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Fending Off Hospital Superbugs

On a cruise to Bermuda in 2007, Baltimore resident Wilhelmina Watnoski was surprised to find that passengers were required to clean their hands when entering and leaving the ship’s eatery. “There was actually a person standing there making you do it,” Watnoski recalls. Her reaction? A note of thanks to the ship’s management.

Watnoski is all too aware of the destruction a tiny, unseen germ can wreak. Two of the most dangerous and most common bugs that stalk U.S. health care facilities infected her 80-year-old father in late 2004 after he was hospitalized for a urinary tract infection. Sent to a rehabilitation facility to regain his strength, Walter Wiatr instead developed uncontrollable diarrhea and lost his appetite. That, Watnoski learned, was thanks to an organism called Clostridium difficile (C. diff). She moved him to another facility. But soon a painful red swelling appeared on his neck, the sign of another infection—this time it was methicillin-resistant Staphylococcus aureus, or MRSA, a bacterium that’s spread by person-to-person contact and is resistant to common antibiotics. Two months after his initial hospitalization, Wiatr, who’d been independent and healthy, was gone.

“He went downhill so fast, I still can’t believe it happened like that,” his daughter says.

American hospitals are treating sicker patients with more complex, invasive techniques—and helping people live longer. But every year in these same facilities some 90,000 Americans pick up infections that kill them.

Hard-to-treat superbugs are an increasing problem as widespread use of antibiotics produces new germs that are drug-resistant—and few new medications are in the pipeline. In the 1970s only a tiny percentage of hospital staph infections were MRSA. By 2004 MRSA accounted for two out of three staph infections, usually attacking patients with weakened immune systems or those using catheters, intravenous lines or ventilators.

Clostridium difficile also is a rising threat. Few Americans had heard of this intestinal bug until November, when a study showed its prevalence is as much as 20 times higher than previous estimates. Sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC), the study looked at C. diff cases in nearly 650 U.S. health care facilities on a single day between May and August 2008. Findings suggest that on an average day, nearly 7,200 hospitalized patients—13 of every 1,000—are colonized or, more often, infected with C. diff, and about 300 patients will not survive it. The young and older patients are especially vulnerable. Infection often follows the use of antibiotics, which strip the gut of certain bacteria, allowing C. diff to proliferate there.

Because the chief symptom is profuse diarrhea, the bug is easily spread everywhere—onto hands, bed rails, sheets, IV poles. “The primary mode of transmission,” says William Jarvis, M.D., lead author of the prevalence study, “is person-to-person transmission on the hands of health care workers or contaminated equipment.”

Research has shown that health care workers clean their hands effectively only about half the time, and the hardiness of the C. diff spores adds a twist to the challenges they face. At one time the U.S. Centers for Disease Control and Prevention (CDC) routinely recommended cleaning the hands with alcohol-based rubs. But alcohol won’t kill C. diff—it takes a scrubbing with soap and warm water to eliminate the spores. Similarly, only bleach will kill spores on surfaces; but the APIC study found that even in an outbreak, about a third of institutions don’t clean with bleach.

These facts underline the urgent need for all health facilities to adopt the best practices to stop the spread of germs—sanitizing rooms and equipment; washing hands thoroughly; inserting catheters in sterile conditions; monitoring for dangerous organisms; and taking special precautions with patients who carry them.

The proliferation of superbugs is a daunting problem, but one that has the attention of consumer advocates, insurers, federal and state governments, as well as hospitals and health care providers.

How to beat the superbugs:

Follow the money. Hospital-acquired infections cost an estimated $20 billion a year, according to the CDC, and a lot of human suffering. For example, the knee replacement Margaret Day, of Fort Lauderdale, Fla., had in 2006 would have been a great success—except for the C. diff infection that kept her in the hospital 20 days, some spent semiconscious in the ICU. This ordeal was not only costly for Medicare and the hospital, it also cost Day, an active 88-year-old, thousands of dollars a month in medicine and for help at home during her recovery.

On Oct. 1, Medicare stopped paying for complications arising from certain infections (but not C. diff) and conditions that result from hospital care and are “reasonably preventable.” The government wants hospitals to make safety measures job one, says Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. “Hospitals have heard that,” she says, and are adopting new strategies to protect patients.

Some private insurers, including CIGNA, WellPoint and United Healthcare, are following Medicare’s lead on not paying for medical errors in hospitals.

Name names. Consumer advocates say that public scrutiny can prod health facilities into action. “Hospitals begin to be more aware and evaluate their processes as soon as the state passes a law that says they’re going to have to report infection rates to the public,” says Lisa McGiffert, head of Consumers Union’s campaign against hospital infections.

To date, 25 states have done just that. The quality of data may vary from state to state and even facility to facility, but the first reports show that some hospitals are safer than others. [See “To Learn More.”]

Set an example. For years, hospitals have accepted certain kinds of infection as inevitable. One example: About 250,000 Americans a year get a bloodstream infection after having a catheter inserted into a large vein to give fluids or medications. Such infections have had a death rate as high as one in four. But last month, a CDC study in the Journal of the American Medical Association indicated that preventive measures had helped lower the rate of MRSA bloodstream infections by nearly 50 per­cent from 1997 to 2007, based on reports from 1,684 ICUs.

Certain hospitals are ahead of the game. With help from the CDC, 32 hospitals in southwestern Pennsylvania adopted a rigorous protocol and slashed the rate of bloodstream infections in their ICUs by 68 percent from 2001 to 2005. And 108 hospitals in Michigan in 2003 embarked on a voluntary program that virtually wiped out bloodstream infections.

Streamline for success. In March 2008 the U.S. Government Accountability Office reported that the government recommends 1,200 separate practices to prevent infection in hospitals, 500 of which are “strongly recommended.”

In October a consortium of leading health care professional societies, the American Hospital Association and the Joint Commission, an agency that accredits hospitals, published a document boiling down the government verbiage into six strategies targeting major problems.

The Michigan program used an even simpler method to protect patients from infection. Doctors and nurses were required to follow a five-step checklist—washing hands, wearing sterile gowns and gloves, and protecting the patient with antiseptics and sterile drapes and dressings—developed by a Johns Hopkins University team of safety experts led by Peter Pronovost, M.D.

After 18 months, according to the December 2006 New England Journal of Medicine, the median rate of bloodstream infections in the Michigan ICUs had plunged to zero, saving an estimated 1,500 lives.

Experts say that controlling the spread of superbugs isn’t rocket science. Indeed, Pronovost has said that precisely because the stakes are high and the problems complex, the to-do list must be “ruthlessly simple.” That way there’s no excuse for not following these lifesaving measures.

Now Pronovost’s approach is being tested in England, Ireland, Spain and in many U.S. hospitals. It’s already keeping patients safe at the 77-bed Gerber Memorial Hospital in Fremont, Mich., where doctors and nurses convene each day to plan care for ICU patients. Stephanie Gustman, R.N., the unit’s clinical coordinator, says, “We want to make sure we’re doing everything that’s proven best practice for that patient.”

Katharine Greider lives in New York and writes about health and medicine.

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