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Drug Resistant Bacteria and The Importance of Cleanliness-Part II of a III Part Article

(10/10/13)- The Centers for Disease Control and Prevention estimates that more than one million patients are infected by bacteria in health care facilities in this country and that more than 100,000 deaths a year occur as a result of these infections.

According to a 2010 study, a disciplinary program at the University of Kentucky Medical Center in Lexington included suspending doctorsí privileges if they failed to wash their hands before and after dealing with patients.

Some hospitals have turned to electronic sensors, thermal imaging and video cameras to monitor hand hygiene, and some are issuing badges that wirelessly record staffersí use of hand hygiene stations before entering a patientís room.

Many medical facilities are encouraging patients to ask the medical people taking care of them if they have washed their hands before attending to the patientís needs.

(12/10/09)- The findings of a study that surveyed the infection status of more than 13,000 patients from 1,200 non-cardiac intensive care units in 75 countries on a single day (May 8,2007) was published in the December 2nd issue of The Journal of the American Medical Association.

The study found that 51% of patients had infections, most commonly of the lung, while 71% were being treated with anti-microbial agents. One-fourth of those with infections died, compared with just over one-tenth of the infection free patients.

The longer a patient spent in intensive care, the greater the risk of an infection. Thirty-two percent of the patients who had been in the I.C.U for a day or less came down with an infection, while 70% of those who had been in the unit for more than a week came down with an infection.

(7/30/07)- The federal Centers for Disease Control and Prevention projected this year that one in every 22 patients would get an infection while hospitalized, and that about 99,000 would die from this infection. This translates to 1.7 million cases, costing billions of dollars from what began as a routine hospital procedure.

Methicilin-resistant Staphyloccoccus aureus (MRSA) has become resistant to antibiotics and are one of the biggest problem in most hospitals in this country. It first emerged in our hospitals in 1968 and it now accounts for 63% of hospital staphylococcus infections, up from 22% in 1995. It has now spread to places even outside the hospital environment.

The V.A. began to phase in a program to deal with this problem in its 140 acute-care centers in March. Every room and corridor is equipped with special hand sanitizer dispensers. Blood pressure cuffs are discarded after use and each room is assigned its own stethoscope to prevent the transfer of microorganisms.

Hand cleanliness programs are promoted to all staff and visitors.

At the V.A. hospital in Pittsburgh, officials say the number of infections with the MRSA bacteria infection have dropped to 17 cases last year from an average of 60 before the program started. The 40-bed surgical unit that began the experiment in 2001 has cut its infection rate by 78%.

Three state legislatures, including Pennsylvania, have passed bills that require hospitals to routinely test high-risk patients, like those in IC units. Eighteen states now require hospitals to publish their infection rates. Legislatures in New Jersey and Illinois approved bills that would make those states the first to require hospitals to screen all IC patients for MRSA.

(12/31/06)- As the costs continue to rise as a result of the treatment for bacteria resistant to antibiotics, hospitals are taking more aggressive steps to combat this problem, including the "search and destroy" approach borrowed from Europe.

The CDC estimates that staph infections and other powerful bacteria that thrive in hospitals kill almost 90,000 patients and result in $4.5 billion in excess costs to the medical establishment. A study published earlier this month in the American Journal of Medical Quality found hospitals lost $27,000 for each patient who gets a preventable infection there. This increased costs arises from the fact that insurers only pay by the diagnosis rather than per day, and payments drop off the longer the patient stays in the hospital.

Antibiotic drug-resistant bacteria now account for about two-thirds of infections associated with health care. Vancomycin is most often used to treat these infections, but some of the bacteria have now become resistant to this drug.

Betsy McCaughey, founder of the non-profit Committee to Reduce Infection Deaths, said that there are three steps that could be taken to dramatically reduce infection deaths in hospitals. The steps that should be taken are- meticulous hand washing between procedures, proper cleaning of equipment between usage, and identifying infected people before they enter the hospital.

"About 90% of patients treated in a hospital know well ahead of time they will be admitted, and can be tested in a doctor's office a week before," Ms. McCaughey said.

European hospitals have operated under a "search and destroy" system for many years now, and in countries like the Netherlands hospital acquired infections are rare.

