text:
Patients Become Partners

There's more than one way to skin a cat. Just ask Maryanne McGuckin, Dr.ScEd., who designed and implemented a creative program that resulted in a 34 percent increase in handwashing activity, based on calculated soap-usage, among a study-group of healthcare workers in New Jersey. Instead of enlisting the cooperation of the workers directly (as is typically the case when handwashing-compliance programs are re-emphasized in hospital settings), McGuckin and her research team went directly to the patients.

"Once we educated patients about the importance of handwashing, they became eager participants in our study," explained McGuckin, senior research investigator at the University of Pennsylvania Medical Center. After learning that handwashing is the single most important procedure that can be performed to prevent the spread of hospital-acquired (or nosocomial) infection, newly-admitted patients to the West Jersey Health System were invited to participate in the research effort.

Some 441 patients agreed to become "Partners in Your Care" for the duration of their hospitalization. As part of the six-week protocol, patients agreed to ask every healthcare worker who entered their room, "Did you wash your hands?" (For patients too shy or uncomfortable with such a direct approach, playful blue weebles -- with an attached "Did you wash your hands?" banner -- were attached to their hospital gowns.)

After conducting follow-up phone interviews (with 276 of the original 441 patients) and calculating handwashing rates (based on soap-usage per bed day and handwashings per bed day), the researchers concluded that soap usage by healthcare professionals increased 34% at all four participating hospitals. To translate, handwashing activity increased from 2 to 12 handwashings per 24-hour shift.

"Our findings document, for the first time, that the education of patients about their role in promoting handwashing compliance among healthcare workers can increase that compliance, as well as provide continuous reinforcement of handwashing principles to healthcare workers," said McGuckin.

The study results were presented by Dr. McGuckin at the seventh annual meeting of The Society for Healthcare Epidemiology of America, which was held in St. Louis, Missouri.

"This isn't rocket science," admits McGuckin, of her study, "but it's going to have a real impact." McGuckin and her team believe that patient-based educational programs such as the one designed by them can be quite effective in increasing handwashing compliance among healthcare workers - which, in turn, can reduce the risk of hospital-acquired infections in patients. "It's a win-win proposition," she adds, "because the patient's risk of acquiring a nosocomial infection is reduced and, over time, could impact on the hospital's infection rates."

For more information:

Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach

Didier Pittet, University of Geneva Hospitals, Geneva, Switzerland. © 2001 Centers for Disease Control and Prevention (CDC)

Abstract and Introduction

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol-based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

Hand hygiene is the simplest, most effective measure for preventing nosocomial infections [1,2]. Despite advances in infection control and hospital epidemiology, Semmelweis' message is not consistently translated into clinical practice [3,4], and health-care workers' adherence to recommended hand hygiene practices is unacceptably low [3,5-10]. Average compliance with hand hygiene recommendations varies between hospital wards, among professional categories of health-care workers, and according to working conditions, as well as according to the definitions used in different studies. Compliance is usually estimated as <50%.

Promotion of hand hygiene is a major challenge for infection control experts [3,19-21]. In-service education, distribution of information leaflets, workshops and lectures, and performance feedback on compliance rates have been associated with transient improvement [3,6,13,22,23]. No single intervention has consistently improved compliance with hand hygiene practices[24]. This review summarizes factors influencing lack of adherence by health-care personnel to hand hygiene procedures and suggests strategies for improvement.

Two major groups of microorganisms are found on the skin: organisms that normally reside on it (resident flora) and contaminants (transient flora) [25]. Unless introduced into body tissues by trauma or medical devices such as intravenous catheters, the pathogenic potential of the resident flora is low [26]. Transient flora, which are easily removed by handwashing, cause most hospital infections resulting from cross-transmission [27-29].

The term hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved through handwashing or hand disinfection. Handwashing refers to washing hands with an unmedicated detergent and water or water alone. Its objective is to prevent cross-transmission by removing dirt and loose transient flora [10,30].

Hygienic handwash refers to the same procedure when an antiseptic agent is added to the detergent. Hand disinfection refers to use of an antiseptic solution to clean hands, either medicated soap or alcohol. Some experts refer to the action of "degerming" as the use of detergent-based antiseptics or alcohol [21]. Hygienic hand rub is rubbing hands with a small quantity (2 mL to 3 mL) of a highly effective, fast-acting antiseptic agent.

Hand Hygiene Agents

If hands are known to be or suspected of being contaminated, transient flora must be eliminated by washing or disinfecting the hands to render them safe for the next patient contact. Plain soap with water can physically remove a certain level of microbes, but antiseptic agents are necessary to kill microorganisms [10,31-33]. Hand antiseptic agents are designed to rapidly eliminate most transient flora by their mechanical detergent effect and to exert an additional sustained antimicrobial activity on remaining flora. The multiplication of resident flora may be retarded as well, so that hand disinfection may be useful in situations in which microbiologically clean hands are required for extended periods.

Rotter showed that hand hygiene with unmedicated soap and water removed some transient flora mechanically; preparations containing antiseptic or antimicrobial agents not only removed flora mechanically but also chemically killed contaminating and colonizing flora, with long-term residual activity [30,34]. Alcohol-based preparations have more rapid action than products containing other antiseptics (e.g., chlorhexidine gluconate or providone iodine) [30,31,35].

Semmelweis observed that normal handwashing did not always prevent the spread of fatal infection [1] and recommended hand disinfection in a solution of chlorinated water before each vaginal examination. Hand disinfection is substantially more efficient than standard handwashing with soap and water or water alone [2,30], particularly when contamination is heavy[14,36-40]. Frequent handwashing may result in minimal reduction or even an increase in bacterial yield over baseline counts of clean hands [21,41].

Because alcohols have excellent activity and the most rapid bactericidal action of all antiseptics, they are the preferred agents for hygienic hand rubs, so-called "waterless hand disinfection." In addition, alcohols are more convenient than aqueous solutions for hygienic hand rubs because of their excellent spreading quality and rapid evaporation. At equal concentrations, n-propanol is the most effective alcohol and ethanol the least [30].

Alcohol-based hand rubs are well suited for hygienic hand disinfection for the following reasons: optimal antimicrobial spectrum (active against all bacteria and most clinically important viruses, yeasts, and fungi); no wash basin necessary for use and easy availability at bedside; no microbial contamination of health-care workers' clothing; and rapidity of action. After extensive reduction following hand disinfection with an alcohol preparation, it takes the resident skin flora several hours to become completely restored[30]. Since alcohol alone has no lasting effect, another compound with antiseptic activity may be added to the disinfection solution to prolong the effect. These antiseptics have recently been extensively reviewed by Rotter [30].

Prevention of bacterial contamination and subsequent infection requires timely hand cleansing. Guidelines have delineated indications for hand cleansing [10,32,42] but without reliance on evidence-based studies of microbiologic contamination acquired during routine patient care. To provide such evidence, we studied the dynamics of bacterial contamination of health-care workers' hands in daily hospital practice [43]. Our findings should help identify patient-care situations associated with high contamination levels and improve hand cleansing practices.

Structured observations of patient care were conducted by trained external observers, who took an imprint of the fingertips of the health-care worker's dominant hand to quantify bacterial colony counts at the end of a defined period of patient care[43]. Bacterial contamination on ungloved hands increased linearly during patient care (mean 16 CFU per minute, 95% confidence interval [CI][11-21]. Activities independently associated with higher contamination levels were direct patient contact, respiratory care, handling body fluids, and disruption in the sequence of patient care (all p <0.05).

Contamination levels varied according to hospital location, with the medical rehabilitation ward having the highest levels (>49 CFU, p = 0.03). Both the duration and type of patient care influenced hand contamination. Furthermore, simple handwashing before patient care, without hand disinfection, was also associated with higher colony counts (>52 CFU, p = 0.03), which suggests that hand antisepsis is better than standard handwashing. These findings suggested that intervention trials should explore the role of systematic hand disinfection as a cornerstone of infection control to reduce cross-transmission in hospitals.

Factors Influencing Noncompliance with Hand Hygiene

Risk factors for noncompliance with hand hygiene have been determined objectively in several observational studies or interventions to improve compliance [3,14,20,24,44-47]. Factors influencing reduced compliance, identified in observational studies of hand hygiene behavior, included being a physician or a nursing assistant rather than a nurse; being a nursing assistant rather than a nurse; being male; working in an intensive care unit (ICU); working during weekdays rather than the weekend; wearing gown and gloves; using an automated sink; performing activities with high risk for cross-transmission; and having many opportunities for hand hygiene per hour of patient care.

In the largest hospital-wide survey ever conducted[9], we also identified predictors of noncompliance with hand hygiene during routine patient care. Variables included professional category, hospital ward, time of day or week, and type and intensity of patient care, defined as the number of opportunities for hand hygiene per hour of patient care.

