Sink, the Culprit Behind Infection Outbreak

Gooseneck faucets, shallow sinks behind deadly hospital infection outbreak
Canadian Press, December 2008

TORONTO — It's a cruel irony that in a setting where clean hands are critical, the sinks turned out to be the problem.

The design and placement of hand hygiene stations in hospital rooms housing transplant patients was responsible for an outbreak of bacterial infections that left 12 patients dead and two dozen others sickened, Toronto doctors who cracked the mystery behind how the bugs were spreading reveal in a new study.

The outbreak is history, having occurred - without much public attention - between December 2004 and March 2006 at Toronto General Hospital.

But the infection control specialists who tracked down the source of the multi-drug resistant bug involved in the outbreak believe other hospitals could learn from the tragedy that befell their transplant unit.

"The main reason that we published this is because we thought that this was an important lesson. People need to know this," says Dr. Michael Gardam, senior author of the article, published in the January issue of the journal Infection Control and Hospital Epidemiology.

"The message from this for us was that hand hygiene sinks are obviously really important - and they have to be the right design. And they have to be in the right place. And they can't be splashing."

The bug behind the outbreak was Pseudomonas aeruginosa, a moisture lover. It thrives in drains, where it forms what scientists call biofilms. The rest of us call that slime, sludge or gunk.

Pseudomonas bacteria are everywhere. In fact, the bug would probably be found in most household drains if anyone bothered to check. But no one would. The bacteria pose no threat to healthy people.

But it's a different story for patients who have just received an organ transplant. These patients are on drugs that suppress their immune systems so their body doesn't reject the donor organ and their systems are already weakened by whatever caused the need for the transplant.

In these and other seriously ill hospitalized patients, Pseudomonas can trigger skin, wound or bloodstream infections or pneumonia. And if the bacteria become resistant to antibiotics - as bacteria in hospitals are wont to do - the infections they cause can be challenging to treat.

"You had to be sick to get the infection. The infection makes you sicker," explains Gardam, head of infection control for the University Health Network (Toronto General is one of its three hospitals) and director of infectious diseases prevention and control at the Ontario Agency for Health Protection and Promotion.

"And when you've got an organism that is resistant to everything, there's not a lot of treatment we can offer you. That was basically the situation we were in."

When it became apparent transplant patients in the hospital's medical and surgical intensive care unit, transplant step-down unit and transplant ward were becoming infected with a multi-drug resistant strain of Pseudomonas, the infection control team began an intensive investigation to determine how patients and bugs were coming into contact.

Initially the cases were patients who were located near one another, leading infection control to suspect health-care workers were transferring the bugs on their hands. But when other patients started cropping up, it became apparent the answer wasn't that simple.

In all, 36 patients were either infected or colonized with the outbreak strain. (Colonized means a person is carrying the bacteria on the skin or in cavities like the nostrils, but the bacteria isn't causing illness.)

Two-thirds of the patients were infected and 17 died. A retrospective review of the deaths concluded the outbreak strain killed five patients and contributed to the deaths of seven others, the article says.

Given Pseudomonas aeruginosa's fondness for moisture, the infection control team began testing sinks. Bacteria were found in some but not others, and in some it was only found intermittently.

"It was really only when we said: 'OK, we're going to test every single bloody sink multiple times' that we started finding it in some of the sinks. It was never in all of the sinks. It was only ever in some of the sinks," Gardam says.

And how it was getting from drains to patients wasn't clear. "This was the kind of thing that kept us all up at night," he admits.
The painstaking investigation led to the conclusion that the design of the sinks was responsible.

Each single-patient room in the medical and surgical intensive care unit had its own hand hygiene station. They were located just over a metre from the head of the patient's bed and adjacent to a counter top health-care workers used to prepare medication and sterile dressings for the patient.

The sinks had shallow basins and high, gooseneck spouts that flowed directly into the drain below. Because of that design, the pressure from the spout splashed water out of the drain, spraying nearby surfaces.

If the drain contained Pseudomonas, it meant that using the sink ended up showering the counter top and maybe even the bed with droplets of bacteria-laced water.

The infection control team proved this using a CSI-like approach. Hospital room surfaces were covered with black paper, a fluorescent gel was injected deep into the drain and someone washed his or her hands.

Using an ultraviolet light in the blacked out room, the investigators saw fluorescent splatter had travelled at least one metre - as far as the head of the bed and onto the preparatory counter. The authors believe smaller droplets probably carried further.

On the strength of that evidence, the hospital took the step of removing the sinks. No new cases were reported after that. New sinks with a different design were installed, with splash guards between the sink and the treatment preparation area. Testing showed the splatter problem had been solved.

Dr. Andrew Simor, an infection control expert at Toronto's Sunnybrook Health Sciences Centre, says the outbreak report identifies two issues of which hospitals should take note.

While single rooms with sinks are ideal for cutting the risk patients will pick up hospital-acquired infections, those sinks shouldn't be located too close to beds or treatment preparation areas.

And the design of sinks is critical. Simor says hospitals can't prevent biofilms from forming in drains, despite their best efforts. But by limiting the potential for splashing, they can perhaps keep those biofilms where they can't hurt patients.

"We're always learning," says Simor, who heads the microbiology department of his hospital.

"And that's why this was an instructive report. Because it does remind us that it's not just as clear cut as having a private room with a sink."

Experts Say Cases of the Diarrhea Bug Are Now in All 50 States

C. diff Epidemic Likely to Get Worse
by Charlene Laino

WebMD Health News Reviewed by Louise Chang, MD

Oct. 30, 2008 (Washington, D.C.) -- The nation's epidemic of the nasty superbug Clostridium difficile, or C. diff, will likely get worse before it gets better, says a panel of experts.

Cases of the potentially dangerous diarrhea bug have now been seen in all 50 states, says L. Clifford McDonald, MD, of the CDC's Division of Healthcare Quality and Promotion. And "we haven't hit bottom yet," says Lance Peterson, MD, of the Evanston Northwestern Healthcare Research Institute in Illinois.

Most cases of C. diff occur in people taking antibiotics. Spores enter the body through the mouth, which is the entryway for the gastrointestinal tract. The overgrowth of the C. diff bacteria in the colon, or large intestine, can cause diarrhea, which is often severe and accompanied by intestinal inflammation known as colitis.

Antibiotics can kill "good" bacteria in the colon that keeps C. diff at bay, explains M. Lindsay Grayson, MD, vice chairman of the committee that chose which studies to highlight at the meeting and an infectious diseases specialist at Austin Health in Melbourne, Australia.

Infection often runs rampant in hospitals and nursing homes, where patients and health care workers are in close proximity. Typically, the bug can't be wiped out by standard cleaning agents, he tells WebMD.

The experts spoke here at a joint meeting of the American Society for Microbiology and the Infectious Diseases Society of America.

Deaths Up Fivefold

Hospital discharge data reveal a fourfold increase in C. difficile rates since 2001, according to McDonald. Associated deaths have increased fivefold, he says.

Overall, C. diff is responsible for tens of thousands of cases of diarrhea and at least 5,000 deaths a year, according to the CDC.

