Peyton Manning's Staph Infection

Here is the scary note of today.

It turns out that part of the setback in Peyton Manning's recovery from his knee injury was a staph infection.

With the controversy over Kellen Winslow's medical problem and with Tom Brady reportedly having multiple procedures to clean out a knee infection, this has officially become an epidemic in sports.

Last week it was reported that Kenny George, the 7-foot-7 center for UNC-Ashville had part of his foot amputated from a staph infection complication.

George developed MRSA, a form of infection that could be life threatening and has become a particular concern in locker rooms.

Bob Kravitz of the Indianapolis Star reports that the Colts superstar had a staph infection attack his bursa leading to two procedures on his knee complicating Manning's return to the field.

"Staph infections are an issue across our country in all walks of life,'' NFL spokesman Greg Aiello told Kravitz. "Our medical staffs are well aware of the national issue. They heard a presentation on it in Indy at the combine in 2006 from the CDC (Centers for Disease Control). And our medical staffs have discussed it at other meetings over the past several years and have shared information on prevention and treatment of staph.''

THE COLTS STATEMENT JUST ADDED: “Peyton Manning developed swelling in his left pre-patella bursa in late February. The swollen bursa was treated conservatively beginning in February with drainage and anti-inflammatory medication. The first signs of infection occurred while he was in New Orleans in July. It should be noted that infection developed prior to any surgery. Upon manifestation of the signs of infection, he immediately had surgery to remove the bursa sac. Concurrently, he was treated aggressively with antibiotics, and the infection was eliminated. The second procedure (tacking of the skin to eliminate the bursal space) was designed to ensure the complete and swift resolution of the bursal problem. The procedure was successful.

The second procedure was in no way, shape or form, related to the infection. The second procedure did not delay his rehabilitation or recovery materially. It also should be noted emphatically that, at no time, did he have MRSA. It is clear from consultation with our physicians, including infectious disease specialists, that staph is a societal medical problem. There is no empirical evidence that indicates to our physicians there is a problem related to resistant staph (MRSA) with respect to the Indianapolis Colts.”

Here is at least some good news. Noted doc James Andrews says Tom Brady is getting better and Patriots dispute stories that they are mad at their QB.

Community MRSA Getting More Dangerous, CDC Says

By Anne Zieger

Until recently, the healthcare industry was primarily focused on fighting the spread of MRSA within hospitals and other health facilities. However, community-acquired MRSA is becoming increasingly common, and causing far more serious illnesses than in the past, according to a new study.

MRSA is increasingly showing up in settings like schools or among players on sports teams, according to a study by the CDC. To examine this trend, researchers tested samples of the most common community MRSA strain, USA300, in a network of hospitals in nine cities and states over the last few years.

The CDC study suggested that 10 percent of the common community strains of staph infection are now resistant to antibiotics, and not just penicillin and drugs of its type. These 10 percent could also evade clindamycin, tetracycline, Bactrim or other antibiotics. In some cases, antibiotics that are so old that their patents have expired are being pulled off the shelf to fight the staph infections. These drug-resistant staph bacteria cause 95,000 serious infections and 20,000 deaths every year.

Worse still, when these infections come into hospitals, they are able to swap gene components with other bacteria-and become even more drug resistant. Doctors are saying that it's becoming a major epidemic in this country.

Staph Germs Harder Than Ever to Treat

By MARILYNN MARCHIONE

Drug-resistant staph bacteria picked up in ordinary community settings are increasingly acquiring "superbug" powers and causing far more serious illnesses than they have in the past, doctors reported Monday. These widespread germs used to be easier to treat than the dangerous forms of staph found in hospitals and nursing homes.

"Until recently we rarely thought of it as a problem among healthy people in the community," said Dr. Rachel Gorwitz of the Federal Centers for Disease Control and Prevention.

Now, the germs causing outbreaks in schools, on sports teams and in other social situations are posing a growing threat. A CDC study found that at least 10 percent of cases involving the most common community strain were able to evade the antibiotics typically used to treat them.

"They're becoming more resistant and they're coming into the hospitals," where they swap gene components with other bacteria and grow even more dangerous, said Dr. Keith Klugman, an infectious disease expert at Emory University. "It's really a major epidemic."