In 2,834 observed opportunities for hand hygiene, average compliance was 48%. In multivariate analysis, compliance was highest during weekends and among nurses (odds ratio [OR] 0.6, 95% CI 0.4-0.8). Noncompliance was higher in ICUs than in internal medicine (OR 2.0, CI 1.3-3.1), during procedures with a high risk for bacterial contamination (OR 1.8, CI 1.4-2.4), and when intensity of patient care was high (21 to 40 opportunities [OR 1.3, CI 1.0-1.7], 41 to 60 opportunities [OR 2.1, CI 1.5-2.9], >60 opportunities [OR 2.1, CI9 1.3-3.5]) compared with a reference level of 0 to 20 opportunities.

In other words, compliance with handwashing worsened when the demand for hand cleansing was high; on average, compliance decreased by 5% (±2%) per increment of 10 opportunities per hour when the intensity of patient care exceeded 10 opportunities per hour. Similarly, the lowest compliance rate (36%) was found in ICUs, where indications for handwashing were typically more frequent (on average, 20 opportunities per patient per hour).

The highest compliance rate (59%) was observed in pediatrics, where the average activity index was low (on average, eight opportunities per patient per hour). This study confirmed modest levels of compliance with hand hygiene in a teaching institution and showed that compliance varied by hospital ward and type of health-care worker, thus suggesting that targeted educational programs may be useful. These results also suggested that full compliance with current guidelines may be unrealistic[9,20,48] and that facilitated access to hand hygiene could help improve compliance.

Perceived Barriers to Hand Hygiene

Several barriers to appropriate hand hygiene have been reported [9,14,24,44-47]. Reasons reported by health-care workers for the lack of adherence with recommendations include skin irritation, inaccessible supplies, interference with worker-patient relation, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload and understaffing, and lack of scientific information demonstrating impact of improved hand hygiene on hospital infection rates.

Risk Factors for Noncompliance

Some of the perceived barriers for the lack of adherence with hand hygiene guidelines have been assessed or even quantified in observational studies [3,14,20,24,44-47]. The most frequently reported reasons associated with poor compliance, in addition to those mentioned above, are inconveniently located or insufficient numbers of sinks; low risk for acquiring infection from patients; belief that glove use obviates need for hand hygiene; and ignorance of or disagreement with guidelines and protocols.

Skin irritation by hand hygiene agents is an important barrier to appropriate compliance [49]. The superficial skin layers contain water to keep the skin soft and pliable and lipids to prevent dehydration of the corneocytes. Hand cleansing can increase skin pH, reduce lipid content, increase transepidermal water loss, and even increase microbial shedding. Soaps and detergents are damaging when applied to skin on a regular basis, and health-care workers need to be better informed about their effects. Lack of knowledge and education on this topic is a key barrier to motivation. Alcohol-based formulations for hand disinfection (whether isopropyl, ethyl, or n-propanol, in 60% to 90% vol/vol) are less irritating than antiseptic or nonantiseptic detergents. Alcohols with added emollients are at least as well tolerated and efficacious as detergents. Emollients are recommended and may protect against cross-infection by keeping the resident skin flora intact, and hand lotions help protect skin and may reduce microbial shedding [21].

The value of easy access to hand hygiene supplies, whether sink, soap, medicated detergent, or waterless alcohol-based hand rub solution, is self explanatory. Asking busy health-care workers to walk away from the patient bed to reach a wash basin or a hand antisepsis solution invites noncompliance with hand hygiene recommendations [9,48]. Engineering controls could facilitate compliance, but hand hygiene behavior should be carefully monitored to identify negative effects of newly introduced devices [50].

Wearing gloves might represent a barrier for compliance with hand hygiene [8,51,52]. Failure to remove gloves after patient contact or between dirty and clean body site care for the same patient constitutes noncompliance with hand hygiene recommendations[9]. Washing and reusing gloves between patient contact is ineffective, and handwashing or disinfection should be strongly encouraged after glove removal. In a study involving artificial contamination, organisms were cultured from 4% to 100% of the gloves and observed counts were up to 4.7 log on hands after glove removal [53].

Additional barriers to hand hygiene compliance include lack of active participation in promotion at the individual or institutional level, of a role model for hand hygiene, of institutional priority assigned to hand hygiene, of administrative sanctions for noncompliance; and of an institutional climate encouraging safety [14,22,41,54,55]. A system change may be necessary for improvement in hand hygiene practices by health-care workers.

Impact of Improved Hand Hygiene

Lack of scientific information on the definitive impact of improved hand hygiene on hospital infection rates has been reported as a possible barrier to adherence with recommendations. Hospital infections have been recognized for more than a century as a critical problem affecting the quality of patient care provided in hospitals. Studies have shown that at least one third of all hospital infections are preventable [56]. A substantial proportion of infections results from cross-contamination, and transmission of microorganisms by the hands of health-care workers is recognized as the main route of spread [57]. Seven quasi-experimental hospital-based studies of the impact of hand hygiene on the risk of hospital infections were published from 1977 to 1995 (Table 2) [7,22,58,60-63]. Despite limitations, most reports showed a temporal relation between improved hand hygiene practices and reduced infection rates.

We recently reported the results of a successful hospital-wide hand hygiene promotion campaign, with emphasis on hand disinfection, which resulted in sustained improvement in compliance associated with a significant reduction in hospital infections and methicilllin-resistant Staphylococcus aureus cross-transmission rates over a 4-year period [63]. The beneficial effects of hand hygiene promotion on the risk of cross-transmission have also been reported in surveys conducted in schools, day-care centers [64-68], and a community [69-71]. Although additional scientific and causal evidence is needed for the impact of improved hand hygiene on infection rates, these results indicate that improvement in behavior reduces the risk of transmission of infectious pathogens.

Improving Adherence with Practices

In 1998, Kretzer and Larson [46] revisited hand hygiene behavioral theories in an attempt to better understand how to target more successful interventions. These researchers proposed a hypothetical framework to enhance hand hygiene practices and stressed the importance of considering the complexity of individual and institutional factors in designing behavioral interventions. Behavioral theories and secondary interventions have primarily focused on the individual, which is insufficient to effect sustained change [46,72,73]. Interventions aimed at improving compliance with hand hygiene must be based on the various levels of behavior interaction [20,46,74]. Thus, the interdependence of individual factors, environmental constraints, and institutional climate should be considered in strategic planning and development of hand hygiene promotion campaigns.

Factors associated with noncompliance with recommendations are related not only to the individual worker but also to the group to which he or she belongs and, by extension, to the parent institution. Factors influencing compliance at the group level include lack of education and performance feedback; working in critical care (high workload); downsizing and understaffing; and lack of encouragement or role models from key staff. Factors operating at the institutional level include lack of written guidelines; lack of appropriate hand hygiene agents; lack of skin care promotion and agents; lack of hand hygiene facilities; lack of atmosphere of compliance; and lack of administrative leadership, sanctions, rewards, and support. Interventions to promote hand hygiene in hospitals should take into account variables at all these levels.

The complex dynamic of behavioral change involves a combination of education, motivation, and system change. Various psychosocial parameters influencing hand hygiene behavior include intention, attitude toward the behavior, perceived social norms, perceived behavioral control, perceived risk of infection, habits of hand hygiene practices, perceived model roles, perceived knowledge, and motivation [46]. Factors necessary for change include dissatisfaction with the current situation, perception of alternatives, and recognition, both at the individual and institutional level, of the ability and potential to change. While the latter implies education and motivation, the former two necessitate primarily a system change.

Among reasons reported for poor adherence with hand hygiene recommendations, some that are clearly related to the institution (i.e., the system) include lack of institutional priority for hand hygiene, need for administrative sanctions for noncompliance or rewards for compliance, and lack of an institutional climate that encourages safety. Whereas all three reasons would require a system change in most institutions, the last would also involve management commitment, visible safety programs, an acceptable level of work stress, a tolerant and supportive attitude toward reported problems, and belief in the efficacy of preventive strategies [20,46,73,75].

Strategies for Improvement

Improvement in infection control practices requires questioning basic beliefs, continuous assessment of the stage of behavioral change, interventions with an appropriate process of change, and supporting individual and group creativity [46]. Because of the complexity of the process of change, single interventions often fail, and a multimodal, multidisciplinary strategy is necessary.

A framework for change should include parameters to be considered for hand hygiene promotion, together with the level at which each change must be applied: education, motivation, or system. Some parameters are based on epidemiologic evidence and others on the authors' and other investigators' experience and review of current knowledge. Some parameters may be unnecessary in certain circumstances and helpful in others. In particular, changing the hand hygiene agent could be beneficial in institutions or hospital wards with a high workload and a high demand for hand hygiene when waterless hand rub is not available [9,61,62,76]. However, a change in the recommended hand hygiene agent could be deleterious if introduced during winter, when skin is more easily irritated.

