Gram Negative Bacteria


Gram-negative bacteria are bacteria that do not retain the crystal violet dye in the Gram stain protocol. Gram-negative bacteria will thus appear red or pink following a Gram stain procedure due to the effects of the counterstain (for example safranin).

Gram-negative bacteria have a characteristic cell envelope structure very different from Gram-positive bacteria. Gram-negative bacteria have a cytoplasmic membrane, a thin peptidoglycan layer, and an outer membrane containing lipopolysaccharide. There is a space between the cytoplasmic membrane and the outer membrane called the periplasmic space or periplasm. The periplasmic space contains the loose network of peptidoglycan chains referred to as the peptidoglycan layer.

The Gram negative cell envelope contains an additional outer membrane composed by phospholipids and lipopolysaccharides which face the external environment. The highly charged nature of lipopolysaccharides confer an overall negative charge to the Gram negative cell wall. The chemical structure of the outer membrane lipopolysaccharides of Gram-negative bacteria is often unique to specific bacterial strains and is responsible for many of the antigenic properties of these strains. Many species of Gram-negative bacteria are pathogenic, the pathogenicity often being associated with the lipopolysaccharide layer of the Gram-negative cell envelope.

Escherichia coli


Adam Brochert, M.D.
February 21, 2009

As you may know, we all have millions of bacteria in our gastrointestinal tracts, primarily in the colon (or "large" bowel). These bacteria are important for normal bowel health and function. Klebsiella is the genus name for one of these bacteria. When Klebsiella bacteria get outside of the gut, however, serious infection can occur.

As a general rule, Klebsiella infections tend to occur in people with a weakened immune system. Many of these infections are obtained when a person is in the hospital for some other reason. The most common infection caused by Klebsiella bacteria outside the hospital is pneumonia.

Klebsiella pneumonia tends to affect people with underlying diseases, such as alcoholism, diabetes and chronic lung disease. Classically, Klebsiella pneumonia causes a severe, rapid-onset illness that often causes areas of destruction in the lung.

Infected persons generally get high fever, chills, flu-like symptoms and a cough productive of a lot of mucous. The mucous (or sputum) that is coughed up is often thick and blood tinged and has been referred to as "currant jelly" sputum due to its appearance.

Mortality in Klebsiella pneumonia is fairly high due to the underlying disease that tends to be present in affected persons. While normal pneumonia frequently resolves without complication, Klebsiella pneumonia more frequently causes lung destruction and pockets of pus in the lung (known as abscesses).

There may also be pus surrounding the lung (known as empyema), which can be very irritating to the delicate lung tissue and can cause scar tissue to form. At times, surgery may be needed to "rescue" a lung that is trapped in irregular pockets of pus and scar tissue.

Klebsiella can also cause less serious respiratory infections, such as bronchitis, which is usually a hospital-acquired infection. Other common hospital-acquired infections caused by Klebsiella are urinary tract infections, surgical wound infections and infection of the blood (known as bacteremia). All of these infections can progress to shock and death if not treated early in an aggressive fashion.

Many hospital-acquired infections occur because of the invasive treatments that are often needed in hospitalized patients. For example, intravenous catheters used for fluid administration, catheters placed in the bladder for urine drainage and breathing tubes for people on a breathing machine can all increase the susceptibility to infection.

While these devices may be needed in certain patients, they allow bacteria to bypass the natural barriers to infection and get into a persons body. The result may be an infection if the persons immune system cannot fight the bacteria. Unfortunately, the people who need invasive treatments often have weakened immune systems because of their underlying disease.

Klebsiella bacteria are generally resistant to many antibiotics, such as penicillin. Often, two or more powerful antibiotics are used to help eliminate a Klebsiella infection. Usually, a culture of the suspected infection site is required before a doctor can know that Klebsiella is the cause of the infection.

This may involve getting sputum samples (patients are asked to cough up phlegm into a jar), blood samples (using a needle to draw blood from a vein), urine samples or a swab (with a q-tip) of a surgical wound.

Once the samples are obtained, they are taken to a laboratory and put in a special substance which allows bacteria to grow (this is known as "culturing" the bacteria). If bacteria begin to grow, the lab can determine which type of bacteria it is.