The germ is methicillin-resistant Staphylococcus aureus, or MRSA. People can carry it on their skin or in their noses with no symptoms and still infect others — the reason many hospitals isolate and test new patients to see if they harbor the bug. MRSA mostly causes skin infections. Cleveland Browns tight end Kellen Winslow was just hospitalized for a staph infection, his second in recent years, and the team reportedly has had at least six cases in the past three years.

But the germ can be life-threatening if it gets into the bloodstream, lungs or organs. Pneumonia, sinus infections and even "flesh-eating" wounds due to MRSA are on the rise, doctors reported Monday at an infectious diseases conference in Washington.

About 95,000 serious infections and 20,000 deaths due to drug-resistant staph bacteria occur in the United States each year.
To treat them, "we've had to dust off antibiotics so old that they've lost their patent," said Dr. Robert Daum, a pediatrician at the University of Chicago.

The CDC used a network of hospitals in nine cities and states to test samples of the most common community MRSA strain, USA300, over the last few years.

MRSA usually is resistant only to penicillin-type drugs. But 10 percent of the 824 samples checked also could evade clindamycin, tetracycline, Bactrim or other antibiotics.

"The drugs that doctors have typically used to treat staph infections are not effective against MRSA," and family doctors increasingly are seeing a problem only hospital infection specialists once did, Gorwitz said.

Even more worrisome: many of these community strains had features allowing them to easily swap genes and become even hardier.

Also at the conference:

Doctors from Spain reported the first hospital outbreak of MRSA resistant to linezolid, a last-resort drug sold by Pfizer Inc. as Zyvox in the United States and Zyvoxid in Europe. A dozen intensive care patients got pneumonia and bloodstream infections last spring and the outbreak was controlled after use of the antibiotic was severely curbed, said Dr. Miguel Sanchez of Hospital Clinico San Carlos in Madrid.

Georgetown University saw a spike in sinus infections due to MRSA. The germ accounted for 69 percent of the staph-caused cases in the hospital between 2004 and 2006 compared with 30 percent from 2001 to 2003.

Henry Ford Hospital in Detroit found that more than half of staph-caused pneumonia cases from 2005 through 2007 were due to MRSA.

Doctors from Case Western Reserve University and the VA Medical Center in Cleveland found that by the time hospitals isolated and tested new patients to see if they harbored MRSA, many had already contaminated their skin and surroundings. Within about a day of being admitted, roughly a third had already started to spread the germ.

Hospital screening is controversial, and has had mixed success, said Dr. M. Lindsay Grayson, an infectious diseases expert at the University of Melbourne in Australia.

The nation's Veterans Affairs hospitals began universal MRSA testing in 2007. Illinois and some other states have adopted or are considering laws requiring hospitals to test high-risk and intensive-care patients for MRSA.

The conference is a joint meeting of the American Society for Microbiology and the Infectious Diseases Society of America.

NFL Stars No Match for Bacteria

By Elizabeth Landau
CNN

A 6-foot-4 football player is more than a million times the size of a typical Staphylococcus bacterium. But under the right conditions, that athlete could find himself defenseless against the microscopic bug.

Kellen Winslow recently had a second staph infection and has accused his team of covering it up.

The problem came to the forefront last week with Cleveland Browns player Kellen Winslow, who recently had his second staph infection. He is reportedly the sixth player to acquire staph among the Browns in five years.

Winslow recently said the Browns treated him like a "piece of meat" when he was hospitalized for the condition, and he claimed they covered up the cause of his illness.

After Winslow spoke out, the organization suspended him for one game, then rescinded the suspension after a settlement with Winslow over the weekend. The Browns said in a statement Saturday that the team and Winslow had worked through their differences, and that the team looked forward to his return. Winslow joined the team again Monday.

Peyton Manning of the Indianapolis Colts was revealed to have a staph infection, the Indianapolis Star reported Friday. University of North Carolina-Asheville fans also recently learned that Kenny George, the 7-foot-7 center on the basketball team, had a staph infection complication that led to part of his foot being amputated.

It's unclear how these high-profile athletes acquired their infections, but locker rooms have been found to habor staph bacteria in previous outbreaks. The topic is generating buzz throughout the sports world as more players' staph cases are revealed. Hospitals have long been known to be hot spots for transmitting staph, but recently cases have cropped up in other community settings. Regardless of where these players got their infections, the close quarters of a locker room raise questions about overall risks.

About 30 percent of people carry staph in their noses without exhibiting symptoms, according to the Centers for Disease Control and Prevention.

