By John Roark
Since 1983, the Centers for Disease Control and Prevention (CDC) guidelinesfor barrier protection have recommended that patients infected or colonized withepidemiologically important pathogens should be placed under contactprecautions. In spite of these published guidelines, incidence ofantibiotic-resistant pathogens like MRSA and VRE continue to escalate.
In 1980, methicillin-resistant Staphylococcusaureus (MRSA) accounted for 2 percent of all of all staph infections, saysBarry M. Farr, MD, professor of internal medicine in the Department of InternalMedicine within the University of Virginia Health System. Now its 50percent, maybe higher. The problem of MRSA is out of control. It seems to be clearthat the reason its out of control is weve been looking the other way,hoping that something really bad wouldnt happen. In northern Europeancountries, where theyve taken a different approach, theyve controlled MRSAto less than 1 percent of staph aureus infections, and they keep doing it yearafter year after embarrassing year. These countries battle the same MRSA strainsthat are spreading in our communities (including new mec-4 strains foundspreading in prisons, in some sports teams and Native American communities)containing increased numbers of virulence genes. Theyre nasty and can kill acompletely healthy young person in short order, and have done so, Farrcontinues. Theyve done it in the United States, and theyve done it inthose northern European countries, but guess what? Our rate in the hospitalkeeps going higher and higher, and theirs doesnt. Theirs may be creeping up atiny bit, but its still less than 1 percent.
If we were trying to control antibiotic-resistant pathogenslike MRSA, and if we had patients coming in who were high-risk for MRSA, then itwould be a smart thing to do a culture and know who has it in order to preventspread, says Farr. Its been shown and published, and more studies arestill coming out that are confirming that theres a high relative risk ofspread from patients who are merely colonized. The tradition in this country hasbeen to look the other way, says Farr. I think that is why we have notcontrolled it.
Inertia is a powerful force in physics, and tradition ispowerful in human systems. Were all human beings, and in healthcare wetend to do what others are doing, says Farr. We just keep networking anddoing what the others are doing. If everybody else was doing it, and yourhospital was the only one that wasnt, your policy would change so fast thatpeoples heads would spin, so that they could keep up with the others. But ifthe others are doing nothing, taking no responsible action to control it, thentheyre not going to do it, even if they see the data that shows that it worksbetter the way the northern Europeans do it. There are now more than 70 studiesthat show you can control MRSA and VRE that way in healthcare settings. But mostpeople in this country keep on doing what they have been doing and what othersare doing.
Doing the Math
If you take a look at the studies on the reduction ofexposure risk, the costs involved in reducing that exposure are almost alwaysoffset by not having to deal with problems on the back side when it comes toemployees and/or patients who might be exposed and seroconvert in the healthcarefacility, says Carolyn Twomey, a clinical nurse consultant for RegentMedical. I think that overwhelmingly, people realize that theres a payofffor good barrier protection. Its just a matter of finding the right barrierprotection that works for everybody and getting everyone to comply with it.
Normally, if a person comes into the hospital waiting roomand theyre coughing and sneezing, nobody does anything, says Jay Sommers,PhD, director of clinical and scientific documentation for Kimberly-Clark. Nowtheres a big concern, not only for the other patients, but for the healthcareworkers.
On our posters, weve basically mimicked the guidelinesof the CDC on respiratory etiquette, Sommers continues. For example,someone with upper respiratory symptoms anybody with a runny nose, cough,sneeze, headache, fever give them a mask, show them how to put it on andtake it off. If theres no mask available, give them tissues. We are supportive of those guidelines theyre key because ofthe unknown. The fact that weve run out of flu vaccine exacerbates thesituation. We have people running around who havent been inoculated. Theresthe concern that if they do come down with something, you dont know whetherits flu or SARS.
People dont really know what to do. They see someonecome in and they think, are they symptomatic? Are they asymptomatic? What dothey have? Theres a thought process that goes into it, but unfortunately,they dont have a lot of time to think. Thats why some of the infectioncontrol guidelines have caused problems in the past what do we do? Who makesthat decision?
One of the topics being talked about are the new Society forHealthcare Epidemiologists of America (SHEA) guidelines on precautions withregard to MRSA and VRE. They want to do active surveillance, which means youtest the patient coming in, says Sommers. And they want to use gowns,gloves and face masks for the symptomatic. Theres enough evidence out, ifsomeone has VRE or MRSA, it can be airborne or droplets, and the healthcareworker should wear a face mask in dealing with these people.
It all adds up. Can cost-conscious hospital administrators seethe forest for the trees when faced with upfront expenses?
A culture costs something, a gown costs something, glovescost something, says Farr. For the past 11 or 12 years, people have beentrying to have healthcare as cheap as they can get it. Thats sort of anational imperative we had to lower our costs. They keep trying to be cheap,but they dont look at the studies that show that if you control theseinfections, which are more expensive and more deadly, then you actually havelower costs. Its sort of penny-wise and pound-foolish. Theyre not lookingat the entire picture; theyre just looking at what their purchase costs arefor the materials. Theyre not looking at the downstream effect of controllingit. Thats like saying, Im not going to invest anything, because thatwould cost money. Theyre not looking at the long-term outcome of havinginvested at the end of the day you have dividends. Theyre ignoring thedividends part of the picture.