The Infectious Diseases Society of America and the Society of Healthcare Epidemiology of America have published guidelines aimed at reducing the spread of the superbug. Among its recommendations are to avoid overuse of antibiotics, use bleach to clean surfaces during outbreaks, don gowns and gloves when caring for patients, and follow strict hand washing and other good hygiene practices.

The antibiotics vancomycin and metronidazole are typically used to treat the infection, but the drugs are failing to help many patients, especially those with repeat bouts, says Dale Gerding, MD, of Hines VA Hospital in Chicago.

"We've had the same therapies for 30 years and new ones are desperately needed," he tells WebMD.

One procedure that does seem to work, but has been slow to catch on in the U.S., is a "fecal transplant," Gerding says.

Doctors obtain a stool sample from a healthy relative of the patient, typically a spouse, filter the sample, and infuse it into the C. difficile patient, typically via a nasal tube.

The idea is that the fresh stool will restore whatever bacteria were depleted from the infected person's intestines by antibiotic treatment, Gerding says.

"It's highly effective, with success rates of about 90%. But hospital safety boards are reluctant to approve its use as they fear other pathogens could also be introduced [into the patient]," he says.

In Europe, especially Scandinavia, the procedure has gained better acceptance, Gerding says

New Report Shows High C-difficile Infection Rates in U.S. Hospitals

Nov. 11, 2008
AUSTIN, Texas, Nov 11, 2008

Consumers Union called on hospitals today to take more aggressive steps to protect patients from Clostridium difficile (C.-diff.) infections in light of a new report showing that they are much more common than previous estimates had indicated. As the rate of hospital acquired C.-diff. infections has jumped in recent years, an increasing number of patients have developed antibiotic-resistant strains of the infection that are more difficult to treat and more deadly.

The report released by the Association for Professionals in Infection Control and Epidemiology (APIC) found that 13 out of every 1,000 patients or approximately 7,178 inpatients on any one given day were infected or colonized with C.-diff (94.4 percent were infected). The rate is 6.5 to 20 times higher than previous incidence estimates that were based on more limited data. The report estimated that on any given day these infections cost between $17.6 million to $51.5 million and kill between 165 and 438 patients.

The APIC report is based on a survey of infection control professionals from 648 health care facilities throughout the country who collected data about all of their patients with C.-diff. infections on one day between May and August 2008.

"C-diff. infections are much too common in our nation's hospitals and threaten the health of thousands of patients every year," said Lisa McGiffert, Director of Consumers Union's Stop Hospital Infections Campaign ( "Most hospitals aren't doing enough to protect patients from these deadly, preventable infections."

C.-diff. bacteria is released into the hospital environment in feces. It is found on surfaces throughout hospitals and nursing homes and can be spread to patients through hand contact. In one study, C.-diff. was found on the hands of nearly 60 percent of doctors and nurses caring for infected patients. Studies have found C.-diff. contamination of almost all objects in the hospital environment, ranging from stethoscopes and blood pressure cuffs to mops.

When patients undergo antibiotic therapy, beneficial bacteria in the colon are killed off, but C.-diff. survives and multiplies. The bacteria release toxins that cause inflammation and damage the mucosal lining of the colon leading to severe diarrhea. An antibiotic-resistant strain of C.-diff. has developed in recent years that can result in colitis, sepsis, and death. Elderly patients, patients with severe underlying illness, and patients undergoing immunosuppressive therapy are at higher risk of becoming infected since their immune response to the bacteria and its toxins is diminished.

According to the federal Agency for Healthcare Improvement's Healthcare Cost and Utilization Project, the number of hospital patients with C.-diff. infections more than doubled between 2001 and 2005 to 301,200 patients. As infection rates have increased, so have mortality rates. According to data from death records and the National Inpatient Sample, fatality rates rose from 1.2% in 2000 to 2.2% in 2004, indicating that C.-diff. infections are becoming more dangerous and deadly.

APIC's survey found that 54.4 percent of patients with C.-diff. were identified within 48 hours of admission and that most were admitted to the hospital already infected. However, APIC estimates that 72.5 percent of the patients with C.-diff. infections developed them as a result of exposure to bacteria in a healthcare facility. In other words, many patients who were admitted with an infection picked it up during a previous stay at a hospital or nursing home.

The most basic way to prevent infections is to keep patients from being colonized by C.-diff. The Center for Disease Control and Prevention's (CDC) Guidelines for Infection Control in Health Care Facilities notes that proper hand hygiene is the single most important factor in protecting patients from C.-diff. and other hospital-acquired infections. To complicate matters, the CDC advises that hands must be washed with soap and water when caring for C.-diff patients, as the commonly used alcohol-based hand gel is ineffective against this bacteria. Unfortunately, studies have repeatedly shown that handwashing compliance rates in hospitals are generally less than 50 percent. Other key infection control strategies include using contact precautions, including gloves and gowns with C.-diff. patients and separating them from other patients.

Improved cleanliness in hospital wards is also necessary to limit the spread of C.-diff. Use of a hypochlorite (bleach) cleaning solution is the most effective way to eliminate the bacteria. Hospitals that have stepped up efforts to more thoroughly clean hospital wards have effectively controlled the spread of C.-diff. However, reports show that hospital cleaning budgets are being cut every year and that these reduced numbers of cleaning staff are often inadequately trained.

Finally, since being on antibiotics is a risk factor for C.-diff., hospitals that restrict the use of the type of antibiotics frequently associated with these infections have had more success in protecting patients.

"Health care consumers need to be aware that most U.S. hospitals are not consistently following basic infection control practices against C.-diff.," said McGiffert. "Patients are already having to remind doctors to wash their hands, but they shouldn't have to bring bleach with them to make sure their rooms are clean. Hospitals need to make sure that rooms are properly disinfected and that staff are following strict infection control practices at all times."

Consumers Union, publisher of Consumer Reports, is an independent, nonprofit testing and information organization serving only the consumer. We are a comprehensive source of unbiased advice about products and services, personal finance, health, nutrition, and other consumer concerns. Since 1936, our mission has been to test products, inform the public, and protect consumers., a project of Consumers Union, advocates for public disclosure of hospital-acquired infection rates.

SOURCE Consumers Union

Copyright (C) 2008 PR Newswire. All rights reserved

A Deadly Bug Invades Our Towns

by Dr. Ranit Mishori
Parade: 12/07/2008

A few years ago, I began noticing an unusual number of patients coming in with what they described as spider bites. In clinics and emergency rooms across the U.S., colleagues were seeing it, too: Young people and old, male and female, complaining about a skin sore not unlike a pimple, often red and swollen, sometimes oozing and painful. The only thing was, very few of these patients recalled being bitten by a spider or any other kind of insect.

That’s because, in most of these cases, it wasn’t an insect. But it was a bug—a bacterium called methicillin-resistant Staphylococcus aureus, better known to most of us now as MRSA. These patient complaints were clear signs of what is now a MRSA epidemic.

According to a recent article in the Journal of the American Medical Association, MRSA caused more than 94,000 life-threatening infections and nearly 19,000 deaths in the U.S. in 2005. One study in The New England Journal of Medicine found MRSA 59% of the time when adults came to emergency rooms with skin infections.