If the bacteria are Klebsiella, the lab will need to run special tests to determine which antibiotics are best to treat the infection (this is known as sensitivity testing). This is important because different Klebsiella bacteria are resistant to different antibiotics, so what works for one Klebsiella infection may not work for another.

These culture and sensitivity tests may take two to three days to complete. A doctor may not wait for the test results to start antibiotics. Often, a powerful antibiotic or two is started right away once infection is suspected. The antibiotic can be switched a few days later if the results of the culture and sensitivity tests suggest a more appropriate drug to treat the infection.

Klebsiella bacteria are a part of normal life and live inside almost all of us. Although it is something we generally dont like to think about, we need Klebsiella in our colon to keep us healthy. Unfortunately, once Klebsiella escapes the gut, it can be one nasty bacteria.

Gram Negative Bacteria Report Overview from IDSA
February 20, 2009

We spoke to Dr. Helene Boucher, director of the Infectious Diseases Fellowship Program at Tufts Medical Center and lead author for the Infectious Diseases Society of America report on gram-negative bacteria. Here are some notes:

CNN: Give us an overview.

Dr. Helene Boucher: The big reason that we wrote report at this time is to make a point and try to get some interest in a big problem that we're facing: infections due to gram-negative organisms. MRSA, which most everyone knows about now, is gram-positive. We know about MRSA, but there has been an increase in infections caused by gram-negative bacteria, and they are resistant to many, or sometimes all, drugs. Another point: There has been a decrease in investment in antibiotics to treat these infections, for which we have limited or no treatment options. There is no antibiotic drug in Phase II or beyond, in patients.

CNN: Where is this cropping up? Mostly in hospitals?

Boucher: We see these infections a lot in hospital settings. Acinetobacter is seen in servicemen, Iraq war vets. Vets often have wound infections. There is difficulty with treating them, deformities that they leave. Some people at risk: ICU patients; very young or old patients; people with a lot of other health problems who are already immunocompromised. Some patients who have had a transplant, a burn or some other thing happen to them. We also worry about infection control problems. We saw this in Brooklyn. A lot of infections spread.

CNN: How does this spread in hospitals? Same way as with MRSA?

Boucher: All infections are thus far in hospitals. Most commonly, it spreads from not washing hands when going between patients. We really emphasize hand hygiene. Sometimes doctors call for private rooms for patients who are infected.

CNN: Do you fear that this will become another MRSA? Or worse?

Boucher: It has borne out in Brooklyn, infection gone from rehab centers to nursing homes to hospitals. Patients move around faster: They go to rehab, go home, go to the dialysis center, etc. That's a lot to worry about, where these bugs tend to be moving. The concern is, this could be as bad as, if not worse than, MRSA. At least with MRSA, we have some drugs to treat it.

CNN: What would it take for this to become more like MRSA, to spread into the community?

Boucher: That's a hard question. It takes a bug being strong enough over time. It takes some change that makes it more transmissible. It takes a breakdown in infection control: not washing hands, not paying attention, etc. This bug gets a little "better" over time. With MRSA, it took football players who took whirlpools in same tub, sharing the same towels. Men having sex with men. If you put people factors and bug factors together, then you see the spread. It depends on how "fit" the bug is, how able it is to grow and replicate when gets resistant to antibiotics.

A lot of people are trying to understand this. Some people -- John Bartlett at Johns Hopkins is one scientist -- have predicted a linear increase over time in these infections. We can predict that in several years, we will get a lot worse off. We can't predict whether or when it would end up being something we see in healthy adults, kids, etc.

One thing we have seen is a number of urinary tract infections in women caused by one of these bad bugs; the key is that the women have never been in the hospital, not gotten antibiotics.

CNN: Why haven't we heard about this much until now?

Boucher: Depends on whom you ask: We infectious disease experts have been talking about it. War victims have gotten some press, but this is not a sexy story. The is not always a community interest, unless there's a famous patient/victim, like the Brazilian model.

CNN: The "double membrane" makes it harder to fight these infections; why? Why are they so tough to fight?

