Hand Hygiene Prevents Infections

Some Metro Detroit hospitals will start swabbing the noses of arriving patients to test them for one of the most problematic bacteria, in response to the growing threat of drug-resistant infections.

Those patients found carrying Methicillin-resistant Staphylococcus aureus (MRSA) -- even if they don't have infections -- will be isolated in rooms where hospital staff take special precautions (such as wearing gowns and gloves) to keep the organism from spreading.

"We know that isolation works," said Paula Keller, technical director of epidemiology at Beaumont Hospital in Royal Oak. "It limits transmission, or reduces it."

Keller and doctors at other health systems say they are aggressively screening in light of the increased rates of MRSA infections and the results of recent studies that show early screening and isolation works.

Faced with a rise in hospital-acquired infections that risk the lives of patients and cost billions of dollars annually to treat, hospitals across the country are aggressively trying to lower infection rates.

According to the Centers for Disease Control and Prevention, health care-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year in American hospitals. Hospitals are particularly concerned about containing the spread of infections by drug-resistant bacteria like MRSA, which first emerged in the U.S. in 1968 and is especially difficult and costly to treat because of its resistance to antibiotics.

Veterans Affairs hospitals in Ann Arbor and Detroit must start screening every patient for MRSA by September, in response to a mandate from the Department of Veterans Affairs this spring that requires all 155 VA medical centers in the U.S. test for the bacteria. VA hospitals have been phasing in testing since the spring in intensive care units, said Dr. Carol Kauffman, chief of infectious diseases at the Veterans Affairs Ann Arbor Healthcare System.

Beaumont Hospital, Royal Oak started screening open-heart surgery patients for MRSA in July, and in September will begin testing patients deemed a high risk for carrying MRSA and another organism called Vanocomycin-resistant Enterococci (VRE). High-risk patients include those transferred from other hospitals and patients who live in nursing homes or assisted living facilities.

Henry Ford Health System has been screening patients in intensive care units for MRSA for about three months, and will begin testing surgical patients in September. The health system is planning to screen more high-risk patients in the future.

The infection is costly for hospitals. Each case of a MRSA infection adds about 10 days to hospital stays and $30,000 to $60,000 in direct costs per patient, said Dr. Marcus Zervos, division head for infectious disease and director of infection control for the Henry Ford Health System.

Many people carry bacteria like MRSA normally in their nose and throat. Most of the time the bacteria aren't a problem to the person carrying it or the people around them, unless they are undergoing surgery or are ill.

Most efforts to prevent the spread of infections in hospitals have focused on making contact with patients more sterile, like with judicious hand-washing. But more hospitals across the country are screening patients with no symptoms of infections.

The process has generated a national debate over whether it's really necessary and actually works.

"Strict hand hygiene is what prevents infection," said Dr. George Alangaden, infectious disease specialist at Harper University and Karmanos Cancer hospitals. He notes the science is still undecided about the benefits of aggressive screening of MRSA, and says it has a number of downsides.

Focusing on one organism can mean missing others that could cause infection, Alangaden said, and testing and isolating patients carrying MRSA costs hospitals a lot of money. At the VA in Ann Arbor, it will reach into the hundreds of thousands of dollars per year for the test and the extra gowns and gloves for patients in isolation, Kauffman said.

But doctors who support aggressive screening argue that it's needed. "What we know for sure is that the status quo is not working," Zervos said

Staph Infections Go Beyond NFL

By Alex Marvez

NFL players aren't the only athletes who have been afflicted with staph infections in recent years. Toronto Blue Jays outfielder Alex Rios had a standout 2006 season derailed when he contracted staph from what he believes was a bruise caused by fouling a baseball off his foot. Phoenix Suns forward Grant Hill's recovery from severe ankle problems was slowed after he was infected following one of his four surgeries. And the infection even proved fatal for a Division III football player in 2003, as wide receiver/kicker returner Ricky Lannetti of Lycoming College died after contracting an extremely strong form of staph known as MRSA (Methicillin-resistant Staphylococcus aureus).

Staph also is affecting the world of mixed martial arts fighting, where an epidemic has sidelined several competitors who train under the renowned Pat Miletich in Iowa. Ultimate Fighting Championship veteran Drew McFedries will reportedly be sidelined for the next six-to-eight months, while Spencer Fisher was forced to withdraw from the UFC Fight Night 11 special Sept. 19 on Spike TV emanating from Las Vegas. Heavyweight Ben Rothwell said former UFC heavyweight champion Tim Sylvia and Miletich trainer/fighter Steve Rusk also were affected.

MMA fighters seem particularly susceptible to staph because of the close physical contact inherent in training. The bacteria attacks open wounds and can cause boils, blisters, fever, illness and even death.

Rothwell, a member of Militech's renowned International Fight League team, said a previous knowledge of staph made him realize how potentially dangerous the initial infection suffered by McFedries and Rusk could be. Rothwell said he told Miletich, Rusk and McFedries about the best way to treat staph but the latter didn't follow his advice, leading to a recurrence of the infection. Rothwell said McFedries is suffering from the effects of a much stronger form of staph known as MRSA."I worked with Steve and he did fine," Rothwell said Thursday in a telephone interview. "Drew did whatever because he didn't have insurance or something. A doctor just gave him basic antibiotics and the (MRSA) came back."

Rothwell said the staph problem at Miletich's camp in Bettendorf, Iowa is now under control. That's good news for the Miletich-coached Quad City Silverbacks MMA squad, which will be attempting to win its second consecutive IFL team championship Sept. 20 in the league finals against the New York Pitbulls in Hollywood, Fla. The final will air on September 23 on Fox Sports Net.

"You can have brand new gym equipment, but if one guy comes in that is infected, people are going to get it," said Rothwell, who will be facing New York's Bryan Vettel in the IFL team finals. "The problem is you can have no signs of infection, but if you've got it in your nose, it can lead to an infection. It's really bad (stuff)."

Superbug on Rise

The deadly MRSA infection is a growing problem in Hertfordshire hospitals in the U.K. with the number of cases rising to almost double those expected, alarming new statistics have revealed.

The latest information from the East and North Hertfordshire Trust, which includes the QEII Hospital in Welwyn Garden City and the Lister Hospital in Stevenage, shows that the number of cases of the MRSA superbug has risen to twice the target.

Conservative MP for Welwyn Hatfield, Grant Shapps, said: "Residents will be concerned that after years of Government programmes and initiatives, we still can't quite seem to deliver clean hospitals which are fit for purpose.

"It seems wrong that people should have to worry about going to hospital and contracting MRSA or C-Difficile.

"I urge the local NHS trust bosses to finally get on top of this worrying situation."

Statistics just published reveal that in the three months from April to June, 12 patients had contracted MRSA, double the trust's target for that period.

A spokesman for the East and North Hertfordshire NHS Trust said: "In the four months since April, there have been 15 recorded cases.

"There have been none so far in August.

"Every year, our target for reducing MRSA blood infections is lowered and every year we have made very real improvements.

"The trust's staff have put a great deal of effort into combating infections but evidence now exists showing that up to half of all MRSA were actually acquired before the patient came into hospital. A growing case for how much more vigilant healthcare facilities need to be in order to ensure that patients are safe as they are administered care.

By Carly Griggs

Medicare Says It Won’t Cover Hospital Errors

WASHINGTON, Aug. 18 — In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.