Experts say Methicillin-resistant Staphylococcus aureus, or MRSA, a form of staph resistant to common antibiotics, has become a more prevalent problem in settings such as contact sports that involve skin-to-skin touching.

Most MRSA infections acquired in community settings present themselves as sores or boils and often appear red, swollen, painful or with drainage such as pus, the CDC says. Infections often occur in cuts and abrasions but also on body parts covered in hair, such as the back of the neck, armpit or groin.

Schools, prisons and other crowded environments are particularly known for transmitting MRSA, said. Elaine Larson, professor of epidemiology at Columbia University's Mailman School of Public Health.

MRSA may spread particularly easily among athletes because they have repeated skin-to-skin contact, share items and surfaces that touch skin and have a hard time staying clean, the CDC says. Athletes often get cuts and abrasions; MRSA can enter uncovered skin breaks and cause infection.

Dr. James Steinberg, medical director at Emory University's Crawford Long Hospital in Atlanta, Georgia, said that environment plays a role in the spread of MRSA but that it's less a factor than coming into contact with a person's skin.

"If you have somebody who has an infection -- he has a draining infection -- and he gets some of his pus on a bench, that staph's going to be there for hours or days before it dries out," he said. "But the higher concentration is going to be on that person's skin."

A second infection in the same person could result from re-exposure or from treatment that didn't get rid of the bacteria colonization, he said.

MRSA has been around in hospital settings since the 1970s, but community-associated MRSA was born in the late 1990s, and is now widespread in the community, said CDC spokesperson Nicole Coffin. A report from the CDC said that the deaths of four children from MRSA in North Dakota and Minnesota during the late 1990s "demonstrate the potential severity of community-acquired MRSA infections."

A study on the St. Louis Rams published in the New England Journal of Medicine in 2003 found that during the 2003 football season, there were eight MRSA infections among five of the 58 Rams players.

To protect against MRSA, the CDC recommends practicing good personal hygiene and taking care of your skin, which includes wearing protective clothing and covering cuts and abrasions with clean, dry bandages. Also, do not share items that come into contact with your skin, such as towels, razors and ointments. Put something between your skin and shared equipment -- for example, sit on a towel on a bench.

Larson said she is not directly familiar with Winslow's situation but understands the dilemma that a team would face if a player contracted a staph infection. There could be economic and psychosocial repercussions -- for example, another team might not want to play against that one, she said.

But in general, other team members should be made aware of the situation so they do not share towels or engage in other behaviors that might transmit the infection.

Still, there is a danger of overreaction, she said. In some instances when a child in a public school has died, the whole school panicked and fumigated the facility, she said.

"It's a good idea to avoid that level of fear, because it's costly and it scares people unnecessarily," she said.

On Thursday, the Brown's General Manager Phil Savage said the team did not alert players to Winslow's staph infection partly because of the health privacy laws and partly because the team was in "game mode" when Winslow had a confirmed diagnosis.

"To come out and talk about that just was going to be another distraction," Savage said on his regular weekly appearance on WTAM radio in Cleveland, Ohio. "That's our job, is to limit distractions as much as we can."

Winslow said in a statement released through his publicist, Denice White of EAG Sports Management, that he had been discouraged from making the issue public.

"This has nothing to do with football, and this has nothing to with my current contract situation," he said. "This is a health concern."

A spokesperson for the Browns did not return a request for comment. An NFL representative said the league has no statement on the issue.

MRSA and Flu Can Overlap into Pandemic Proportions

The importance of MRSA in a flu pandemic by Maryn McKenna
Excerpted from her blog.
http://www.marynmckenna.com/about.html

Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I've been following since writing the first story in the American media about avian influenza H5N1. And people concerned about MRSA realize that flu and MRSA have an important overlap. For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we've been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA. Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place.

Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Flu Shot Might Have Prevented MRSA Pneumonia

College student dies of rare ailment; MRSA pneumonia case brings warning
By CHERIE BLACK

A college student in Whatcom County died from a rare case of MRSA pneumonia -- prompting health officials to urge state residents to be vigilant about their health and to get a flu shot if they haven't.

Chris Feden, 20, a student at Western Washington University, died from what county health officials said was MRSA pneumonia, a rare staph infection that he may have contracted after getting the flu.

Separately, an 18-year old Pacific County resident died from respiratory failure, which wasn't caused by MRSA pneumonia, although it was believed to have been flu-related.