Boucher: There are difficult challenges to developing drugs for gram-negative infections. These infections produce a lot of toxins that make people sick fast. Basically, these gram-negative infections make enzymes that chew up antibiotics. Some make enzymes that chew up penicillin or chew up other antibiotics. So you don't have to get an antibiotic that fights one enzyme but multiple enzymes.

Now, these gram-negatives have become resistant to carbapenems; these are the "smartest" antibiotics. It's not likely we're going to find one drug that overcomes every enzyme; it will be more likely a variety of approaches and drugs.

CNN: Are antibiotic drugs hard to get into a clinical study?

Boucher: It's definitely harder than getting drugs for diabetes or obesity, something you take your whole life. Also, there are regulatory hurdles for people trying to make antibiotics. We're trying to make paths more clear for developing new antibiotics. We hope that encourages investment back in this area.

[The National Institutes of Health] this week signaled interest in sponsoring some studies in this area. The NIH hasn't traditionally been into antibiotic development, so that's promising. Government agencies and industry are banding together to get this done. I see that as good news.

CNN: Is this a big public health problem now or on the horizon?

Boucher: This is a public health problem now. The problem is here and now. Doctors have had people in their hospital succumb to these infections. Maybe there is one, and sometimes no, option for treatment.

CNN: Bottom line?

Boucher: We at IDSA advocate a three-pronged strategy for fighting these gram negative infections:

1) Infection control: prevent people from getting an infection in first place.

2) Prudent use of antibiotics: not overusing antibiotics.

3) Developing new antibiotics: generating interest at NIH, CDC, private industry. Get all key stakeholders more involved with developing effective antibiotics to stem infections.

Gram Negative Bacteria May Be Next Wave of Concern

February 20, 2009

A new crop of drug-resistant superbugs is in our midst, and experts believe that they could rival the deadly superbug MRSA.

A new report from the Infectious Diseases Society of America says these superbugs are creeping onto the radar in hospitals across the country, and our ability to fight them is next to none.

Are these new superbugs poised to be the next MRSA?

Dr. Sanjay Gupta, CNN Chief Medical News Correspondent: They just may be, according to that new report by the Infectious Diseases Society of America, but we can't say that just yet. MRSA is still a much bigger problem.

First, let's define what these superbugs are. They're called "gram-negative" bacteria. They are extremely drug-resistant; they have long, complicated names like "acinetobacter baumanii" and "klebsiella pneumoniae." Two important issues related to these bacteria: They are increasingly cropping up in hospitals, and they are nearly impossible to treat. Dr. Gupta's Blog: Here's why you should be scared of superbugs

Is this related to the Brazilian model who recently died from a bacterial infection?

Gupta: Yes. A gram-negative bacterial infection killed Brazilian model Mariana Bridi da Costa last month. She had her hands and feet amputated and kidneys removed to try to stem the infection's spread before she died. Gram-negative bacteria are also responsible for a spate of infections among returning Iraq war vets.

We've talked a lot about MRSA -- methicillin-resistant Staphlyococcus aureus -- and the core issue there is that very few antibiotics can treat it. The biggest concern with gram-negative bacteria is, there are virtually no drugs to effectively treat them. One drug, Colistin, is the only option that sometimes works, but it is incredibly toxic -- can cause kidney damage.

So how do these infections spread?

Gupta: Gram-negative infections are spread almost exclusively in hospitals, whereas MRSA has escaped the hospital confines and can now be found in the community. But keep in mind that MRSA started in hospitals.

Doctors see gram-negative infections among patients who are already very ill. Might be babies in the NICU, very old patients, patients who've just had surgery, burn patients in the ICU, for example. Gram-negative bacteria can enter the body by way of catheters, IVs, ventilators or wounds.

How common are gram-negative infections?

Gupta: The exact number of gram-negative-related infections or deaths is hard to pin down, because these infections are not reported routinely to the CDC. But doctors we spoke with say that the numbers could one day rival MRSA numbers, and that's really raising eyebrows among infectious-disease experts.

If there are virtually no drugs to treat gram-negative bacteria, then what are the options to stem the spread of these infections?

Gupta: Hospitals have to practice infection control: handwashing between patients; patient families also washing hands. Sometimes isolating patients in a different room if they are found to have an infection. Like with MRSA, not overprescribing antibiotics; that's how these bacteria learn how to adapt and become less treatable. And finally, more research into treatment.