In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products.

“If a patient goes into the hospital with pneumonia, we don’t want them to leave with a broken arm,” said Herb B. Kuhn, acting deputy administrator of the Centers for Medicare and Medicaid Services.

The new policy — one of several federal initiatives to improve care purchased by Medicare, at a cost of more than $400 billion a year — is sending ripples through the health industry.

It also raises the possibility of changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission.

Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case.

The Centers for Disease Control and Prevention estimates that patients develop 1.7 million infections in hospitals each year, and it says those infections cause or contribute to the death of 99,000 people a year — about 270 a day.

Intravenous catheters are widely used to provide hospital patients with medications, nutrition and fluids, but complications are relatively common.

One state, Michigan, has had spectacular success with systematic efforts to reduce infection rates in intensive care units.

Susan M. Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group, said, “Private insurers will take a close look at what Medicare is doing, with an eye to adopting similar policies.”

Consumer groups welcomed the change. And while hospital executives endorsed the goal of patient safety, they said the policy would require them to collect large amounts of data they did not now have.

Lisa A. McGiffert, a health policy analyst at Consumers Union, hailed the rules.

“Hundreds of thousands of people suffer needlessly from preventable hospital infections and medical errors every year,” Ms. McGiffert said. “Medicare is using its clout to improve care and keep patients safe. It’s forcing hospitals to face this problem in a way they never have before.”

Christine K. Cahill, a registered nurse who used to inspect hospitals for the California Department of Public Health, said: “This is a great start. Infection-control specialists have been screaming for 20 years that federal and state officials should pay more attention to this problem because hospital infections hurt patients and cost money.”

The Bush administration estimates the new policy will save Medicare $20 million a year. But other experts say the savings could be substantially greater.

Nancy E. Foster, a vice president of the American Hospital Association, agreed that doctors and hospitals knew how to prevent the transfusion of incompatible blood products and should not be paid more if they accidentally left objects in patients during surgery.

But Ms. Foster said that some of the conditions cited by Medicare officials were not entirely preventable. Commenting on the proposed rules in June, the American Hospital Association said, “Certain patients, including those at the end of life, may be exceptionally prone to developing pressure ulcers, despite receiving appropriate care.”

In most states, Ms. Foster said, hospital records do not show whether a particular condition developed before or after a patient entered the hospital. Under the new rules, she said, hospitals will have to perform more laboratory tests to determine, for example, if patients have urinary tract infections at the time of admission.

The rules, first reported in The Star-Ledger of Newark, carry out a directive from Congress included in a 2006 law. When they were proposed in May, consumer advocates said they feared that some hospitals might charge patients for costs that Medicare refused to pay.

But that is forbidden. “The hospital cannot bill the beneficiary for any charges associated with the hospital-acquired complication,” the final rules say.

Eileen O’Neill-Pardo of Everett, Wash., said her experience showed the need for the rules. Her 82-year-old mother, Margaret M. O’Neill, died of an infection that developed during intestinal surgery at a Seattle hospital in 2004.

“The operation — to remove scar tissue — was successful, but the patient died,” Ms. O’Neill-Pardo said. “The hospital staff did not take steps to control the infection, which took over her body. My mother died less than a week after the operation.”

Michigan hospitals have been extremely successful in reducing bloodstream infections related to such catheters, researchers reported recently in The New England Journal of Medicine. The hospitals did not use expensive new technology, but systematically followed well-established infection-control practices, like covering doctors and patients from head to toe with sterile gowns and sheets while the catheters were inserted.

Hospital executives said these techniques had saved 1,700 lives and $246 million by reducing infection rates in intensive care units since 2004.

Some of the complications for which Medicare will not pay, under the new policy, are caused by common strains of staphylococcus bacteria. Other life-threatening staphylococcal infections may be added to the list in the future, Medicare officials said.

Dr. Kenneth W. Kizer, an expert on patient safety who was the top health official at the Department of Veterans Affairs from 1994 to 1999, said: “I applaud the intent of the new Medicare rules, but I worry that hospitals will figure out ways to get around them. The new policy should be part of a larger initiative to require the reporting of health care events that everyone agrees should never happen. Any such effort must include a mechanism to make sure hospitals comply.”

Illinois Screenings for Staph are Now the Law

Illinois will become the first state to screen hospital patients for dangerous drug-resistant staph infections under legislation signed by the governor on Monday.

The new law puts Illinois at the forefront of efforts to battle methicillin-resistant staphylococcus aureus (MRSA) infections, which strike more than 1 million patients and kill tens of thousands of people each year.
With its passage, Illinois leads the nation in addressing MRSA, the most common type of hospital-acquired infection, said Pat Merryweather, senior vice president at the Illinois Hospital Association.

Pennsylvania and New Jersey both enacted similar laws this year, but their laws will be implemented later. Illinois' new law, Senate Bill 233, becomes effective immediately.

It calls for hospitals to test all patients in hospital intensive-care units for MRSA infections and to isolate patients with the bacteria so they won't pass it on to others. Medical providers will be required to wash hands and to wear masks and gloves when dealing with infected patients.

Although several European nations mandate similar measures to combat MRSA, they're not yet accepted practice in the U.S. The Illinois bill was highly controversial.

It sat for well over a month on Gov. Rod Blagojevich's desk while a group of hospital infection-control practitioners lobbied vigorously against the measure. They claimed it would interfere with their ability to respond flexibility to emerging threats, such as Clostridium difficile and Vancomycin-resistant enterococci, also dangerous superbugs.

Instead, the infection-control providers advanced a competing piece of legislation, HB192, requiring hospitals to analyze which infections posed the greatest risks in their institutions and come up with plans to prevent their spread. They argued the approach was both less prescriptive and more comprehensive.

Supporters of mandatory screening for MRSA countered that what was needed wasn't further studies but strong action. The only proven way to reduce infections is to test patients, isolate those who are positive, and institute hygienic measures meant to control the bacteria's spread, they argued.

Until midday Monday, it wasn't clear what the governor would do. In the end, he surprised both camps by signing both pieces of legislation. But in a press release, the governor commented only on HB192.

"People should feel confident that when they go to a hospital, a nursing home or other health facility for medical care, they will not end up worse off with a dangerous infection. This bill will help make sure facilities are safe and clean and will help reduce the risk of infections," Blagojevich said.

Reaction was, predictably, mixed.

Jeanine Thomas, an advocate who has devoted the last two years to advancing mandatory screening for MRSA, was beside herself with excitement. "This is fantastic; it's going to save so many lives," said Thomas, who contracted MRSA in 2000 in a Chicago hospital.

Michael Vernon, president of the metro Chicago chapter of the Association of Professionals in Infection Control & Epidemiology, couldn't hide his disappointment.

"Oh my goodness. I'm shocked," he said, upon learning of the governor's move from a reporter. "I think this will pose a significant problem for hospitals trying to implement these two bills."

The administration's position now appears to be that the varied approaches embodied in the two pieces of legislation are complementary.

"They're both aimed at protecting patients," said Dr. Craig Conover, medical director of the office of health protection for the Illinois Department of Public Health. The MRSA law is more focused and action-oriented, while the other legislation is more comprehensive and will attack a wider variety of pathogens, he said.