Respiratory illnesses, including the flu, typically peak in Washington in February and March and can be serious and even fatal. Cases of MRSA -- methicillin-resistant staph aureus -- are increasing in number nationwide, including in Washington, and can complicate influenza and other respiratory illnesses.

MRSA pneumonia, a relatively new infection that wasn't on national health officials' radar until about five years ago, is rare, but it may also be on the increase, health officials say.

MRSA infections have been common in health care settings for decades, and in recent years have spread into the community at large, particularly in relatively crowded facilities.

Although MRSA can be deadly, the infection itself is relatively common, and most people show no symptoms. The bacteria can be living in the nose and not cause problems.

But if an infected person catches the flu or other severe respiratory illness that becomes pneumonia, the lungs are weakened and people can infect themselves by inhaling the MRSA they already carry.

MRSA pneumonia first gained attention during the 2003-04 influenza season, when 15 cases linked to the flu were diagnosed across the country, according to the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report from April 2007. No formal surveillance was conducted, and few additional cases of MRSA pneumonia were reported to the CDC between the 2004 and 2006 flu seasons.

Between December 2006 and January 2007, there were 10 reported cases of severe MRSA pneumonia, including six deaths, in previously healthy children and adults in Louisiana and Georgia.

No statistics are kept for MRSA pneumonia in Washington, the state Health Department said.

"It's a combination of a community-acquired infection and flu season," said the state's health officer, Dr. Maxine Hayes. "It can cause catastrophic events, which is what happened to this young man," she said, referring to Feden. "Influenza is serious, and sometimes people think it's just a bad cold, but here we have a staph infection superimposed to that."

"Now we have MRSA and now we have more complications, and it's a killer."

Hospitals can test for MRSA through a nasal swab culture or a culture from a wound, which yields results in an hour or a few days, depending on which test is used.

Though MRSA is contagious through human contact, local public health authorities said the risk of MRSA infection to members of the Western Washington campus is very low.

"While this is a tragic loss of a young life, and our thoughts are with the family and friends of this young man, there is no evidence of an outbreak of severe MRSA in our community. This appears to be an unusual and random event," said Dr. Greg Stern, the health officer for Whatcom County.

The state Health Department is providing support to health officials in Whatcom and Pacific counties while they investigate the deaths. Health Secretary Mary Selecky said people should be aware that are in the middle of flu season, and while it has been an average one in Washington so far, getting a flu shot is still recommended, and it's not too late.

As for MRSA, simple steps such as covering coughs, washing hands and alerting a physician if there is a history of MRSA infections help reduce infection, she said.

"MRSA pneumonia is uncommon in this country, but we're still in flu season, and it can lead to pneumonia."

Feden's death, she said, "is an unfortunate reminder of the seriousness of the disease."

WHAT IS MRSA PNEUMONIA?

Methicillin-resistant staph aureus pneumonia is a relatively new and rare infection described as pneumonia with complications of MRSA, which is a common bacterium resistant to antibiotics.

ABOUT MRSA PNEUMONIA

How do you get it? A victim already has a MRSA infection, which may or may not make him sick. The victim then gets influenza or another severe respiratory illness that turns into pneumonia. The MRSA infection spreads to the weakened lungs, resulting in MRSA pneumonia.

How is it spread? MRSA is commonly spread by direct human contact. Although flu can spread from a sufferer, MRSA pneumonia is not an airborne disease and is not contagious.

How common is it? MRSA pneumonia is relatively new, and there are no statistics in Washington and no formal U.S. surveillance. Nationwide, there were 15 cases during the 2003-2004 flu season and 10 cases, including six deaths, between December 2006 and January 2007 in Louisiana and Georgia, according to the Centers for Disease Control and Prevention.

How deadly is it? MRSA pneumonia often affects young, otherwise healthy people and can be fatal. The patients who died did so within three to five days of the onset of respiratory symptoms. MRSA should be suspected in people with severe pneumonia, especially during the influenza season, and in those with a history of MRSA infection, according to the CDC.

MORE ONLINE

For more information about MRSA, visit the state Health Department's Web site at goto.seattlepi.com/r1087 or the Western Washington University MRSA information page at www.wwu.edu/mrsa.

P-I reporter Cherie Black can be reached at 206-448-8180 or cherieblack@seattlepi.com.
Read her To Your Health blog at blog.seattlepi.com/toyourhealth.