(4/20/06)- The CDC issued hand-hygiene guidelines in 2002, and at that time it requested that hospitals track and monitor compliance with the guidelines. Compliance has been found to be woefully inadequate, with only 40%-50% of the guidelines being adhered to. The agency, in collaboration with the nonprofit Institute for Healthcare Improvement (IHI), a two leading infection control professional societies is launching a program to boost compliance using behavioral-modification techniques.

The IHI program recommends a serious activist approach that will hold hospital administrators and staffers responsible for non-compliance. John Boyce, an infectious-disease specialist who helped write the CDC guidelines has a free Web site, www.handhygiene.org that contains many of the items in the program.

The IHI guidelines points out such items as making sure employees knowing that they have to clean their hands after removing rubber gloves, because bacteria from the gloves can be transferred to the hands. Hospitals must insure that alcohol-rub dispensers are refilled and working at all times..

(3/6/06)- The CDC has called for a conference, scheduled for May 11 to be held at its auditorium in Atlanta to discuss 2 types of deadly bacterial infections. Fifteen to 20 scientists who have studied the bacteria will present their research findings at the meeting. Attendees who wish to attend must register by April 15.

One of the bacteria that will be discussed killed four California women who took the abortion pill Mifeprex or RU-486. The two bacteria are Clostridium sordellii and Clostridium difficile. Both of these bacteria thrive in environments with limited oxygen, and generally infect the human intestinal tracts.

Both of the bacteria produce a toxin that causes something similar to toxic shock syndrome. As a general rule the bacteria do not cause a high fever when the infection first sets in. Because of the abortion debate that is raging in this country right now, security will be extremely tight at the meeting.

One of the more puzzling aspects of the mystery is while all four lethal Clostridium sordellii infections occurred in California. The Clostridium difficile bacteria has been responsible for the widespread outbreak of diarrhea and colitis in hospitals and nursing homes across the nation.

(12/5/05)- The CDC has reported that the bacterium Clostridium difficile has grown resistant to certain antibiotics that work against other colon bacteria. The bacterium has been blamed for 100 deaths over an 18-month period at a hospital in Quebec.

What has become so worrisome is that the bacterium is appearing more often in healthy people who have not been admitted to hospitals or even taken antibiotics. "What exactly has made C-diff act up right now, we don't know," said Dr. L. Clifford McDonald, an epidemiologist at the CDC.

C. difficile is found in the colon and can cause diarrhea and a more serious intestinal condition, colitis. Spores in feces that are difficult to kill with conventional household cleaners spread it. Because the bacterium has grown more resistant to the usual antibiotics used against it, competing bacteria die off and C. difficile multiplies exponentially.

The CDC report centered on 33 cases reported since 2003. Twenty-three of those cases involved healthy individuals in the Philadelphia area who had not been admitted to a hospital in the last three months. The more were otherwise healthy pregnant women or women who had recently given birth and who had been in the hospital briefly. Those reports came from Oho, Pennsylvania, New Jersey and New Hampshire. One of the 33 patients died..

(11/11/05)- Doctors at Johns Hopkins University are using an antibiotic first developed in the 1960s as a weapon in the battle against drug resistant bacteria. The antibiotic called colistin is being used very sparingly because it can damage kidneys and nerves. According to John Bartlett, chief of the infectious-diseases division at the university's medical school colistin is being used only in "a case of desperation."

(11/06/05)-Abigail Zuger, M.D. in an article in the October 25 edition of the New York Times entitled, "Scare Yourself Silly, but the Real Terrors Are at Your Feet" wrote as follows:

"If you want something to be scared of, how about the drug-resistant Klebsiella that is all over this very hospital, an ordinary run-of the-mill bacterial strain that has become so resistant to so many antibiotics that we've had to resurrect a few we stopped using 30years ago because they were so toxic.
That Klebsiella is one scary germ, It's in hospitals all over the country, and by now it's probably killed a thousand fold more people than the avian flu.
But you don't hear much about our Klebsiella. Like our bad habits and our dismally insoluble health insurance tangles, our antibiotic-resistant bacteria are with us, right here, right now. Apparently they all lack the drama, the suspense, the titillating worst-case situations that energize our politicians and turn into a really newsworthy health scare."

Yes right now our politicians are all in a dither over the avian flu and doing nothing about the drug resistant bacteria that is killing hundreds of thousands of people yearly in this country. What will it take to make these same politicians to act on this life-threatening problem?

