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Norway’s solution: Stop taking so many antibiotics

January 2010

OSLO, Norway (AP) — At Norway’s hospitals, there is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated facilities of Europe, North America and Asia last year.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway’s public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world proves that Norway’s model can be replicated with extraordinary success, and public health experts are saying these deaths — 19,000 in the U.S. each year alone, more than from AIDS — are unnecessary.

“It’s a very sad situation that in some places so many are dying from this, because we have shown here in Norway that methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort,” said Jan Hendrik-Binder, Oslo’s MRSA medical adviser. “But you have to take it seriously, you have to give it attention, and you must not give up.”

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by the Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway’s simple solution, there’s a glimmer of hope. The Scandinavian country’s model is surprisingly straightforward:

Norwegian doctors prescribe fewer antibiotics than doctors in any other country, so people do not have a chance to develop resistance to the drugs.

Patients with MRSA are isolated, and medical staff who test positive stay at home.

Doctors track each case of MRSA by its individual strain, interviewing patients about where they’ve been and who they’ve been with, testing anyone who has been in contact with them.

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

“We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better,” said infectious disease specialist Dr. John Birger Haug.

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection
after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics.

Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus, while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares with 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

Cases have soared in the U.S., and MRSA cost $6 billion last year. Rates have increased from 2 percent in 1974 to 63 percent in 2004.

A mysterious adversary preys on the war's wounded

A strange, drug-resistant bacterium was infecting troops. Few had heard of it, and no one was sure of its origin.

Rui Chong, LA Times Staff Writer

The young Army medic would not stop bleeding. He had been put on a powerful regimen of antibiotics by doctors aboard the hospital ship Comfort in the Persian Gulf. But something was wrong. He was in shock and bleeding from small pricks where nurses had placed intravenous lines. Red, swollen tissue from an active bacterial infection was expanding around his abdominal wound. His immune system was in overdrive.

How odd, thought Dr. Kyle Petersen, an infectious disease specialist. He knew of one injured Iraqi man with similar symptoms and a few days later encountered an Iraqi teenager with gunshot wounds in the same condition.

Within a few days, blood tests confirmed that the medic and the two wounded Iraqis were all infected with an unusual bacterium, Acinetobacter baumannii. This particular strain had a deadly twist. It was resistant to a dozen antibiotics. The medic survived, but by the time Petersen connected the dots, the two Iraqi patients were dead.

It was April 2003, early in the Iraq war -- and 4 1/2 years later, scientists are still struggling to understand the medical mystery.

The three cases aboard the Comfort were the first of a stubborn outbreak that has spread to at least five other American military hospitals, including Walter Reed Army Medical Center in Washington and the Army's Landstuhl Regional Medical Center in Germany.

Hundreds of patients -- the military says it has not tabulated how many -- have been infected with the bacterium in their bloodstream, cerebrospinal fluid, bones or lungs. Many of them were troops wounded in Iraq or Afghanistan; others have been civilians infected after stays in military hospitals.

At least 27 people have died in military hospitals with Acinetobacter infections since 2003, although doctors are uncertain how many of the deaths were caused by the bacteria.

The rise in infections has been dramatic. In 2001 and 2002, Acinetobacter infections made up about 2% of admissions at the specialized burn unit at Brooke Army Medical Center in Texas. In 2003, the rate jumped to 6%, and then to 12% by 2005. Other military hospitals have reported similar increases.

In the early days of the war, there were so many infections in an intensive care unit on the Comfort that a nurse posted a sign: "Acinetobacter Alley." In two months, the bacterium was found in 44 of the 211 patients wounded in battle.

It was getting out of control. Petersen pleaded for help on an infectious disease mailing list.
"Can anyone familiar with [the] soil biology of Iraq or the drug-prescribing practices of the pre-regime medical system explain the severe drug resistance pattern we are seeing among our trauma victims?"

It was no surprise that Petersen knew little about Acinetobacter -- which has long been seen as the slacker of the bacterial world. It's called Acinetobacter, from the Latin word for "motionless," because the bacterium lacks flagella or cilia to move. "Organisms that are relatively wimpy pathogens . . . are not high on people's list," said Fred Tenover, a microbiologist at the Centers for Disease Control and Prevention in Atlanta. The bacterium is persistent, however, and requires few nutrients. It lives naturally in soil and can survive for days on dry surfaces, such as doorknobs or hospital equipment. Acinetobacter usually threatens only the weakest of the weak, those whose immune systems are compromised because of old age, trauma or disease. Even then, garden-variety Acinetobacter is easily controlled with common antibiotics.

But the situation started to change about two decades ago.

Acinetobacter followed an evolutionary path trod by numerous other bacteria since World War II, when antibiotics were introduced widely. Bacteria not killed by an antibiotic would pass on their resistance to later generations. The process was quickened by the often profligate use of the drugs, which allowed more bacteria to develop resistance.

Today a host of diseases, such as tuberculosis and gonorrhea, have highly antibiotic-resistant strains.