Jump Seen in Staph-Linked Flu Deaths in Kids

By LINDSEY TANNER , AP Medical Writer, Medicine & Health / Health

(AP) -- More children have died from flu because they also had staph infections, according to a new government report that urges parents to have their kids get the flu shot. The number of deaths wasn't high - 73 during the 2006-07 flu season - but there was more than a fivefold increase in hard-to-treat complications. And preliminary figures indicate deaths rose again during this past winter's flu season.

Public health officials say the numbers underscore the importance of a brand new recommendation that all children, from 6 months through 18 years, get routine flu shots. Before this year, shots were recommended for kids under 5 years.

More than half the children who died were between ages 5 and 17 and had been healthy until they got the flu.

Parents shouldn't panic, "but it's an important message to say even healthy children develop complications and die almost before anything much can be done for them," said Dr. Gregory Poland, a Mayo Clinic infectious disease specialist. He was not involved in the federal study, but has worked with a federal vaccine advisory committee and has consulted for vaccine makers.

Flu season is just beginning, and this year's vaccine should be widely available this month.

While few children die from the flu virus, it puts about 20,000 U.S. kids in the hospital each year.

Only 6 percent of the children studied who died had been fully vaccinated against the flu. Two doses are recommended each flu season for children ages 6 months to 8 years who have not been vaccinated previously; for older kids, just one dose a year is needed.

The study, appearing in the October edition of Pediatrics for release Monday, is based on an analysis of reported flu deaths from the 2004-05 through 2006-07 seasons. Flu deaths in children during those seasons totaled 47, 46 and 73, respectively.

The percentage of those who also had bacterial infections jumped from 6 percent to almost 36 percent. Most had staph infections, and 60 percent of those involved the dangerous MRSA bug, which is resistant to antibiotics.

More recent data suggest flu deaths among children have continued to rise, with 86 tallied for the 2007-08 season in a preliminary report last month, said Lyn Finelli, the study's lead author, who is a researcher for the Centers for Disease Control and Prevention.

Preliminary information also suggests there has been no drop in fatal flu-staph cases in children, and those could still be on the rise too, she said.

Staph germs commonly live in the nose or skin without causing illness; more than one-fourth of U.S. children and adults carry them.

These bugs can become deadly when they get into the bloodstream, sometimes through wounds. The flu is thought to make people more susceptible to bacterial infections like staph, Finelli said.

Details on how children in the study died were not available, but some developed bacterial pneumonia, seizures and shock.

Finelli said parents should take children to the doctor when they have flu symptoms and signs of other complications. These could include extreme fatigue, no thirst, or in older children complaints about feeling very ill.

Hand Washing: Time Well Spent

Reston Hospital Center has boosted its hand-hygiene compliance, which has led to a drop in the infection rate.

By Manoj Jain
Special to The Washington Post
Tuesday, August 5, 2008

One morning on hospital rounds, I saw a physician colleague enter the intensive care unit where a patient lay intubated and sedated. With his hands unwashed and ungloved, the physician palpated the patient's abdomen, scratched his own head and then placed his stethoscope on the patient's chest to listen to his heart. Then he walked to the nurses station, rubbed his nose and entered a note in the patient's chart.

There was nothing unusual about this. Not washing hands scrupulously remains common practice for professionals at most hospitals, even though abundant research shows that it controls outbreaks of infectious disease, reduces transmission of resistant organisms and cuts infection rates among hospitalized patients.

That same day in a public restroom, I noticed a man go straight from the urinal to the door, bypassing the sinks. Unfortunately, that's a common occurrence, too.

Despite recommendations, nearly 60 percent of health-care workers do not wash hands while on duty. Among the general public, according to a Harris Interactive survey conducted last year, 12 percent of women and 34 percent of men do not wash their hands after using a public restroom. Why?

For one thing, rigorous hand washing is time-consuming. Guidelines advise that we first rinse, then soap for 20 seconds, then rinse again for 30 seconds; after this, we paper-dry our hands and turn the faucet off using the paper towel. For health-care workers, the procedure is supposed to be followed before and after every patient encounter. That means two minutes per patient visit, which adds up to an hour for a doctor who sees an average 30 patients a day, and 2 1/2 hours per shift for an ICU nurse. I have yet to find a doctor or a nurse who is so diligent.