It does cost more, and it takes more time. You look at costvs. benefits, reasons Sommers. Whats it going to cost a box oftissues, a face mask? But the benefit is youre preventing that infection fromspreading, even assuming somebody may have just the flu. If you can contain it,the costs are insignificant compared with what may happen. Another equation youcan use is cost vs. risk. Whats the risk of not doing the respiratoryetiquette? Its almost the same thing. The benefit is the protectivepart, the avoidance part, but then theres the risk also. What is the cost vs.the risk of not doing it?
Why exactly, arent adequate precautions being effectivelytaken? I think a lot of people wait until the CDC says Thoushalt do this, says Farr. The CDC started saying in 1983 that we shouldisolate the cases that were suspected or confirmed, whether infected orcolonized. But people have not read between the lines and thought:colonization is invisible. To know theyre colonized, we would have to do aculture, and we probably should to do it in the high-risk patients like they doin northern Europe. People here have not really gotten that message, partly, Ithink, because theyve never seen it in black and white. I hate to say that,but the CDC has never said that in black and white. So, people may just bewaiting to see that.
Which raises the question, why doesnt the CDC take adefinitive stand on this issue?
Well, theyre people too, says Farr. The CDC hasthose same forces of tradition and doing what others do, and not rocking theboat, and not making waves. If its their tradition, and they think that theywould make a lot of waves, or it would cost a lot of money, then maybe theyshouldnt go there: Maybe we just have to let this stay out of control andhope it doesnt get too bad. I heard about a hospital where 80 percent oftheir staph infections are now MRSA. So it can get worse. Were heading there. The voyage has begun.
Farr believes that we are on the way to bigger, badder bugs. There is the next threat, which is VRE and MRSA gettingtogether late at night and exchanging genetic information, and creating thegodzilla of the microbial world that can be more of a problem because itsmore antibiotic resistant. There have been two of those that have been seen.There have been some more that had intermediate susceptibility, and a study bythe CDC shows that the strains that were MRSA with intermediate susceptibilityto vancomycin were more deadly than infections due to plain MRSA. Now we knowthat we can have strains that are highly vancomycin-resistant, by the twogetting together and exchanging genetic information. The prospects are not realgood if we continue the present course. As Dickens said in A Christmas Carol,If these shadows remain unaltered, the child will die. Many Tiny Timsare going to die from antibiotic-resistant infections in U.S. healthcare. Andmany elderly Tims are going to die of this as well.
Problem Pathogen Partnership
In an effort to reduce and control the rates of MRSA and VREin hospital facilities, Farr created the Problem Pathogen Partnership, avoluntary program for facilities interested in helping protect their patients.
I was talking to Bill Jarvis, who was the head of theoutbreak investigations section at CDC for 17 years in the hospital infectionsprogram, says Farr. Jarvis had written an article in the New EnglandJournal of Medicine detailing how the Siouxland health district was able tocontrol VRE for three years. They had an epidemic going on in this healthdistrict, and people were worried and wanted to know what to do. Jarvis said ifyoure having a problem with this you should probably do some surveillancecultures, see who has it, and then use contact precautions, as the CDC hasrecommended. They did, and all 32 facilities (28 nursing homes and fourhospitals) agreed to participate. They identified who had it, they startedcontrolling it, and it got better year after year. At the end of three years,they had significantly reduced or eliminated VRE in all 32 facilities. It wasvery impressive, says Farr. Its the only place that has tried that forVRE in the U.S. Just think, what if an entire state was doing this whatwould the effect be?
Farr worked at setting up a partnership among area hospitals.We didnt have tons of money, being just barefoot doctors as we are, hesays. We tried to share the data, showed them Jarvis studies and otherstudies. What if we all tried it? A number of hospitals in Virginia and NorthCarolina started joining, a website was created, inviting people to share dataabout how this approach could work, included algorithms to tell people who wewould culture and when we would do it, and some basic recommendations.
Everybody basically should start a program and then modifyit as local conditions dictate to control the problem. Use the method to controlit. There are 300 hospitals in the two states, and probably 25 orso not quite 10 percent joined. They were not ordered to do that by theCDC; they did it because they wanted to help protect their patients. A number ofthem showed improvements.
Caution, vigilance and attention published guidelines are thefirst steps on the road to lower rates of infection. I honestly think thatyou have to remind people that its a jungle out there, says Sommers Themost basic of the infection control practices that are recommended are the mostimportant things you can do. That will help a lot of situations. Wash yourhands. Use a tissue. Dont touch a problematic area and then touch somethingelse, even if youve got gloves on. We work really hard to make sure that youremind people that its those kinds of behaviors that are going to make thebiggest difference.