Using New Strategy, Lee County Hospital System Chokes Pneumonia

No ventilator-associated cases in last two years at Cape Coral
FEBRUARY 15, 2009

A few years ago, patients in a hospital intensive care unit on a ventilator could almost bet on their chances of acquiring pneumonia. They had a 20 percent to 30 percent chance of bacteria traveling down the breathing tube and lodging in the lungs, increasing their risk of death and adding extra days — and an estimated $40,000 — to their hospital stays. But increasingly, infection isn’t the case, and one local hospital has made strides against the disease.

Cape Coral Hospital last week announced it has gone two years without a case of ventilator-associated pneumonia, the result of an effort launched 41/2 years ago to use emerging scientific evidence to prevent the disease. On any given day, the hospital has seven to 10 patients on ventilators. As of January, its ICU had gone 3,798 ventilator days without a pneumonia case.
“The numbers are almost unbelievable,” said Dr. Razak Dosani, a pulmonologist. “We knew (the rates) would decrease, but zero came as a surprise.”

Cape Coral is part of Lee Memorial Health System. Other hospitals within the system are making similar strides against pneumonia and other common hospital infections. Lee Memorial’s mortality rate last quarter fell to 1.33 percent — its lowest ever — largely because of interventions that prevent complications such as infections, faster response to changing symptoms and other efforts.

Infection reduction is important. Stephen Streed, Lee Memorial’s lead epidemiologist, said hospital-acquired infections are the nation’s fifth-leading cause of death, taking 103,000 lives a year, according to 2000 data he crunched from the Centers for Disease Control and Prevention.

Of all such infections, ventilator-associated pneumonia is considered to be the worst — the mortality rate for patients on a ventilator jumps from 32 percent to 46 percent if they develop pneumonia, according to The Institute for Healthcare Improvement, a Massachusetts-based organization running a national campaign to reduce incidents of medical harm. Lee Memorial is among the group’s 4,050 participating hospitals.

Cape Coral Hospital adopted the institute’s five-pronged approach, known as a care “bundle,” for caring for ventilated patients. It consists of keeping the patient’s head elevated at 30 degrees at all times; cleaning the mouth every two hours to prevent growth and spread of bacteria; “sedation vacations” — waking up patients at least once a day to assess whether they are ready to be weaned from the ventilator; preventing deep vein thrombosis, a kind of blood clot; and preventing stomach ulcers.

In addition, there were other changes, such as care and handling of the ventilator itself and the tubing that runs into a patient’s body, and a hospitalwide educational push so all departments understand, for example, the importance of head elevation. Multidisciplinary rounds — or teams of caregivers reviewing patient progress daily — also are considered key to the infection-fighting success.

Kelly McCutcheon Adams, who directs one of the institute’s improvement projects and has worked with Cape Coral Hospital, said experts expected the care bundle would improve outcomes for ventilator patients. But no one expected the pneumonia rates to drop dramatically. “It’s absolutely incredible,” she said.

Nationally, the institute knows of 65 hospitals that have gone a year or more without a case of ventilator-associated pneumonia and another 35 going a year or more without a central line-associated bloodstream infection, another serious risk for patients.

Cape’s nursing staff is pushing things one step further. For the first time last week, nurses and other caregivers helped a patient on a ventilator get out of bed to walk. That’s almost unheard of, but may not be much longer. New research has emerged showing the long-term physical and psychological effects of ICU stays, and medical professionals are now looking for ways to keep patients less sedated and more mobile.

“It’s one patient, one day, one change,” said Dr. Marilyn Kole, the system’s medical director for intensive care.

The transition hasn’t been easy. Nurses, who are largely responsible for carrying out the changes, said they believed their managers had “lost it” when they proposed the pneumonia-reducing initiative. Some of what they were asked to do ran counter to their training and longstanding — but newly outdated — care protocols. Many of them left the ICU.

“It was a lot at first. It was overwhelming,” said ICU nurse Dorothy Taylor, who stayed. And Lee Memorial administrators have heard their share of doubters.