"If we use antibiotics to kill off everything else, what is left standing is very, very drug resistant," said CDC epidemiologist Arjun Srinivasan. "Acinetobacter is one of those left standing."

Tenover first noticed a strain of Acinetobacter with some drug resistance in the mid-1980s while working at a veterans hospital in Seattle. Several years later, he met with Ghassan Matar, a visiting Lebanese scientist at the CDC, whose samples of Acinetobacter baumannii from patients in a Beirut hospital raised another red flag.

The infections were a legacy of years of fighting. Positive tests for Acinetobacter more than tripled at the hospital from 1983 to 1984 and stayed high for years after. The samples Matar brought were already resistant to two important classes of antibiotics.

In the following years, civilian hospitals in the U.S. and around the world reported sporadic outbreaks of drug-resistant Acinetobacter.

"You have an organism of relatively low virulence that became more important because you've run out of drugs to treat it with," Tenover said.

The question that Petersen struggled with was how this bug had found its way into modern military hospitals.

Doctors could beat back an infection with the strongest antibiotics, and hospitals could try to scrub away the bacteria. But those weren't solutions. They had to find the source of the contamination.

A Canadian soil scientist who worked in Iraq in the 1970s described high rates of antibiotic-resistant Staphylococcus bacteria in dirt samples.

The scientist surmised they were caused by the erratic distribution of antibiotics in Iraq. A shipment of drugs would arrive and doctors would use them until they ran out. Then they would prescribe whatever other antibiotic was sent next, the scientist said.

A microbiologist wrote to Petersen about Australian patients injured in the 2002 nightclub bombings in Bali, Indonesia, who returned home with astronomically high levels of very drug-resistant bacteria, including Acinetobacter.

"It gave me an idea that maybe it was something related to the process of aeromedical evacuation or the injury process," said Petersen, now 39.

After Comfort reported its first Acinetobacter cases, infections sprang up in military hospitals in the Middle East, Germany and the U.S. The facilities took the cases seriously.

The night Marine Maj. K.C. Schuring arrived at Andrews Air Force Base in Maryland, a doctor told him point-blank that if his fever didn't subside within three days, his left leg would probably have to be amputated. Schuring, barely conscious and lying on a gurney, heard the doctor tell him that the infection could spread: "This can kill you." He was taken to the National Naval Medical Center in Bethesda, Md., and immediately isolated. He heard the word Acinetobacter for the first time.

Schuring, who had been shot in both legs in Iraq, could take bad news, but this worried him. "I was happy they could treat it, though they said they couldn't necessarily cure it," he said. Whenever he left the room, he wore a yellow gown to alert others of his infection. Everyone who visited him donned yellow gowns and gloves.

In 2003, Dr. Clint Murray, then a 33-year-old Army major at a frontline aid station in Iraq, began to dig for answers. He started at the beginning.

Though some wounded soldiers were sent to aid stations such as Murray's, most were airlifted directly to more advanced facilities like the Combat Support Hospital in Baghdad.

Murray, an infectious disease specialist, asked a critical care doctor there to take samples from soldiers wounded by guns, improvised explosive devices, mortars or other weapons. As doctors scrambled to stabilize patients, the wounds were swabbed to collect bacteria. Most of the samples were taken within 20 to 40 minutes of the soldiers' injuries.

But out of the samples taken from 49 patients, the doctors found no Acinetobacter, though there were plenty of other bacteria, such as Staphylococcus.

That still left the possibility that dirt and dust from beyond the battlefield had blown into a wound.

Murray joined a group, including Petersen and Srinivasan, that focused on dirt around field hospitals in Iraq and Kuwait -- the next step in the medical evacuation chain that started at frontline aid stations and ended at hospitals in the U.S.

The group gathered 18 dirt samples around seven field hospitals, and also looked at 31 archived soil samples from around the combat zone. Only one of the soil samples -- taken from outside a field hospital mess hall -- turned up positive. The group compared it with strains collected from casualties at the field hospital in Baghdad and larger hospitals including Landstuhl in Germany, and found they were not related. Dirt, it seemed, was not the culprit.

In late 2004, Murray returned to Brooke Army Medical Center. He wondered whether soldiers were carrying the bacterium on their skin and infecting themselves when wounded. He set to work on a study swabbing the nostrils of 293 soldiers at Ft. Sam Houston, Texas, who had never been to Iraq or Afghanistan. None of the soldiers tested positive for Acinetobacter, Murray and colleagues reported in the journal Infection Control and Hospital Epidemiology in 2006. They seemed to be running up against a wall.

As the search continued, military doctors struggled to find an effective strategy to combat the bug. The treatment could be difficult.

Schuring said doctors experimented with different drugs. Schuring's situation was complicated by his allergy to penicillin. At one point, he was taking four antibiotics. The infection had already taken away his appetite and made him queasy. It took doctors about two weeks to narrow down his treatment to a relatively new intravenous antibiotic, tigecycline.