Both laws will yield far more robust information about drug-resistant infections circulating in Illinois hospitals. They call for yearly reports on MRSA and C. difficile and routine reports on other superbugs that lead to bloodstream infections and pneumonias.

Also, under the new legislation, the Illinois Department of Public Health will begin tracking MRSA infections acquired in community settings such as gyms or housing complexes, a growing problem throughout the area.

By Judith Graham
Tribune staff reporter
August 21, 2007
Copyright © 2007, Chicago Tribune

Researchers Verify Link Between Heartburn Medication And Community-Acquired C. Difficile

A new study conducted by MUHC (McGill University Health Centre) researchers adds further evidence to the link between proton pump inhibitors, such as heartburn medications, and Clostridium difficile infection outside of hospitals. The findings published in the Canadian Medical Association Journal (CMAJ) today used a clinical research database to confirm that proton pump inhibitors are a risk factor for C. difficile infection.

Numerous studies worldwide have documented increases in hospital C. difficile associated disease, but this study is one of only a handful to suggest this trend is mirrored in the general community.

"Our results show that drugs known to suppress stomach acid, such as heartburn medications, are associated with an increased risk of C.difficile associated disease," says Dr. Sandra Dial, an MUHC researcher and lead author of the new study. "By reducing gastric acidity, we believe proton pump inhibitors provide a more hospitable environment within which C. difficile bacteria can colonize."

The researchers also discovered that almost half the patients who had been diagnosed with C.difficile in the community had not received antibiotics - another known risk factor. Until recently, it had been assumed that C.difficile occurred almost entirely in patients who had taken antibiotics in a hospital setting. "These results highlight the fact that patients may develop C.difficile without receiving antibiotics in settings such as the community where antibiotic use may be less common," noted Dr. Dial who is also Attending Staff in the Department of Critical Care at both the MUHC and Jewish General Hospital (JGH) and an Assistant Professor of Medicine at McGill University.

The Research Institute of the McGill University Health Centre (RI MUHC) is a world-renowned biomedical and health-care hospital research centre. Located in Montreal, Quebec, the institute supports over 500 researchers, nearly 1000 graduate and post-doctoral students and operates more than 300 laboratories devoted to a broad spectrum of fundamental and clinical research.

Scientists Find Ancient Bacteria in Antarctica

PHILADELPHIA - Researchers at Rutgers University have found that, as the world warms, organisms that had been trapped in glacial ice, and which scientists are unfamiliar with, may come alive and resume growing.

Chunks of glacier dug up from Antarctica have revealed a startling cargo, Rutgers scientists announced Monday: bacteria that had apparently lain dormant in the ice for up to 8 million years. And despite their badly degraded DNA, some of the ancient microbes were able to reproduce after being warmed up in a New Brunswick, N.J., laboratory, and their genetic code has offered a snapshot of the distant past.

The team said its findings, published in the online edition of Proceedings of the National Academy of Sciences, could help tackle a wide range of scientific questions: from the threat of antibiotic-resistant bacteria to the mysteries of life on Mars.

Also on the horizon is the question of what would happen if glaciers, continuing to melt as a result of global warming, were to release DNA from long ago into the oceans.

Eight million years is by far the oldest estimate for microbial life frozen in ice, and Monday's report is being met with some skepticism. Yet the research draws on a broad range of evidence from geology and microbiology, winning admirers such as John C. Priscu, a microbial ecologist at Montana State University.

Barely a decade ago, this line of research was non-existent. Ice was thought to be virtually devoid of life, and thus Antarctica, with 70 percent of the world's fresh water locked in its frozen grip, was assumed to be a barren landscape. No more. Some researchers have speculated that, as glaciers continue to melt, the release of ancient microbes could be harmful to modern organisms.

But Kay Bidle, a Rutgers assistant professor of marine and coastal sciences, called that a remote possibility, as the recovered bacteria were not the kind that cause disease. Nor were numerous fragments of DNA from a variety of other bacteria found in the samples.

Tom Avril
Philadelphia Inquirer
Aug. 7, 2007 12:00 AM

Hospital, Infect Me Not

Patients in hospitals should not end up worse off than when they were admitted because of an infection acquired during treatment. Yet thousands of people are stricken this way in Massachusetts and across the nation. Hospitals know their infection rates, and it's about time they made them public, to inform prospective patients of the risk and to put the staff on notice that they need to do better to prevent the spread of germs.

A report by a special investigative committee funded by the Legislature recommends that the state mandate reporting of infections in three common procedures: hip replacements, knee replacements, and the insertion of "central line" catheters, which can remain in patients for weeks to deliver chemotherapy or liquid food. Hospitals would report rates of other less common procedures to the Department of Public Health, but not have to release the information to the public.

Karen Nelson, RN, vice president of the Massachusetts Hospital Association, likes the idea, but inquiries to hospitals in Boston suggest a certain reluctance. For instance, Boston Medical Center said in a statement: "Until a standardized mechanism for reporting these rates is agreed upon, any information released to the public by an institution would not provide an accurate method of comparison." John Auerbach, the state commissioner of public health, would like to wait six to nine months before releasing comparative data, while DPH and the hospitals work out a strategy to reduce infections.

There's no need to delay. Since December Paul Levy, chief executive of Beth Israel Deaconess Medical Center, has been publicizing his hospital's rates of central line infections, dating back to October 2005. Combined with an intensive internal education campaign, it has caused the infection rate to drop significantly. BI-Deaconess follows a standard set by the US Centers for Disease Control and Prevention. That ought to be an adequate model for the other hospitals in the state.

The Department of Public Health set up the special committee as part of the Health Reform Law approved in 2006. Legislators wanted expanded access to health insurance to be accompanied by improvements in healthcare quality. Compared to the difficulties of providing coverage to the uninsured, publication of the comparative data is a simple matter.

Next month the Legislature's Committee on Health Care Finance will be examining a bill to require better reporting as part of a package of health quality improvements. If DPH and the hospitals don't release the data on the three infection rates soon -- say, by Jan. 1 -- the Legislature would be justified in imposing a mandate, so that Massachusetts residents can compare how well hospitals fight infections before they cross the threshold as patients.

© Copyright 2007 Globe Newspaper Company.
Boston Globe
August 12, 2007

Administrators Give Thumbs-Up to Screening

In Scotland, infections such as MRSA and clostridium difficile (C-diff) remain at a high rate, although they are on the decrease according to new figures. Experts believe some people might already be carrying the bugs before they are admitted, despite the general assumption patients pick up the infections while in hospital.

The new chairman of NHS Lothian, Dr Charles Winstanley, has asked Health Secretary Nicola Sturgeon to discuss screening and she has offered her backing.

The initiative would see patients tested when entering hospital and then isolated from other patients if they proved positive for an antibiotic-resistant superbug. As well as helping identify the source of the infection, this would prevent it spreading from patient to patient.

"If it emerges that high levels of MRSA or C-diff are prevalent in the community, it is likely a major awareness campaign would be needed to promote better hygiene in places such as care homes.

Dr Winstanley said: "Patients are right to be concerned if they think they're going to leave hospital with an infection they didn't go in with.

"Our figures are in line with national expectations - the actual rates are not cause for alarm, but I want to see the figures improve.

"I've taken up with the Scottish Executive the suggestion that we discuss the case for screening patients on arrival at hospital so that we get some idea of what's being taken in, as opposed to what might be picked up there.