Several parameters that could potentially be associated with successful promotion of hand hygiene would require a system change. Enhancing individual and institutional self-efficacy (the judgment of one's capacity to organize and execute actions to reach the objective), obtaining active participation at both levels, and promoting an institutional safety climate represent major challenges that exceed the current perception of the infection control practitioner's role.

More research is needed to determine whether education, individual reinforcement technique, appropriate rewarding, administrative sanction, enhanced self-participation, active involvement of a larger number of organizational leaders, enhanced perception of health threat, self-efficacy, and perceived social pressure [20,46,83,84], or combinations of these factors would improve health-care workers' adherence to recommendations. Ultimately, compliance with hand hygiene could become part of a culture of patient safety in which a set of interdependent elements interact to achieve a shared objective [85].

More readily achievable than major system change, easy and timely access to hand hygiene in a timely fashion and the availability, free of charge, of skin care lotion both appear to be necessary prerequisites for appropriate hand hygiene behavior. In particular, in high-demand situations, such as in critical care units, in high-stress working conditions, and at times of overcrowding or understaffing, having health-care workers use a hand rub with an alcohol-based solution appears as the best method for achieving and maintaining a higher level of compliance with hand hygiene. Alcohol-based hand rub, compared with traditional handwashing with unmedicated soap and water or medicated hand antiseptic agents, may be better because it requires less time [48], acts faster [30], and irritates hands less often [21,30]. This method was used in the only program that reported a sustained improvement in hand hygiene compliance associated with decreased infection rates[63].

Finally, strategies to improve compliance with hand hygiene practices should be multimodal and multidisciplinary (Table 3). It is important to note, however, that the proposed framework for such strategies needs further research before implementation.

Future Research

Among key questions regarding the practices of hand hygiene in the health-care setting today, the following need to be addressed in controlled studies: What are the key determinants of hand hygiene behavior and promotion? Should hand disinfection replace conventional handwashing? What are the best hand hygiene agents? Should hand hygiene solution include a long-lasting compound? What are the most suitable skin emollients to include in hand hygiene solution? How can skin irritation and dryness from hand hygiene agents be reduced? How does skin care protection with hand cream affect the microbiologic efficacy of hand hygiene agents? and What are the key components of hand hygiene agent acceptability by health-care workers?

Additional research questions include - How can researchers generate more definitive scientific evidence for the impact of improved compliance with hand hygiene on infection rates? What is the acceptable level of compliance with hand hygiene (i.e., What percentage increase in hand hygiene results in a predictable risk reduction in infection rates?) and To what extent should the use of gloves be encouraged or discouraged? Finally, recognizing that individual and institutional factors are interdependent in terms of behavioral changes in health-care settings, what is the best way to obtain top management support for hand hygiene promotion? These questions are addressed to infection control practitioners, laboratory research scientists, and behavioral epidemiologists.

The challenge of hand hygiene promotion could be summarized in one question: How can health-care workers' behavior be changed? Tools for change are known; some have been tested, and others need to be tested. Some may prove irrelevant in the future; others have worked in some institutions and need to be tested in others. Infection control professionals should promote and conduct outstanding research and provide solutions to improve health-care worker adherence with hand hygiene and enhance patient safety.

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Early E, Battle K, Cantwell E, English J, Lavin JE, Larson E. Effect of several interventions on the frequency of handwashing among elementary public school children. Am J Infect Control 1998;26:263-9.
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Master D, Hess Longe SH, Dickson H. Scheduled hand washing in an elementary school population. Fam Med 1997;29:336-9.
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Shahid NS, Greenough WB, Samadi AR, Huq MI, Rahman N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res 1996;14:85-9.
Stanton BF, Clemens JD. An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. Am J Epidemiol 1987;125:292-301.
Teare EL, Cookson B, French G, Gould D, Jenner E, McCulloch J, et al. Hand washing--A modest measure-with big effects. BMJ 1999;318:686.
Teare EL, Cookson B, French GL, Jenner EA, Scott G, Pallett A, et al. U.K. handwashing initiative. J Hosp Infect 1999;43:1-3.
Larson EL, Bryan JL, Adler LM, Blane CB. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997;25:3-10.
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Raad I, Darouiche RO, Dupuis J, Abi-Said D, Gabrielli A, Hachem R, et al. Central venous catheter coated with minocycline and rifampine for the prevention of catheter-related colonization and bloodstream infections. A randomized, double-blind trial. Ann Intern Med 1997;127:267-74.
McGuckin M, Waterman R, Porten L, Bello S, Caruso M, Juzaitis B, et al. Patient education model for increasing handwashing compliance. Am J Infect Control 1999;27:309-14.
Veenstra DL, Saint S, Saha S, Lumley L, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection. A meta-analysis. JAMA 1999;281:261-7.
Harbarth S, Sudre P, Dharan S, Cadenas M, Pittet D. Outbreak of Enterobacter cloacae related to understaffing, overcrowding and poor hygiene practices. Infect Control Hosp Epidemiol 1999;20:598-603.
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The author thanks members of the Infection Control Program at the University of Geneva Hospitals, who have been involved in research and institutional projects related to hand hygiene compliance and promotion since 1993, and Rosemary Sudan for editorial assistance.

Dr. Pittet is Professor of Medicine and Director, Infection Control Program, the University of Geneva Hospitals, Switzerland. He is a member of the Board of Directors of the Society for Healthcare Epidemiology of America, and recipient of the first Ignaz P. Semmelweis award (1999), the Hygiene-Preis des Rudolf Schülke Stiftung, 1999, and the Pfizer Award for Clinical Research 2001.

Address for correspondence: Didier Pittet, Infection Control Program, Department of Internal Medicine, University of Geneva Hospitals, 24, Rue Micheli-du-Crest, 1211 Geneva 14, Switzerland; fax: 41-22-372-3987; e-mail:

Winning the War Against Catheter-Related Infections

Waging war against nosocomial catheter-related infections in the ICU may seem a daunting task. However, the care team of the Weinberg ICU, The Johns Hopkins Hospital, Baltimore, tackles the battle against catheter-related infections with a successful strategy of empowerment, consistency, and education. With the entire staff working as a unit, the fight has gained significant ground. Since June 2003, the care team has had only two catheter-related infections, the fewest for any ICU in The Johns Hopkins Hospital.

“We have clearly raised the bar,” says Donna Prow, RN, BSN, nurse manager of the Weinberg ICU. “As of January 2006, all patient care units have adopted the checklist the Weinberg ICU instituted; it is now a hospital-wide protocol for central line insertion and management. And other hospitals across the U.S. have also adopted the guidelines The Johns Hopkins Hospital pioneered.”

Having proper equipment available is key in the prevention of catheter-related infections, according to Prow. The Weinberg ICU staff maintains a complete and mobile catheter insertion cart within the unit. The cart is restocked every four hours with everything needed to insert any type of arterial or central-venous line, including single, double, and triple-lumen catheters; dialysis catheters; Swan-Ganz lines; and sterile draping and gowning equipment. The accessibility of the catheter-insertion cart helps the staff maintain strict sterile technique.

“Everything needed is right at hand, so you do not have to interrupt the setting up of sterile fields to leave the room and get additional supplies,” says Prow. Anyone present during insertion and replacement procedures is outfitted in full barrier protection, including sterile gowns and caps. Direct, hands-on care requires wearing sterile gloves as well; others don
non-sterile gloves unless asked to directly assist in the procedure.

To reduce the risk of introducing bacteria into the field, complete sterile draping of the patient is also important. “The patient is always covered with a sterile sheet from head to toe,” says Prow.

Ensuring staff have proper protection and equipment is only a part of the strategy in the campaign against catheter-related infections. Prow also credits the success to the nurses’ consistent use of a simple procedural checklist. The checklist includes reminders to wash hands, correctly position the patient, sterilize the procedure site, properly drape the patient and maintain a sterile field, and use a sterile site dressing. Most important, there is a place to document the corrections taken when sterile technique is breached.

Initially nurses were skeptical about the effectiveness of implementing the checklist. They knew that enforcing a code of strict sterile technique without the full support and cooperation of the attending physicians would be difficult; however, the physicians were willing and have empowered nurses to carry out the standards on the checklist.

“The nurses have the authority to say, ‘Stop! Sterile technique has been broken, and we are going to start over again,’“ explains Prow.

In addition to supportive physicians, the unit boasts the advantages of a consistent RN staffing pattern and the skills of five acute-care NPs as well. The NPs perform about one third of the central-line insertion procedures, and Prow views them as an additional boon in the defense against catheter-related infections.