Doctors operated on him nearly every other day to clean out dead tissue in his legs. When the infection began to settle down, doctors installed a 21-inch stainless steel plate along his left thigh. The surgery made Schuring dizzy, but the doctors didn't want to give him a blood transfusion for fear of inciting a new infection. The treatment, Schuring said, was like going "through hell."

Evidence was building that the cause of the infections was something in the military trauma system. The hospital-based transmission made sense since the bacterium had already taken up residence in civilian hospitals.

Though preliminary typing found no link between the U.S. civilian strains and the military casualty strains, the conditions in military hospitals were just right for the bacterium, said Srinivasan, the CDC epidemiologist.

In the hectic environment of field hospitals, it was also difficult to impose strict infection-control measures, such as thorough cleaning of hands and equipment after each patient, Murray said.

The field hospitals had become the center of a perfect storm of trauma -- battle- hardened bugs preying on the weakest patients at their most vulnerable moments.

"Soldiers now survive injuries they wouldn't have survived before," Srinivasan said.. "That challenge creates soldiers who are sick, who are living in healthcare facilities for a long time and are more susceptible to hospital-associated infections."

It took about three years for Murray and his colleagues to look through the entire chain of trauma, from the battlefields to the field hospitals to the tertiary care center in Landstuhl and finally to the military hospitals in the U.S.

The results of their labor, published this May in the journal Clinical Infectious Diseases, showed that all seven field hospitals tested in Iraq and Kuwait had Acinetobacter in patient care areas.

"We can't be 100% sure, but the data supports that patients are probably getting exposed to Acinetobacter in field hospitals in Iraq," Murray said. How the bacteria became entrenched in the field hospitals is still unknown. But in many ways, it is irrelevant. It is there, and, as civilian hospitals have also found, it is not going away easily. The military strain of the bacterium has caused at least one civilian death. Acinetobacter was growing in the lungs and bloodstream of a 35-year-old man whose immune system was suppressed because he had a kidney transplant at Walter Reed in 2005. There were no signs of infection until the man came down with acute shortness of breath one evening and died soon after.

For the most part, doctors have figured out the most effective drugs against the bacterium -- an antibiotic called imipenem and an older class of drugs known as polymyxins. The drugs have made the infections fairly manageable. Through stricter controls, such as monitored hand-washing, infection rates have shown signs of dropping in some hospitals.

Petersen, who worked at National Naval Medical Center in Bethesda after the Comfort's mission ended, treated just one or two Acinetobacter infections in July, down from the highs of 15 to 20 a month in 2004 and 2005. This year, there have been only a few cases each month, according to hospital figures.

But Murray now wonders whether Acinetobacter was really the culprit after all. He and others looked at patients with the worst outcomes at Brooke's burn unit and found that Acinetobacter was associated with larger burns but was not causing more deaths by itself.

A study of 35 returning soldiers with the most extreme kinds of shin bone fractures found that Acinetobacter was the most common bacterium around fracture sites when the patients arrived, but it was easy to clear. Those who later suffered serious complications, including amputations, tended to be infected with other serious bacteria, such as Staphylococcus and Pseudomonas aeruginosa. Acinetobacter, it turns out, may only be a marker of vulnerability. "It is not the worst bug," Murray said.

The battle between bacteria and humans never ends. Recently, scientists have noted signs that Acinetobacter strains are growing resistant to polymyxins and imipenem, said Tenover, the CDC microbiologist.

There are, however, small victories for humans.

Just before Christmas, after a month of treatment, Schuring returned to his home in Farmington Hills, Mich. Schuring's wife, Lynn, was nervous about this strange bug her husband had brought back from the war. What if they kissed? What if her husband put down a drink and one of their young children took a sip? Would her parents, who are in their 70s, be at risk if they visited? Doctors assured her that this bug was no danger to the strong. So far, no one in the family has gotten sick.

But Schuring's doctor warned them that they must keep an eye out for any sign of the bacteria, which could lie dormant for years.

Schuring, now a 38-year-old lieutenant colonel, has continued to improve and hobbles around on his own two legs. He has one last surgery at Bethesda in January and then, perhaps, he will run marathons again.

"You know, this is a long process for these guys and their families," Lynn Schuring said. "I think we just take it one step at a time. . . . "Everything we've been through has taught me to take it one step at a time."

You've heard of MRSA, but what about Acinetobacter?

LA Times
December 24, 2009

In the antibiotic-resistance world, MRSA gets most of the press. Sometimes, C. difficile works its way into a headline or two. But here's a reminder that other bacteria are growing stronger as well.

A study published online Wednesday in the journal Infection Control and Hospital Epidemiology found that Acinetobacter is building up resistance to the antibiotic imipenem, often used as a last resort to combat blood infections and pneumonia in hospitalized patients. The bacterium is usually only a problem in intensive-care units -- but has also infected troops wounded in Iraq and Afghanistan.

The research was supported by Extending the Cure, which is trying to call attention to antibiotic resistance or, more specifically, "extend antibiotic effectiveness."

Here's the research brief. And more on Acinetobacter from the CDC. Plus two earlier Los Angeles Times stories on the bacterium:

A mysterious adversary preys on the war's wounded: "A strange, drug-resistant bacterium was infecting troops. Few had heard of it, and no one was sure of its origin."

