H5N1

Picard: Rita MacNeil’s death should make us angry

Via The Globe and Mail, André Picard writes a remarkable column about the death of Rita MacNeil, a singer whose death last week saddened Canada. Instead, he says, Rita MacNeil’s death should make us angry.

The death of Ms. MacNeil, a remarkable woman who overcame poverty, sexual and physical abuse, depression, addiction and obesity to become a star, should not only make us sad – it should make us angry. 

Angry because it underscores the scourge of hospital-acquired infections; angrier still because we have missed a glorious opportunity to take a larger lesson from her death, one that is a fitting tribute to a singer who was a social activist. 

Hospital-acquired infections sicken 250,000 patients annually and kill between 8,000 and 12,000 Canadians. The bugs patients catch while in care are one of the leading causes of death in this country; they kill twice as many people as breast cancer. 

Many, but not all, of the deaths are preventable. After all, people who are in hospital are often gravely ill; they are susceptible to infections. Sometimes, an infection can even bring about a merciful death: For a long time, physicians called pneumonia the “old man’s friend” because it is a relatively painless death. 

But people dying of hospital-acquired infections are not all frail seniors and not all are dying painlessly. They are suffering – and suffering horribly – from increasingly difficult-to-treat bugs like Clostridium difficile (where you essentially defecate to death) and methicillin-resistant Staphylococcus aureus (MRSA), which causes painful boils and can lead to the shutdown of your organs. These pathogens are increasingly resistant to treatment. 

We need to be careful not to point fingers of blame but, at the same time, we cannot simply ignore some damning facts. 

One of the greatest dangers after surgery is infection. The surgical wound can be a point of entry for a lot of nasty bugs. This is particularly true for patients with cellulitis. Their wounds must be cared for meticulously because, paradoxically, when you are being treated with antibiotics, you become more susceptible to infection. 

During Ms. MacNeil’s stay, part of the hospital was closed because of an outbreak of Norwalk virus. In that same period, several patients contracted MRSA. 

These are not airborne infections. There are two principal routes of spread of hospital-acquired infections: shared toilets combined with inadequate housekeeping and health professionals who don’t adequately wash their hands. 

The Cape Breton Regional Hospital, where Ms. MacNeil was treated and died, has a troubling patient safety record. 

When the Canadian Institute for Health Information published the first hospital standardized mortality rates (a comparison of expected deaths and actual deaths), the CBRH had the worst record in the country – with a mortality rate 37 per cent above average. (And let’s not forget that the average rate in Canada is pretty poor to begin with.)

Canada: Seniors in long-term care getting antibiotics for too long

Via CBC News: Seniors in long-term care getting antibiotics for too long. Excerpt:

Many seniors in long-term care are given antibiotics for longer than likely needed, a new Canadian study suggests. 

Most long-term care residents with common bacterial infections such as lower respiratory tract or skin infections can be treated with antibiotics for seven days or less, according to randomized control trial findings. 

"High rates of institutional antibiotic use are driving increased rates of antibiotic resistance, Clostridium difficile infection, antibiotic-related adverse events and healthcare costs; yet up to half of antibiotic use in acute and long-term care institutions is unnecessary or inappropriate," Dr. Nick Daneman of the Institute for Clinical Evaluative Sciences in Toronto and his co-authors said in Monday's online issue of JAMA Internal Medicine, previously known as the Journal of the American Medical Association. 

Daneman and his team investigated antibiotic use among 66,901 people aged 66 and older living at long-term care facilities in Ontario. They found nearly 78 per cent or 50,061 patients received a course of antibiotics in 2010. 

The antibiotics were most commonly prescribed for seven days. But nearly 45 per cent of the treatments, 21,136 courses, exceeded a week, the researchers found. 

Some doctors repeatedly prescribed the medication for longer periods. 

If all doctors followed the prescribing practices of their peers with the shortest courses of antibiotics, the researchers estimated the number of days antibiotics are used in long-term care would drop by 19 per cent. 

"Shortening that tail end of treatment, at which point antibiotics are putting people at potential risk without any potential benefit, seems to be a real feasible way to reduce antibiotic overuse," said Daneman, an adjunct scientist at the institute and an infectious disease specialist.

