New York, New York: If MRSA was epidemic there, could it be epidemic anywhere?

Home is where the heart is – and MRSA. Researchers studied an outbreak of MRSA in homes like this one throughout the Bronx and Manhattan. It raises the question: Why couldn’t the same thing happen in any urban center?

Wow, that was quite the study published this week by U.S. researchers trying to figure out what was behind an epidemic of skin and soft-tissue MRSA infections that occurred in Manhattan and the Bronx between 2009 and 2011.

The study, published April 21 in the Proceedings of the National Academy of Sciences, is heavy on genetics and requires a subscription, however, easy to read reports can be found in Nature and by CBS.

Anyway, in the effort to come to grips with the outbreak in New York City, the study offers a number of very instructive lessons about MRSA in general.

To begin with, it’s now abundantly clear that MRSA should no longer be thought of as just a hospital-bound phenomenon – simply put, it has also taken root in our homes. Specifically, the researchers found that MRSA had become “endemic,” i.e. regularly found, in private homes, and that the home plays a critical role as “reservoirs for transmission and diversification.”

Second, we see once again the effect our increasingly mobile society has on the spread of germs and disease. Because it wasn’t the case here that a single local infection spread throughout the NY community. Instead, researchers found that the MRSA had been brought into New York on multiple occasions from California and Texas. We have previously addressed this in the context of international travel where it was said: “Disease is just a plane trip away, and an outbreak anywhere is a threat everywhere.” The present study shows us that the same phenomenon is at work within the large borders of the U.S., and, we would assume, Canada too.

Third, the study illustrates the concept of “strains” of MRSA. As we pointed out recently: “We tend to think of MRSA as a single organism that remains the same over time. But that’s far from the truth and it’s also dangerously misleading. The fact is, there are hundreds of different strains of MRSA – and counting. Which strains predominate will change over time and also over place – not just between hospitals and communities but also between countries. What’s more – and this is key – many of the newer strains are more drug resistant and virulent (toxic) than earlier strains thus making MRSA harder, or even impossible, to treat.”

In this case the focus was on just a single strain of MRSA, called USA 300. While it’s the dominant strain found in U.S. communities the authors note that it was responsible for only 75% of the infections found. Moreover, even this single strain was found to be mutating.

Fourth, the researchers linked the MRSA outbreak – and the resistance of the MRSA to drug therapy – to a time of high-frequency outpatient antibiotic use. In other words, the MRSA outbreak was associated with the overuse of antibiotics. This is a phenomenon that involves physicians willing to please patients at the expense of their health, and demanding patients who insist on getting antibiotics for non-bacterial illnesses like a viral-based cold, as we’ve pointed out before in our discussion of the over-prescription problem.

Finally, even though they found that the MRSA had been brought into New York on multiple occasions from California and Texas, the study notes how MRSA is still very much prevalent in hospitals. Therefore, the authors say, further studies are needed to evaluate how hospitals might be involved in spreading the bacteria back into the community. Which leads us directly to the questionable hospital policy of not treating patients colonized with MRSA, thus sending them home with a 15 – 33% increased risk of infection to themselves, and the risk of spreading their MRSA to others. And that is is exactly what the study found: household members spread their MRSA to the people they live with.

So, in trying to understand why there was a MRSA outbreak in New York the researchers did not uncover factors unique to that city with the possible exception of it simply being a large urban center. Therefore, with this one qualification in mind, it would seem that the answer to the question, Can there be such an outbreak anywhere, is an emphatic, Yes.

We Typically Don’t Treat MRSA-Colonized Patients. Instead, We Let Them Run The Risk of Acquiring A Serious Infection. Why Is That?

Swabbing a patient to see if they’re MRSA-positive. But what happens next?

Canada has the second highest health-care associated infection rate in the world compared to other high-income countries. Every year at least 200,000 people become infected after they go to a hospital. Somewhere between 8,000 and 12,000 of those people will die as a result. And Canada’s Chief Public Health Officer says it appears that these numbers are rising. For example, the healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infection rate increased more than 1,000% from 1995 to 2009. If we were at war and suffering these kinds of casualties it would be front page news and we would be doing all we could to stop the bleeding.

Whether we’re doing all we can to stop the harm caused by infections contracted at hospitals has arisen in the context of the MRSA-colonized patient. Infection is a 2-step process that begins with the patient being “colonized” by the bad bug: the bug gets into open areas of the body’s exit sites such as the tips of the nostrils but the patient isn’t yet infected – they haven’t become ill – so far. But since studies show that between 1 in 4 and 1 in 7 patients who become colonized also become infected, good health care practice would suggest that you should get rid of the bad bug as soon as you know it’s there – you “decolonize” the patient.

Surprisingly, though, most hospitals do no such thing. For example, Prairie Mountain Health Authority in western Manitoba does not recommend treatment for colonization by MRSA. Dr. Greg Large, a general physician there, explains that the golden rule in medicine is “First, do no harm.” So if someone isn’t infected it means that no harm is being caused by the colonization – so leave the person alone. Because when you treat/decolonize you run the risk of creating irritation, toxicity, and antibiotic resistance; and it taxes hospital resources. Therefore, since 75 – 85% of the patients who are colonized never become infected, why risk harming them?

