Staph Infections: Stealth Killers
By Thomas G. Dolan
Today’s Dietitian
Vol. 7 No. 9 P. 70

A menace in hospitals, it’s now spreading to the community.

Infectious diseases, most notably methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), are wreaking havoc in the nation’s hospitals—and the problem is getting worse, according to experts. The irony, according to some, is that infectious diseases are almost entirely preventable, but an obdurate public policy prevents the necessary steps from being taken. MRSA is now spreading through communities and researchers don’t know why. They also don’t know how to stop it.

Barry Farr, MD, professor of medicine at the University of Virginia in Charlottesville, says, “Staphis is a pathogen that has affected the human race for thousands of years. The boils of the biblical Job were probably staph.” He adds that infectious diseases are still the leading cause of death on the planet. In the United States, they are lumped together as an aggregate, placing them third behind heart disease and cancer.

The fact that staph thrives in a hospital environment is hardly news, Farr says. “Some 160 years ago, in 1842, Oliver Wendell Holmes, a great physician and dean of the Harvard Medical School, published an article in The New England Quarterly Journal of Medicine and Surgery stating that doctors and nurses needed to take better care in preventing the spread of staph from one patient to the next because their hands and clothes can be contaminated and they can take the disease to another patient where it can colonize. Exactly the same thing is going on in hospitals today,” he says.

Farr says one key difference, however, is that the new strains of MRSA have become resistant to antibiotics. “Antibiotics have been said to be one of the greatest triumphs of modern medicine,” he says. “But now we’re in a situation in which between one quarter and one half of all patients in hospitals—and all patients in intensive care—receive antibiotics. In theory, you could stop giving antibiotics and MRSA would fade away in hospitals, but then people would be susceptible to all the diseases cured by antibiotics.”

Good Hygiene Is Key
There is a realistic solution available that, Farr says, is not rocket science or some new technology breakthrough, but rather is based on keeping hands and equipment clean, the same principles Holmes wrote about in 1842.

This approach has worked in other countries. “In Denmark, MRSA was causing one third of bloodstream infections,” Farr says. “It took them about a decade to bring it under control, to less than 1%, and they kept it under control at less than 1% for the next quarter century. Similar dramatic results have been reported in the Netherlands, Finland, and western Australia.”

Betsy McCaughey, PhD, founder and chairman of the Committee to Reduce Infection Deaths, reports that a few U.S. hospitals are proving that good hygiene solutions work. For example, the University of Virginia Hospital has eradicated MRSA; Pittsburgh’s Veterans Hospital reduced MRSA by 85%; the University of Pittsburgh Medical Center-Presbyterian Hospital slashed MRSA by 90% in its intensive care units; and 29 healthcare institutions in Iowa eliminated VRE, another drug-resistant germ.

McCaughey says these institutions have tackled the staph problem through rigorous hand hygiene, the meticulous cleaning of equipment and patient rooms, and the testing of incoming patients to identify those carrying MRSA. Wheelchairs and other equipment used to transport patients who test positive for MRSA are not used for other patients. Also, hospital staff must change their uniforms and footwear after entering the MRSA patients’ rooms before they are permitted in other areas of the hospital.

Hospitals Need to Clean Up Their Act
These may seem like routine precautions that most hospitals would implement. However, McCaughey, in a booklet titled “Unnecessary Deaths: The Human and Financial Costs of Hospital Infections,” shows that typical hospital hygiene falls far short in terms of adequately dealing with these diseases. She says more than one half of the time, caregivers fail to clean their hands before treating patients. Gloves are not a solution because pulling them on with dirty hands contaminates them. Nearly three quarters of patients’ rooms are contaminated with MRSA and VRE. These bacteria are on cabinets, countertops, over-the-bed tables, bed rails, and other surfaces. Once patients and caretakers touch these surfaces, they become vectors for disease. Ordinary cleaning solutions are effective against these bugs, but surfaces need to be drenched for several minutes, not just sprayed and dried quickly.

On top of the failure to clean, there’s the matter of identifying carriers. “Most U.S. hospitals don’t routinely test patients to determine which ones are carrying MRSA and other bacteria,” says McCaughey. “Seventy [percent] to 90% of patients carrying MRSA bacteria are never identified.”

Clothing is frequently a conveyor belt for infections. According to McCaughey, when doctors and nurses lean over a patient who has MRSA, the white coats and uniforms pick up bacteria 65% of the time and carry it to other patients. Hospitals that are conquering infection require their staff to put on fresh gowns or disposable aprons every time they treat patients with MRSA. (The aprons cost a nickel and are ripped off rolls like clear plastic dry cleaning bags.)

McCaughey cites the case of a major academic hospital in New York City that is struggling to control the spread of Clostridium difficile, an infection usually caused by fecal material from one patient entering another patient’s mouth. How could that happen? Doctors there suspect it’s because clinical nursing assistants wear the same clothes while doing two jobs: emptying bed pans and delivering food trays.

The privacy curtains that surround a patient’s bed are seldom changed, though they are often the last thing a caretaker touches before treating a patient and the first thing touched afterward, when the caretaker uses contaminated gloves to pull open the curtain. Stethoscopes, blood pressure monitors, and other pieces of equipment frequently carry live bacteria. “Does your doctor clean the stethoscope before listening to your chest?” asks McCaughey. “Probably not, though the American Medical Association recommends it.”