UK: New wave of 'superbugs' poses dire threat, says chief medical officer

Via The Guardian: New wave of 'superbugs' poses dire threat, says chief medical officer. Excerpt:

Antibiotic-resistant bacteria with the potential to cause untreatable infections pose "a catastrophic threat" to the population, the chief medical officer for Britain warns in a report calling for urgent action worldwide. 

If tough measures are not taken to restrict the use of antibiotics and no new ones are discovered, said Dame Sally Davies, "we will find ourselves in a health system not dissimilar to the early 19th century at some point". 

While antibiotics are failing, new bacterial diseases are on the rise. Although the "superbugs" MRSA and C difficile have been reduced to low numbers in hospitals, there has been an alarming increase in other types of bacteria including new strains of E coli and Klebsiella, which causes pneumonia. 

These so-called "gram negative" bacteria, which are found in the gut instead of on the skin, are highly dangerous to older and frailer people and few antibiotics remain effective against drug-resistant strains. 

As many as 5,000 patients die each year in the UK of gram negative sepsis – where the bacterium gets into the bloodstream – and in half the cases the bacterium is resistant to drugs. 

"Antimicrobial resistance poses a catastrophic threat," said Davies. "If we don't act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can't be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection. 

"That's why governments and organisations across the world, including the World Health Organisation and G8, need to take this seriously." 

There has been an 85% reduction in MRSA (methicillin-resistant Staphylococcus aureus), which has meant that many large, acute hospitals have no more than two or three cases a year. But there are now 50 to 100 cases of gram-negative bacteria infection for every MRSA case, according to Professor Mike Sharland of St George's hospital in London, an adviser to the Department of Health on the use of antimicrobials (antibiotics and antivirals) in children. 

"This is your own gut bugs turning on you. Between 10% and 20% are resistant to drugs. We do not yet know why they are on the rise, although some hospital procedures, such as the use of catheters, may be implicated. Many are in the very young or older population," he said. 

"There is a lot of work going on through Public Health England and the Department of Health to try to work out why it has suddenly risen." 

In the second volume of her annual report, Davies calls for politicians to treat the threat of the new bugs and the failing antibiotics as seriously as they did MRSA. She wants action across government departments – involving the Department for Environment, Food and Rural Affairs in particular – because of the use of antibiotics in farming. 

She is asking for the threat to be added to the government's strategic risk register, which will make it easier to raise as an issue abroad. Drug resistance is a global problem as the resistant strains of bacteria travel the world.

Still another doctor's take on CRE

Via the blog Controversies in Hospital Infection Prevention, Dr. Eli Perencevich has some Further thoughts on CRE. Click through for the full post and a lot of links. Excerpt:

I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail. 

This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." 

And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. 

And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequence stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. 

Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE. 

My recommendations: 

(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics. 

(2) Invest in studies to improve compliance with hand hygiene – only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands. 

(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors? 

(4) Undertake studies to further optimize environmental source control 

(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other other messaging techniques that have a chance to be effective.

This is the most interesting online debate I've seen in ages.

Canada: Fighting hospital superbugs with a robot

Via The Vancouver Sun, a report from The Canadian Press: A first in Canada: Vancouver hospital to use 'Trudi,' a bug-killing robot armed with UV light. Excerpt:

When Trudi the robot is plugged in and armed, it sounds more like a space shuttle launch system than a germ-killing machine. 

"Disinfecting will commence in 15 seconds; please leave the room," Trudi — as staff at Vancouver General Hospital have named it — calls out in a digital monotone from inside a treatment room. 

"Disinfecting process started," it continues, as its thin, vertical bulbs blast out powerful ultraviolet rays, killing germs and viruses that might be lurking nearby. 

The hospital is the first facility in Canada to use Trudi — whose formal name is Tru-D SmartUVC — as health officials across the country look for ways to protect vulnerable patients from catching potentially deadly bugs such as norovirus and C. difficile. 