MRSA is not new. It has been plaguing our hospitals for decades. It kills by infecting the blood and lungs of very sick patients or those recovering from surgery. But at least doctors knew—or thought—that if you weren’t a hospital patient in weakened condition, MRSA wasn’t going to find you.

“That is no longer true,” says Dr. Robert Daum, a pediatrician and infectious-diseases specialist at the University of Chicago. “Hospital transmission is not what’s driving the epidemic disease we see everywhere.” New strains of MRSA have been born outside hospital walls and are finding anybody and everybody. That includes, says Dr. Rachel Gorwitz of the Centers for Disease Control and Prevention, “otherwise healthy people in the community, including children.”

Consider Susan Wagoner, 49, a businesswoman from Scottsdale, Ariz. MRSA first appeared as a small abscess on her upper leg. Even though she was treated with antibiotics, the abscess grew larger, and then another one developed elsewhere. The pain became excruciating. As weeks turned into months, her illness forced Wagoner to quit her job, and she says, “I began looking into funeral arrangements.”

Grant Hill, the NBA all-star, contracted MRSA a few years ago as a skin infection near his ankle, and he had to spend a week in the intensive-care unit. “I was lucky to survive,” Hill says.

Not so lucky was an 18-month-old in Chicago named Simon Sparrow, in good health before MRSA got into his lungs. Once it took hold there, even the most aggressive treatment could not rescue the toddler.

These new strains of MRSA—not all as deadly as the one that afflicted Simon—are showing up all over the community: in homes, schools, gyms, military bases, prisons, or any place people get in close proximity with each other. They are transmitted through skin-to-skin contact with uncovered infections, such as shaking hands or bumping up in a football game. MRSA also can spread by sharing objects that are contaminated: towels, clothing, and razors. Indeed, the pattern of infection has earned this variant of the bug a new name: CA-MRSA, for community-associated.

The infection usually shows up as a skin sore. At that point, it’s generally not life-threatening and can be treated by draining the pus, with or without antibiotics. The only problem is that the antibiotics used for most bacterial infections won’t work.

It’s the R in MRSA, which stands for “resistant,” that tells the story. Just after antibiotics were introduced, tiny organisms—Staphylococcus aureus—became “immune” to our first line of antibiotic drugs. These variants survived, thrived, and spread. “Staph Aureus is a very smart bug,” says Dr. Daum. “It figured out every antibiotic we humans have thrown at it and has developed resistance mechanisms to them one by one.”

The nightmare scenario is a world in which we don’t have a pharmaceutical answer for some of the most common germs making us sick. Our experience with MRSA and other infections suggests we’ve taken a step or two in that direction. The current epidemic, says Dr. Daum, has put “tremendous pressure on our antibiotic treatment armamentarium.”

Still, it is way too soon to panic. In most cases, doctors can find drugs that kill the bug. Some—such as Bactrim, clindamycin, and tetracycline—haven’t commonly been used to treat staph infections. There’s also a range of super-powerful antibiotics that have been used successfully in hospitals.

Yes, bugs are smart, and we can’t change that. But the resistance of bacteria also stems from human misuse. We all know people who want to take antibiotics even though their infection is likely caused by a virus. Or doctors who prescribe antibiotics just because patients demand them. Or people who use leftover antibiotics given to them by friends and relatives. Or people who fail to finish the entire dose of a prescription, allowing the “toughest” germs to survive and reproduce.

Many experts believe that antibiotics given to animals also contribute to the development of resistance in humans and that the use of antibacterial soaps is another problem.

Just the other day, a patient came to see me with an infection on her chest. When I mentioned MRSA, it scared her. “Is it that bad bug I’ve heard about?” she asked. I told her “yes” but was able to add, “This is still something we can take care of.” The question is, how long will that be true?


► Know the signs of MRSA. A staph infection may appear as a boil, bump, or insect bite.

► See your doctor if a skin lesion becomes red, warm to the touch, is filled with pus, painful, or accompanied by a fever.

► Wash your hands regularly. Plain soap and water or alcohol-based gels (with at least 60% alcohol) are enough.

► Do not share personal items, such as towels or razors.

► Cover all cuts and scrapes with a bandage until they heal, especially if the wound oozes pus.

MRSA Carried by Staff as Well as Patients

MRSA, a drug-resistant germ, lurks in Washington hospitals, carried by patients and staff and fueled by inconsistent infection control. This stubborn germ is spreading here at an alarming rate, but no one has tracked these cases — until now.

By Michael J. Berens and Ken Armstrong
Seattle Times staff reporters

What is MRSA? MRSA — methicillin-resistant Staphylococcus aureus — is an antibiotic-resistant form of the common staph germ. It survives on most any surface but thrives on moist areas of the skin. Over time, it has gained more resistance to antibiotics and developed strains tougher to treat.

How it's transmitted. It is spread by touch or contact. The pathogen enters the body through breaks in the skin, such as a cut or during surgery. Minor skin infections, such as blisters and boils, are the most common symptom. But the bacteria can develop into serious, even life-threatening, problems such as infections of the heart, blood and bones.

Where people get it. About 85 percent of people infected with MRSA get the germ at a hospital or other health-care facility. MRSA increasingly is spread in the community in such settings as playgrounds or locker rooms.

What you can do. Avoid sharing towels, razors and bar soap. Before having surgery, talk to your doctor about getting a MRSA test. Other preventive measures include washing hands and covering wounds with bandages.

Year after year, the number of victims climbed. But even as casualties mounted — as the germ grew stronger and spread inside hospitals — the toll remained hidden from the public, and hospitals ignored simple steps to control the threat.

Over the past decade, the number of Washington hospital patients infected with a frightening, antibiotic-resistant germ called MRSA has skyrocketed from 141 a year to 4,723.

These numbers don't appear in public documents. Washington regulators don't track the germ or its victims, and Washington hospitals do not have to reveal infection rates.

The Seattle Times analyzed millions of computerized hospital records, death certificates and other documents to track the swath of one of the nation's most widespread, and preventable, epidemics.

In its investigation — the first comprehensive accounting of MRSA cases in Washington hospitals - The Times gained access to state files that revealed 672 previously undisclosed deaths attributable to the infection.

MRSA, methicillin-resistant Staphylococcus aureus, is spread by touch or contact. It can slip into breaks in the skin as tiny as a mosquito bite.

Six out of seven people infected with MRSA contract it at a health-care facility.

Many people first learned about the germ last fall when the federal Centers for Disease Control and Prevention set off a media frenzy with its announcement that invasive MRSA infections claim at least 18,000 lives a year, more than AIDS.

But MRSA has been quietly killing for decades. And all along, there has been a simple diagnostic test that could have saved countless lives. This quick and painless test, which costs about $20, lets hospitals know who's infected or a carrier. Once identified, people with the germ can be isolated from other patients and treated.

Federal veterans hospitals screen all patients for MRSA, which has reduced their cases to near zero. Yet not a single community hospital in Washington screens every patient for the pathogen.

Many hospital officials say widespread screening is unnecessary and too burdensome. They say broad infection-control measures, such as washing hands and wearing protective garments, can thwart MRSA's spread.

But Washington hospitals violate these fundamental safety measures time and again, state and federal inspection reports reveal, from the Tacoma surgeon who refused to wear a mask during surgery to a Spokane blood technician who carelessly brushed her contaminated hands against supplies destined for other patients.