In the past few years, the hand-washing exercise has gotten simpler, with the increased acceptance of alcohol-based gels. I enter a patient's room, squirt gel onto my palms from the wall dispenser, then rub the back of my hands, my fingertips and my thumbs as I introduce myself and ask the patient why he or she is there. Then as I exit, I gel my hands again as I ask, "Do you have any questions?"

Despite the ease of using alcohol gel, studies show that nearly a quarter of health-care workers do not regularly disinfect their hands. Few realize that our bodies are like petri dishes teeming with 300 trillion organisms and that our hands are like swabs for the transmission of antibiotic-resistant bacteria such as MRSA, pseudomonas and C. difficile.

What can we do to improve hand-washing rates?

First, we must admit that the "Just do it!" approach of the past 150 years has failed. Behavioral theory tells us that changing behavior in a change-resistant culture cannot be accomplished with a single intervention.

We need a carrot-and-stick approach. Let the carrot be a campaign of incentives and awards for hand washers, similar to the eat-more-vegetables campaigns that many parents conduct with their children.

Then we need the stick. Health facilities need to monitor the hand-washing rate for each unit and provide feedback and improvement strategies to health workers at the bedside. Observers need to be stationed in ICUs and hospital wards, much like traffic cops at the bottom of a hill. Repeated failures to comply, as in the case of my physician colleague, would result in a letter to the offender and a note in his credentialing file or employment record.

Hospital administrators, not just their staffs, also need a stick over their heads. Starting in October, hospitals will be penalized for the consequences of unwashed hands: Medicare will no longer pay for complications arising from certain hospital-acquired infections, which in many cases result from poor hand hygiene. This will be a powerful incentive for health executives to improve hand-washing compliance.

An aggressive approach to hand washing has worked. At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998.

At Novant Health hospitals in Charlotte and Winston-Salem, N.C., a 2005 hand-washing campaign -- complete with billboards and computer screen savers -- brought about a sustained drop in MRSA and hospital-acquired infections. At Reston Hospital Center, an awareness campaign introduced in 2006 has boosted hand-hygiene compliance to more than 90 percent; it also led to a drop in the hospital's infection rate.

A 2007 study from John Hopkins showed that using simple checklists as reminders about basic hygiene such as hand washing and about proper draping, gloving and masking reduced the central intravenous line infection rate by 66 percent in ICUs.

About my physician colleague: I approached him and gently reminded him. "The patient likely has resistant bacteria -- it is really important that we wash our hands after every encounter." Suddenly self-conscious, he groped for the alcohol gel dispenser just a few feet away.

As for the man in the public restroom: I'm sure that I got his germs on my hands from the door handle.

Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:health@washpost.com.

10 Germy Surfaces You Touch Every Day

Experts Tell Where Cold and Flu Viruses and Other Germs Lurk
By JOSEPH BROWNSTEIN and RADHA CHITALE
ABC News Medical Unit
Sept. 5, 2008

Many surfaces and objects you come in contact with every day are covered in germs -- but then again, so are you. Many of the surfaces that we come into contact with on a daily basis are a breeding ground for dangerous germs -- including the viruses that can lead to cold and flu.

"Ninety percent of you is composed of germ cells," said Philip Tierno, director of clinical microbiology and immunology at NYU and author of "The Secret Life of Germs." He explained that while we are constantly in contact with germs, only a small minority will cause any harm. "Of the 60,000 types of germs that people come in contact with on a daily basis ... only about 1 [percent] to 2 percent are potentially dangerous to normal people with normal immunity," he said.

That works out well for us, because pretty much any surface contains some of these microscopic organisms. "There's very few surfaces that are truly clean," said Dr. Aaron Glatt, president and CEO of New Island Hospital in Bethpage, N.Y., and a spokesman for the Infectious Disease Society of America. "You're almost never going to culture something and not find some germs on it."

With that in mind, there is a simple activity that anyone can engage in to stay as safe as possible from surface germs.

"People should know that washing their hands is the single most important mechanism we have to prevent infection," said Glatt. While he stressed that "the optimal goal is to practice good personal hygiene, good household hygiene and good food hygiene," Tierno also noted the importance of clean hands. "You don't need to live in a bubble ... but you do need to be aware," he said. "You can touch surfaces, but just clean up before you eat or drink or before you touch your face." "If you wash your hands prior to touching your face or prior to eating or drinking, which should be the norm, you cut your risk to virtually nil."