"Screening already happens in a few high-risk specialities but it's not universal and I think there should be discussion on a standard arrangement across Scotland.

"Screening can take time and could cause some delay so it does create difficulties, but it would isolate which bits of MRSA were incubated at home and taken into hospital, and which bits were acquired in a hospital environment. I would have thought that's the first piece of information we need to know.

"It may be we're simply incubating levels of MRSA that are in the community."

Screening already takes place with vulnerable patients who undergo heart surgery or hip operations, but testing is limited due to the high cost involved.

It could cost as much as £20 million a year to screen all NHS Lothian patients on admission.

But Health Secretary Nicola Sturgeon said: "If experts give the go-ahead, I am determined that we will fund an MRSA screening programme."

New figures show that the number of MRSA cases fell from 234 in 2005/06 to 201 in the most recent financial year.

Cases of C-diff also fell, from 1571 to 1455, however instances of MSSA, a less deadly relative of MRSA, rose marginally, from 236 to 238.

A national surveillance report on C-diff found rates across Scotland rose by 50 per cent earlier this year, but the Lothians bucked the trend.

Dr Alison McCallum, director of public health with NHS Lothian, said: "We know from our figures and reports from other agencies that - through the hard work of our dedicated staff - we are continuing to keep the rate of healthcare-associated infections stable and have been doing so for the last five years.

"We are implementing a multifaceted strategy to control infections and would like to thank the public for their help in keeping infections out of hospital.

"Over the last couple of years, we have invested in 50,000 copies of a patient information booklet, a number of poster campaigns, the provision of alcohol gel dispensers and participated in national campaigns, led by the Scottish Executive, on hand hygiene."

HEALTH REPORTER (aroden@edinburghnews.com)
HEALTH chiefs in the Lothians believe all patients should be screened before they enter hospital to tackle superbugs.

Non-disposable Wires Put Patients at Risk

Excerpted from: Electrocardiography Wires: A Potential Source of Infection by: Donna Quinton Brown, RN

Drug-Resistant Streptococcus pneumoniae (DRSP) and gram negative bacilli possessing the ability to produce Extended Spectrum Beta-Lactamases (ESBL) have become frequent pathogens causing infections in both hospital and community settings. The increase in resistance leads to greater morbidity, mortality, and cost, and has challenged the medical field and pharmaceutical industry in the development of prevention and treatment strategies.

... Using disposable equipment has become a credible method of reducing the risk of transmission of nosocomial infections through cross-contamination. Not only is the use of such disposables more sanitary and convenient, but the high cost of each nosocomial infection allows us to make a case for disposable items being more cost-effective.

Historically, from metal reusable bedpans to multipatient pulse oximetry probes, the understanding that bacteria are transmitted from patient to patient via reusable equipment vectors has led to this drive toward disposable, single-patient-use medical equipment.

Incredibly, one potential source of infection has yet to be significantly examined. Where once everything from bedpans and enema bags to patient drains and tracheostomy tubes was reusable, now the only pieces of medical equipment that come in contact with the patient’s torso that are not single patient use and disposable are the electrocardiography (ECG) wires. How
these nondisposable wires used on multiple patients have escaped close scrutiny until now is difficult to understand.

According to Infection Control Today, the American Society of Microbiology did a study in which they found that 47.6% of 42 neckties worn by male clinicians “harbored potential pathogens.” The study concluded, “the link between a necktie and the potential for transmission (of pathogens) must be considered.”

A physical barrier is usually present between a patient’s skin and a clinician’s tie. If clinicians’ ties are contamination risks, how much more of a risk are ECG monitoring wires, which are in direct contact with patients’ skin? These wires have multiple surfaces that are difficult to reach with cleaning agents. The wires also frequently come in contact with patients’ blood and body fluids, which seep into the smallest recesses of connections, thereby providing a perfect, virtually unreachable medium for the growth of bacteria.

ECG wires attached to even the least mobile patients can be found wrapped around endotracheal tubes, tracheostomy tubes, chest tubes, drains, urinary catheters, and so on, and the methods used to clean these reusable wires between patients is usually not effective enough to prevent cross-contamination of bacteria. A recent article in Cardiology News stated that antibiotic-resistant bacteria were found on 77% of ECG lead wires that were cultured after they were reprocessed and just before they were attached to new patients in the intensive care unit (ICU).

The researcher, Dr. Paul R. Brookmeyer of the University of Wisconsin Hospital and Clinics, Madison was quoted as saying the wires are “‘an unappreciated reservoir’ of multidrug-resistant nosocomial pathogens.” In addition, the article concluded that “attachment of contaminated lead wires to a new patient can result in colonization and ultimately in invasive infection by multiresistant nosocomial microorganisms.”

ECG wires, thus identified as carriers of resistant strains of bacteria and an invasive infection risk, were thus linked directly to the root cause of cross-contamination infection in an article from the Division of Infectious Diseases at the University of Texas, Medical Branch in Galveston. The burn unit of that university hospital experienced “an outbreak of colonization and infection caused by vancomycin-resistant enterococci.” Five weeks after the apparent eradication, the outbreak reoccurred. The reemergence of the infection was traced to one ECG lead wire.

In addition to this account, Wisconsin hospital epidemiologists attributed an outbreak of Serratia marcescens infection to insufficiently decontaminated ECG leads. Unfortunately, these reports show that merely following a cleaning protocol for ECG wires is not sufficient to eliminate the risk of cross-contamination. What unit would be more diligent in decontamination
than a burn unit attempting to eradicate an outbreak of vancomycin-resistant enterococci?

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers infection control of sufficient import to include it as 1 of 3 goals in each of its 2005 patient safety goal categories. The overwhelming JCAHO focus is on prevention. They state: “Prevention of health care-associated infections (HAIs) represents one of the major safety initiatives an organization can undertake.” They further state that “Joint Commission standards focus on reducing the risks of such infections and, in the case of hospitals, call for at least one activity in the infection control process to be aimed at preventing the transmission of infections.”

Elimination of an identified source of transmission of resistant bacteria, such as reusable ECG wires, would be an ideal response to JCAHO guidelines; but more importantly, use of disposable leads would improve patients’ safety. An action plan to eliminate this patient safety risk by incorporating it in infection control measures can be developed by using the JCAHO publication titled Failure Modes and Effects Analysis in Health Care: Selecting a High-Risk Process and Assembling a Team as a guide.

Separately, 2 hospitals in south Florida and 1 in Southern California initiated the use of disposable ECG leads in their cardiovascular ICUs as part of a program to reduce the incidence of sternal wound infections.

The frequency of sternal wound infections decreased more than 90% in all 3 hospitals. Hospital administrators attribute those results, in significant part, to the use of disposable ECG leads. Bon Secours St. Frances Hospital, in Midlothian, Va, opened its doors for the first time in September 2005. Ricky DeJesus, administrative director of criticalcare, states, “The concept of Bon Secours St. Frances is that we are the medical facility of the future.

In keeping with this, we started using disposable leads from the beginning in our critical care and telemetry areas. There is enough evidence out there to convince me that there is a significant risk of infection in reusable ECG wires. Although we have had many central [catheters] and surgical patients, we have not had 1 nosocomial infection attributable to ICU and telemetry since we opened our doors 4 months ago. I credit that statistic, at least in part, to the use of disposable ECG leads.”