Maintaining consistency also means that new recruits to the unit quickly learn the catheter-insertion drill. Resident physicians, who insert catheters under the supervision of the fellow physician, arrive monthly. On their first day on the unit, an NP or nurse manager ensures their basic training and orients them to the cart, the checklist, and the procedures.

Another way to reduce catheter-related infections is the quick replacement of catheters inserted during an emergency. With these catheters, such as those inserted in the field or the ED, sterile technique may have been compromised because of the patient’s emergent condition. Education plays a major role in minimizing resistance from patients who may dread facing another major invasive procedure.

“Patients are generally willing to consent to have catheters reinserted once they understand the reasons,” says Prow. Physicians have also been very willing to reinsert these catheters.

Other important procedures include the timing and technique of tubing changes. Per protocol, tubing is changed every 96 hours and is never changed near the insertion site. Adapters keep any opening of the closed sterile system as far away from the insertion site as possible. Insertion site dressing changes are also performed as sterile procedures with the use of both sterile fields and sterile gloves.

Even prior to insertion of a catheter, careful thought is given to the possible risk of future infection. “Important decision-making happens at the time of catheter insertion,“ says Prow. “The best option is always to use a single-lumen catheter if there clearly is not a need for a multi-lumen catheter. When you add another lumen, you add another potential port of entry for bacteria.”

In addition, patients are not discharged from the ICU with central lines in place unless absolutely necessary. If continuation of a central line is deemed essential to a patient’s care, the line is not capped or locked but retains a dedicated IV fluid line.

Waging war against catheter-related infections may seem like an uphill battle; however, Prow attributes much of the success of their program to the commitment of a consistent and empowered staff who work diligently to carry out proper procedures from start to finish.

Catherine Spader, RN, is a freelance writer for Nursing Spectrum.

Safer Surgery - Standardized Practice Improves Patient Outcomes

Two North Carolina hospitals are continuing to make strides in their quality-of-care initiatives to standardize practice to prevent surgical site infections (SSIs) and improve surgical care safety.

Moses Cone Health System in Greensboro, N.C., and CaroMont Health in Gastonia, N.C., are focusing on evidence-based practices outlined by the Institute for Healthcare Improvement (IHI) to get a better handle on normothermia, antibiotic administration, glucose control, hair removal, and more, which target areas where the incidence and cost of complications of SSIs are high. This focus comes as the pressure mounts for hospitals to reveal their rates of hospital-acquired infections and other preventable errors.

In 2003, the Centers for Medicare & Medicaid Services and the CDC initiated the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications.

SCIP was initiated because of the high toll SSIs take on patients and finances. SSIs account for 14% to 16% of all hospital-acquired infections and are among the most common complications of care. SSIs occur in 2% to 5% of patients after clean extra-abdominal operations and in about 20% of patients who undergo intra-abdominal procedures. Hospitals that participate in SCIP could see savings of about $3,152 per patient and a reduction in length of stay by seven days for patients who develop SSIs, according to the Sept. 14, 2004, article “Making Surgery Safer Project Overview.”

After implementing components of the collaborative to reduce SSIs – part of the IHI’s 100k Lives Campaign - Moses Cone Health System reduced its SSI rates.

The cornerstone of the collaborative is to infuse the appropriate preventative antibiotic within 60 minutes prior to incision. When nurse anesthetists began running antibiotics while preparing patients for the OR, it improved Moses Cone’s compliance within a one-hour time frame from 50% to more than 80%, according to Marion Martin, RN, MSN, MBA, patient safety officer at Moses Cone Health System.

Moses Cone staff has also implemented maintenance of normothermia preoperatively, intraoperatively, and postoperatively as well as skin prep with an electric clipper instead of a razor.

“Doing away with razors, thought to be the hardest to accomplish, has turned out to be the simplest. Over 95% of patients receive appropriate hair removal,” Martin says. “Removing the razors from unit supply carts made all the difference.”

Maintaining patient normothermia intraoperatively proved to be one of the biggest challenges. Pre and post-operative normothermia was maintained at well over 80%. Intraoperatively, the rates fell to less than 50%, despite use of warmed blankets and fluids. “Implementation of the Bair Hugger system eliminated the intraop temperature drops,” Martin says.

The goal of the initiative was to double the number of days between infections or double the number of cases between SSIs. While seeing a drop in reported surgical site infections, Moses Cone Health System, like all other hospitals, continues to strive to improve on its methods to collect SSI cases, Martin says.

CaroMont Health is reporting success with SCIP – a program with a goal to reduce surgical complications by 25% by 2010.

For its patients undergoing coronary artery bypass graft, the hospital is almost 100% compliant in administering on-time antibiotics, selecting appropriate prophylactic antibiotics, and discontinuing antibiotics within 24 hours after surgery. The staff has initiated standardized programs for SSIs and other medical issues. They have achieved near 100% compliance for glucose control in cardiac patients and patients with diabetes undergoing noncardiac surgery; proper hair removal; temperature control in patients; perioperative beta blockers for adverse cardiac events; DVT-pulmonary embolism prophylaxis; and ventilator-associated pneumonia, according to Jan Mathews, RN, MPHA/ MBA, CPHQ, CNAA, director of clinical performance improvement at CaroMont Health’s Gaston Memorial Hospital.

The CaroMont team has since spread the SCIP initiative to all surgical patients, Mathews says, and normothermia and antibiotic administration were among the easy implementations because SCIP recommendations were already in place. The biggest challenge has been implementing the suggested DVT prophylaxis.

“Not every patient gets pharmacological and nonpharmacological prophylaxis, so, basically, you had to change your practice,” Mathews says. “We implemented an order set that goes on every surgical patient’s chart so that the physicians can address what they’d like to have as far as DVT prophylaxis.” Having the cooperation of a multidisciplinary team of physicians and clinicians, hospital-wide, has been key, Mathews says. Since the hospital started collecting data in July, Gaston Memorial patients have had no SSIs during hospitalization. Mathews says the next step is to look at rates 30 days after hospitalization; they now are determining how to collect that data. Implementing changes designed to eliminate SSIs takes constant monitoring and flexibility, Mathews says. “We call it ‘hard wiring,’ or making changes a part of our everyday care of patients. It takes constant monitoring and change to improve the process".

Excerpts above by Lisette Hilton

Permaguard Invention Fights Spread of Bacteria

Student nurses in Kent and Medway are testing a new type of uniform designed to help in the fight against the hospital superbug MRSA. The fabric contains an anti-microbial treatment which "electrocutes" harmful bacteria to stop them spreading. Canterbury Christ Church University believes it is the first in the UK to trial the product, called Permagard.

It is a new antimicrobial finish that controls the growth of bacteria. It can be applied to a wide range of fabrics and surfaces and is intended for use in the food, healthcare and pharmaceutical industries. Unlike most antimicrobial products it does not rely on the slow release of a poison to kill the bacteria but utilises a mechanism that penetrates the cell wall and on contact destroys them.

There are two sorts of antimicrobial agent - the migrating and the non-migrating. Migrating antimicrobials create a zone of inhibition in order to affect as much bacteria as possible. However, some of the bacteria in this zone are not always killed outright and can learn to survive and recover, and therefore build up a resistance to the antimicrobial used.

Permagard is a non-migrating antimicrobial and as explained above uses a physical kill method. It breaks the cell wall and kills the bacteria outright. As it does not create a zone of inhibition but kills only what comes into contact with it, no bacteria can learn to recover from it.

Field trails followed by microbiological testing have shown that Permagard is still effective after 100 washes @ 85ºC. Its performance has also been evaluated and verified by the Hospital Infection Control Research Laboratory of the Birmingham City Hospital NHS Trust, UK.

Hospital acquired infections have attained much greater public awareness in recent times and a somewhat notorious reputation because of the emergence of species of micro-organisms, in particular MRSA, which have become resistant to antibiotics. Figures issued by the National Audit Office report that 100,000 infections a year are acquired in hospitals in the UK equating to 1 in 10 patients. All this at a cost of £1 billion to the UK NHS.

Recognizing the need for an anti-microbial product that is effective and durable, Carrington Career & Workwear Ltd, the UK's largest supplier of healthcare fabrics has developed Permagard to help in the fight against hospital acquired infections.

It is effective against MRSA. In addition, it provides effective control against the growth of a wide range of bacteria, fungi, algae and yeasts. There is no known risk of bacterial mutation with Permagard. Because it destroys bacteria by physical rather than chemical means it will not cause the bacteria to adapt and become resistant to it.

It protects both the wearer and the patient. The moist warm environment in a fabric worn next to the skin is a good breeding ground for bacteria. These can transfer from person to person and from patient to healthcare worker. Such hospital acquired bacteria can than be transferred to the home environment as healthcare uniforms are usually worn to and from work and washed domestically. Treated uniforms will aid in the prevention of such transfer.

