% when you had to take 2 pills a day, but dropped markedly to 73% when you had to take 3 pills a day.

So what’s the problem?

Forgetfulness is the number-one barrier to compliance, experts believe, although a survey of 10,000 patients found that only 24% ascribed noncompliance to forgetfulness.  Up to 20% failed to take medications because of perceived side effects, 17% had cost issues, and 14% didn’t feel the need to take medication; they believed it would have little or no effect on their disease.

But researchers caution that the reasons may be more troublesome, emanating from the murky depths of human psychology, and which the patients (not to mention medical researchers) may not fully understand.

So for example even when doctors are patients, they tend to act just like everyone else. So if you ask an audience of physicians for a show of hands of who has ever taken an antibiotic, many hands are raised. And if you  then asks how many doctors took the full course of antibiotics even after their symptoms abated many  hands go down.

This points to a deeper concern that says higher compliance rates may not even be possible.  “We’re asking patients to adopt obsessive-compulsive behavior,” admits internist Edmund Pezalla, MD, MPH, National Medical Director of Pharmacy Policy & Strategy for the health insurer Aetna. “Taking medication every day is hard to do. We’re asking people to deal with the same boring situation over and over again. We’re not programmed to do that. Machines do that. Humans don’t do it very well.”

So what’s the answer?

With more than 40,000 peer-reviewed studies on the subject conducted over several decades, you’d think we’d at least be at Compliance 2.0 by now in the state of our knowledge. In reality, it’s more like Compliance 1.5. We are not on the verge of solving this immensely complex problem. The outlines of what is, at best, a partial solution are only just starting to emerge, say the authors of a special report on patient noncompliance.

Yikes!

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