... Using disposable equipment to avoid spreading nosocomial infections must remain at the forefront of prevention measures. In this clinical path of prevention, no reusable equipment that comes in direct contact with the patient’s body can be overlooked. Reusable ECG wires have been identified in several studies as a carrier of resistant bacteria and a cause of nosocomial infection. Therefore, these wires must be considered a potential source of hospital-acquired infection in any institution that uses them.

Disposable ECG wires would eliminate this threat to both patients’ safety and healthcare economics. The move toward eliminating reusable ECG wires is not only the natural progression in the process toward standardization of the use of disposable equipment that comes in contact with patients, but it is the next step in a strong infection control program. Moving toward the exclusive use of disposable ECG leads has only positive implications for medical patients and the healthcare facilities providing for them.

C. Diff Out of Control

March 8, 2007

More than 1,000 Ohioans every month last year came down with diarrhea-inducing -- and sometimes deadly -- infections during hospital or nursing home stays.

That was the finding in a report released Wednesday by the Ohio Department of Health on the first year of tracking Clostridium difficile (C. diff) infections in 210 hospitals and 966 nursing homes. There were about 14,300 cases statewide in 2006, the report said.

Long-term care hospitals -- where patients stay about 25 days, on average -- had the highest rates of infection. The Akron area's long-term care hospitals saw monthly C. diff rates as high as 45 and 53 cases per 10,000 patient days, compared with rates ranging from 1.1 to 15.1 cases per 10,000 patient days for other local hospitals.

Patient days are the number of patients a hospital sees in a given month divided by the number of days in that month.

Statewide, the report found that hospitals had seven to eight C. diff cases per 10,000 patient days, while nursing homes had two to three cases per 10,000 patient days.

C. diff infections have long been known as a byproduct of antibiotic use, especially among hospital patients and nursing home residents. However, the bacterium gained prominence in 2004 when a more toxic strain appeared across the United States and Canada. This strain caused severe diarrhea, colon damage (resulting in surgical removal of the colon) and more deaths.
In Ohio, C. diff-related deaths have increased by nearly 325 percent -- from 112 in 2000 to 473 deaths in 2005.

The report released Wednesday does not discuss C. diff-related deaths, however. The purpose of the report is to establish a baseline for C. diff cases, so that future outbreaks can be more easily identified, said state epidemiologist Dr. Forrest Smith.

The report also does not differentiate between different strains of C. diff. Though identifying strains may be important in an individual patient's care, Smith said, it's not as important when tracking cases at a statewide level.

'I'm sure we have a mixture here of all strains of C. diff,' he said.

The newest C. diff strain has 20 times the amount of toxin as other strains. In most cases, it is treated with two specific antibiotics: metronidazole (Flagyl) or vancomycin (Vancocin ). If treatment fails, the toxins can cause tissue to die, requiring surgery to remove the colon.

C. diff proliferates and causes sickness when 'good' bacteria in the intestinal tract is killed off by antibiotic use. Smith said it's important for people to understand that antibiotics do not come without risk. They should be taken as prescribed by the doctor.

The 2006 report is available on the state health department's Web site, though Smith said consumers should be careful in using the data to compare one hospital or nursing home to another.

Though the data are adjusted for patient volume, he said, they are not adjusted for the severity of illness. The yearlong reporting and surveillance behind the report cost state and local health departments, hospitals and nursing homes about $2.5 million.

In addition to tracking infections, Smith said, the state department of health is educating the medical industry about C. diff and how to prevent it. In 2006, the department presented 19 seminars to long-term care facilities.

Smith said finding out why long-term care hospitals have much higher rates is 'a question we're all grappling with.'

It's true that long-term care hospitals, which help patients make the move from hospital intensive-care units to nursing homes, have sicker patients, he said, but it's still important for these facilities to recognize and respond to outbreaks.

Excerpt from OHIO.COM

Getting C. Diff Under Control

Excerpt from RN Web
By TERRI METULES, RN, BSN, clinical editor

Clostridium difficile, the most common cause of antibiotic-associated diarrhea, poses a huge threat to hospitalized patients. But do you know all you should about the new therapies that are in the pipeline, and what you can do to protect your patient - now?

Surfing the Web, I stumbled upon a professional chat room in which a nurse had asked for information about Clostridium difficile, the spore-forming, anaerobic bacillus that causes most cases of antibiotic-associated diarrhea. The response she received from a colleague was that "C diff," as it's nicknamed, is the "in" bacteria and companies are making a lot of money selling drugs to treat it.

A physician in the same chat room disagreed with a nurse's decision to place a patient diagnosed with C. difficile-associated disease (CDAD) in isolation. He told the nurse that "C. difficile isn't infectious." The nurse asked if anyone "knew for sure" if CDAD is no longer considered contagious, and wondered if there was research to back it up.

As I read on, it became clear to me that there was more confusion than clarity surrounding C. difficile. The organism is indeed infectious; it can easily be spread from patient to patient, and is now on the growing list of antibiotic-resistant organisms.

C. difficile's toxins damage the gut wall, causing problems ranging from mild diarrhea to severe pseudomembranous colitis, toxic megacolon, and bowel perforation. Immunocompromised patients are among those at highest risk for severe infection.

The good news is that there are several developments underway—a new drug, a vaccine, and a rapid test for detecting the bacteria—that could bring an end to C. difficile's scourge. But until these developments (summarized in "New weapons are poised to combat CDAD") make their way to the bedside, nurses need to know how to stem the spread of this infection and help patients who have the disease heal.

C. difficile is destructive when given the chance:

The organism known as C. difficile inhabits the gut of up to 70% of healthy newborns and 3% of healthy adults, so it hasn't always been considered a pathogen. (This may be why some practitioners don't consider it infectious.) The microbe's destructive nature emerged only after the use of broad-spectrum antibiotics came into vogue.

During normal human growth and development, bacterial competitors crowd this slow-growing anaerobe out of the gut of the majority of people. Whatever C. difficile remains is held in check by the gut's normal flora. However, if the bacterial competition is killed off—which is what happens when patients are given broad-spectrum antibiotics—C. difficile can grow out of control and CDAD develops.

Symptoms include loose, watery, and foul-smelling stools that smell like horse manure; crampy abdominal pain; and in most cases, fever. Severe diarrhea is confirmed when there is more than 10 stools a day. Patients can develop signs and symptoms within the first week of antibiotic therapy and up to 10 weeks after its discontinuation.

For antibiotics to "cause" CDAD, a person must be exposed to the C. difficile organism or already have the bacteria in his colon. Most people who come into contact with C. difficile do so during a hospital stay. Studies show that more than 30% of all hospitalized patients in the United States become infected with C. difficile. Of those infected, 60% are diagnosed after admission. Also noteworthy: A full 97% of the cases of diarrhea acquired in ICUs are caused by C. difficile.

Hospitals have become the major source of C. difficile infection because infected patients shed thousands of these organisms in each stool. The expelled organisms rapidly develop a protective coat and live for months as spores, cocooned from conditions that would normally kill them. Animal studies show that it takes only two C. difficile bacteria to trigger infection. If that's also the case in humans, almost all hospitalized patients may be at risk.