“We have had skeptics in our own community who are saying there’s no way we had no VAPs in two years,” said Annette Forlenza, director of the Cape Coral intensive care unit. She and other directors re-examined their data and believe it to be accurate. The system uses the CDC guidelines for defining ventilator-acquired pneumonia.

Results like the Cape’s are spurring a paradigm shift in hospitals, suggested Linda Greene, the director of infection prevention and control at Rochester General Health System in New York. She’s also a lead author of the Association for Professionals in Infection Control and Epidemiology’s position paper on ventilator-associated pneumonia.

Infections are shifting from “the price of doing business” to something that can be prevented. Now, the challenge is not resting on the success. “I think the whole issue now is this issue of sustainability,” Greene said.

Brian Swartz, a North Fort Myers resident, said the Cape Coral Hospital’s staff has impressed him. His 76-year-old father is in intensive care now with a rare form of prostate cancer and pneumonia, which he developed prior to going on a ventilator. Swartz said his dad’s condition has improved since going into the ICU, although he still has a way to go.

The family has been included in the multidisciplinary team’s rounds, so they understand what’s going on, Swartz said.

“The care that he’s getting is superb,” Swartz said. “The passion to make people comfortable is just unbelievable. And the comfort they give the families is unbelievable.”

Staph Risk at the Beach Leads to Discovery of Disease Fighting Drugs

Scientists from NOAA's National Ocean Service have recently discovered a wide array of potential pharmaceuticals from the ocean. The discovery parallels the news that going to the beach exposes us to staph infection. NOAA researchers have also discovered disease fighting, natural occurring drugs.

While exploring environmental issues in the ocean and among the coral reefs that impact human health, researchers also found natural, non-toxic chemicals that should lead to the development of new antibiotics, anti-cancer drugs, anti-fungals, and anti-viral drugs to help humans fight disease.

The natural chemical compounds discovered in the ocean carry fewer side effects, and are much less toxic to humans than drugs currently used. The scientists believe they may have found the answer to antibiotic resistance in the ocean's chemicals. "We believe that one could apply many of these chemical mechanisms or novel pharmaceuticals to human disease resulting in a number of alternatives to deal with growing antibiotic resistance."

The group from NOAA saw how the brown tube sponge Agelas conifera has the ability to protect itself from disease by creating a biofilm that disrupts the protective layer that makes bacteria difficult to eradicate. The discovery of the substances, known as ageliferin derivatives, may also have other disease fighting applications in humans.

The recent finding that our beaches can expose us to risks of Staph infection also brings good news about how marine life can help us fight disease. We do have environmental threats to human health, but scientists are also finding cure for many human diseases from exploring our delicate ecosystem.

Paul Sandifer, Ph.D., former member of the U.S. Commission on Ocean Policy, chief scientist of NOAA's Oceans and Human Health Initiative tells us, "While the marine environment can indeed be hostile to humans, it may also provide new resources to help reduce our risks from illnesses such as those caused by water borne staph or seafood poisoning."

NOAA research scientist Peter Moeller, Ph.D says, "We've found significant new tools to fight the antibiotic resistance war. Discovery of the ageliferin derivatives…" could lead to a new class of helper drugs and result in a rebirth for antibiotics no longer thought effective. Its potential application to prevent biofilm build-up in stents, intravenous lines and other medical uses is incredible."

Exposure to staph infection at the beach is certainly newsworthy. Scientists warn that bathing before and after swimming, as well as good skin care are important to prevent staph infection after swimming in the water of our coastal regions. We can also embrace the discovery of new drugs from the ocean that can promote rather than destroy human health.

The ocean poses some threat to human health, and the new research warns of the risk of staph infection. The same discovery also brings hope for the development of natural compounds that can help humans fight disease. Natural compounds from the ocean have shown no toxic effects after two rounds of sophisticated testing, and the news is exciting.

Beaches May Harbor Staph Bacteria: U.S. Study

Fri Feb 13, 2009
By Julie Steenhuysen

CHICAGO (Reuters) - Swimmers at crowded public beaches are likely to bring home more than a bit of sand in their bathing suits, according to U.S. researchers, who said as many as one in three swimmers may be exposed to contagious staph bacteria.