At Harborview Medical Center in the early 1980s, 17 people died during a MRSA outbreak fueled by the failure of the state's premier trauma center to isolate all infected patients immediately. But to this day, according to confidential records obtained by The Times, Harborview still rooms some MRSA patients with those who don't have the germ.

Meanwhile, MRSA is infecting and killing more people this year than ever before.

In October 2005, Joyce Allen went in for open-heart surgery at St. Joseph Medical Center in Tacoma. Doctors told her to expect a quick recovery. But during the operation, MRSA slipped into her chest. Doctors had cut through her sternum, a flat bone that binds the rib cage and protects the heart. When they fused the sternum back together, the contagion was entombed inside.

The blood-rich bone marrow was a perfect hiding spot. Within a week, the germ pushed into her arteries and crept into vital organs.

Physicians resorted to their most powerful antibiotic — vancomycin — known as the "drug of last resort." For six weeks, twice a day, Allen received intravenous infusions. A suction system sealed her chest and drained away toxic fluid.

"The pain was excruciating. I wanted to die, it hurt so bad," Allen says.

Antibiotics failed to conquer the infection. By April 2006, as Allen hovered near death, surgeons made the decision they had dreaded: Cut out the sternum.

They sheared away 6 inches of bone with a diamond-coated blade. Then they severed her abdominal muscles near the groin, and stretched the flaps tight across her chest, to shield her heart.

Allen, 57, is crippled for life. She measures each day by the level of pain. On her worst days, she's unable to pick up her small grandson.

"This germ destroyed my life," she says.

Disabled, she gave up her customer-service job at a Tacoma cabinet company. She now lives in a trailer in Spanaway, surviving on $877 a month in government benefits.

Nobody knows how the germ got into St. Joseph's operating room.

Allen says her surgeon was devastated by the infection. Hospital officials suggested that she might have carried the pathogen into the facility, on her skin.

If that were so, screening likely would have detected the germ and allowed doctors to eradicate it beforehand.

Cardiac patients like Allen are among the most vulnerable to MRSA infections and often face prolonged and expensive recoveries, medical research shows.

But St. Joseph didn't test her for MRSA, according to medical records. When it comes to most cardiac patients, the hospital still doesn't. On Friday, it said that policy is under review.

Who gets tested for MRSA, and who does not, is a medical game of chance.

Washington hospitals make their own rules. There are no federal or state mandates for screening.

The result is a haphazard array of infection-control policies that often fail to protect the most vulnerable patients, according to a Times survey of the state's 25 largest hospitals.

MRSA infections often strike critically ill patients or those with weakened immune systems — patients typically treated in a hospital's intensive-care unit.

But Swedish Medical Center in Seattle doesn't routinely screen patients in its ICU. Instead, it screens patients having elective surgery.

Sacred Heart Hospital in Spokane does test ICU patients — but not those seeking elective surgery.

The University of Washington Medical Center tests only premature babies.

Valley Medical Center in Renton doesn't routinely screen any patient group.

The bottom line is that most Washington patients don't get tested.

Whether to test, and whom to test, are at the core of a bitter national debate within the U.S. health care system.

Those who oppose testing all patients often argue that it undermines patient safety to dedicate limited resources to just one germ.

The reality, they say, is that hospitals often lack the staff, lab resources or space to ramp up existing testing programs or isolate large numbers of patients.

Swedish Medical Center would be hard-pressed to screen its 41,000-plus admissions each year, officials said. Harborview Medical Center, the state's most crowded hospital, doesn't have enough private rooms to isolate every patient, officials said.

Some hospitals fear lawsuits. If they screened every patient, results would show who already had the germ upon admission — and who picked it up while in the hospital. Patients could then blame the hospital for their infections.

Federally funded researchers called MRSA a possible epidemic in the early 1980s, following a series of outbreaks in large hospitals nationally. Yet most Washington hospitals began limited screening only within the past three years, The Times found.

"Many hospitals have ignored MRSA for decades," said Dr. William Jarvis, who retired in 2003 from the federal Centers for Disease Control and Prevention, where he was once acting director.

MRSA can cause painful and treatable skin lesions or slip into the blood. About 1 percent of infections prove fatal, while many others result in crippling injuries.

No one knows how many people carry the germ on their skin. Nationally, medical researchers have estimated that it's 1 or 2 percent of the general population. Washington hospitals that have initiated selective screening have discovered significantly higher levels — up to 11 percent.

Some surgeons around Seattle so dread the pathogen that they order tests when hospitals won't.

MRSA cases hidden. To control an infection, health officials need to know where it's been. They need counts, patterns, examples. But in Washington, MRSA's tracks have largely been obscured.

The state Department of Health asks physicians or medical examiners filling out death-certificate forms to give not only the primary cause of death, but the "chain of events" — the "diseases, injuries, or complications" — that contributed. Without such detail, these forms, when compiled in a database, may miss signs of emerging threats to public health.

But omissions undercut these certificates' value.

In 2005, Brenda L. Smith, 47, of Puyallup, died at Swedish Medical Center/Providence in Seattle. For "final anatomical diagnosis," her autopsy lists, at the top, MRSA pneumonia. But her death certificate — which relied on the autopsy report — says only pneumonia, with no mention of MRSA.

That same year, Willie Pompey, of Everett, died at age 58. His death certificate lists kidney failure, but does not account for an underlying reason. Pompey received a kidney transplant in 2002 at Virginia Mason Medical Center, but, because of a post-surgical MRSA infection, his body rejected the new organ. On his death certificate, MRSA is nowhere to be found.

How many examples are there like this? It's impossible to say. Finding them requires working backward — as The Times had to do — scouring lawsuits or other documents for indications of someone with MRSA, then comparing them against the public health records to see what, if anything, is missing.

A Bainbridge Island plaintiffs' lawyer, Christopher Otorowski, believes doctors may sometimes omit MRSA from death certificates because the infection is typically picked up in a hospital.

"Unless MRSA is the primary, explanatory cause of the death, I would think the physicians are going to be reluctant to put MRSA on the death certificate because it might implicate the hospital," he says.

For years, the state health department released a database of death certificates that is used by academics, journalists and others to report on public-health issues. But the state excluded a key component, a field that included doctors' notes that expanded on factors contributing to the person's death. The Times discovered the omission this year and insisted upon a complete database.

This new database links 672 deaths to MRSA between 2003 and 2006. The old database didn't attribute a single death to the germ. It couldn't have. The state relies on a standardized coding system, used internationally, that has more than 13,000 diagnosis codes — but not a single one for MRSA.

To gauge the prevalence of MRSA, The Times also analyzed a second database, which compiles diagnoses and billing records for patients discharged from Washington hospitals. The state uses this data, which has no individual names, to identify health trends and to analyze costs.

But as with the death certificates, this data set proved incomplete. The Times found dozens of examples where alternative records showed a patient had been treated for MRSA, while the billing database made no mention of it.

Because of these holes, the number of MRSA cases and deaths generated by the newspaper's analysis amounts to a minimum count, not a complete one.

Nationally, exact numbers are not available either, leaving public-health officials to estimate or extrapolate the scope of the epidemic.