C. difficile spores have been cultured from specimens taken from bed rails, blood pressure cuffs, thermometers, telephones, tabletops, and other surfaces in the rooms of infected patients. Healthcare workers caring for an infected patient, pick up the spores on their hands, and inadvertently spread them to other patients. Nosocomial outbreaks of C. difficile are common and are directly related to poor handwashing by caregivers.

Taking a look at who's at risk:

Not all patients exposed to C. difficile will become ill. Infants generally don't because the cells of a newborn's colon are too immature to bind the toxins produced by the bacteria. As the "Bacterial invasion of the gut wall is progressive" box explains, these toxins cause the damage seen in CDAD.

Normal gut flora and a healthy immune system usually prevents exposed adults from acquiring the microbe. However, some adults become colonized, meaning that C. difficile is present in their colon, but is either not causing damage or the damage is too insignificant to cause symptoms. These adults are referred to as asymptomatic carriers.

Because antibiotics destroy the normal gut flora that keeps C. difficile in check, or out of the gut in the first place, any adult patient taking antibiotics is at risk for developing CDAD. Any antibiotic can cause it, including those that might be used to treat it. The most potent offenders are amoxicillin (Amoxil, Trimox, others), clindamycin (Cleocin), and all generations of the cephalosporins, such as cefazolin sodium (Ancef, Kefzol, others), cefuroxime sodium (Zinacef, Kefurox), and ceftriaxone sodium (Rocephin).

While antibiotic therapy is the major cause of CDAD, any breach in the gut's mucosal layer can lead to it. CDAD has developed after nasogastric tube insertion, or during enteral feedings from the tip of the tube hitting the gut wall, enema administration, and gastric surgery. It can also develop in patients receiving chemotherapy, because of the antibiotic-like action of some antineoplastic agents.

Why some exposed adults remain asymptomatic carriers while others develop severe disease is directly related to the strength of a person's immune response to the C. difficile toxins. Patients who produce high levels of antibodies against the toxins fare better than those who don't. A poor antibody response to the toxins is associated with severe, prolonged, and recurrent CDAD. Groups at highest risk for severe CDAD include the elderly, the immunocompromised, and the critically ill.

Confirming a diagnosis can take a bit of time:

Endoscopy is the best way to confirm a fulminant case of CDAD when a rapid diagnosis is needed. For example, pseudomembranous plaques found during endoscopy can confirm CDAD in patients with suspected antibiotic-associated diarrhea. Endoscopy is less useful in mild to moderate diarrhea; results may be normal in mild cases and may show nonspecific colitis in moderate cases.

The gold standard for diagnosing CDAD is the tissue culture cytotoxicity assay. For this test, a stool sample is obtained and tested for toxins. The test takes 48 hours to complete.

While it's the most accurate test for "ruling in" CDAD, a negative cytotoxicity test does not completely rule out the disease. If the stool sample isn't fresh or placed on ice immediately, the toxins will be destroyed and the accuracy of the results affected.

Therefore, the lab test most widely used to detect C. difficile toxins is the enzyme-linked immunoassay (EIA). It's less expensive, needs no special equipment for testing, and provides results in two to six hours. While the EIA is highly specific, it's not as sensitive and, therefore, not as accurate as the cytotoxicity assay. In addition, the most frequently used EIA detects only one of the two toxins produced by C. difficile: toxin A. The EIA of choice should have the capacity to detect both toxin A and its counterpart—toxin B.

Treatment depends on the severity of CDAD:

Early identification and treatment of CDAD can often keep diarrhea from becoming severe. For a patient with only mild diarrhea, discontinuation of the offending antibiotic may be all that's needed.1,5,7 For patients who have or are at high risk for severe disease, or who must remain on antibiotics for another condition, the current treatment of choice is an antibiotic.

We don't fully understand why some antibiotics are more strongly associated with the development of CDAD than others. However, we do know that narrow-spectrum antibiotics, such as metronidazole (Flagyl) and vancomycin HCl (Vancocin, Vancoled), rarely cause diarrhea; therefore, these two antibiotics are the drugs of choice for treating CDAD. When either metronidazole or vancomycin is used to treat antibiotic-associated diarrhea, the diarrhea resolves within 10 days of initiating therapy in 96% of the cases. However, 25% of patients relapse when the antibiotic is stopped.

Metronidazole is preferred over vancomycin because it can be given orally or parenterally, is less expensive, and, unlike vancomycin, isn't associated with the development of resistant strains of enteric bacteria. When used to treat CDAD, the usual dose of metronidazole is 250 – 500 mg three or four times a day for 10 – 14 days. Adverse effects such as nausea, vomiting, and a metallic taste make oral metronidazole less appealing to patients than vancomycin.

Vancomycin is given orally to treat CDAD. When given IV, the drug won't reach concentrations high enough to eradicate C. difficile from the gut. Because vancomycin is poorly absorbed in the gut, it has few side effects and is, therefore, the drug of choice for treating CDAD in pregnant women and children under 10.

When used for mild to moderate diarrhea, the recommended oral adult dose of vancomycin is 125 mg four times a day for 10 days. Vancomycin is also the drug of choice for treating CDAD in critically ill patients and in patients who have pseudomembranous colitis, ileus, or colonic dilation. The recommended dose in these cases is 500 mg four times a day for 10 days.

Other strategies and treatment options:

In addition to giving vancomycin or metronidazole, there are other things you can do to stop or slow down the progression of CDAD. If a patient must remain on antibiotics for another condition, that antibiotic may need to be changed to one that's less likely to cause diarrhea. Examples include IV aminoglycosides, macrolides, or rifampin (Rifadin, Rimactane).

Make sure a patient with CDAD doesn't receive medications like loperamide HCl (Imodium) or diphenoxylate HCl plus atropine sulfate (Lomotil). By slowing down gastric motility, these drugs can impede toxin removal from the gut, triggering toxic megacolon.

Cholestyramine resin (Questran) has been used as an adjunct to treatment because it binds toxins A and B, similar to the way it binds cholesterol. It's been used with moderate success—but only in chronic cases. Because cholestyramine also binds with vancomycin, the two drugs should be given at least an hour apart.

Intravenous human immunoglobulin (IVIG) has also been studied as a treatment for CDAD. One study showed that it boosted the anti-toxin antibody production in patients with severe colitis who didn't respond to metronidazole or vancomycin. IVIG is now considered an alternative treatment for severe cases.

Probiotics, which are live microorganisms, are often given to bolster the gut's normal flora. They've been used with some success to manage recurrent infection. The probiotics most frequently used to treat CDAD include Lactobacillus GG, which is a concentrate that can be added to skim milk; Lactobacillus acidophilus, found in yogurt; Saccharomyces cerevisia, which is found in brewer's or baker's yeast; and Saccharomyces boulardii, a nonpathogenic yeast that's given in capsule form.

Emergency surgery is the last-ditch effort in life-threatening cases of CDAD. It may be necessary, for example, for patients with severe colitis that doesn't respond to medical therapy or for patients with impending bowel perforation. The operation of choice is subtotal colectomy and ileostomy.

Supporting the patient with CDAD:

The nurse's role in caring for patients with CDAD includes supporting the patient while he fights the infection, monitoring for complications of the disease, and preventing a nosocomial outbreak of C. difficile.