They said people who swim in subtropical marine waters have a 37 percent higher risk of being exposed to staph bacteria, including an antibiotic resistant staph known as Methicillin-resistant Staphylococcus aureus, or MRSA.

"We think that people are the instruments for bringing their organisms into the water and leaving it behind," Dr. Lisa Plano of the University of Miami told reporters at the American Association for the Advancement of Science meeting in Chicago on Friday.

"I don't know if that is the only source. The bacteria may still be in the sand left over from other people, but we haven't studied that. These are things we plan to do in the future."

People who have open wounds or are immune compromised have the greatest risk of infection, she said.

In one experiment with more than 1,000 bathers on a popular Florida beach, people spent 15 minutes dunking themselves in the sea, then bringing sea water back with them in a jug.

They then tested the water for staph and MRSA and found 37 percent of the samples contained staph, and 3 percent of those contained MRSA.

"I don't think you should fear going to the beach," Plano said, particularly if they take a few simple precautions.

She recommends people shower before going to the beach, to keep from depositing their own germs into the water. And she suggests they shower once they leave, to wash off any pathogens.

"If you don't go into the water with a gaping wound, you should be fine," Plano said.

(Editing by Will Dunham)

A Skeptic Becomes A True Believer

By Manoj Jain
Special to The Washington Post
Tuesday, February 10, 2009

I was skeptical when my hospital embarked several years ago on an initiative to reduce the number of hospital-acquired infections in our intensive care unit.

These are infections that originate from the tubes and catheters inserted into the body -- for example, ventilator-associated pneumonia, related to a tube lodged in the windpipe to assist in breathing; urinary tract infection, related to a catheter inserted into the bladder to drain the urine; and bloodstream infection, related to a catheter threaded in the veins reaching the upper chamber of the heart.

Mind you, the tubes are critical for life-sustaining functions (breathing, nourishing, medicating and eliminating waste) during a serious illness when the body's organs are failing. The problem is that during the recovery period, some of the trillions of bacteria that live on a normal person's skin and in the alimentary, urinary and respiratory tracts begin to tunnel alongside the tubes into places they don't belong. Here they can cause life-threatening infections.

Before our initiative, for every 1,000 "device days" (for example, 100 ICU patients using one of those devices for 10 days), seven patients would get pneumonia, six would get blood infections and four would get a urine infection. That was the norm. In fact, for years I thought that hospital-acquired infections were the price we had to pay for intensive care. "You stay two weeks in the ICU and you get an infection -- that's not unusual," we would tell families.

And, honestly, it seemed to be a fair price. Patients with severe congestive heart failure and fluid in the lung are kept breathing by a ventilator until the heart recovers, the lung fluid clears and they are breathing on their own. Within a week they're back at home. So what if 10 percent of patients develop infections? We have powerful antibiotics to combat them. And so what if the treatment is expensive? (A ventilator-associated pneumonia or a bloodstream infection typically adds nearly $25,000 to the patient's hospital bill.) Medicare or an insurance company is paying.

Most important, without the devices, many of these patients would surely have died.

So as I said, I was skeptical when my hospital joined the quality improvement initiative led by the Institute for Healthcare Improvement, a nonprofit founded by Harvard pediatrician Donald Berwick.

Berwick is in the vanguard of nationwide efforts to reduce medical errors, standardize treatments, cut waste and bring patient-centered medical care to the bedside. Some 4,000 hospitals, including ours, participate in his institute's programs. In the case of our staff, Berwick insisted that we could reduce and even eliminate hospital-acquired infections.

Within a week after our first collaborative meeting (this was in the fall of 2002), the IHI team suggested that the ICU doctors and nurses at our hospital begin to use a checklist for every patient. For a patient on a ventilator, for example, it would include raising the head of the patient's bed to 30 degrees to prevent gastric secretions from going into the lung; seeing if ventilated patients could handle reduced sedation, so they could be extubated earlier; giving peptic ulcer prevention medicine to prevent gastric bleeding; and giving blood thinners to prevent clots in the leg that could potentially travel to the lung and cause a fatal pulmonary embolus.

Those sets of orders became known as an IHI "ventilator bundle." Similarly we had a "UTI bundle" for people with urinary catheters and a "central line bundle" for those getting catheters into the deep vessels close to the heart.