Deadly bacteria defy drugs, alarming doctors: "A new category of bugs becomes more resistant to treatment, and their toll -- which already includes a Brazilian beauty queen -- is expected to rise."

Think of it as an incentive for staying well. And using antibiotics wisely.

Patients Carry MRSA Between Hospitals

Source: CDC/Janice Haney Carr

Emerging Health Threats: Disinfecting hospital patients can stop further spread, but community strains could slip under the radar.

By tracing the strains of multidrug-resistant Staphylococcus aureus (MRSA) that turned up in 450 hospitals across Europe over six months, scientists have discovered that patients transport the bug between healthcare centres. The research, published this week in PLoS Medicine, suggests that identifying and treating patients harbouring the ‘superbug’ could help to control infection rates.

“[C]ontrol efforts aimed at interrupting the spread [of MRSA] within and between health care institutions may not only be feasible but ultimately successful and should therefore be strongly encouraged,” write Hajo Grundmann, from the Dutch National Institute for Public Health and the Environment in Bilthoven, and colleagues.

This type of control strategy is likely to be effective, say experts. The UK already has policies in place which were designed to tackle spread of the bacteria between patients. But some scientists fear the picture is more complicated, suggesting that strains of MRSA emerging in the community may alter the dynamics of the disease in the future.

For their study, Grundmann and colleagues recruited 450 hospitals in 26 European countries and asked them to collect bacterial samples from patients with invasive S. aureus infections picked up while in hospital. Regional laboratories analysed more than 3000 isolates of the bacteria, and assessed how they related to each other by looking at one region of a specific gene, known as spa. The researchers then mapped these results geographically to get a better idea of the genetically diversity of MRSA strains on the continent.

Different spa MRSA types appeared in different countries, and the dominant ones clustered together in distinct geographical areas. The clustering suggests that the bacteria are spreading within networks of healthcare facilities, say the authors, and this shows that MRSA is spread by patients who are repeatedly admitted to different hospitals.

According to Barry Farr, from the University of Virginia Health System, USA, many other studies have reported the spread of MRSA clones within an individual hospital or a group of local healthcare facilities. This research helps to confirm that specific MRSA strains spread through healthcare facilities and suggests that better infection control in these locations could be “very beneficial”, he says.

“More than 120 epidemiological studies have reported that screening to detect MRSA colonisation coupled with contact isolation can control healthcare related spread,” adds Farr.

Screening patients to stop transmission

Despite these findings, there is no policy in place for MRSA screening in US hospitals. UK health authorities have taken a different tack. In England, since early 2009 patients admitted to hospital for non-emergency surgery have been screened for MRSA, says Richard James, from the University of Nottingham. By 2011, all patients — including those admitted for medical emergencies — will be screened, he adds.

This policy can potentially break the chain of MRSA transmission between healthcare facilities, says James. But for now, the tests used to identify MRSA in hospital patients take three days to complete. By the time healthcare staff receive the results any infected patients admitted for a short period may have left the hospital, and could have potentially spread the bug to others.

There are quicker testing alternatives, but these cost more, according to James. Some might say the testing is done simply to tick a box, he adds.

Nevertheless, screening policies still allow health authorities to intervene. The spread of MRSA could be reduced if patients released from hospital and known to be carrying the bug are given follow-up treatment with antiseptic shower gels and nasal creams to eliminate the bacteria. “If we use this information it will help us stay ahead of the game,” says James.

Community strains in the mix

Strains of the bacteria arising outside hospitals, known as community-acquired MRSA, are becoming an increasing problem in the UK and elsewhere in the world. In the USA, more than half of all MRSA infections are now picked up in the community. Scientists predict that once inside hospitals, community strains will take over from their healthcare counterparts as a source of infection.

James says that MRSA prevention policies focused on hospitals could miss this growing problem. “It would be a great surprise if community-acquired MRSA rates in England don’t follow what is seen in the USA,” says James. Health authorities in the UK are not actively looking for community MRSA.

Unlike strains circulating in hospitals, which typically affect vulnerable and older patients, community strains generally affect young, healthy people, causing skin and soft tissue infections. Most patients are treated outside the hospital by general practitioners, but studies in the USA have suggested these strains of the bacteria can still find their way into healthcare facilities.

Michael Millar, from Barts and The London National Health Service Trust, believes community MRSA strains can play a role in altering infection dynamics. “The past does not allow us to predict the future,” he says.

The paper gives us a snapshot in time of the MRSA situation in Europe, explains Millar, where so far MRSA has been mainly a hospital problem. “Unfortunately this data does not tell us what will happen next.”

Nose treatment cuts hospital-acquired infections

Gene Emery
Wed Jan 6, 2010

BOSTON (Reuters) - If you're checking into the hospital for surgery, doctors may soon be swabbing your nose in an effort to prevent an infection from appearing after your operation.