Repeat offenders. To impede MRSA and other infectious germs, Washington hospitals typically rely on basic strategies — washing hands, isolating patients, sterilizing equipment.

But most of the state's 25 largest hospitals have been cited for unsanitary conditions or failure to adhere to fundamental safety standards, state and federal regulatory reports since 2005 show.

Last year, at Spokane's Holy Family Hospital, state Department of Health inspectors discovered the following:

A nurse entered Room 520 and dropped two packets of pills on the floor. Instead of throwing them out, she scooped up the packets and put them in a paper medication cup. She then pried the pills from the packets, dumped them into the contaminated cup and handed it to the patient.

An hour later, in a different room with an infectious patient, a staff member began to leave without washing hands. A second staffer tried to leave without discarding a contaminated gown. Both were headed for public areas of the hospital before state inspectors stopped them.

That afternoon, inspectors watched a phlebotomist draw blood from an infectious patient. Afterward, she brushed her gloved hands against items in a nearby supply cart — supplies destined for other patients.

In all, the four-day inspection cited seven staff members for violating basic infection-control standards, state records show.

Physicians can be the most lackadaisical about infection control.

In April 2006, doctors at the UW Medical Center carried personal items from home into sterile operating rooms and dropped them on the floor. These items included backpacks and satchels, made of porous materials friendly to germs. Hospital administrators told inspectors this was "common practice."

In November 2006, a physician at St. Joseph Medical Center in Tacoma removed his surgical mask during an operation. He had complained it was uncomfortable. Hospital officials told inspectors the physician was a "repeat" violator and had been warned before to keep his mouth and nose covered.

In hospitals, the most common violation is the failure to wash hands upon entering or leaving a patient's room.

In the worst cases, as few as 40 percent of staff members comply with hand-washing standards. Doctors are the worst offenders, according to confidential hospital records reviewed by The Times.

Even the best hospitals typically boast no better than 90 percent compliance — which means one out of 10 practitioners may have contaminated hands.

Hospitals remedied all violations spotted during the inspections, records show.

But these violations were all the more brazen because hospital officials — benefiting from a new law — knew the exact day that state inspectors were coming.

No surprise inspections. In the past, the state health department conducted surprise inspections to ensure that hospitals adhered to health and safety codes, from patient care to building maintenance.

But in 2002, the Washington State Hospital Association issued a 28-page report: "How Regulations are Overwhelming Washington Hospitals." In it, hospital administrators claimed surprise inspections disrupted patient care.

In Olympia, lawmakers voted unanimously to eliminate surprise inspections starting in July 2004. Today, the Department of Health must provide four weeks' notice — even the exact hour of arrival.

Hospital officials also had complained that some state inspectors were abrupt and unfriendly.

Lawmakers approved a Band-Aid: Hospital officials now can anonymously evaluate state regulators on whether they were polite enough.

The Legislature receives an annual compilation of these critiques. One hospital official wrote that state inspectors could "do a better job of highlighting the positive," instead of just looking for problems.

Washington is the only state that legally empowers hospitals to rate the conduct of regulators, according to the Consumers Union, a nonprofit organization that monitors hospital-related legislation.

"What kind of message does that send?" said Lisa McGiffert, who directs the organization's Stop Hospital Infections project.

Federally commissioned hospital inspectors began surprise inspections in 2004 — the same year Washington eliminated them.

The Joint Commission on Accreditation of Healthcare Organizations sets health-care standards and certifies hospitals to receive federal funding, such as Medicare. For decades, the commission had provided at least a month's notice before inspections.

But dozens of hospitals exploited the advance notice to temporarily hire more staff, cart in rental medical equipment — which was returned when inspectors left — and conduct dramatic makeovers with fresh sheets and pillows, according to inspector general reports at the U.S. Department of Health and Human Services.

Responding to public criticism, the commission stopped giving notice.

In some Washington hospitals, makeovers now take place just before state inspections, three registered nurses told The Times. The hospitals beef up staffs during planned inspections and, in some cases, have hired extra cleaners to disinfect beds and equipment, the nurses said.

The state hospital association recognizes "more needs to be done" to combat MRSA and is pushing to standardize patient-isolation procedures and increase hand-hygiene compliance, association president Leo Greenawalt said.

"My doctor was stunned"

When Chuck Velte first saw the woman at a flower show — sitting in a wheelchair, her right leg missing at the knee — he tried not to stare.

It was the spring of 2006, and Velte had knee surgery pending. He couldn't help but wonder: What happened to the woman's leg?

So he asked.

"She said that her knee was infected after routine surgery. She called the germ MRSA. I'd never heard of it," says Velte, who's now 64.

"I looked at her missing leg and was scared: This could be me."

Velte asked medical practitioners at Valley Orthopedic Associates in Renton about the germ's threat. He says they told him: Don't worry. This infection targets people with weak immune systems, and you're healthy.

Velte was unconvinced. A former senior analyst at Boeing, he launched into research. He learned patients could infect themselves if dormant MRSA germs were on their skin. The bacterium could drop into a wound during surgery and touch off numerous complications, even death.

Velte didn't know it, but at least 66 patients who underwent joint surgery the year before suffered amputation of legs, arms or fingers after contracting MRSA, a Times analysis of Washington hospital-billing records shows. For the past decade, the number of such patients stands at 512.

But Velte's research also turned up a simple safeguard: a nasal swab test that can detect if someone's a carrier.

Velte demanded to be screened. Doctors questioned its need, but sent him to a laboratory at Valley Medical Center in Renton, where the surgery was scheduled.

"I get there, and my knees are killing me, and the lab guys said they don't do a MRSA test. They told me to go home," Velte says.

Velte hobbled to the hospital's executive offices and plopped in a chair. "I want to see the highest-ranking person here," he recalls saying. "I'm not leaving here until I get a MRSA test."

An apologetic administrator arranged for a test. Results arrived four days later.

"I tested positive for MRSA," Velte says. "My doctor was stunned. He said that if he had operated, it could have been catastrophic."

To get rid of the germ, Velte scrubbed himself with over-the-counter soap containing chlorhexidine, an antibacterial chemical. He also wiped his house down with bacteria-killing bleach.

He was screened for MRSA again, was cleared and underwent surgery. It was successful.

A year later, MRSA invaded Velte's life again.

His 92-year-old mother, Rita, lived at a nursing home in Eau Claire, Wis. Last fall, Velte learned she had a festering wound, resembling a giant boil, on her buttocks. He demanded a MRSA test.

"After what I'd been through, I knew it was a possibility," he says.

A lab report confirmed his suspicions. His mother was infected with invasive MRSA, the worst kind. Within two days, she was gripped by pneumonia, followed by sepsis — blood poisoning — which reached into every vital organ, medical records show.

She suffered a fatal heart attack on Nov. 1 — less than two weeks after she was diagnosed with the germ.

Yet, MRSA did not appear on her death certificate. The official causes of death were heart attack, pneumonia and sepsis.

Velte says he demanded a correction — the truth. After reviewing medical records, the certifying doctor added MRSA.

"I wonder," Velte says, "how many people die of MRSA and nobody ever knows."