That last bundle required doctors to wear a sterile gown, mask and gloves before placing a central line -- a fairly obvious idea. I questioned how repeating such routine injunctions could have much effect on our infection rates.

But the truth is, at most hospitals in America, we have been far from 100 percent consistent on routine procedures. Berwick and the IHI realized that following those orders every time without a written guide was unrealistic. Airline pilots are not expected to do pre-flight checklists based on memory.

The quality improvement initiative forced us to look at the process, measure the results, provide feedback to key people and develop strategies to improve the care of our patients. Yet it all started with those checklists.

In fact, checklists may be one of the great medical innovations of recent years. Take the work of Peter Pronovost, an anesthesiologist at Johns Hopkins Hospital, rated one of the top 100 most influential people in the world last year by Time magazine. By implementing a checklist on the insertion and management of central venous lines with the help of Pronovost and his team, ICUs in Michigan hospitals reduced bloodstream infections to nearly zero.

Last month the New England Journal of Medicine published an international study led by Atul Gawande, a surgeon at Harvard, on implementing a checklist for surgical patients. It included common-sense things such as confirming the correct surgical site (left leg, not the right, for amputation) as well as technical checks, such as making sure antibiotic prophylaxis is given zero to 60 minutes before surgery, when it is most effective.

One item on the list is "Confirm all team members have introduced themselves by name and role." Studies have shown that a member of a health-care team is more likely to speak up when something is wrong if the members know each other by name.

That team concept has been key to the initiative at our hospital. Each morning, the ICU physician leads multidisciplinary rounds with the patients' nurses, ICU charge nurse, pharmacist, dietician, respiratory therapist and many others. That was a major change in our behavior, and its benefits were quickly apparent. With everybody on the team feeling responsible for reducing the number of infections, nurses became more vigilant, criticisms were welcomed rather than resented, and administrators began tracking infection rates like they tracked the budget and hospital census.

What was the result of all that effort?

After two years, we saw a 50 percent decline in our ICU infection rate, with a 21 percent (or $702) reduction in cost per ICU discharge. I was no longer skeptical; in fact, I often joked, "If this trend continues, I'll be out of a job as an infectious-disease consultant." Our hospital team, along with Berwick, went on to publish the results in the journal Quality and Safety in Health Care.

An interesting footnote: There were some resisters at our hospital -- often, unsurprisingly, the traditionally autonomous physicians. One afternoon in our infection-control meeting, an ICU nurse complained about a surgeon who refused to fully drape and wear a mask when placing a central line. He argued there was "no need." The nurse asked me what she should do.

With the firmness of a convert, I told the nurse: "Be a Rosa Parks. If it is not an emergency, and the surgeon refuses to follow the protocol, do not assist the surgeon in placing the line. I will back you up."

Thereafter, the surgeon complied. The hospital's culture of patient safety and quality had changed. And our efforts continue.

Manoj Jain is the medical director at Medicare's quality improvement organization in Tennessee and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. Comments:

Michael Jackson Has Potential Flesh-Eating Infection

Thursday, February 12, 2009
FOX News

Michael Jackson may have a severe infection that has spread throughout his entire body. The singer is receiving antibiotics through an IV drip, reports The Sun.

The paper says the 50-year old singer may have contracted a staph infection following cosmetic surgery on his nose.

“The infection has spread throughout his face and body and is being aggressively treated by doctors," a source told The Sun. "There’s a chance it could turn into a flesh-eating disorder where it begins to kill off his skin so he’s being very carefully monitored.”

Jackson was photographed outside a health clinic, where his hands and face appeared inflamed and blotchy.

Professor Battles Bacteria

Wednesday, February 4, 2009

If there were a superhero devoted to fighting infectious disease, Michael Mahan would be the man. As a UCSB professor and researcher, he is fighting a war against opponents with names like salmonella, streptococcus, and pseudomonas, on a daily basis. Could he change the future of the world as we know it? You bet.

“We are limited by our imagination, not by our tools,” he said.

Unlike most comic book superheroes, however, Mahan wages his battles in a lab, researching and developing vaccines in the Molecular, Cellular, and Developmental Biology Department at UCSB. Most recently Mahan, a soft spoken, enthusiastic professor, developed a vaccine against salmonella.