A patient with moderate to severe diarrhea is at high risk for dehydration and electrolyte imbalance because inflamed areas of the bowel can no longer absorb fluid and electrolytes. In addition, cramping abdominal pain may make the patient reluctant to eat or drink.

Monitor your patient for signs of dehydration, such as sunken eyes, dry mucous membranes, elevated urine specific gravity, and a drop in blood pressure greater than 10 mm Hg when taken immediately after the patient has risen from a lying to a sitting or standing position. Late signs of dehydration include tachycardia and sustained hypotension.

Because lethal dysrhythmias can arise from an electrolyte imbalance, assess the patient's heart rate for irregularities. Also monitor intake and output and serum sodium, potassium, calcium, magnesium, and phosphorus levels. Be prepared to administer oral or IV fluids and electrolytes. In addition, watch for signs of systemic infection, including a rise or drop in body temperature.

Prevent the spread of C. difficile:

Use contact isolation precautions when caring for patients known to have CDAD, as well as those suspected, or colonized with C. difficile. That means wearing gloves whenever you enter the patient's room and when touching the patient, anything he touches, or any surface or piece of equipment in his room.

Strict handwashing is imperative, and one way to prevent the spread of this infection. Wash your hands before and after all patient contacts, and between procedures on the same patient. Wash thoroughly after removing gloves in contact with any body fluids, non-intact skin, or potentially contaminated equipment and surfaces.

Wear gowns and masks when changing grossly contaminated linens. Place all soiled linen in leak-proof bags marked biohazard or marked in a way that indicates the bags contain potentially infectious material.

If possible, use disposable equipment, such as thermometers or blood pressure cuffs when caring for infected patients. Clean all surfaces in the infected patient's room with a hypochlorite-based disinfectant.

Finally, educate all staff about CDAD, how it develops, how it's treated, and how to prevent the spread of infection. Misconceptions about C. difficile clearly abound, as I found during my visit to a professional chat room. But armed with this article, you can clear up confusion wherever you find it.

Almost Any Antibiotic Can Lead to C. Difficile Infection

Almost any antibiotic can lead to C. difficile intestinal disease. Diarrhea usually begins 4 to 9 days after the patient starts an antibiotic, but it can also develop up to 8 weeks after an antibiotic is discontinued. Generally, C. difficile disease is caused by genotypes and strains that are resistant to the precipitating antibiotic. Penicillins, the cephalosporins, and clindamycin are most apt to precipitate the disease. However, even vancomycin—which is effective in treating C. difficile disease—can cause the disease. This probably occurs because vancomycin suppresses both normal flora and the vegetative forms of C. difficile, but not its spores. When vancomycin is discontinued, the spores germinate and the new vegetative forms flourish in the altered bacterial environment.

Brief History of C. Diff

In the early 1970's it was discovered that numerous patients who were taking clindamycin were getting diarrhea and colitis. At that time, clindamycin had been on the market for only a few years.

Larry Hoberman, Dick Norgaard, and Lannie Hughes, who were gastroenterology fellows, gathered data on 16 cases from Parkland Hospital, the Veterans Affairs Hospital, Methodist Hospital, and Baylor University Medical Center (BUMC). No pathogenic organisms could be cultured in any of these patients, and there was no evidence of staphylococcal overgrowth. All 16 patients had severe colitis, and 7 had pseudomembranous colitis. None had small bowel disease. The average age of the patients was 53, and 13 of the 16 were women. Four patients—25%—died.

Several possible etiologies were considered, including direct toxicity from or an allergy to clindamycin, bowel ischemia induced by the antibiotic, an altered bacterial flora, emergence of a new bacterial pathogen, and a virus. Since the physicians did not know the cause of the disease, they treated the patients as if they had ulcerative colitis. Fourteen patients received systemic steroids; 7, steroid enemas; 6, Lomotil; and 2, colectomies. None of the patients received vancomycin because they were not thought to have staphylococcal enterocolitis.

Within just a few years, C. difficile was discovered as the etiologic agent of antibiotic colitis. Ironically, C. difficile turned out to be sensitive to vancomycin, which might have been used in our patients had we not done tests to rule out staphylococcal enterocolitis.

C. difficile bacteria had been discovered years earlier, in 1935. In their attempt to understand the development of normal bacterial flora in neonates, Hall and O'Toole found a new anaerobe—which they called Bacillus difficilis because of the difficulty involved in its isolation and study. It wasn't pathogenic in newborns infants, but it was pathogenic in guinea pigs via a toxin. The bacillus has since been placed in the genus Clostridium. Although the spores are inactive, they can rapidly change into vegetative forms, which can then induce disease under the right circumstances.

C. difficile is resistant to most antibiotics. When a person takes an antibiotic, the normal colonic bacteria are reduced. Under these conditions, C. difficile is uninhibited by the normal bacterial products that tend to suppress it, and it has access to additional colonic nutrients. The C. difficile then proliferates. If it lacks the gene for toxin production, no disease develops. However, if it produces toxins A and B, it may cause colitis. The mechanism by which C. difficile toxins damage colonocytes is shown in Figure 2. The result of this damage is a loss of polarity of colonocytes, impaired cell migration, and cell death, which lead to colonic inflammation and in some cases pseudomembranous colitis.

C. difficile does not invade the colonic mucosa, and it does not cause disease if no toxin is produced. Even when a toxin is produced, some people become carriers or develop a mild, self-limited diarrhea while others develop severe colitis and may have multiple relapses of the disease. The clinical result depends on the briskness of the serum antibody response to the toxin. Aboudola et al showed that after infection with C. difficile, symptom-free carriers of the infection had a median of 3 enzyme-linked immunosorbent assay (ELISA) units per mL of serum IgG antitoxin A, and patients with a single episode of C. difficile–associated disease had 6 ELISA units. On the other hand, those patients with recurrent disease had only 0.7 units. Recurrent C. difficile colitis, then, appears to be associated with a lack of protective immunity to C. difficile toxins.

The serum antibody level to C. difficile can be increased with a vaccine, which is still experimental. In 2005, Sougioultzis et al tested the vaccine in three patients with serious, recurrent disease that was unresponsive to treatment. After vaccination, all three subjects had no further recurrence of diarrhea and were able to discontinue treatment with vancomycin. Further, in two of the three, the increases in serum IgG antibodies were striking: 3-fold and 4-fold increases in antitoxin A antibodies and 52-fold and 20-fold increases in antitoxin B antibodies. In 1997, researchers showed that passive immunotherapy with intravenous immunoglobulin was also effective in patients with impaired serum antitoxin response and refractory C. difficile colitis. The antibodies are believed to block the effects of the toxins until the normal flora can recover; the antibody effect is on the toxins and not on the organism itself.

Almost any antibiotic can lead to C. difficile intestinal disease. Diarrhea usually begins 4 to 9 days after the patient starts an antibiotic, but it can also develop up to 8 weeks after an antibiotic is discontinued. Generally, C. difficile disease is caused by genotypes and strains that are resistant to the precipitating antibiotic. Penicillins, the cephalosporins, and clindamycin are most apt to precipitate the disease. However, even vancomycin—which is effective in treating C. difficile disease—can cause the disease. This probably occurs because vancomycin suppresses both normal flora and the vegetative forms of C. difficile, but not its spores. When vancomycin is discontinued, the spores germinate and the new vegetative forms flourish in the altered bacterial environment.