Researchers in the Netherlands said on Wednesday they were able to cut the risk of a common bacterium by nearly 60 percent by first looking for signs of it in the nose and then treating it with an antibiotic nasal gel and full body wash.

The treatment combination also shaved two days off a typical 14-day stay in the hospital.

Hospital-acquired infections are a major problem in medicine, so doctors are always looking for the best way to reduce the risk.

About 27 million surgeries are done just in the United States each year, and in as many as half a million cases, infections occur at the site of surgery.

Up to 30 percent of those infections are caused by strains of the bacterium Staphylococcus aureus, which otherwise benignly resides in the nose and on the skin.

The new study, published in the New England Journal of Medicine, used a rapid test to identify which patients, most of whom were scheduled to undergo surgery, had the bacteria in at least one nostril.

The 504 patients treated with the antibiotic nose gel mupirocin, also known as Bactroban, and washed with chlorhexidine, a common ingredient in mouthwash, developed an S. aureus infection 3.4 percent of the time. The rate for 413 volunteers given placebo treatment was 7.7 percent.

The research team, led by Dr. Lonneke Bode of Erasmus University Medical Center in Rotterdam, estimated that 250 patients would need to be screened to prevent one infection.

"Preventing one infection will pay for thousands of these screenings," Dr. Henri Verbrugh of Erasmus, a coauthor of the study, said in a telephone interview.

Infections are also a problem when doctors put tubes into the body. Although his team did not evaluate enough patients to study the problem directly, "We feel this technology is capable of preventing those types of infections as well," Verbrugh said.

A second infection study, also reported in the journal, found that a chlorhexidine-alcohol combination produced 41 percent fewer surgical-site infections as the commonly used mixture of povidone and iodine, which gives a yellow-orange tinge to the skin.

In a commentary, Dr. Richard Wenzel of the Virginia Commonwealth University in Richmond said the chlorhexidine-alcohol mixture should replace the older disinfectant when scrubbing people for surgery, and the nasal disinfection technique should primarily be used for people undergoing cardiac surgery, receiving an implant, or whose immune system is likely to be affected.

HAI-Related Litigation: What Infection Preventionists Need to Know

Kelly M. Pyrek, Infection Control Today

Litigation related to healthcare-acquired infections (HAIs) is a trend that should be on every infection preventionist (IP)’s radar for the coming decade, especially in light of the fact that the frequency of hospital professional liability claims is increasing. According to a new study released by Aon Corporation in conjunction with the American Society for Healthcare Risk Management, these claims are on the rise and are expected to continue increasing at a 1 percent annual rate.

The study, the 10th annual Hospital Professional Liability and Physician Liability Benchmark Analysis, examines trends in frequency, severity and overall loss costs related to hospital and physician professional liability; 100-plus healthcare organizations representing more than 1,500 facilities ranging from small community hospitals to large multi-state healthcare systems provided loss and exposure data for the study. The study attributes the rise in claims to the downturn in the U.S. economy, changes to the Centers for Medicare and Medicaid Services (CMS) reimbursement rules regarding so called “never-events” and changes in public sympathy toward healthcare providers.

“Worsening economic conditions in 2008 may have influenced individuals to assert claims against hospital systems,” says Erik Johnson, healthcare practice leader for Aon’s Actuarial and Analytics Practice and author of the analysis. “From 2003 through 2007 public attention was directed on tort reform activity and prohibitive medical malpractice costs for physicians. This coincided with significant reductions in professional liability claims. As public attention shifted to other subjects, the momentum of the reductions dissipated. Recently, the public focus has evolved to discussions regarding waste, inefficiency and defensive medicine. It remains to be seen how this will influence the frequency of professional liability claims.”

The study also found that 1 out of every 4 claims and 24 percent of hospital professional liability costs are associated with hospital-acquired conditions such as infections and injuries, medication errors, retained objects during surgery and pressure ulcers. Juries may be starting to take notice of this trend; Hsieh (2009) reports that recently, a jury in Suffolk County, New York awarded $13.5 million to a 40-year-old woman who died of a flesh-eating bacteria that she contracted during chemotherapy treatment at Dana-Farber Cancer Institute. Hsieh (2009) also quotes Gloria Seidule, an attorney at Seidule & Webber, as noting, “Anyone providing healthcare to an individual is no longer going to have immunity for transmitting infections.” Seidule is also litigating a hospital-acquired infection lawsuit involving methicillin-resistant Staphylococcus aureus (MRSA). Hsieh (2009) also reports that Mary Coffey, an attorney at Coffey Nichols, recently won a $2.58 million verdict for a 69-year-old man who contracted MRSA through an IV that was administered in the ambulance following a heart attack. When doctors inserted a pacemaker, the infection spread, ultimately resulting in the loss of a kidney and a leg.

During the “Changing Legal and Regulatory Landscape” conference sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC) held in November, a panel of experts addressed the legal issues surrounding HAIs. Panelist Russell Nassof, director of strategic initiatives at TRC, says, “Changes in the regulatory environment, reimbursement practices and legal standards along with drastic changes in healthcare itself are creating a potential ‘perfect storm’ of liability and increase risk for healthcare-associated infections in healthcare facilities today.”

