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?
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:
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’tneed 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?
Recently 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.
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.
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.
Disinfecting 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.
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.
Dr. Elizabeth Bryce led the research team that changed the way Vancouver General Hospital prevents surgical site infections
The Journal of Hospital Infection is the official journal of the prestigious London, England-based group, the Healthcare Infection Society. We are proud to announce that just this week, The Journal published Dr. Elizabeth Bryce’s year-long study at the Vancouver General Hospital on the effect of MRSAid on surgical site infections. But let’s begin at the beginning …
Undergoing major surgery is tough stuff. Having undergone spinal surgery I can speak from experience. The whole ordeal is fraught with anxiety and whether it works or not is life-changing, not to mention potentially life-saving. When you get out of the OR and wake up in a fog of pain and anesthetic you immediately have just one question: Did it work? When you’re told it has, it’s like a comfort drug rushes through you and for the first time since you were told you needed the operation – in my case 5 weeks – you are able to relax.
But here’s what I can’t imagine: being told that you’ve contracted an infection in the surgical wound. You’re already physically and psychologically broken down. To have to cope with an additional injury at the very place in your body that has already given out would be – devastating.
Surgical site infections (SSIs), however, are common. They represent almost 1/3 of all hospital infections and affect about 5% of surgery patients. That’s a ton of people given that about 16 million operative procedures are performed each year in acute care hospitals in the United States.
Hospitals have a standard way of preventing SSIs: cleaning the skin with an antiseptic, usually chlorhexidine (CHG) wipes, and/or nasal decolonization (a lot of germs live in the nose) with an antibiotic ointment, usually mupirocin.
But there are 2 problems with this: (1) antibiotics are increasingly losing their effectiveness, so much so that the World Health Organization and others consider antibiotic resistance to be a worldwide crisis, and (2) compliance: you have to apply the antibiotic over a period of 5 – 7 days and studies show that outpatients forget or otherwise just don’t do it; and if you’re in the hospital it takes up valuable nursing time to get it done.
So Canada’s Vancouver General Hospital, the second largest hospital in the country, decided to try something different: they replaced the antibiotic ointment – which causes both the resistance and compliance problems – with photodisinfection therapy (PDT). PDT is a promising antimicrobial strategy that uses light energy to activate a colored dye applied inside the nose (where the antibiotic ointment was applied) which in turn kills the germs (see Figure 1 at the back of the study for a photo display of how it works).
The VGH study, led by Elizabeth Bryce, MD, and reported just this week in The Journal of Hospital Infection, did this over a 1 year period with 3068 cardiac, orthopedic, spinal, vascular, thoracic, and neurosurgical patients. They used PDT and CHG wipes in the surgery holding-area in the 24 hour period before surgery (vs the protracted 5 – 7 days with the antibiotic ointment). The researchers compared the rate of SSIs using this procedure, versus the SSI rate over the previous 4 years using the former CHG-antibiotic ointment procedure, which involved some 12,387 patients.
The result? They found a “significant reduction” in the SSI rate with this procedure versus the former one. The greatest decreases in SSI rates were found in orthopedic and spinal patients: a 42% reduction in SSIs was realized, the majority which would have been hard-to-treat deep/organ space infections.
But it was something else in the study that caught my eye: “Importantly,” they say, “immediate [decolonization] ensured a very high degree of compliance (94% of patients) without interrupting normal workflow. Intranasal PDT took approximately 10 min compared with five to seven days with traditional mupirocin. In fact, the nurses were able to treat 1,912 patients in addition to those targeted for intervention.”
From a patient and staffing point of view that’s huge because the researchers, to their credit, are talking about the effect of this procedure on real-world medicine: i.e. PDT not only fits the hospital environment, it actually helps nurses do their jobs.
While my surgeon showed up once or twice a week after the surgery, it was the nurses who were my lifeline: they managed my pain, they dealt with my fears, and they helped me take my first steps again.
But that was decades ago. These days, nurses increasingly find themselves overwhelmed by their workloads. For example, an investigation conducted last year by the CBC’s Fifth Estate found that nurses “Carry out a dizzying array of … tasks during each shift … Nearly 40 per cent told us they feel burnt out to a high degree. Research shows nurse burnout is associated with risks to patient safety. Nurses we heard from also expressed fear that stress is leading to mistakes.”
A recent opinion piece in the New England Journal of Medicine also argues for more technology to deal with infection control: “Infection prevention eliminates the need to use antibiotics. Traditional infection-prevention efforts must be buttressed by new technologies that can more effectively disinfect environmental surfaces, people, and food.”
The Vancouver General Hospital has done just that and they continue to use PDT as part of their universal pre-operative decolonization protocol.
This study was reported previously at the International Conference of Infection Prevention and Control, and awarded first place at the Innovation Academy, Geneva, Switzerland, June 2013.
Tomorrow morning around 6:35, Carolyn Cross, the head of the company who produce the PDT technology will discuss its applications and the VGH study on a Vancouver radio program.