Rising Foe Defies Hospitals' War On 'Superbugs

by Laura Landro
Wall Street Journal
September 2008

Shortly after being admitted to a Cleveland-area hospital with severe abdominal pain, 52-year-old Maureen O'Hearn was transferred to intensive care. An intestinal infection had distended her abdomen so badly she appeared to be six months pregnant. To save her life, a surgeon had to remove her colon.

The cause of Ms. O'Hearn's illness was an epidemic strain of Clostridium difficile -- C. diff for short -- that is fast emerging as one of the most dangerous and virulent foes in the war against antibiotic "superbugs." C. diff is spawning infections in hospitals in the U.S. and abroad that can lead to severe diarrhea, ruptured colons, perforated bowels, kidney failure, blood poisoning and death.

Katie Lancey follows special procedures for cleaning a patient's room at SSM St. Joseph Hospital West in Lake Saint Louis, Mo.
Even as hospitals begin to get control of other drug-resistant infections such as MRSA, a form of staph, rates of C. diff are rising sharply, and a recent, more virulent strain of the bug is causing more severe complications. The Centers for Disease Control and Prevention estimates there are 500,000 cases of C. diff infection annually in the U.S., contributing to between 15,000 and 30,000 deaths. That's up from roughly 150,000 cases in 2001.

"We've been trying to sound the alarm repeatedly since 2004 that the trend is continuing upward," says Cliff McDonald, a CDC epidemiologist. He adds that C. diff, once mainly a concern for older patients, is now a growing risk for pregnant women, children and healthy adults.

Many patients get C. diff infections as an unintended consequence of taking antibiotics for other illnesses. That's because bacteria normally found in a person's intestines help keep C. diff under control, allowing the bug to live in the gut without necessarily causing illness. But when a person takes antibiotics, both bad and good bacteria are suppressed, allowing drug-resistant C. diff to grow out of control.

As a result, hospitals are more closely monitoring and limiting their use of antibiotics. It's a strategy that also has shown some success in preventing the spread of other drug-resistant bacteria. Once patients do contract a C. diff infection, hospitals sometimes can treat them with certain "last ditch" antibiotics, such as vancomycin, but many patients relapse after treatment.

Other efforts to stop the spread of C. diff include isolating infected patients; suiting workers and visitors from head to toe with scrubs, masks and gloves; and blasting patient rooms with super-strength bleach solutions. Milder "green" cleaners don't kill C. diff, undermining some hospitals' efforts to use these products.

Spreading Spores

One problem: C. diff produces spores that can dry out after cleaning and hang around on hospital cart handles, bed rails and telephones for months. Hand cleaning with alcohol, many hospitals' standard practice for keeping staff from spreading infection, can actually help disperse C. diff spores. Many hospitals now have special rules requiring staff to wash their hands with antibacterial soap when dealing with C. diff patients.

Clostridium difficile spores can last a long time and make the bug hard to kill.

Katie Lancey, lead environmental services aide at SSM St. Joseph Hospital West in Lake Saint Louis, Mo., says she spends up to an hour cleaning a room after a C. diff patient leaves. She wears protective garments and wipes down everything in the room with a bleach solution, including the TV, pillows, mattress and lower structure of the bed. "Anything you can think of, you make sure you wipe it down thoroughly," she says.

If a patient coming in to SSM St. Joseph is suspected of having C. diff infection -- severe diarrhea is one symptom -- they are put in isolation even before lab tests come back, says James Hinrichs, the infectious-disease specialist charged with the hospital's C. diff-prevention program. He says that when C. diff patients are discharged, he advises them to eat yogurt with so-called pro-biotics to help restore a healthy balance of bacteria in their intestines. He also tells families to follow strict cleaning and hand-washing rules at home.

The efforts, along with more careful use of antibiotics, have helped SSM St. Joseph reduce the rate of C. diff infections to 0.5 cases per 1,000 patient days currently from 2.5 cases in 2006, Dr. Hinrichs says.

C. diff was first recognized in the 1970s, when it was readily treatable. The more virulent strain was first identified at the University of Pittsburgh Medical Center in 2000, killing 18 patients. By 2004, the new C. diff strain was reported elsewhere in the U.S. and around the world, and studies showed it was producing 20 times more toxin than older strains.

Carlene Muto, medical director of infection control at the University of Pittsburgh, says the hospital was able to reduce its C. diff infections by 50% after the 2000 outbreak and has sustained that rate since then. It instituted strict cleaning practices, restricted its use of antibiotics and began relying on its electronic medical-record system to quickly flag lab tests of patients most at risk so they can be isolated. "You have to be constantly vigilant," Dr. Muto says.

Only 3% to 5% of healthy, non-hospitalized adults carry C. diff in their gut, but that rate is much higher in hospitals and nursing homes, where carriers can spread the bacteria to others. Studies at several hospitals in recent years have shown that 20% or more of inpatients were colonized with C. diff, and a 2007 study of 73 long-term-care residents showed 55% were positive for C. diff. Even though the majority had no symptoms of disease, spores on the skin of asymptomatic patients were easily transferred to the investigators' hands.

The CDC is launching a national surveillance effort to gather more precise data about the prevalence of C. diff. It is working with states to identify local outbreaks. It also is working with Medicare and the Environmental Protection Agency to develop new guidelines for fighting C. diff.

Nursing Home Infections

Ms. O'Hearn, the Cleveland-area patient, says she took an antibiotic for a sinus infection and then visited a nursing home, where she may have picked up the C. diff bug. During her hospital treatment, Ms. O'Hearn says she suffered an irregular heartbeat and dehydration, and required additional surgery to temporarily attach her small intestine to the abdominal wall to bypass the large intestine. "It was the worst nightmare that anyone could imagine," says Ms. O'Hearn, a nurse by training. Though she has returned to work and a more normal lifestyle, she continues to have digestive troubles, and must take medications to regulate her heart.

Kettering Medical Center near Dayton, Ohio, had 305 cases of C. diff last year and has had 165 cases so far this year. Even newborn babies have gotten the disease from their mother during birth, says Rebekah Wang-Cheng, Kettering's medical director for clinical quality. She says that among other measures, the hospital has cut its post-operative antibiotic doses for all joint-replacement surgeries to two from three to avoid C. diff infections. Patients who come into the hospital with suspected pneumonia now get an antibiotic within six hours, instead of four hours previously, to allow more time to assess the need for drugs.

Fecal Transplants

One controversial strategy: fecal transplants. For one patient with recurrent C. diff, Kettering suggested a stool transplant from a relative, to help restore good bacteria in the gut. But Jeffrey Weinstein, an infectious-disease specialist at the hospital, says the patient "refused to consider it because it was so aesthetically displeasing."

The Greater New York Hospital Association in March began a 40-hospital effort to halt the spread of C. diff from patient to patient. This included placing signs on patient rooms with pictures of a bottle of bleach and soap and water to remind staff the room needs special cleaning. The association also asks visitors not to use patient bathrooms.

Hospitals face growing legal concerns if they don't take such measures; relatives of 16 patients who were infected or died from a C. diff outbreak are suing a Quebec hospital, claiming that infection-control practices weren't followed.