C. Diff Outpacing Aids Fatalities

The C Difficile bacteria is being blamed for more than 2000 deaths since it's discovery in a Quebec hospital in 2003.

The finding appears in the Quebec institute for statistics annual report.

Between January 2003 and June 2004, exactly 2,067 deaths were attributed to infections provoked by the bacteria.

80 percent of the victims were age 75 and up.

According to the report that makes C Difficile the number one killer among infectious diseases, out pacing deaths linked to AIDS.

What a CA-MRSA Infection Looks Like

Community Acquired Infections on the Rise

Five or six years ago, if Dr. Michael Edmond treated an outpatient for an antibiotic-resistant staph infection, the person had almost always picked up the bug during hospital care.

Not anymore.

"We are seeing so many people in the community who are healthy, often young, have no underlying disease, have never been in the hospital, and they are getting MRSA infections," said Edmond, a professor of internal medicine, epidemiology and community health at VCU Medical Center.

MRSA is methicillin-resistant Staphylococcus aureus, a staph bacteria that is no longer cured by methicillin and similar antibiotics that are the usual first choices for treating staph infections. MRSA can cause mild skin infections that show up as abscesses or boils, Edmond said. Or it can be severe, leading to potentially lethal complications, including pneumonia and blood poisoning.

Two recent reports suggest the MRSA problem is getting worse.

Last week, the federal Agency for Healthcare Research and Quality released a report showing that MRSA hospitalizations in the United States increased from 38,100 in 1995 to 128,500 in 2000 to 368,800 in 2005.

In June, the Association for Professionals in Infection Control and Epidemiology released a survey suggesting that MRSA cases in health-care facilities are eight to 11 times more common than previous estimates.

Understanding what is going on with MRSA in hospitals is important, experts say, because increasingly MRSA infections are showing up in the community. Evidence suggests there are new strains, and there is fear community-associated MRSA will become just as hard to treat as the infections that hospitals struggle to suppress.

"The staph aureus that's in the hospital gets exposed to a fairly broad range of antibiotics over time," said Dr. Christopher Novak, a medical epidemiologist at the Virginia Department of Health. "And it's kind of selecting or breeding for the strongest strain. Over time it can acquire resistance to a very wide range so that there is almost nothing left to treat it. There are a few antibiotics that are left, but typically they are IV drugs and they are very strong."

As people leave the hospital or nursing homes with staph infections or with it colonized but not causing an infection, they can expose others to it, said Dr. Richard Wenzel, an infectious-disease expert at VCU.

"We are sending patients home with IVs to complete their therapies," Wenzel said. "They have catheters and come back periodically to get their chemotherapy. All those kinds of things. People are carrying the organism home. At the same time the community-acquired MRSA in the last 10 years has become a global problem.

"There are two epidemics, and the traffic is going in both directions," Wenzel said.

Dr. Thomas Murphy, a family medicine physician at the Patient First office near Parham and Woodman roads in Henrico County, said patients will come in with a raised, reddish bump they think is a spider bite.

"At one time we never used to worry about methicillin-resistant staph," Murphy said. "We used to treat them with cephalosporins or a combined antibiotic. That would be the end of it. We are more cognizant of the fact they may need to be treated with Bactrim or doxycycline."

In healthy people, infections generally clear up, he said. "If you have people with ... multiple medical illnesses, they may need more advanced treatment to get rid of it," Murphy said.

Edmond, at VCU, says everyone is probably exposed from time to time. "When I see patients that are getting it over and over, some of the things we try to do is we culture their nose to see if they are carrying it in their nose. If they are, there are antibiotic ointments we can put in their nose to try to decolonize them from the organism," he said.

Outbreaks have been reported among members of sports teams, in prisons and jails and other places or situations where folks are in close contact.

Virginia high school coaches get information on preventing skin infections among players, said Dr. Vito Perriello, a Charlottesville pediatrician and chairman of the Virginia High School League's sports medicine advisory committee. Perriello said he has heard of outbreaks among a rowing team, wrestling teams and football teams.

"When we were growing up, you took off your sweaty athletic stuff, stuffed it in your locker and came in the next day and put the same stuff on," Perriello said. Now players are advised to shower and change clothes after practice or play, he said.

While doctors may not do cultures on every patient suspected of having staph, cultures can be important to understanding the epidemic, Novak said. "You see exactly what it is resistant to and what it is sensitive to and you use the right drug to treat it.

"If you are a physician out there, and you know your patient was on dialysis and was in the hospital regularly, you might have a suspicion that it's going to be slightly harder to treat than, say, the boy who comes in from soccer practice who has a big abscess," Novak said. "You might think perhaps it's going to be more susceptible, but you still really should get the cultures and be sure. You don't know if that boy had contact with a mom or grandma or father who ended up in the hospital and brought home a more resistant form."

By Tammie Smith: Staff Writer at Media General's Richmond Times-Dispatch.

Patients Want More Information

It lurks beneath the surface, a sharklike predator that slips in undetected. As a surgeon secures a bodily opening in an otherwise successful operation, this stealth invader begins to feast upon its prey. While medical proficiency has risen to great heights, the rate of infections also has soared. It has gotten to the point that candidates for surgery include infection risk in their decision-making process.

On July 20, Gov. Rendell signed an overdue law that will pressure hospitals to police their environments.

Nearly two years ago, I underwent a procedure at one of Philadelphia's top hospitals to remove a thyroid lobe. The surgery was quite successful, and the surgeon did a masterful job of closing the wound and restoring my neck nearly to its original state. But beneath the stitching, something was at work.

The drainage wouldn't stop. Ten days after surgery, I was readmitted overnight and administered antibiotics while a new draining process began. In all, four rounds of antibiotics and a consult with an infectious-disease specialist during the next few months revealed that I had staphylococcus aureus, better known as staph infection. After several months, the infection went away and the wound healed.

But then the bleeding started again. Tests revealed that there was a surface infection caused by the still open wound. It eventually healed for good. But during the nearly yearlong process, this non-worrier considered normally unthinkable ramifications - imbedding of the infection in the bones, amputation of infected limbs, death.

Since my case, I have learned of similar infections at a number of hospitals.

The new law will require hospitals to screen high-risk patients - especially those admitted from nursing homes - as well as staffers in close contact with them. Public disclosure will encourage underachieving facilities to improve and reward improvement with higher state reimbursements.

The seeds for this market-driven response have been cultivating. The Pennsylvania Health Care Cost Containment Council (PHC4), in the nation's first hospital-by-hospital disclosure in November, found reports of 19,154 hospital infections in 2005, up from 13,711 in 2004. The PHC4 also noted that commercial insurers paid an average of $60,678 for each infected patient, as opposed to $8,078 for those infection-free. National fatalities were estimated at 90,000 each year.

Consumers crave this kind of information. A paper presented at the Society for Healthcare Epidemiology in Chicago last year found that that infection rate would influence hospital selection of 93 percent of consumers.

Noted philosopher and mathematician Alfred North Whitehead once illustrated cause and effect using the analogy of a "flash of light, feeling of eye closure, instant of darkness." For hospitals, the flash has occurred. Now let them open their eyes and prevent the entry of predators who negate masterful work.

Opinion & Editorial
Aug. 01, 2007
The Philadelphia Inquirer
Commentary by Jeff Hurvitz