Health officials in British Columbia have started a pilot project that will see Tru-D and a similar device each tested for five months to determine whether the technology should be used permanently in health-care facilities across the province. 

"We've been very impressed with the almost complete eradication of organisms, even when we take it to high concentrations," Dr. Elizabeth Bryce, the medical director for infection control at Vancouver Coastal Health, said after a demonstration of the device on Friday. 

"We hope it will decrease the rates of hospital-acquired organisms like superbugs." 

The Tru-D device is 1.65 metres tall with long bulbs running vertically up a round, clear shaft — think R2-D2 from "Star Wars" instead of Rosie from "The Jetsons." It can't move on its own and must be manually wheeled from room to room. 

A large sensor on the top of the device measures reflections from the UV light to determine the size of the room and how much exposure will be required to disinfect it. The process can take anywhere from 15 minutes to an hour. 

It must be used in an empty room that has already been cleaned by hospital staff, said Bryce, providing an extra layer of disinfection rather than replacing existing cleaning.

Branswell: Fecal transplants cure most cases of C. difficile

Via The Province, a report by Helen Branswell of The Canadian Press: Fecal transplants cure most cases of C. difficile, first clinical trial shows. Excerpt:

Fecal transplants cure most cases of persistent C. difficile infection, a landmark study has shown. 

That comes as no surprise to the increasing numbers of people who have turned to this unorthodox treatment for relief from the debilitating condition. 

But this publication marks the first time a randomized controlled trial — the most reliable type of study — has shown that the treatment is effective. 

"Overall I think this paper is an important paper to say that performing fecal transplants does work," said Dr. Tom Louie, an infection prevention and control expert in Calgary who has performed more than 100 fecal transplants. He was not involved in this study. 

"It will lead us to the tipping point where ... people may be more aware of the value of the normal bowel flora. This is verification that good bugs help." 

The study is published Wednesday in the New England Journal of Medicine, one of the most prestigious medical journals in the world. It was done by researchers from the Netherlands.

This is the big story of the day. Mike Coston at Avian Flu Diary has the story too, with useful commentary. Maryn McKenna at Superbug has a new post on it as well, and Ed Yong has a report in Nature News & Comment. All highly recommended.

Canada: Court approves $9M settlement over deadly C. difficile outbreak at Ontario hospital

Via The Globe and Mail, a report by The Canadian Press: Court approves $9M settlement over deadly C. difficile outbreak at Ontario hospital. Excerpt:

An Ontario court has approved a $9-million settlement for people affected by a deadly C. difficile outbreak at a Burlington, Ont., hospital. 

More than 200 people were diagnosed with C. difficile and 91 of them died after contracting the bacteria at Joseph Brant Memorial Hospital between May 2006 and December 2007. 

C. difficile can cause severe diarrhea, vomiting, dehydration and in some cases, death. 

Dozens of people who either contracted C. difficile at the hospital or whose relatives died after becoming infected with the bacteria there sued the hospital alleging negligence. 

The Ontario Superior Court of Justice has approved a settlement of $9-million, $1.2-million of which will go to lawyers.

"In some cases, death"? Looks like almost a 50 per cent case fatality rate, which puts this outbreak in the same league with human H5N1. C. diff in general kills about an estimated 15,000-30,000 Americans a year—which puts it in the same league as gunshot wounds. It's surprising that we usually ignore such a serious public health problem.

Canada: Synthetic feces for fighting C. difficile

Via The Chronicle Herald, a report from The Canadian Press: Fake poop could replace real stuff in fecal transplants. Excerpt:

Researchers have created a synthetic “poop” aimed at treating recurrent infections of C. difficile, a toxin-producing bacterium that causes severe and often debilitating diarrhea. 

The fake stool, dubbed “RePOOPulate,” is intended to replace donated human stool used in fecal transplants, a treatment that’s been successful in overcoming intractable cases of C. difficile infection. 

Clostridium difficile can take hold when a person is exposed to the highly contagious bacteria while taking antibiotics for another infection. Because those drugs destroy healthy, protective bacteria in the gut, C. diff is allowed to overpopulate the large intestine. 