Nassof notes that events that were previously thought of as risks are now considered to be preventable adverse events, and that IPs will play an even bigger role in protecting their hospitals against liability in the future. At issue is the increased transparency created within the healthcare system in general, which also triggered public reporting of infection rates data. Currently, just a handful of states do not have or have not considered adopting legislation mandating public reporting, and a federal bill related to MRSA is under consideration. According to Nassof, state hospital associations have opposed these reporting requirements due to fear of increased exposure to liability, issues related to reporting logistics, efficiency issues such as diverting resources from patient care and/or prevention efforts; and conflicting reporting requirements such as infection site and organism.

There are unanswered legal questions that are in this complicated mix, according to Nassof, and they include whether or not prescreening for infections such as those caused by MRSA is a Pandora’s box or a solid legal defense. Another wrinkle is the fact that CMS is currently not paying the differential related to hospital-acquired infections and conditions (as of Oct. 1, 2008, Medicare has stopped reimbursing for certain types of hospital-acquired infections; see related article on page 18), and Nassof says the door is open for CMS to cease payment completely for certain infections and conditions, and requiring hospitals to conduct root cause analyses or to apologize to patients and their families. “It’s a tricky legal situation,” Nassof says. “Can a facility apologize and still defend a claim before a jury?”

While the burden has always been on the plaintiff, Nassof says a recent case in the U.S. had the burden of proof shifting to the hospital, which had to prove that the patient did not get the infection at its facility. “There is the perception that there is potential negligence on the part of hospitals for not protecting patients. A strict liability standard has not been applied to HAIs... yet,” Nassof says. “Hospitals must develop legally defensible protocols and best practices, train staff to follow them, and document that they are being done.” Nassof advises IPs to don their legal hats because infection rate data that IPs collect could be damaging to the hospital and/or be used against it in a lawsuit.

APIC conference panelist Emily Rhinehart, RN, MPH, CIC, CPHQ, vice president of healthcare risk consulting for Chartis Insurance, says that at the present, HAI-related lawsuits are “few and far between but the legal landscape is changing.” She recommends that hospitals stick with evidence-based practices and carefully document in the patient’s medical record any departures from these protocols. “You can’t make it up when you are defending a case, so documentation is key,” Rhinehart says. She also recommends that expectations for patient care be made unambiguous, that compliance is ensured through the use of checklists and other tools, and that the entire process is monitored and documented. A good example is hand hygiene, Rhinehart says. “There is a strong public perception of the lack of hand hygiene in hospitals. The plaintiff could be perplexed by it and pursue a case.”

To that end, panelist Nicholas McConnell, director of the law firm Jackson & Campbell PC, added that most healthcare-related lawsuits are not about the quality of care but rather the atmosphere at the healthcare institution, and how healthcare providers present the clinical actions that were taken. “The hospital must explain why a particular outcome was allowed to happen, and so the imperative here is the standard of care, which can be found in the hospital’s own policies and procedures,” McConnell says. “At the heart of the case is did anyone depart from that standard of care? The proof is simple if the compliance is clearly lacking. And did that departure cause harm to the patient?” McConnell explains that while the law admires excellence, it does not demand it; however, a departure from the standard of care is a significant challenge to defend.

Antibiotic Overuse Threatens Modern Medicine: Experts

Kate Kelland
Tue Nov 10, 2009

LONDON (Reuters) - Overuse of antibiotics in Europe is building widespread resistance and threatening to halt vital medical treatments such as hip replacements, intensive care for premature babies and cancer therapies, health experts say.

Dominique Monnet of the European Center for Disease Prevention and Control's (ECDC) scientific advice unit said the "whole span of modern medicine" is under threat because bugs are become resistant to antibiotics, rendering the drugs useless.

"If this wave of antibiotic resistance gets over us, we will not be able to do organ transplants, hip replacements, cancer chemotherapy, intensive care and neonatal care for premature babies," he told reporters at a briefing.

Antibiotics are needed in all these treatments to prevent bacterial infection. But drug-resistant bacteria are a growing problem in hospitals worldwide, marked by the rise of superbugs such as methicillin-resistant Staphyloccus aureus (MRSA).

Such infections kill about 25,000 people a year in Europe and around 19,000 in the United States

On top of the risks to future treatments, Monnet said the costs of antibiotic resistance were already hurting -- and may hit healthcare budgets across the European Union yet harder if the problem is not addressed.

The six most common multi-drug-resistant bacteria -- often referred to as superbugs -- cause around 400,000 infections a year in Europe, killing around 25,000 people and using 2.5 million hospital days a year.

The ECDC, which monitors and advises on disease in EU, calculates that with a hospital day costing an average of 366 euros ($548), superbug infections are already sucking up 900 million euros a year in extra hospital costs, and a further 600 million euros a year in lost productivity.

"Across the European Union the number of patients infected by resistant bacteria is increasing and that antibiotic resistance is a major threat to public health," the ECDC said.