You may be surprised that he chose salmonella, which, while it causes some deaths in the United States, it is most often associated with food poisoning. Worldwide, however, this bacteria is a real killer. About 16 million people worldwide are infected with one salmonella strain or another, Mahan said, and hundreds of thousands die. It is a salmonella strain that causes typhoid fever.

There was another reason as well. “It’s the Cadillac of genetic systems,” said Mahan. It is a model genetic engine, and naturally good for gene swapping, he said. It has a short generation time: 20 to 30 minutes. Other disease-causing bacteria take longer to grow. It takes about four weeks to produce a tuberculosis colony.

Yet another reason for the attention to salmonella is that it is rife throughout the food industry. Mahan found 20 strains of salmonella at a California dairy, and this was not unusual, but the norm. He said that farmers may not even know their animals are infected. While younger cows may die from salmonella, older ones often don’t show any signs of infection. You may feel safe if you’re a vegetarian, but you’re not in the clear. Mahan said salmonella is found all over – in pigs, chickens, cows, and vegetables. “We get salmonella because we are eating contaminated animals and vegetables,” he said.

The vaccine Mahan developed is unique in that it targets a variety of salmonella strains. He said this was important since targeting only one would not stem the tide of infection. The vaccine is being tested in animals, but eventually could be used in humans.

Vaccines are especially important since antibiotic-resistant bacteria are on the rise. “The bacteria are getting smart,” Mahan said. They have an attitude of been there, seen that. With about 2,000 antibiotics on the market, which target bacteria that may have developed a resistance after being exposed to the same drugs for more than 50 years, the battle may not be a fair fight.

Some of these drug-resistant bacteria, such as staphylococcus infections, are most often seen in people in the hospital. “If you’re healthy, the hospital is not a place you want to be,” he said. “If you need to go to the hospital, fine,” he hastened to add. He explained that hospitals have become home to multiple-drug-resistant bacteria, which take the opportunity to set up house when someone has surgery. “Staph is very good at colonizing where sutures are, and in traumatized tissue,” Mahan said. In addition, these bacteria can be easily transported from room to room and person to person.

While you might try to avoid hospitals as a safety measure, this is not the only place you’ll encounter deadly types of bacteria. The pseudomonas bacterium is found in the soil, and can enter our bodies through a cut. It has become antibiotic resistant. “Our bodies are built like castles. They are very good at keeping stuff out,” Mahan said, “but once it gets in . . . .” He trailed off.

A recent high-profile case involving pseudomonas occurred in Brazil. A Brazilian model in her twenties contracted a urinary tract infection that turned into septicemia and eventually killed her. Mahan said her infection was caused by pseudomonas, which is a particularly virulent type of bacteria. Most urinary tract infections are caused by e-coli. The antibiotics she was given didn’t kill the type of bacteria that was attacking her body. Mahan, who is teaching a class on infectious disease at UCSB, said he received many e-mails from his students about this story.

While this case may seem like an unfortunate tragedy, Mahan said these types of infections may become more common. He can foresee a time when they hit the general population with greater frequency. He added, “It’s not like the clock’s ticking. It’s already rung.”

Mahan said drug companies are hesitant to produce new antibiotics for fear of litigation. When new drugs are tested, there may be serious side effects for the users, and the drug companies could get sued, he explained. It was the same with vaccines in the past, he added. Companies were hesitant to produce vaccines, until the government offered them protection from lawsuits.

Mahan’s research is also seen as a form of counter-terrorism. There is a fear that terrorists might use our food, or other means, to transmit deadly diseases. And it has happened. There was the incident with a cult in Oregon in the 1980’s who put salmonella bacteria on food at a fast food restaurant, hoping to infect customers, and alter an election, Mahan said. While this group was unsuccessful, other attacks have been lethal. Anthrax, a type of bacteria commonly found in animals, has been used by domestic terrorists here and elsewhere, killing postal workers and others exposed to it.

One of the challenges in developing live vaccines is to provide optimum protection without adversely affecting those with compromised immune systems, the very young, or the old, he said. Mahan emphasized that the three most important things are “Safety, safety, safety.”