Purses and Wallets:
Although they serve similar functions for women and men, purses and wallets are germy for entirely different reasons.
"It behooves you not to put your purse on the floor or outside ground if you can help it," said Tierno. But many women don't follow that bit of advice, so their purses pick up the bacteria from wherever they're placed -- from the soiled ground to the bathroom floor.

While some might be willing to put it there because they think the floors are cleaned regularly and thoroughly, that isn't always the case. "The way these places are cleaned is not ideal all the time," said Tierno. Instead, he recommends putting your purse on a bench or a seat.

Wallets, meanwhile, pick up a lot of bacteria from what goes into them."Men's wallets were pretty bad on the inside," said Charles Gerba, a professor of microbiology at the University of Arizona whose work has earned him the nickname "Dr. Germ."

Paper currency has a way of getting around, from germ-filled hand to germ-filled hand. It picks up germs, viruses and often trace amounts of illegal drugs -- that's not just an urban legend; several studies have confirmed that a majority of U.S. currency contains trace amounts of cocaine. And of course, all of that ends up in your wallet.

Because men keep wallets in their pockets, the wallet is close to body temperature -- an ideal temperature for bacteria to breed. "When handling the contents of your wallet, after it, wash your hands," said Tierno.

The problem isn't as bad with coins, largely because the metals -- particularly nickel -- often kill many of the bacteria.

Remote Control:
The next time you sit down for a late-night movie at home, you may want to keep your hand out of the popcorn bowl if you've been handling the remote. People are constantly handling their remote controls -- and, as Gerba points out, nobody ever disinfects them.

No wonder, then, that it is often the dirtiest object in a hotel room. Tierno recommends wiping it down at least once a week, and more often if someone who is sick handles it. Gerba points out that sickness will make the remote even worse, because people who have a cold or the flu tend to "jump in bed with the remote control and contaminate it."

The laundromat is hardly a bower of cleanliness, but even laundry done at home is rife with germs. There is about 0.1 gram of fecal material in a piece of underwear, Gerba said. That amounts to approximately 100 million E. coli bacteria in an average undergarment load.

Unfortunately, only 5 percent of people use very hot water to wash their clothes and then dry them for a full 45 minutes, a process Gerba said would kill more bacteria. Skipping these steps means that transferring wet clothing into a dryer leaves a film of germs all over your hands.

To minimize exposure to harmful bacteria, Gerba recommends doing laundry that requires bleach as a first load to disinfect the machines and saving undergarments for a final load. He also cautions against using the same sorting tables for clean and dirty laundry since the E. coli from the dirty clothes will transfer to the table and then back onto your freshly laundered clothes.

"Your clothes are a lot germier than they were 50 years ago," Gerba said. "Never kiss anyone who has just done laundry for you."

Foodwise - You may be better off preparing your food on another surface than a cutting board.

According to Gerba, there are 200 times more fecal bacteria on a cutting board than a toilet seat. The reason, he explained, is that many people rinse off their cutting board rather than thoroughly washing it. "You have potential pathogens when you're dealing with food," said Tierno. He recommended preparing a solution of a quart of water and "a jigger of bleach" and then wiping down food preparation surfaces before making anything on those areas of the kitchen.

Your Phone:
The telephone provides a convenient meeting place for two different sources of germs -- your hands and your mouth. After all, as Tierno, pointed out, "People are the source of most of the germs."These germs are not just from your hands, but sources like your saliva as well -- which is why the mouthpiece is often even dirtier than the handle.

And again, it's not a device people clean too often, which is why both land lines and mobile phones present a problem. A study done in Israel last year showed that 20 percent of hospital workers' cell phones had some form of harmful bacteria on them.

Buttons:
These innocuous-looking offenders are difficult to avoid, which is part of the reason why push buttons can be crawling with germs. Further, ubiquitous buttons, found on ATMs, elevators, telephones and drink machines, among other things, are located in areas that are not often cleaned and disinfected to kill bacteria and viruses.

Gerba noted that the first-floor buttons in elevators were the dirtiest."Everyone needs to go to the first floor," he said. Worse, these germs get transferred to the body part that comes in contact with faces the most -- fingers and hands. While avoiding these types of buttons can be almost impossible, Gerba does have a few recommendations. "Knuckle it or wait for someone else to push it for you."