Antibiotic-Coated Medical Devices Could Cut Infections

In the future, hospital patients may have a new weapon to fight infection after surgery: powerful antibiotic coatings attached to implants, catheters, surgical instruments and other medical devices. Researchers at the University of Southern Mississippi say they've developed a way to attach penicillin, and potentially other antibiotics, to these types of devices.

Almost 2 million patients in the United States get an infection in the hospital each year, and about 90,000 of those patients die each year as a result of their infection, according the U.S. Centers for Disease Control and Prevention (CDC). Many of these infections are linked to medical devices. But, "modifying [device] surfaces to adhere penicillin kills bacteria," explained lead researcher and professor of polymer science Marek W. Urban. "The penicillin is able to destroy the colony of bacteria," he said.

Urban's team has found a way to modify the surface of poly(tetrafluoroethylene), a material similar to Teflon, so that penicillin sticks to it and remains highly active. This polymer is used in medical procedures ranging from blood vessel grafting to plastic and reconstructive surgery. The trick was to modify the surface of poly(tetrafluoroethylene) so that arms would stick out from the surface, which the penicillin could stick to, and that would, in turn, surround bacteria and kill it, Urban said.

In their experiments, expected to be published in the Feb. 12 issue of the journal Biomacromolecules, the researchers showed that these penicillin-coated surfaces could effectively kill Staphylococcus aureus, a bacterium responsible for many serious infections.

However, since more than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the antibiotics most commonly used to treat them, Urban's group is hoping to find other antibiotics that are able to coat the surfaces of medical devices. In addition, the researchers are also working on modifying other types of surfaces to hold on to antibiotics.

"We want to develop coatings that can be applied to any surfaces to kill bacteria, Urban said. "This is the first step. The trick is to make the antibiotic remain active after it is attached," he said. One expert believes this may be a breakthrough in reducing the number of hospital-acquired infections.

"It is a very good idea to affect surfaces not only to have an antimicrobial in place there, but also to disrupt bacterial activity," said Dr. Philip Tierno, the director of clinical microbiology and immunology at New York University Medical Center and author of The Secret Life of Germs. "Most artificial materials, when they are placed in or on the body, serve as a platform for the growth and proliferation of bacteria," he said. This is a big problem with catheters, Tierno noted. "It seems that this method could cut down on infections, but you really have to test the hypothesis," he said. "However, based on this paper, it appears that you can disrupt the growth of bacteria by coating the surface of devices."

January 19, 2007 (HealthDay News)

Staph Bug Causes New Pneumonia

WASHINGTON (Reuters) - A nasty staph germ circulating in and out of hospitals produces a poison that can kill pneumonia patients within 72 hours, researchers said on Thursday.

Staphylococcus aureus bacteria - or S. aureus - can pass one another the gene for the toxin and are apparently swapping it more often, the researchers report in Friday's issue of the journal Science. The toxin, called Panton Valentine leukocidin or PVL, can itself cause pneumonia and can kill healthy tissue.

Luckily, people infected with the bacteria quickly develop a high fever and astute doctors can identify it, said Gabriela Bowden of the Texas A&M Health Science Center in Houston, who led the study.
"This is a scary situation. We are trying to put the word out and to educate people about it," Bowden said in a telephone interview.

S. aureus is the most common cause of hospital-acquired infections, and can cause inflammation of the heart, toxic-shock syndrome and meningitis. A new strain called MRSA resists the antibiotic methicillin, but it can be treated with antibiotics like doxycycline and vancomycin. An outbreak of methicillin-resistant S. aureus carrying the new toxin killed two patients in a British hospital in December with a new type of pneumonia called necrotizing pneumonia. This infection destroys lung tissue and also kills some of the immune system cells sent to battle it.

Dr. Marina Morgan, consultant medical microbiologist at Exeter Nuffield Hospital in Britain, said the PVL toxin "turbo-charges" an already dangerous bacteria. "PVL is strong enough on its own to destroy the lungs," she said in a statement. And the toxin is immune to antibiotics. "The reason most patients die is that despite killing the bug, PVL toxins already formed continue to digest lung tissue, so we desperately need some way of removing the toxins," Morgan said.

S. aureus, which commonly live on the skin and cause pimples, boils and other minor infections, can cause a serious wound if the toxin-producing strains get into a cut.

Old-fashioned hygiene is the best line of defense, Bowden said. "This is a community-associated strain, which means that in schools, the kids can carry it. Anybody can be colonized with it," she said. "I tell my kids if you scrape your knee, go to the bathroom immediately and wash it with soap." Hospitals must impose strict hygiene to control it.

Bowden's team tested the PVL-producing Staph on mice and found that two days after infection, their lungs were filled with immune cells and lung tissue was starting to bleed and die. A stretch of DNA known as a cassette carries the code for the PVL toxin. Such a little segment is easily passed from one strain of bacteria to another, said Bowden, and viruses called bacteriophages can also carry them.

Understanding how this happens could provide a way to develop new drugs or vaccines and shed light on how bacteria acquire new and dangerous qualities.

"The appearance of PVL toxin in severe Staphylococcal pneumonia is a recent phenomenon. Previously the toxin was only found in less than 5 percent of strains," said Dr. Ronald Cutler of the University of East London. Some companies are working on staph vaccines but none is on the market.

By Maggie Fox, Health and Science Editor

Law Calls for Mandatory Education and Penalties

A new health insurance law calls for mandatory education for healthcare workers and penalties for employees and facilities that don't comply with infection prevention measures, which health officials are developing.

State Senator Richard T. Moore, an Uxbridge Democrat who is chairman of the Health Care Financing Committee, filed legislation yesterday that eventually would require health officials to make public the infection rates for individual hospitals, and state health officials said public disclosure probably would be part of any new reporting requirements placed on hospitals.

Because hospitals are not required currently to report hospital-acquired infections to public health agencies, researchers don't know how often they occur. But patient safety and public health specialists estimate that nationally hundreds of thousands of hospital patients a year contract infections. Bacteria spread down tubes, also called central lines or catheters, placed in their veins to deliver medicine or in their lungs to help them breathe, and through incisions made during surgery.

The Federal Centers for Disease Control and Prevention estimates that each year patients contract 250,000 infections from catheters alone, infections that kill between 12 percent and 25 percent of patients who get them and cost about $25,000 each to treat. A small Massachusetts study published in 2002 suggested that 13 percent of 1,953 cardiac bypass patients suffered infections at the site of their surgery, including ones detected after patients were discharged.

Aside from the risk to patients and the cost to the healthcare system, another reason for the industry's growing focus on the problem is the increasing proportion of hospital infections that are resistant to common antibiotics, which makes them more dangerous and difficult to treat. At the same time, specialists believe that many infections are preventable with proper sterilization techniques and timely administration of antibiotics and more judicious use of catheters and ventilators.
"Hospital-acquired infections lead to significant harm to patients and significant unnecessary cost in the healthcare system," said John McDonough, executive director of the consumer advocacy group Health Care For All, which is also pushing legislation to require hospitals to reduce infection rates. "A variety of folks across Massachusetts are attempting to draw more focus on this problem so Massachusetts can assume a strong leadership position and perhaps be one of the first states to drive rates down to zero."

Hospitals are required by several federal agencies and organizations to have infection-prevention programs and have been monitoring their rates internally and trying to lower them for years. But the 2006 law that requires all Massachusetts residents to have health coverage by this July included $1 million for the Massachusetts Department of Public Health to implement a mandatory statewide infection prevention program in healthcare facilities. The program will begin in hospitals.
Health officials recently hired an outside consulting company to oversee development of the program and appointed advisory boards to make recommendations on how to collect incidence data from hospitals and what specific infection-control practices should be put in place and monitored, said Paul Dreyer, director of the Division of Health Care Quality. He said health officials probably will be ready to implement the program in a year.

The department has authority to discipline hospitals for poor infection-control practices, but health officials generally know about problems only if they get a complaint, which Dreyer said they rarely do.

"For a long time, there's been a sense that hospital-acquired infections are inevitable and the cost of doing business," Dreyer said. "Partly because of the patient safety movement, people don't think that's the right way of looking at them anymore. They're no more the cost of doing business than wrong-side surgery."

This shift in thinking has been reinforced as some hospitals have shown it's possible to reduce infection rates to near zero by focusing more on prevention. Michigan hospitals that rigorously implemented infection-control procedures, such as doctors and nurses washing their hands and cleaning patients' skin with an antibacterial agent before inserting intravenous lines, reduced catheter-related blood stream infections in intensive-care patients from an average of 7.7 per 1,000 days of catheter usage to 1.4 per 1,000 days a year and a half later, researchers reported in the New England Journal of Medicine last month. And 32 hospitals in Pennsylvania reported in October 2005 that they reduced catheter-related infections 68 percent through similar measures.