Britain's government was criticized by a parliamentary committee on Tuesday for failing to tackle the majority of hospital-acquired infections by narrowing its focus to two high profile ones -- MRSA and Clostridium difficult.

The ECDC conducted an "antibiotic awareness" campaign in November to urge doctors to stop overprescribing antibiotics.

Patients demanding antibiotics for viral infections often are not aware that they will not work, it said, but doctors are and should stop giving in to pressure.

Sarah Earnshaw of the ECDC's communications unit, pointed to a 2002 survey that showed 60 percent of patients do not know that antibiotics do not work against viruses like flu and colds.

"Patients often demand antibiotics," she said. And doctors often think, she said, that giving in is a quicker way to deal with a demanding patients than persuading them otherwise.

(Editing by Louise Ireland)

Antibiotic Overuse? Not in Norway

Associated Press Writers

OSLO, Norway (AP) -- Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.

Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospitals of Europe, North America and Asia this year, soaring virtually unchecked.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway's public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world prove that Norway's model can be replicated with extraordinary success, and public health experts are saying these deaths -- 19,000 in the U.S. each year alone, more than from AIDS -- are unnecessary.

"It's a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort," said Jan Hendrik-Binder, Oslo's MRSA medical adviser. "But you have to take it seriously, you have to give it attention, and you must not give up."

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by The Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway's simple solution, there's a glimmer of hope.

Dr. John Birger Haug shuffles down Aker's scuffed corridors, patting the pocket of his baggy white scrubs. "My bible," the infectious disease specialist says, pulling out a little red Antibiotic Guide that details this country's impressive MRSA solution.

It's what's missing from this book -- an array of antibiotics -- that makes it so remarkable.

"There are times I must show these golden rules to our doctors and tell them they cannot prescribe something, but our patients do not suffer more and our nation, as a result, is mostly infection free," he says.

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What's here? Medicines considered obsolete in many developed countries. What's not? Some of the newest, most expensive antibiotics, which aren't even registered for use in Norway, "because if we have them here, doctors will use them," he says.

He points to an antibiotic. "If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail," he says, "and rightly so because it's useless there."

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

"We don't throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better," says Haug.

Convenience stores in downtown Oslo are stocked with an amazing and colorful array -- 42 different brands at one downtown 7-Eleven -- of soothing, but non-medicated, lozenges, sprays and tablets. All workers are paid on days they, or their children, stay home sick. And drug makers aren't allowed to advertise, reducing patient demands for prescription drugs.

In fact, most marketing here sends the opposite message: "Penicillin is not a cough medicine," says the tissue packet on the desk of Norway's MRSA control director, Dr. Petter Elstrom.

He recognizes his country is "unique in the world and best in the world" when it comes to MRSA. Less than 1 percent of health care providers are positive carriers of MRSA staph.

But Elstrom worries about the bacteria slipping in through other countries. Last year almost every diagnosed case in Norway came from someone who had been abroad.

"So far we've managed to contain it, but if we lose this, it will be a huge problem," he said. "To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can't prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics."

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics. Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares to 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

In the U.S., cases have soared and MRSA cost $6 billion last year. Rates have gone up from 2 percent in 1974 to 63 percent in 2004. And in the United Kingdom, they rose from about 2 percent in the early 1990s to about 45 percent, although an aggressive control program is now starting to work.

About 1 percent of people in developed countries carry MRSA on their skin. Usually harmless, the bacteria can be deadly when they enter a body, often through a scratch. MRSA spreads rapidly in hospitals where sick people are more vulnerable, but there have been outbreaks in prisons, gyms, even on beaches. When dormant, the bacteria are easily detected by a quick nasal swab and destroyed by antibiotics.

Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway's solutions in varying degrees, and his agency "requires hospitals to move the needle, to show improvement, and if they don't show improvement they need to do more."

And if they don't?

"Nobody is accountable to our recommendations," he said, "but I assume hospitals and institutions are interested in doing the right thing."

Dr. Barry Farr, a retired epidemiologist who watched a successful MRSA control program launched 30 years ago at the University of Virginia's hospitals, blamed the CDC for clinging to past beliefs that hand washing is the best way to stop the spread of infections like MRSA. He says it's time to add screening and isolation methods to their controls.

The CDC needs to "eat a little crow and say, 'Yeah, it does work,"' he said. "There's example after example. We don't need another study. We need somebody to just do the right thing."

But can Norway's program really work elsewhere?

The answer lies in the busy laboratory of an aging little public hospital about 100 miles outside of London. It's here that microbiologist Dr. Lynne Liebowitz got tired of seeing the stunningly low Nordic MRSA rates while facing her own burgeoning cases.

So she turned Queen Elizabeth Hospital in Kings Lynn into a petri dish, asking doctors to almost completely stop using two antibiotics known for provoking MRSA infections.

One month later, the results were in: MRSA rates were tumbling. And they've continued to plummet. Five years ago, the hospital had 47 MRSA bloodstream infections. This year they've had one.