Implementing all the necessary hygiene practices is clearly an onerous task. After all, it took Denmark, a much smaller country than the United States, 10 years to get it right. But what is the result of maintaining the status quo? “Multiple studies show that diseases are not only deadly, but also, by ignoring them, we are wasting money, [not only] for the people who buy insurance and pay taxes, but also for hospitals,” says Farr.

In agreement is McCaughey, whose recent report updates these multiple studies. “One out of every 20 patients gets an infection in the hospital,” she says. “Infections that have been nearly eradicated in some countries—such as MRSA—are raging through hospitals in the U.S.”

Patients who do survive MRSA often spend months in the hospital and endure repeated surgeries to remove infected tissue. “In 1974, 2% of staph infections were MRSA. By 1995, the number had climbed to 22%; in 2003, an alarming 57% and still rising,” McCaughey reports.

The Costs
In terms of costs to hospitals, McCaughey says the following:

• Postsurgical wound infections more than double a patient’s hospital costs. When a patient develops an infection after surgery, the cost of care increases 119% on average at a teaching hospital and 101% at a community hospital.

• Urinary tract infections increase a patient’s hospital costs by 47% at a teaching hospital and 35% at a community hospital.

• The average ventilator-associated pneumonia infection (a type of infection contracted when a patient is on a respirator) adds $40,000 to a patient’s hospital costs.

• On average, a central catheter-related bloodstream infection increases a patient’s hospital costs by approximately $30,000.

• Staph infections are especially costly. These more than triple the average hospital costs.
McCaughey reports that there are approximately 2 million hospital infections per year that cost the average patient an additional $15,275, which means $30 billion is spent annually to treat the problem. This figure does not include doctors’ bills, home nursing care, lost time at work, and other nonhospital costs.

“The Institute of Medicine recently estimated that as many as 18,000 [people] a year may die prematurely because they don’t have health insurance,” McCaughey says. “But consider this even more tragic fact: Five times that many people die each year from hospital infection, and most of them are insured. Hospital infection kills an estimated 103,000 people in this country each year—as many deaths from AIDS, breast cancer, and auto accidents combined. Most of these infections are preventable.”

In terms of costs, McCaughey points out a recent study that shows that the 4.9% of patients who developed infections in hospitals wiped out 61% of the operating profits in those hospitals.

Blame Game
Since the solution—a commitment to cleanliness—is known and verified, why is it not a priority in this country? “People blame those ... doctors who order too many antibiotics and won’t wash their hands,” says Farr. “This is true to an extent. But I think our healthcare workers are as good as those in Denmark and the other countries that have successfully implemented good hygiene. It may sound silly, but tradition is very big in medicine. On the administrative level in hospitals and on the national level, the mantra has been ‘cut costs.’ True, these new measures would cost, to an extent, but that cost is nothing compared to the unnecessary costs incurred and lives lost by doing nothing.”

McCaughey says the Centers for Disease Control and Prevention (CDC) is partly to blame. “The CDC has delayed calling on all hospitals to institute the rigorous precautions that are working in other countries and in the few U.S. hospitals that have tried them,” she says. “CDC standard precautions are much less effective in preventing hospital infections. In fact, the CDC guidelines result in these infections traveling from patient to patient 1,500% faster than the workable guidelines. Every year of delay has cost thousands of lives and billions of dollars. The CDC constantly says it is preparing to do more but fails to act. The CDC has spent 25 years tracking the rise of deadly drug-resistant infections in hospitals but has done little to stop it.”

There are two factors that may galvanize change, McCaughey says. “One is from the trial lawyers. Remember asbestos? Hospital infection is the next asbestos. The infection problem has all the hot-button essentials of a successful class action lawsuit: 2 million helpless victims a year, copious evidence that infections are preventable, and a consistent pattern of failure to act.”

Second, says McCaughey, six states—Florida, Missouri, Pennsylvania, New York, Illinois, and Virginia—recently enacted laws to provide the public with risk-adjusted hospital infection report cards. Several other states are poised to follow suit.

Danger in the Unknown
Hospital infections, bleak as they are, at least have an optimistic component in that there is a known solution. That may not be the case for the recent rise of MRSA in the community. On September 7, 2005, scientists at the National Institute of Allergy and Infectious Diseases Rocky Mountain Laboratories published a paper on this matter in The Journal of Immunology. The investigator who directed the study, Frank DeLeo, PhD, says that although community MRSA is currently a much less serious problem than the hospital variety, “it is increasing nationally at an alarming rate and is difficult to treat.”

Farr points to a recent study in which 9,000 people were randomly selected to see how many Americans carried the community strain of MRSA. Researchers found that 32% of all Americans carry the bacteria in some form, whether it be a light infection that can quickly go away or the more serious varieties.

The troubling aspect of this strain is that it can infect healthy people. Often athletes, such as wrestlers and football players, who are in close proximity to each other are at risk. But scientists warn that anyone is at risk and also cite the strain’s ability to have devastating effects in a short time. DeLeo mentions one child who died despite being taken to the hospital just 12 hours after the outbreak occurred.

Although researchers are working on the problem, DeLeo says, “we do not know why cases of community-acquired MRSA infections are increasing, let alone how they flourish. But we do know the community strains can cause more severe forms of the disease.”

— Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.