"One of the keys to making health reform work and getting people to buy and maintain health insurance is to keep costs down without necessarily cutting out" benefits , Moore said. "One of the biggest ways to do this is to prevent infections that occur in hospitals and drive up the costs. Most of it is preventable. We'll be able to save some money and save some lives."
He said public reporting will give hospitals added incentive to improve their infection rates. Several states, including Pennsylvania and Missouri, now require hospitals to publicly report their rates.

Paul Wingle, a Massachusetts Hospital Association spokesman, said the group will work with Moore on his bill to make sure that appropriate infection data is publicly reported. "There's no philosophical barrier to it," he said. "It's all a question of how it's done."

Doctors warn that coming up with ways to fairly compare hospitals through public reporting will be a challenge, partly because hospitals that look harder for problems may have higher rates but not necessarily have more infections. Rates also must be adjusted for patient risk factors, such as obesity.

Last month, Beth Israel Deaconess Medical Center president Paul Levy posted his hospital's rates for central line-related infections on, in part to spur other hospitals to be more transparent about their quality of care. Bacteria on the tubing can flow quickly through the bloodstream and to major organs, making these infections of particular concern.

The hospital's rate was about 3 central line infections per 1,000 patient days about a year and a half ago. Since then, the rate has dropped to an average of 1.5 central line infections, hospital executives said.

Dr. Kenneth Sands, vice president and medical director for healthcare quality, said the hospital started requiring healthcare workers to follow specific procedures for inserting catheters and to document each step, for example, covering the patient's entire body with sterile cloth, rather than just the area immediately around the catheter site.

Beth Israel Deaconess also began investigating each infection as a major event, rather than just collecting data, a key shift in thinking. "We think we saved some lives from our intervention," he said.

By Liz Kowalczyk, Globe Staff
January 11, 2007

Contact Isolation in Practice in S.C.

Piedmont Medical Center in South Carolina is at the head of a national charge to prevent the spread of the antibiotic-resistant staph supergerm MRSA.

For now, people visiting Piedmont's critical care patients must wear sterile gowns and latex gloves until patients are found to be free of the MRSA germ. The practice, which started in August, will expand to the rest of the hospital, possibly by the end of January.

MRSA, or Methicillin-Resistant Staphylococcus Aureus, is spread by skin-to-skin contact. People who are ill or whose immune systems are compromised are more susceptible than healthy people. For them, it can lead to pneumonia and other serious infections, including in the bloodstream or at surgical sites. The germ can be deadly.

Piedmont's battle against MRSA begins with "contact isolation," which involves placing the patient in a room and taking a nasal swab test for the germ. It takes about 48 hours to get results. Meanwhile, hospital staff and visitors to the room must wear disposable gowns and gloves, which immediately afterward are placed in a disposal bin.

"I think we're doing what everybody else should be doing," said Dr. Craig Charles, Piedmont's infectious disease specialist. "We're trying to stop it in its tracks. "Research has shown if you put a greater effort to identifying it and take precautions to prevent it from spreading, you can prevent people from getting it and reduce the pain and suffering," he said.

Assuming the test returns negative, visitors no longer have to wear gowns and gloves. It is recommended that they return to normal precautions of washing hands or using an antibacterial lotion when entering and leaving the patient's room. If the test returns positive, an antibiotic ointment is used in the patient's nose and under the nails. The patient takes baths in chlorhexadine soap. After 10 days, the MRSA infection should be eradicated.

Visitors aren't tested for the germ because the hospital only has legal authority to test patients. A major goal of contact isolation is preventing visitors from carrying the germ from a patient's room to hospital public areas.

PMC is in a consortium with the Duke Infection Control Outreach Group of Duke University Medical Center in Durham, N.C. Those in the consortium share information on MRSA and compare data. "Probably in the future, more hospitals are going to try to do this," said Dr. Deverick Anderson, an infectious disease fellow at Duke. "At this point, most hospitals only do it in specific situations. A lot of focus is on critical care areas."

In October, the U.S. Centers for Disease Control and Prevention issued new guidelines "to halt the rising rates of drug-resistant infections" with "aggressive steps." The guidelines cover all drug-resistant bacteria, but they cite MRSA as "a good example" of a germ with increasing antibiotic resistance. It refers to MRSA as "a growing problem in hospitals and health-care facilities."

The Institute for Healthcare Improvement has recommended "contact isolation" while testing for MRSA, Anderson said. The association just released a campaign called "Five Million Lives" to decrease harm to patients when hospitalized. Active surveillance for MRSA is one of six targets.

Anderson called MRSA "definitely one of the worst infections you can get in a hospital."

"There's a new type emerging in the past four or five years that is causing skin infections," he said. "We would hope to come up with ways to control it, but right now, it's headed in the wrong direction." Fifteen years ago, only people who spent significant time in a hospital got MRSA, Charles said. Then cases emerged in athletic teams and other communities outside hospitals, and standard antibiotics didn't work.

It is bacteria's nature to evolve for survival. "If you keep pressuring them with antibiotics, they will keep evolving," Charles said. Penicillin was a wonder drug when it was invented, but the medical community ultimately discovered it didn't kill staph germs. Methicillin was developed as the anti-staph penicillin. In the mid-1980s, MRSA developed resistance to methicillin.

Another antibiotic, Vancomycin, was developed to combat MRSA. Charles said there now are cases in Japan where MRSA is Vancomycin-resistant. There have been six such cases in the United States, Anderson said. "It's a moving target," he said.

Ironically, some bacteria have evolved to the point they are no longer resistant to older antibiotics that have not been used for a while, Charles said. However, MRSA is not one of them.

Bacteria live in colonies, and most family and friends have been exposed to the same colonies of bacteria. Therefore, visitors do not have to wear face masks, and hugging patients in contact isolation is OK.

Clothing and hands, especially hands, are major carriers. Hands spread germs to doors, counters and elevator buttons, and on throughout the hospital. Hospital staff recommend washing the hands or using a sanitary lotion every time you enter or leave a patient's room, regardless of whether the patient is in contact isolation.

Piedmont has not yet identified unusual clusters of MRSA. If it does, it will research common circumstances for the source. Like most hospitals, Charles said, Piedmont has had isolated cases where MRSA contributed to a patient's death.

PMC is studying the cost of buying disposable gloves and gowns that contain an impenetrable plastic. The gloves and gowns would be distributed to staff and visitors at the 288-bed hospital. A box of 100 gloves costs $4.24 and gowns $7.80 for a package of 10, said hospital spokeswoman Myra Joines. For a critical-care patient, staff use an estimated 50 gowns and 100 gloves a day. That does not include visitors. Hospital officials expect it to be well worth the expense.

"It's the right thing to do," Charles said. "Every dollar spent on infection control saves $5 and countless lives. If you prevent one serious hospital-acquired illness, you pay for the whole program."

By Karen Bair - The Herald, Rock Hill, South Carolina - Updated 12/24/06

Nightmare Scenario is Real ...

MRSA is already notorious for killing the elderly and frail. But now a new form of the 'hospital superbug' is spreading through our parks and playgrounds. You can catch it with a single scratch, and the drugs that used to hold out some hope are rapidly becoming useless. Sarah Boseley reports

Children gash their legs and graze their elbows. It's normal. Usually they recover incredibly fast. Occasionally, if the wound starts to look a little dodgy, they may be given an antibiotic - just in case it's infected. But in Texas, increasing numbers of healthy kids with the ordinary childhood lacerations from falling out of trees or being pushed over in the playground are being admitted to hospital. And some of them never make it home.

They are victims of what has been described as the largest bacterial epidemic in the world. Behind it is the superbug - MRSA - a variant of a common-or-garden bacteria, staphylococcus aureus, which no longer responds to the usual antibiotics, such as methicillin. In the UK, the superbug is notorious for attacking frail, elderly, very sick people in hospital. In Texas, it is killing healthy children.

Matthew Ykema, 14, arrived at Texas Children's Hospital in Houston with a swollen, throbbing knee, a temperature of 40C and a strange greyish hue to his skin. "They didn't expect me to live through the night," he said.

He had picked up a new form of MRSA that is passing from hand to hand and from playing field to swimming pool in parts of the United States. This "community-acquired MRSA", or CA-MRSA, throws out a toxin called PVL - Panton-Valentine leukocidin - that destroys white blood cells. Bacteria are harmless on the skin, but CA-MRSA can be deadly if it gets into the bloodstream through a cut.