Hospitals covered by the Winnipeg Regional Health Authority confirmed by email that they do not have a policy specific to the decolonization of MRSA-colonized patients: “The decision to decolonize MRSA from a patient would be made by the clinical team on a case by case basis in order to protect the most vulnerable patients from infection. Those patients who present to hospital repeatedly with invasive infections would be significantly more at risk of becoming infected and, as a result, would be most likely to be decolonized.”

The most recent research on the subject demonstrates the high stakes that are involved. It found that of the 840 patients studied, 125 died (1 in 7) within six months of MRSA acquisition. Of patients surviving to discharge, 1 in 4 required multiple admissions for complications due to their MRSA infection. And surgery within 30 days as well as admission to an ICU were associated with MRSA infection.

Accordingly, the researchers conclude that “targeting interventions such as decolonization therapy and enhanced efforts to prevent device-associated infection to reduce development of infection in patients who newly acquire MRSA colonization may also have a key role.”

The Vancouver General Hospital took an important step in this direction. In 2012 they began decolonizing all of the roughly 7,000 surgical patients they have every year. As a result, surgical-site infections are down by almost 40%, which also saves the hospital about $2 million a year that it would otherwise have to spend to treat those infections.

Changing how we conceptualize the colonization issue may help as well. For example, we vaccinate healthy people all the time so they don’t run the risk of catching a disease, some a lot less serious than what a MRSA infection can do to you. So why not think of a policy of decolonization as a kind of “vaccination,” a way of preventing the risk of serious harm?

Finally, what about involving the patient in the decision to decolonize? If you were told you were MRSA-colonized and therefore faced a significantly increased risk of multiple hospital admissions, surgery, the need for care in an ICU, and even death, what would you do?

Two-Thirds of Hospital-Acquired Infections are Preventable

The new understanding: these people are now considered a vital part of your hospital health-care team.

About 7,000 Canadians die every year that don’t have to.

This is according to Dr. Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto’s University Health Network. In a statement to CBC’s The Fifth Estate last year he said we have the ability to prevent “about two-thirds of hospital-acquired infections (HAIs).”

The reason this matters so much is the staggering number of people who become infected after they go to a hospital: at least 200,000 a year. Tragically, between 8,000 and 12,000 of those people will die from those infections – each year. In other words, applying Dr. Gardam’s two-thirds statement to the numbers, it means that on average 7,000 Canadians die needlessly every year due to infections they acquire at hospitals across the country.

The number one way to prevent HAIs has focused on hand hygiene, i.e. doctors and nurse should carefully wash their hands before and after each patient visit. But a new Canadian study says we have made a big mistake by overlooking the crucial role played by hospital cleaning staff – or ‘Environmental Services’ (ES) as the study calls them.

The research, published in the American Journal of Infection Control, found that one-third of the respondents – lead infection control professionals – in 119 health-care facilities across Canada, did not rate their hospital’s ES as adequately trained to clean to standards.

What does “clean to standards” mean? It means that if you or I were hired to clean hospital rooms we’d get it wrong. We wouldn’t know, for example, what surfaces to focus our efforts on (the bedrail not the floor), what disinfectants and cleaning products to use, how much we can re-use, say, a cleaning rag – is it actually cleaning surfaces or merely dragging germs from the previous dirty surface and wiping them onto the next one?

The kind of picky detail needed to fix the problem is seen in this example: the use of color-coded housekeeping carts to ensure the appropriate cloths are used on the appropriate surfaces. There are four different colored buckets and clothes – red, yellow, blue and green. Red buckets are for bathrooms only, yellow for isolation rooms, and so on.

However, these kinds of solutions require expertise which can only come from the infection prevention and control people (IPAC), i.e. the highly trained specialist physicians in infectious disease who have to pass their knowledge onto the cleaning people.

And that’s what the study looked at: whether there was a good working relationship between IPAC and ES, if ES are being properly educated and directed by IPAC, and do ES know how to do their job properly.

The one-third statistic mentioned above was disappointing. As was the finding that 37% of hospital infection control experts believe their hospital is not clean enough to prevent the spread of MRSA and other potentially lethal organisms.

“We’re just not achieving the results we need,” said the study’s lead author, Dr. Dick Zoutman, an infectious disease specialist and professor in the school of medicine at Queen’s University in Kingston, Ont. People can get infected if they touch contaminated surfaces, including “high-touch” surfaces such as toilets, bed rails, bedside tables, call bells and door handles, and then their mouths. Hospital staff can  then spread the infection between patients if their hands are contaminated from these surfaces.

Dr. Gardam concludes that a major factor in preventing HAIs is the job done by their cleaning staff. “People don’t really think of them as part of the team, but if you think about how infections are spread in hospitals, they’re actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room.”

The bottom line is that hospitals generally undervalue the importance of cleaning staff, Dr. Gardam said.

To see the subtle way that germs travel in hospitals and the important role played by cleaning staff, watch this  highly “infectious” video – “The Bug Zone” – made by some imaginative doctors at Winnipeg’s Health Sciences Center.

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