(10/1/05)- In a nationwide poll, conducted from August 19 to August 22 by Harris Interactive, 1,013 adults were interviewed about their hand washing habits. Observers were also sent into public restrooms in order to see what people actually did as far as hand washing goes in the bathroom. 6,336 adults were observed as to their hand washing routines in public bathrooms.

Of those interviewed 91% claimed that they washed their hands after using a public restroom. The observers found that only 81% of those who were observed actually did wash their hands after using the bathroom facilities.

That same study of actual behavior found that 90% of the women who were observed actually did wash their hands after using the bathroom facilities. Only 75% of the men who were observed actually did wash their hands after using the bathroom facilities.

The observations for the study were made at restrooms in 6 locations: Turner Field in Atlanta, the Museum of Science and Industry and the Shedd Aquarium in Chicago, Grand Central Terminal and Penn Station in New York, and the Ferry Terminal Farmers Market in San Francisco.

You will hear it said time and time again, but we must repeat it one more time: If you want to prevent the spread of germs, the best thing that you as an individual can do is wash your hands.

(8/1/05)- The Pennsylvania state agency created to study hospital-acquired infections recently released the data from its study of 173 hospitals across the state, and the results are alarming. So far five states have adapted laws to require regular reports of hospital-acquired infections and New York may have a law on the subject shortly.

In the state's study it was found that 11,668 hospital-acquired infections were associated with an additional 1,510 deaths, 205,000 extra hospital days and $2 billion in added hospital costs in 2004. Marc P. Volavka, executive director of the Pennsylvania Health Care Cost Containment Council stated that there were 7.5 hospital acquired infections per 1,000 admissions to the state's hospitals last year. The agency believes that the hospitals in the state are underreporting the number of infections acquired by their patients while in the hospitals.

(4/14/05)-Until recently, dangerous drug resistant staph infections were seen only in hospital or other health-care settings. The problem is now showing up with much greater frequency outside the hospital environment. The problem has shown up with greater frequency among prison inmates, children and athletes. At first researchers at the CDC thought that these outside infections might be just leaking out of hospitals rather than emerging from the general population, but this is no longer the case/

Researchers for the CDC found that in the Baltimore, the Atlanta and the Minnessota areas found that 17% of the drug-resistant staph infections were caught in the community, and did not have any apparent links to health care settings. The results of this study appeared in a recent edition of the New England Journal of Medicine.

The results of a second study that was also published in the NEJM showed that drug-resistant staph has acquired "flesh eating" capabilities even more so than before. There were 14 cases in the Los Angeles area of rare necrotizing fascitis, all of which required surgery and 10 were in intensive care. Strep bacteria usually cause the condition, and there has been only one other confirmed case caused by staph.

(11/22/04)-The results of the recently released Leapfrog Group (consists of a group of major U.S. employers) study showed that 4 out of 10 U.S. hospitals lack policies requiring workers to disinfect hands before and after seeing a patient. For more on this please see our article Medical Errors; a Growing Problem.

(11/14/04) Starting in January 2005 hospitals will be required to meet strict new infection-control standards imposed by the Joint Commission on Accreditation of Healthcare Organization (JCAHO), the nonprofit organization that accredits most hospitals. Four states have already passed bills requiring hospitals to report infection rates, and more than a dozen states are considering such legislation. The CDC is joining JCAHO and infection control groups in a campaign to urge consumers to take a more active role in checking and watching for infection control programs and practices in hospitals. Consumers can check on hand hygiene guidelines at www.cdc.gov/handhygiene .

The CDC issued updated hand hygiene guidelines two years ago, including a new recommendation that hospitals use alcohol rubs for routine decontamination, yet compliance remains "far below" the 80% necessary to significantly reduce infections, according to a report from ECRI, a nonprofit research group. Hand hygiene is often the worst in the areas where it is needed the most i.e. the ICU area of the hospital, surgery, anesthesia and the emergency room.

Even when workers do wash their hands they may skip necessary steps such as wetting hands before using soap and turning off the faucet with a towel, or failing to rub their hands together long enough for alcohol rubs to dry and disinfect thoroughly. In the past hospital infections could be dealt with through antibiotics, but nowadays we have to contend with bugs such as Staphylococcus aureus which are resistant to most commonly used drugs.

Sadly I can say to you that I have seen instances in a major New York city hospital, where those entering the Intensive Care Unit are not checked to make sure that they have washed their hands properly before entering the unit. In one case that I am personally aware of a young male 27 1/2 year old patient developed a drug resistant infection while in the ICU unit, and passed away several days later, since he developed a drug resistant infection while there.