Zacharias Nunley, aged seven, was admitted to another Houston hospital, the Memorial Hermann Children's Hospital, with excruciating pains in his leg. He had no visible injuries. Doctors again diagnosed MRSA, and said that the blood clot caused by the infection could have killed him. It was three months before he could leave hospital. "I said, 'How did he get it? Do I need to throw away my furniture? Was it the food?'," his mother, Charla Rigsby, told the Houston Chronicle. "They said, 'No ma'am, the bacteria is everywhere. There's no telling where he got it.' That's what really, really, truly bothered me."

With the financial backing of the charitable Vivian L Smith Foundation, Texas Children's Hospital has been studying the rise of CA-MRSA since 2000 and has clocked up more than 5,000 cases in all ages - some of them babies less than a month old. The bug infects soft tissue but also bone. Around 200 people have had invasive infections such as necrotising pneumonia, which causes abscesses in the lungs. When PVL causes this type of pneumonia, around 75% of patients die. Most don't last more than about four days.

PVL toxins are also produced by ordinary staph aureus, which is not resistant to methicillin and can be relatively easily treated. But deaths from PVL-producing MRSA have now been confi rmed around the globe, from Australia to the UK. Part of the problem is that these are young people who are not expected to get ill, so the infection is not identified quickly. In October 2004, a young Royal Marine recruit called Richard Campbell-Smith scratched his legs running through gorse bushes 28 weeks through his 32-week training course at the commando training centre in Lympstone, Devon. He was only 18, he was super-fit, but he was never to recover. He felt cold and feverish and three days later collapsed on the floor by his bed. He died of necrotising pneumonia.

Marina Morgan, of the Royal Devon and Exeter Hospital where he was treated, said that although cases were rare, they were difficult to detect and more might be slipping through. "It is the worst bug I have ever seen and people really need to know about it," Dr Morgan said at the inquest. "It is untreatable. It multiplies very quickly. One bug will multiply into 17 million within 24 hours. Usually signs include pneumonia, coughing up blood and very high temperatures, but not everyone will look for it."

Since then, there has been a fatal oubreak of PVL-producing MRSA at a hospital in the West Midlands. Maribel Espada, a 33-year-old nurse undergoing a caesarian section, died, as did another patient in the same hospital, while four others had skin infections such as abscesses and boils. A further two tested positive for the bug. It was the first time that this particularly lethal strain of MRSA had been detected in a hospital setting, where the potential to do harm to vulnerable sick people is enormous.

This looks like a new killer in our midst. In fact, it's not. It's an old bug in a new, deadly garb. PVL-producing staph aureus was first identified in the 1930s. Before 1960, nearly 60% of all staph aureus infections were PVL-producing. Then the introduction of methicillin - a new class of antibiotic to replace the failing penicillin - just about wiped it out. But just about wiping out bacteria is the worst thing you can do. Those that remain come back with a vengeance.

Bacteria are the greatest survivors on the planet. They have been around for three billion years. Like viruses, they adapt to circumstances. If some, but not all, of them are wiped out by an enemy - such as methicillin - any that survive mutate into a form that can resist methicillin. And then they multiply.

What we have with the spread of PVL producing MRSA is another triumph for the world of germs. One antibiotic after another has been rendered almost useless as the bugs mutate to overcome them. This was understood by Alexander Fleming, the discoverer of penicillin. But through the 50s and 60s, as doctors joyfully stamped out infections from tuberculosis to pneumonia and some declared the battle against infectious diseases won, most people expected a constant stream of new antibiotics to replace those that fell by the wayside.

It hasn't happened. Staph aureus bacteria developed resistance to penicillin, the cephalosporins, the fluoroquinolones such as ciprofl oxacin and methicillin; then, in 2002, the first case of resistance to the last-resort drug vancomycin was reported in the US. We are now running on empty and facing what Richard James, director of the Centre for Healthcare Associated Infections at Nottingham University, calls "the post-antibiotic apocalypse".

"We are facing a future where there will be no antibiotics and hospital will be the last place to be if you want to avoid picking up a dangerous bacterial infection," he says. "In effect, cut your finger on Monday and you'll be dead by Friday if there's nothing to prevent it."

James has been rebuked by Christine Beasley, the Department of Health's chief nursing officer, for his crisis talk. She says it is scare-mongering. But he and other scientists say that something must be done urgently to find new weapons against the bugs around us that are regaining the upper hand they had in the pre-drug age.

How have we come to this pass? Two things have happened. We have over-used and ill-used existing antibiotics in a cavalier fashion in the past, expecting another one to come along at any time. A decade ago, for example, every mother who took a sniffling son to the GP came out with a prescription for antibiotics, even though colds and flu and sore throats are caused by viruses, not bacteria, so antibiotics have no effect on them. We, the patients, demanded antibiotics as a cure-all. They, the doctors, handed them out because they would get a hard time if they didn't.

Most of the drug companies, meanwhile, no longer have any interest in hunting down new antibiotics because it's not financially worthwhile. Roche has dropped antibiotic research, while GlaxoSmithKline, BristolMyersSquibb and Eli Lilly have all cut down. The only company to have entered the field is Novartis.

"Virtually all the pharmaceutical companies that were interested in developing antibacterials have pulled out of research in the field," says Richard Wise, who heads the government's specialist advisory committee on antimicrobial resistance.

"We had a plethora of drugs in the 70s to the 90s. In the last two years, only one new agent has come along, called linezolid. The reasons are fairly straightforward. If you were the chief finance officer of a major drug company, you would far rather put your research pounds into developing drugs that were going to be used on a chronic basis for diseases like Alzheimer's, schizophrenia or ulcers, where people have a lifetime's illness."

Drugs such as statins for heart disease are a goldmine - urged on everybody with any sign of heart disease and potentially on an entire generation. And they will be told to keep taking the tablets for life. A course of antibiotics is rarely more than seven days.

And the very reason that we need new antibiotics is a disincentive for the drug companies to invent them. Resistance always sets in. The useful lifespan of the drug will be much shorter than that of any painkiller or antidepressant. The industry claims it costs $800m (£407m) to develop a single new drug - although critics say that figure contains marketing and advertising spend as well as the costs of the many drugs that fall by the wayside. They are unlikely to get the sort of profit their shareholders want in five to 10 years for drugs that matter so much but are used for such a short time - even if the companies set an astronomical price.

"The fact that disease-causing bacteria soon become resistant to any antibiotic has further reduced the interest of pharmaceutical companies in funding the research required to discover new antibiotics and bring them to the market," says Professor James. "They would rather concentrate on developing drugs for 'lifestyle' conditions such as high blood pressure or diabetes that patients need every day to control their health."

The first antibiotics that were discovered after penicillin now appear to have been the easy ones. Even in the glory days of the 1960s, the new drugs coming along were aunts, uncles and cousins of those we already had. And the trouble with families is that a bacteria can become resistant to the whole lot. What are needed now are new classes of antibiotics, and there have been only two in recent times - Wyeth's linezolid, licensed in 2001, and daptomycin from Novartis, licensed in 1997. And researchers found some resistance to linezolid even in the clinical trials to prove its effi cacy.

According to Sir Anthony Coates, professor of medical microbiology at St George's school of medicine in London, there are 18 potential antibiotic drugs at various stages of development. If that sounds promising, compare it with nearly 100 drugs for cancer that are in the very last phase of trials prior to licensing - let alone all the others queueing behind in the pipeline. "That gives you a feel for what's in store in the next five to 10 years," says Professor Coates. Basically, not much.

He is worried about other bacterial infections. Most of the upcoming drugs are aimed at the bug everybody knows, the ubiquitous MRSA, for which we still have the last-resort antibiotic vancomycin. MRSA is part of a group that share certain characteristics called gram-positive bacteria and includes listeria, streptococcus and clostridium (clostridium difficile infections in hospital are rising very fast and causing more deaths than MRSA).

But there is another group called gram-negative bacteria. They include E coli, pseudomonas and acinetobacter and - although they are less common and usually found in the gut rather than on the skin - they can cause infections that are now untreatable. A bacterium called klebsiella is the best known of the pseudomonas family and seems to be a particular danger for patients with cystic fibrosis. Yet there is even less on the way to treat these infections.

This is a global phenomenon, well illustrated by the dramatic comeback of a disease that was the scourge of 19th-century Britain. Consumption - the "white death", which we know today as tuberculosis - is now once again a deadly threat and far, far harder to treat than a few decades ago. First we saw the rise of multi-drug resistant TB (MDR-TB). The germ had evolved to overcome the two most powerful antibiotics used to treat it, isoniazid and rifampicin. Confirmation of the seriousness of the situation came in 1991, with a major outbreak of MDR-TB in the hospitals of New York City. A survey revealed that 19% of TB in the city was resistant to the two drugs.