C. diff is typically treated with a different antibiotic, but can rebound once treatment stops, leading to chronic rounds of re-infection and retreatment. The disease can lead to severe and life-threatening inflammation of the colon. 

Fecal transplants have been successful in knocking out C. difficile by repopulating a person’s colon with donated healthy bacteria, but the “ick” factor makes it difficult for patients to accept. 

“The problem is, of course, that fecal transplants are kind of primitive and disgusting,” said Emma Allen-Vercoe, a microbiologist at the University of Guelph who led development of the synthetic poop. “Patients don’t like it. A lot of them will put up with it because they’re desperate … and donors are not terribly keen usually.” 

The artificial stool is made up of 33 different bacterial strains initially derived from donor stool and grown in the Robo-gut, a lab system designed by Allen-Vercoe that mimics conditions in a human’s large intestine. 

“It looks a little like a vanilla milkshake,” she said of the preparation of bacterial matter in a thick saline solution. “And it doesn’t smell nearly as bad as poop, I must say.” 

The synthetic stool is given to a patient using a colonoscopy, the same way a fecal transplant is performed. But the “ecosystem,” as it’s formally known, doesn’t have to be screened first for infectious diseases as donor stool would and is therefore safer, she said.

Netherlands: The dog who can sniff out C. diff

Via BMJ: Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study. The abstract:

Objective To investigate whether a dog’s superior olfactory sensitivity can be used to detect Clostridium difficile in stool samples and hospital patients. 

Design Proof of principle study, using a case-control design. 

Setting Two large Dutch teaching hospitals. 

Participants A 2 year old beagle trained to identify the smell of C difficile and tested on 300 patients (30 with C difficile infection and 270 controls). 

Intervention The dog was guided along the wards by its trainer, who was blinded to the participants’ infection status. Each detection round concerned 10 patients (one case and nine controls). The dog was trained to sit or lie down when C difficile was detected. 

Main outcome measures Sensitivity and specificity for detection of C difficile in stool samples and in patients. 

Results The dog’s sensitivity and specificity for identifying C difficile in stool samples were both 100% (95% confidence interval 91% to 100%). During the detection rounds, the dog correctly identified 25 of the 30 cases (sensitivity 83%, 65% to 94%) and 265 of the 270 controls (specificity 98%, 95% to 99%). 

Conclusion A trained dog was able to detect C difficile with high estimated sensitivity and specificity, both in stool samples and in hospital patients infected with C difficile.

For an excellent 10-minute video about Cliff the beagle, click here.

C. diff spread 'fast and easy'

Via BBC News: C. diff spread 'fast and easy'. Excerpt:

Two closely-related strains of Clostridium difficile became antibiotic resistant and were able to rapidly spread to hospitals around the world, a study says. 

Researchers were able to show how the bacterium travelled by forensically analysing its genetic code. 

The strains of the hospital infection seemed to become more severe after they became resistant. 

The findings were published in the journal Nature Genetics. 

The US Centers for Disease Control say C. difficile is linked to 14,000 deaths in the US each year. 

The infection has been in hospitals for decades. However, there was growing concern in the last decade after large outbreaks in Europe, the US and Canada. 

They were caused by a once rare variant of C. difficile which has become the most common cause of the infection in North America. 

Tracking 

The genetic code of C. difficile mutates rapidly. By comparing the genetic code of batches of C. difficile, researchers can work out how related different batches of C. difficile are. 

Doing this on a large scale, involving 151 samples from infections in 19 countries, allowed researchers to build up a picture of the spread of the antibiotic resistant strains.  

It showed there was a strain called FQR1 which started in the US and spread across the country and to Switzerland and South Korea. 

A second strain FQR2 started in Canada before spreading across North America, Europe and Australia. It entered the UK on four separate occasions. 

Dr Trevor Lawley, from the Wellcome Trust Sanger Institute, told the BBC: "If we can understand how it happened there are lessons in that. It's a fact that two strains emerged which tells us this is more frequent than we realise and it is driven by antibiotic resistance. 

"It also shows the global healthcare systems are completely interlinked - it showed up in the UK within months."