In April 2000 we wrote about the role of bacterial disease in hospital infections, and the importance of cleaning hands. Reminding people to wash their hands after leaving the bathroom is a major issue. A possible solution may come in patent #6,147,607, issued to John Lynn of Austin Texas. He has designed a hollow rubber bulb, covered with absorbent materials, which attaches to a flush handle on a toilet or urinal, or even on a door. This bulb is filled with a nontoxic substance that oozes out onto the hand when using the flush or door handle. Soap and water are needed to remove the resulting stain. In a hospital or medical center, the substance could be altered to require a more potent cleaning with alcohol or antibacterial soap. The stain on the hand would be a signal to wash hands.

Mr. Lyons is quoted as stating that when a phosphorus substance is used, it would not be visible to the naked eye. "Invisible markings which become easily identifiable when exposed to certain mediums such as UV light would be especially useful in circumstances where an organization wanted to monitor its employees but not its customers." This would seem useful in restaurants, where an employee has a statutory requirement to wash hands, before leaving the bathroom. The next step would seem to be for Mr. Lynn to test his product, showing that people will wash the stain off their hands.

Many of the readers of our web site are probably acutely aware of the increase in resistance of many bacterial pathogens to antibiotics. Many fear that we are seeing the end of the antibiotic era. This is hardly the case, despite the existence of some drug resistant bacteria and quite a number of deaths from bacterial infections. Alternative antibacterial strategies will be developed, particularly as result of progress made in the mapping of the human genome. The genome sequencing will give the researchers an avenue to identify molecular targets involving bacterial growth, survival and pathogenesis, enabling them to develop designer medications specifically focused on the idiosyncratic nature of the bacterial infection. This would prove to be the ultimate weapon against disease. At present, one can only speculate as to where knowledge of the mapping of the human genome may lead to in the medical field.

It should be noted that infectious diseases are rare, due to the natural defenses of the body. This is so despite the fact that we are constantly in contact with a large number of microorganisms, which are quite dangerous. The number one way to combat these potential pathogens is cleanliness i.e. washing of hands.

Except in cases of bites, which penetrate the skin, most bacteria first come in contact with the skin or mucosal membrane in the mouth where they attempt to establish a colony. Washing of hands and keeping fingers out of the mouth is the first line of defense, but not the only defense the body possesses.

The skin has an "army" of defenses including microflora, lysozyme and bacterial peptides, lactoferrin and secretory immunoglobulin A which prevent the bacteria from gaining a foothold on the skin or mucosal membrane.

When certain microorganisms breach this first line of defense and reach the underlying tissue or blood, a new line of defense is mobilized, which can be roughly divided into two categories, one non-specific and the other specifically targeted to the invading bacteria. This one-two punch usually destroys any invading bacteria. The attack on the invading bacteria involves the production of inflammation, the major function of which is to stop the spread of the infection. This in turn buys time for the body to develop a specific line of antibodies, microphages and cytotoxic T cells (the immunological system) which deactivate the pathogen. It is when this final line of defense is breached that systematic infections occur leading to bacteremia and/or colonization of internal organs, and, ultimately to life threatening conditions.

Any process that can enhance the lines of defense, of course, will prevent internal colonization. This is the function of the antibiotic medications developed. A different class of antibacterial medications is coming on line to provide another effective component in the war against infection. However, it is still the natural defenses that provide the most effective weapon we have available to stop these invasions. Again, cleanliness is the major fighter in this war. This means that we need to make sure that personnel treating/examining any person washes their hands. This may reduce the incidence of iatrogenic infections in hospital settings, a not so insignificant problem in our society. The same is true of food handlers as well as washing hands before eating or after use of bathroom facilities. These steps are especially important for the elderly whose immunological system may be weakened as result of the natural stresses and strains placed upon it during a lifetime. Cleanliness is a low technological step that is a highly effective direct intervention method at a minimal cost, the ultimate goal of any treatment program.

See also Drug Resistant Bacteria-Part I
Drug Resistant Bacteria- Part III- A Continuation of Part I

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE " How to Select a Nursing Home"

Allan Rubin and Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated October 10, 2013
 http://www.therubins.com

To e-mail: hrubin12@nyc.rr.com or allanrubin4@gmail.com

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