If that wasn't bad enough, last year a small study presented to the International Aids conference in Toronto put the world on alert for the next inevitable stage of the fi ghtback of the TB bacillus against modern drugs. TB has spread through Africa on the back of the HIV epidemic, because of the damaged immune systems of those with the virus. Doctors found a pocket of XDR-TB - extremely drug resistant TB - in South Africa. These were people with HIV who swiftly died of a form of TB that was resistant not only to isoniazid and rifampicin but also to any fluoroquinolone and at least one of the remaining injectable drugs to treat the disease: capreomycin, kanamycin and amikacin. A study by the World Health Organization estimates that possibly almost as many as one in fi ve cases of "multi-drug-resistant" TB is actually "extremely drug-resistant" TB. This type is still treatable in countries where the whole drug arsenal is available (it is not in Africa), but only 50-60% of patients survive.

With apocalypse on the horizon - according to Professor James - what is to be done? First of all, continue to cut down on antibiotic use by GPs. Now every surgery has notices pointing out the pointlessness of pills for coughs and colds.

There has been a crackdown of sorts on farmers, too - at least within the EU. Antibiotics were sold as growth promoters until the mid-90s. What they really did was stop battery hens and overcrowded animals getting disease. "Shut 25,000 chickens in a shed and close the windows and you can spread infection among them very quickly," says Richard Young of the Soil Association. "We fought a long campaign to get these things banned."

But they were not banned outside Europe, and while countries are forbidden from selling us meat from animals given banned antibiotics, it is very difficult to detect.

Bacteria being as smart as they are, resistance has naturally developed in animals, too. And although scientific proof is short on the ground, Young is not alone in believing that genes from resistant bugs in the meat at our table may mix in our gut with genes from antibiotics we may be taking. In the US, the animal antibiotic virginiamycin was banned for fear that cross resistance might develop to the similar human antibiotic synercid.

Although the medical and veterinary world is on red alert to preserve the failing power of the antibiotics that remain, Professor James says more could be done. He cannot believe the government is doing little more than urge better hospital cleaning and hand-washing.

"Why isn't the government doing something?" he asks. "We are talking about hospitalacquired infection which kills at least 5,000 a year, whereas about 3,000 die in road traffic accidents."

Dangerous bacteria are passed around in hospital and enter wounds through surgical instruments and catheters and the like - but they also come in with the patients and the visitors. "We don't screen on admission," says James. "That is the critical thing."

He says screening would show up an alarmingly high rate of bacterial infection and would have serious financial consequences. "They don't want to know the answer. What would they do with all these people?" Hospitals would need to be redesigned with many more single rooms for isolation. But it happens in other European countries.

Meanwhile, university academics are looking for new ways to tackle the bugs that are increasingly defeating standard antibiotics. "There may be another way," says Professor Coates. Bacteria, he says, can be easily killed by antibiotics while they are multiplying - so their defence mechanism is to stop multiplying for a while. Then, when the threat has died down, they may come back with a vengeance. Coates and his colleagues have designed an antibiotic cream that will give the non-multiplying bacteria a sledgehammer blow, designed to act very fast and hard. "No mercy," he says. "They are all dead." It has taken him 25 years of research. The new drug, which he hopes can be used on wounds in hospitals and in the nose - where bacteria collect - before patients go into surgery, is about to go into clinical trials.

Elsewhere, scientists are coming up with other new strategies, such as drugs that will disable bacteria and render them harmless rather than trying to kill them outright. The theory is that bacteria may not struggle against them as hard as they do in the primitive fight for survival. And there have long been hopes for bacteriophages - naturally occurring viruses that can infect and kill bacteria. But there are only a couple of companies looking at the possibility of harnessing them for use in healthcare, and for all the enthusiasts, there are equal numbers of sceptics who fear that bacteria could just as quickly evolve to resist phages, as they do antibiotics.

Most scientists cannot see a way forward unless the mighty pharmaceutical industry puts its collective shoulder back to the wheel. And it won't do that unless it is off ered a few financial incentives and perhaps a shortcut when it comes to the red-tape for licensing new antibiotics. Professor James says that government must intervene - but acknowledges that any solution to the coming crisis will not be found within the career span of any of today's politicians.

Matthew Ykema was lucky. He is now fit and well. But Texas Children's Hospital has put out warnings to parents, telling them they should "closely watch even the most minor scrapes, bites and injuries for signs of serious infection". Practise good hygiene, it says. "Don't allow your children to share towels or workout clothes with anyone." We're entering a whole new postantibiotic era - and it's scary.

Know your enemy: Some of the most common drug-resistant bugs

MRSA: There were 18,273 cases of staphylococcus aureus infection reported to the Health Protection Agency in the UK in 2005; more than a third - 39.2% - were MRSA (resistant to methicillin). Vancomycin is the drug now used against in such cases, but resistance to this has been detected in the US.

CLOSTRIDIUM DIFFICILE: 51,690 cases in people aged 65 and over in 2005. It causes more deaths than MRSA - 1,300 in 2004 compared with 360 deaths from MRSA. It is susceptible to antibiotics, however - metronidazole and vancomycin are the main ones used.

PVL-PRODUCING MRSA: Some of the staph aureus that produces the toxin PVL can be treated by the antibiotic methicillin but some is resistant. These bacteria are still rare - only 2% of all staph aureus - and in the UK are still normally sensitive to other antibiotics such as tetracycline and ciprofloxacin. The more common the bug becomes, the more likely it is that resistance will develop to other antibiotics.

ENTEROCOCCUS: 904 cases of infection resistant to glycopeptide (the class that includes vancomycin) were reported in 2005.

E COLI: There were 17,215 cases in England and Wales in 2005, 8-9% of which were resistant to cefotaxime and ceftazidime, 19.2% were resistant to ciprofloxacin and 7.6% resistant to gentamicin.

GONORRHOEA: 18% of cases were resistant to penicillin in 2005, up from 11.4% in 2004, and 22% were resistant to ciprofloxacin.

Wednesday January 17, 2007
The Guardian, UK

Hospital Crackdown Beating Superbug

MRSA cases are down in Huddersfield, UK latest figures show. Hospital bosses say it is because strict measures have been put in place to tackle the super-bug infection. Only 20 cases have been recorded in nine months at Huddersfield Royal Infirmary and Calderdale Royal Hospital.

The drop comes after Calderdale and Huddersfield NHS Foundation Trust - which runs the two hospital sites - celebrated a 30% reduction the year before when their MRSA rate dropped from 40 cases in 2004/5 to just 28 in 2005/6. The Trust now looks set to have another record year.

Carole Hallam, lead infection control nurse for the Trust, said: "We have a robust infection prevention and control programme and infection control is given a constant high priority in our Trust. "However, we are never complacent and the work continues across all departments." She said a number of measures had been introduced which included screening patients when they arrived at hospital and moving those found to be MRSA carriers into side rooms.

Alcohol hand gel dispensers at every bedside and training in handwashing had also helped improve the figures.
Greater infection control awareness among both staff and visitors was also helping to keep infection at bay.

The figures come after the Government set all hospital trusts a target in 2004 to halve their MRSA rates by 2008.

A new weapon against MRSA is being developed with more than £3 million of funding from the Wellcome Trust, Britain's leading research charity. Scientists have identified a class of compound that kills the superbug by preventing its ability to divide and multiply. They hope the drugs, code-named CDI 936 cell division inhibitors, will provide a safe alternative to traditional antibiotics. Theoretically they could work against all antibiotic-resistant strains of Staphylococcus bacteria, which include MRSA.

By avoiding the destruction of protective "friendly" bacteria in the gut, which are often targeted accidentally by antibiotics, they may also prevent secondary infections by other bugs. Clostridium difficile, one such bacterium, is becoming an even bigger problem than MRSA after taking advantage of the "open door" provided by antibiotics.

The Wellcome Trust today announced it was pumping £3.5 million into developing the new compounds. The grant to the Oxford-based biotech company Prolysis is one of the first awards from the charity's £91 million Seeding Drug Discovery initiative, which aims to turn promising scientific ideas into practical treatments.

HOSPITAL infections, including MRSA, are said to kill around 5,000 UK patients each year. The MRSA Support Group maintains that the true figure is closer to 20,000. MRSA, or methicillin-resistant Staphylococcus aureus, is difficult to treat because of its resistance to antibiotics. It first appeared in the 1960s and new strains emerged in the 1980s that have caused outbreaks of infection in hospitals throughout the world. MRSA most commonly attacks patients who have undergone operations and can be fatal if it triggers blood poisoning.

There were 3,517 reports of blood-stream infections from MRSA in acute NHS trusts between October 2005 and March 2006.
MRSA is most commonly spread via hands and equipment, and sometimes through the environment.

January 15, 2007
By The Huddersfield Daily Examiner


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