C. diff infections can emerge days or weeks after antibiotic therapy. Earlier this year, Marcus Glover, a 40-year-old mailroom worker for the Greater New York Hospital Association, was discharged from hospital after a successful rotator-cuff surgery, which included antibiotic treatment. Ten days later, he landed in an emergency room with a C. diff infection that required another week in the hospital. Mr. Glover avoided the worst complications and was successfully treated with strong antibiotics.

But C. diff can be fatal. Philadelphia radio personality Hy Lit, 73, contracted a C. diff infection at a rehabilitation center after being treated at a hospital owned by Main Line Health System last fall. He died in another Main Line hospital two weeks later. "It was a multiple train wreck, when the bug permeated his bloodstream and his kidneys failed," says his son, Sam Lit. "It was a tragedy to lose him like that."

Main Line says it can't comment on individual patients but adds that it follows stringent prevention guidelines and is conducting ongoing initiatives to control infections in its hospitals.

Forget MRSA for a Moment, Clostridium Difficile is a Growing Problem

Wall Street Journal
Posted by Jacob Goldstein

With all the attention on antibiotic-resistant staph, or MRSA, you may have overlooked Clostridium difficile, the nasty bacterium behind a growing number of hospital-acquired infection. Turns out C. diff is infecting more than 1 in 100 inpatients, a nationwide survey just found.

APIC, the big infection-control group, asked its members to take a one-day snapshot of C. diff in U.S. hospitals; responses came back from more than 600 facilities in 47 states.

A day in the life of C. diff proved sobering. Thirteen of every 1,000 hospitalized patients are colonized with C. diff, and 94% of those patients show signs of C. diff disease, such as severe diarrhea. The finding suggests that, on any given day, some 7,000 hospital patients have C. diff, and about 300 will go on to die of the disease, the authors wrote.

The one-day-snapshot method is somewhat unusual, so it’s tough to compare these findings with C. diff numbers from earlier studies. But by any measure, it’s clear that C. diff is a growing problem. Check out this analysis, which found that the percentage of hospital patients with C. diff doubled between 2000 and 2005.

C. diff has the nasty habit of flourishing after patients are treated with broad-spectrum antibiotics, which wipe out the intestinal bacteria that normally keep C. diff in check. And it forms hardy spores that are difficult to kill — alcohol-based disinfectant gels, for example, don’t do the trick. What’s more, a recently discovered strain called NAP1 is not only especially virulent, but also appears to pass more easily from person to person than other strains of C. diff.

So what can be done? Solid isolation and hygiene by hospital personnel helps. So does avoiding broad-spectrum antibiotics when possible, and keeping the course of treatment short. For more tips, see this WSJ story.

(APIC) National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities

November 11, 2008

The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities



Clostridium difficile (CD) is a spore-forming, gram-positive bacillus that produces exotoxins that are pathogenic to humans. CD is associated with a spectrum of diseases ranging from asymptomatic colonization to severe diarrhea, colitis, toxic megacolon, sepsis and death. Over the past 30 years, CD initially slowly and more recently rapidly emerged as an important healthcare-associated infection (HAI) pathogen.

Currently, CD is the most common cause of infectious healthcare-associated diarrhea, occurring in about 20% of hospitalized patients with antibiotic-associated diarrhea. A variety of studies have attempted to determine the “true” incidence/prevalence of CD. Archibald et al showed in 2001 that 12.2 CD infections [CDI] per 10,000 patient-days (incidence study) occurred in the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) system’s hospital ICU patients.

McDonald et al analyzed National Hospital Discharge Survey (NHDS) data and found that CDI incidence rates increased from 31 per 100,000 hospital population in 1996 to 61 per 100,000 hospital population in 2003.

A variety of factors are coalescing to potentially cause an increase in CDI. This includes the aging of the U.S. population, the widespread use of broad-spectrum antimicrobials, inadequate healthcare environmental cleaning, and inadequate CDI infection control measures (e.g., delayed diagnosis, delayed isolation precautions, poor hand hygiene or environmental cleaning). These factors, together with the recent emergence of a more virulent strain of C. difficile, the North American Pulse-field type 1 (NAP1) strain, makes it even more urgent that we have a better estimate of the magnitude of CDI in U.S.
healthcare facilities.

Thus, in May 2008, we initiated the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) National Clostridium difficile Prevalence Survey. In this survey, we asked infection preventionists at APIC member healthcare facilities to determine on one day during the period of May - August, 2008, all CDI patients who were inpatients in their facilities. From this, we could calculate the true prevalence of CDI at these facilities and make estimates of the magnitude of CDI at U.S healthcare facilities.


APIC’s National C. difficile Prevalence Study is the largest, most comprehensive of its kind and provides valuable new information about C. difficile infections/colonization in U.S. healthcare facilities. The survey asked infection preventionists (primarily APIC’s 12,000+ members in the U.S.) to collect data about all patients in their facilities who were identified with C. difficile infection or colonization on one day during May-August, 2008.

So in a sense, this survey is a “snapshot” of C. difficile prevalence in the U.S. C. difficile infected/colonized patients were identified using microbiologic, medical, infection control, and/or other types of healthcare facility records.


Survey results include responses from 12.5 percent of all acute care hospitals in the United States (648 facilities – mostly acute care)

Responses were received from facilities in 47 states

Responses were received from facilities caring for virtually every type of patient: acute care, cancer, cardiac, children's, long-term care, rehabilitation facilities. In addition, they included county, private, and public facilities.

Responses were received from all sizes of facilities/hospitals: <100, 100-300, and >300-bed facilities

Survey includes data on both C. difficile infection and colonization.


1. Data shows that 13 out of every 1,000 inpatients in the survey were either infected or colonized with C. difficile (94.4% infected). This rate is 6.5-20 times higher than previous incidence estimates that were more limited in scope (one hospital or hospitals in one state and used different methodologies).

The total number of patients identified with C. difficile colonization/infection was 1,443.

Of those 1,443, the following detailed data was provided for 1062 (73.5%) of the patients:

• 55.9% were female, 44.1 % were male
• 84.7% were on the medical service
• 69.2% were >60 years of age
• 67.6% had co-morbid conditions (renal failure, diabetes, or heart failure)
• 57.9% had an initial episode of mild or moderate disease
• 10.94% had severe to complicated disease
• 89.8% of patients were detected by enzyme-linked immunoassay for A and B toxins (rather than culture)
• 1.98% were detected by culture
• 54.4% were detected <48 hours of admission
• 45.5% were detected >48 hours of admission*
• 72.5% were considered healthcare-associated infection
• 26.6% required ICU admission, 18.2% had shock, and 16.5% required vasopressors.
• 35.1% had long-term facility residence within 30 days of onset
• 79.4% had antimicrobial exposures before onset. (17.14% as surgical prophylaxis)
• 47.4% had hospitalization within 90 days of onset
• 46.5% had resolution of diarrhea within 6 days (CDC definition of cure)

(*many papers in the literature divide HA-C. difficile infection (CDI) from CA-CDI using this artificial cut- off of hours after admission, ignoring the fact that many patients are repeatedly admitted and thus become colonized with C. difficile at one admission and then are detected with infection at a subsequent admission.)