"I was shocked, shocked," says Liebowitz, bouncing onto her toes and grinning as colleagues nearby drip blood onto slides and peer through microscopes in the hospital laboratory.

When word spread of her success, Liebowitz's phone began to ring. So far she has replicated her experiment at four other hospitals, all with the same dramatic results.

"It's really very upsetting that some patients are dying from infections which could be prevented," she says. "It's wrong."

Around the world, various medical providers have also successfully adapted Norway's program with encouraging results. A medical center in Billings, Mont., cut MRSA infections by 89 percent by increasing screening, isolating patients and making all staff -- not just doctors -- responsible for increasing hygiene.

In Japan, with its cutting-edge technology and modern hospitals, about 17,000 people die from MRSA every year.

Dr. Satoshi Hori, chief infection control doctor at Juntendo University Hospital in Tokyo, says doctors overprescribe antibiotics because they are given financial incentives to push drugs on patients.

Hori now limits antibiotics only to patients who really need them and screens and isolates high-risk patients. So far his hospital has cut the number of MRSA cases by two-thirds.

In 2001, the CDC approached a Veterans Affairs hospital in Pittsburgh about conducting a small test program. It started in one unit, and within four years, the entire hospital was screening everyone who came through the door for MRSA. The result: an 80 percent decrease in MRSA infections. The program has now been expanded to all 153 VA hospitals, resulting in a 50 percent drop in MRSA bloodstream infections, said Dr. Robert Muder, chief of infectious diseases at the VA Pittsburgh Healthcare System.

"It's kind of a no-brainer," he said. "You save people pain, you save people the work of taking care of them, you save money, you save lives and you can export what you learn to other hospital-acquired infections."

Pittsburgh's program has prompted all other major hospital-acquired infections to plummet as well, saving roughly $1 million a year.

"So, how do you pay for it?" Muder asked. "Well, we just don't pay for MRSA infections, that's all."

Martha Mendoza is an AP national writer who reported from Norway and England. Margie Mason is an AP medical writer based in Vietnam, who reported while on a fellowship from The Nieman Foundation at Harvard University.

MRSA Leads to Worse Outcomes, Staggering Expenses for Surgical Patients

ScienceDaily (Dec. 17, 2009)

Post-surgical infections significantly increase the chance of hospital readmission and death and cost as much as $60,000 per patient, according to Duke University Medical Center researchers who conducted the largest study of its kind to date.

"We conducted a multi-center study of multiple surgical procedure types among 659 patients to determine clinical and financial outcomes of surgical site infections that are directly attributable to MRSA (methicillin-resistant Stapylococcus aureus)," said Deverick J. Anderson, M.D., MPH, an infectious diseases specialist at Duke University Medical Center and lead author of the study. "We found the impact of methicillin-resistance on surgical patients is substantial and that preventing a single case of surgical site infection due to MRSA can potentially save hospitals as much as $60,000."

Previously published research on surgical site infections provided conflicting conclusions. For the Duke study, researchers looked at the 90-day postoperative period for patients over a five-year period in one tertiary care center and six community hospitals in the Duke Infection Control Outreach Network (DICON). Created in 1997, DICON assists community hospitals in improving quality of care and enhancing patient safety, while minimizing the costs associated with non-evidence based approaches to infection control.

The researchers compared hospital readmission, mortality, length of hospital stay and hospital charges for patients in three groups. Some had surgical site infections due to MRSA, some were infected with methicillin-susceptible Staphylococcus aureus (MSSA), and some were uninfected. The study evaluated deep-incision and organ/space infections, which are more severe than superficial infections at the site of incision. The findings are published in PLoS ONE.

"We found that patients with surgical site infections due to MRSA were 35 times more likely to be readmitted and seven times more likely to die within 90 days compared to uninfected surgical patients," Anderson said. "These patients also required more than three weeks of additional hospitalization and accrued more than $60,000 in additional charges."

The researchers found most of the outcomes for MRSA compared to MSSA were worse, as anticipated, however one finding was surprising, according to Anderson. "Our findings show that methicillin-resistance contributed to longer hospital stays and increased hospital charges but did not increase the risk of mortality," he said. The data shows that patients with surgical site infections due to MRSA compared to MSSA on average required six more days of hospitalization and incurred $24,000 in additional charges.

"For the seven hospitals we looked at, the total estimated cost resulting from surgical site infections due to MRSA was more than $19 million," Anderson said. "That's a staggering amount, which demonstrates an area of cost-saving potential for these institutions and other community hospitals."

The Duke study provides the first cost impact data tied to post-surgical MRSA infection in a large group of hospitals. "Given our estimated cost of one MRSA case, we can conclude that a $60,000 intervention to prevent even one of these infections would be cost-effective for an institution," Anderson said. "With this new financial data, greater emphasis should be placed on an effort to design and evaluate specific preventative interventions."

Other researchers involved in the study include Luke F. Chen, Kenneth E. Schmader, Yong Choi and Daniel J. Sexton of Duke University Medical Center; and Keith S. Kaye, formerly of Duke University Medical Center now at Detroit Medical Center.