MRSA (red) on the microscopic fibres of a wound dressing
Here’s the problem: More than 200,000 patients get infections every year while receiving healthcare in Canada; more than 8,000 of these patients die as a result. Methicillin-resistant Staphylococcus aureus is the most common cause of serious hospital-acquired infections. Its rate increased more than 1,000% from 1995 to 2009. In the United States, MRSA numbers are the same, population adjusted.
Here’s the decades-old solution: Hospitals commonly screen patients for nasal carriage of MRSA. If you test positive, you’re isolated from other patients and treated (if infected) or decolonized (if you’re a MRSA-carrier but not yet sick). In the US, nine states mandate such screening.
Screen and treat seems reasonable enough. However, studies are trickling out suggesting that this is not the way to do it. Instead, they say, decolonize everyone at admission, or at least the “at risk” admissions such as surgery and ICU. This is called universal decolonization.
The prestigious New England Journal of Medicine published a study last summer that found universal decolonization of patients in the ICU was the “most effective strategy” versus screen and treat, or screen and decolonize. Its effectiveness was due to it “significantly reducing” MRSA-positive clinical cultures, and bloodstream infections from any pathogen. The reason, researchers say, is this method gets MRSA as well as other kinds of germs, it gets them right away at admission thus preventing spread to others, and it’s more easily incorporated into regular hospital procedures.
Just today, the British medical journal, The Lancet, published a study (unfortunately, subscription required) saying there’s insufficient evidence to support screening and isolating infected patients. In an interview with the BBC, one of the researchers, Gerd Fatkenheuer, said: “In the haste to do something against the rising tide of MRSA infection, measures were adopted that seemed plausible but were not properly assessed, bundling the effective and harmless with the ineffective and harmful.
With respect to isolating patients he said they found an unintended consequence: “We know for example that isolating patients can result in anxiety and depression and fewer visits by doctors and nurses,” thus lowering the overall standard of care.
And in Canada we have a real-world example of universal decolonization that bears out what the studies are saying. Over a 12 month period, the Vancouver General Hospital universally decolonized all of their 5,000 surgical patients. They found a 39% reduction in the number of surgical site infections, readmissions due to SSIs declined from 4 to 1.25 cases per month, and VGH saved more than $1 million in costs associated with treating patients who develop SSIs.
"Don't tread on me Dude - haven't you read the latest science?"
In 1995 there were 189 cases of MRSA in Canadian hospitals; by 2012, there were 7,206.
In response, The Chief Public Health Officer’s Report on the State of Public Health in Canada (2013), recommends that we re-focus our efforts on prevention strategies; namely, better hand hygiene and improved hospital cleaning.
Obviously the more bugs we kill the safer we’ll be: that’s just common sense — right?
Not so fast, say researchers at the Hospital Microbiome [i.e. bug] Project, whose mandate is to reduce hospital-acquired infections. They say that not only is this approach not fixing the problem, it’s actually making it worse. In other words, that insane rise from 189 MRSA cases a year to over 7,000 – that’s on us.
The thinking is this. Bad bugs don’t exist in isolation. Rather, they exist as a huge minority among hundreds of millions or even trillions of other bugs. Our weapons of destruction – things like antibiotics, bleach, or hand sanitizers – are not laser-guided missiles, they’re like atomic bombs that wipe out almost everything around. Who doesn’t get slaughtered? The bad guys mostly; specifically, the bugs who have already developed resistance to our drugs, etc. – that’s what resistance means, the ability to survive it all.
So once you have a hospital battlefield with a ton of dead harmless and even helpful bugs, guess what happens next? The resistant guys that remain standing reproduce like crazy. That’s because there’s no one left to compete with them for living space and food – as our antibiotics, etc., have killed-off the competition.
Jack Gilbert, PhD, who‘s in charge of the Hospital Microbiome Project puts it this way:
“For the past 150 years, we’ve been literally trying to just kill bacteria. There is now a multitude of evidence to suggest that this kill-all approach isn’t working.” (For example, here and here; and in this popular New York Times essay, “We Are Our Bacteria.”)
Thus, hospital-acquired infections are being drivennot by the existence of harmful microbes but by the absence of helpful species.
"Just open the window."
So the idea is to replace search and destroy with “growing a garden.” You do that by manipulating such things as hospital air temperature, humidity, light intensity, room air and CO2 concentrations, ventilation, and so on, thus cultivating an ecosystem of bugs beneficial to the patient. It’s just like tending a garden: by manipulating light, water, and soil conditions you influence the health of the plant; here, you influence the health of the patient by “weeding out” the bad bugs by, especially, growing and nurturing the good ones.
There’s a more traditional way of putting this paradigm shift in thinking:
“In watching disease … the thing which strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable … are very often not symptoms of the disease at all, but of something quite different – of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these.” - Florence Nightingale, “Notes on Nursing,” 1860.