National estimates**:

If the only U.S. hospital CDI patients were those reported in the survey (1,443 patients):

– Cost: $3.5 million - $10.4 million, average: $6.5 million (based on published rates ranging from $2,454-$7,179 cost per patient)

– Extra hospital days: 5,195 days - 10,101 days, average: 8,081 days (based on published rates ranging from 3.6 to 7 extra days per patient)

– Mortality: 33-88 patients, average: 61 patients (based on published rates ranging from 2.3-6.1 percent).

Extrapolating the impact to all inpatients on any one day:

Based on the average number of U.S. hospital inpatients (using 2006 AHA data of approximately 547,945 inpatients on any day) and our CDI rate (13/1,000 inpatients), we estimate:

– 7,178 CDI patients as inpatients in U.S. hospitals on any one day

– Cost: $17.6 million-$51.5 million, average: $32.1 million

– Extra hospital days: 25,841 - 50,246, average: 40,197 days

– Mortality: On any one day, the number of patients that would die from CDI would range from 165 to 438 with an average of 301.

54.4% of those with C. difficile in the survey were identified within 48 hours of hospital admission, which means that over half of the C. difficile infected patients are being admitted to the hospital/healthcare facility already infected or colonized with the
bug, having acquired it either in a previous healthcare facility stay or in the community at large.

Only 1.98% of C. difficile infected patients were identified by culture and only 4.2% of healthcare facilities routinely perform cultures for C. difficile. This means that most of the patients with C. difficile infection are detected by immunologic means and that their isolates are not available for further testing, e.g., antimicrobial susceptibility or genotyping to detect the NAP1 strain.

84.7% of all C. difficile infected patients were on the medical services, meaning they were being treated for general medical conditions like diabetes and pulmonary and cardiac problems.

79.4% of C. difficile infected patients received antimicrobials before their CDI onset. A wide variety of antimicrobials were associated with CDI. Furthermore, a wide variety of treatment regimens were used to treat the CDI.

Detailed data on the facilities that participated in the survey include:

• There was an average 1.5 infection preventionists at participating facilities
• Of participating healthcare facilities, 65.3% were urban and 34.7% rural
• Facilities had a median of 224 licensed beds and ranged in size from 6-1097 licensed beds
• Facilities had a total of 110,550 inpatients during survey period, averaging 171 patients per facility
• 26.5% of facilities were medical school affiliated and 24.4% were tertiary care facilities
• Most used a hypochlorite solution for environmental disinfection
• 46.7% reported having an antimicrobial stewardship program (62% of medical school affiliated and 41% of non-medical school affiliated facilities.).

**Costs based on published rates ranging from:

Cost (per patient):
$3,669 (Kyne CID 2002;34:346-53)
$2454-$3240 (hospital only) (Dubberke CID 2008;46:505-506)
$5142-$7119 (180 days) (Dubberke CID 2008;46:505-506)
$5325 (excess) (Lawrence ICHE 2007;28:123-30)
Minimum-maximum (Average): $2454-$7179 ($4475)

**Extra days based upon published rates:
Extra hospital length of stay:
3.6 days (Kyne CID 2002;34:346-53)
7 days (Vonberg JHI 2008;70:15-20)
6.1 days (Lawrence ICHE 2007;28:123-30)
Minimum-maximum (Average): 3.6-7 (5.6) days

**Mortality based on published rates:
2.3% (overall unadjusted) (Zilberberg EID 2008;14:929-931)
6.1% (ICU CDAD) (Kenneally Chest 2007;132:418-24)
Average: 4.2%

Study: C. Diff Sickens More Than Previously Estimated

November, 2008

The life-threatening bacterium that causes diarrhea and more serious intestinal conditions, Clostridium difficile, is sickening many more patients than previously estimated, according to a new study released by the Association for Professionals in Infection Control and Epidemiology (APIC).

“The National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities” indicates that 13 out of every 1,000 inpatients were either infected or colonized with C. difficile. Based on this rate, it is estimated that there are at least 7,178 inpatients on any one given day in American healthcare institutions with an associated cost of $17.6 to $51.5 million. The rate is 6.5 to 20 times greater than previous incidence estimates, according to the survey, released at APIC’s conference, “Clostridium difficile: A Call to Action,” in Orlando, Florida.

The APIC survey, the largest, most comprehensive of its kind, presents a one-day snapshot in time of the prevalence of C. difficile infection (CDI) in American hospitals. APIC’s 12,000 members collected data about all of their CDI patients on one day between May and August 2008. Survey results were collected from 12.5% of all medical facilities in the U.S. that care for virtually every type of patient, including those at acute care, cancer, cardiac, children’s, long-term care and rehabilitation hospitals. A total of 1,443 patients were identified with CDI from among the 648 participating hospitals.

CDI is most frequently associated with previous antibiotic use and is most commonly contracted by the elderly and those with recent exposure to hospitals, nursing homes and other healthcare institutions. It is transmitted by hand contact with items contaminated by feces. In the last five years, a more virulent and antibiotic-resistant strain has developed which has been associated with more serious disease, treatment failures and deaths.

“This study shows that C. difficile infection is an escalating issue in our nation’s healthcare facilities,” said William Jarvis, MD, principal investigator of the study and president and co-founder of Jason and Jarvis Associates, a private consulting firm in healthcare epidemiology. “ Clearly, preventing the development and transmission of CDI should be a top priority for every healthcare institution.”

According to the survey, 54.4 percent of patients with CDI were identified within 48 hours of admission and 84.7 percent were on the medical services, meaning they were being treated for general medical conditions like diabetes, pulmonary or cardiac problems and were on wards throughout the hospital.

“Our results show that the majority of CDI patients are admitted to the hospital already infected,” said APIC 2008 President Janet E. Frain, RN, CIC, CPHQ, CPHRM, Director, Integrated Services, Sutter Medical Center in Sacramento, CA. “Hospitals need to be looking for patients with severe diarrhea, and if CDI is suspected, promptly institute appropriate precautions such as gloves, gowns and separating patients, to avoid spreading the infection. Early recognition of CDI is critical so that prevention measures can be implemented.”

To reduce the risk of transmission, APIC has published a “Guide to the Elimination of Clostridium difficile in Healthcare Settings.” APIC recommendations include a risk assessment to identify high-risk areas for CDI within the institution; surveillance program to outline activities and procedures to provide early identification of CDI cases; adherence to CDC hand hygiene guidelines; use of contact precautions (e.g., gloves, gowns and separating CDI patients from other patients); environmental and equipment cleaning and decontamination, especially items that are close to patients such as bedrails and bedside equipment; and antimicrobial stewardship programs with focus on restriction of antibiotics associated with CDI and unnecessary antimicrobial use. APIC’s evidence-based elimination guides translate CDC recommendations into practice.

“Healthcare providers must intensify efforts toward developing prevention strategies that can be consistently applied across the continuum of care,” said APIC CEO Kathy L. Warye. “Control of CDI requires adequate numbers of infection preventionists and environmental services personnel, and prevention practices need to be part of everyone’s job within the institution. As part of our Targeting Zero initiative, APIC will continue to call for the commitment of clinical and administrative leadership to providing adequate resources for infection prevention programs to better protect patients in our nation’s healthcare facilities.”

The APIC National Prevalence Study of Clostridium difficile in U.S. Healthcare Facilities will be published in the American Journal of Infection Control. For more information about the study, visit