Airplane Bathrooms:
"These are probably the worst," Gerba said. "They are the germiest restrooms you'll run across." But bathrooms in general are not as germ-ridden as other areas -- a kitchen sink or laundry machine, for example. Compared to several items on this list, toilets are a beacon of cleanliness because they are cleaned and disinfected on a regular basis, even public toilets.

Airplane bathrooms get cleaned, but the high volume of people they must cater to in a short amount of time leaves them very dirty very quickly.Gerba said a normal aircraft has one bathroom per 50 people. Discount airlines have one bathroom per 75 people.

"There is a thin layer of E. coli over the sink," and other surfaces, Gerba said, adding that many people, especially men, will not wash their hands effectively because the sink is small, and dirty hands transfer germs to the face easily. Interestingly, the cleanest toilets are probably those in public areas of a hospital, Gerba said.

Shopping Carts:
An individual probably has a fairly short interaction with the shopping cart at the local grocery store. Unfortunately, that interaction covers all the danger zones for contamination: hands, faces and food. In one study done by his group, Gerba said he found E. coli on almost half the shopping carts the group tested. These are the microbes and pathogens that are transferred from the cart to your hands, to the food you select and then to the face if the hands touch it.

In addition, children often sit in the seat provided in larger shopping carts, adding to the germ load on the cart. "That's putting a kid's butt where you put your broccoli," Gerba said. A shopping cart is a good example of an item where a quick wipe down with a disinfecting wipe and some alcoholic hand sanitizing gel recommended by the Centers for Disease Control and Prevention can prevent a lot of cross-contamination.

Prevention in a Pump

Sanitizers Give the Upper Hand Against Colds - by Dr. Clifford Bassett

From kindergarten through middle and high school, many schools and classrooms now have an abundant supply of donated liquid hand sanitizers.

These antiseptic gels are quickly becoming an additional level of protection between students and ubiquitous viruses, which, especially during the wintertime cold and flu season, are present on a variety of common surfaces.

Even the kids seem to notice a difference.

"Since we starting using liquid hand sanitizer in our school, my classmates seem to be healthier, with fewer kids getting colds," said Dylan, a seventh grader at East Side Middle School in New York City.

And in many ways, these sanitizers offer a low-cost, low-tech solution to a common, potentially costly seasonal problem.

Hand sanitizers are gaining popularity, as they are portable, easy to use and perfect for places where there is no faucet and sink available for hand washing, such as in the subway or on a train.

Thus far, several studies over the past few years have suggested that hand sanitizers do limit the spread of germs. In a September 2005 study in the journal Pediatrics, researchers showed that families who used alcohol-based gels had a 59 percent lower rate of gastrointestinal illnesses -- which cause diarrhea and vomiting -- caused by germs spread from one family member to another.

Other research has focused more on the germs that cause common colds and the flu, tracking rates of school absenteeism among kids whose families use the products.

As for my New York City based allergy practice, I have personally observed that among my employees and co-workers who aggressively use gel-based alcohol sanitizers, there has been a change in successfully avoiding the vicious cycle of recurrent cold-like infections. The goal is to reduce transmission of a variety of viruses, including the common cold as well as gastrointestinal infections.

The Centers for Disease Control and Prevention have recommended alcohol-based liquid gels over using soap and water, as long as your hands are not very soiled.

Not All Hand Sanitizers Created Equal -
One caveat: It is important to check the bottle for the level of alcohol in a sanitizer.

It is generally thought that it should contain at least 60 percent alcohol -- even better if the concentration is greater than 90 percent. Apparently, less potent solutions are not very helpful in killing the viruses that cause many household infections.

Of course, plain old soap and water is just fine if it's available. But this is not always the case when it comes to our busy lives -- especially bearing in mind that we will be taking on those pesky germs at home, school and work.

Nowadays, many different approaches are used in the fight against germs. We have "foam based" disinfectants, antibacterial soaps, cleaning wipes and aerosolized disinfectants. In a more vigorous environment, especially in health care or medical settings, iodine-based and other chemical disinfectants are frequently utilized for more robust infection-busting capability.

So now for the final question: Can hand sanitizers save you completely from cold and flu? The answer, most likely, is no. But just like conscientious hand washing, avoiding sick co-workers and maintaining a healthy diet may certainly help keep you well this holiday season.

Dr. Clifford Bassett is vice chair of the Public Education Committee for the American Academy of Allergy, Asthma and Immunology. He is also an assistant clinical professor of medicine and otolaryngology at the Long Island College Hospital in Brooklyn, N.Y.