103,000 deaths in 2000 due to nosocomial infection

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Question from an email:

Are we supposed to accept the slogan "Tons of antibiotics for the cows but not one gram for the people"?

They won't wash their hands

Hospitals are in the forefront of the evolution of methicillin-resistant staphylococcus aureus

In a bold new book, evolutionist Paul Ewald argues that viruses and bacteria play a huge, hidden role in heart disease, cancer and other modern plagues

By Geoffrey Cowley, NEWSWEEK, 11-27-00

`` Back in the 1880s, before tuberculosis had a known cause, experts attributed it to a combination of risk factors -- things like depression, bad ventilation, insufficient food and "family predisposition". One standard textbook noted expansively that "the idea of infection being a cause... still prevails in the South of Europe".

FAST-FORWARD TO the 1980s, and you hear similar accounts of peptic ulcers. The highly touted risk factors were stress, smoking, alcohol and, of course, "genetic predisposition." Never mind that an Australian researcher named Barry Marshall was successfully giving himself ulcers by swilling beakers of bacteria -- and curing them with antibiotics. The textbooks didn't even mention his work.

We now know that TB and ulcers are infectious conditions, caused by specific microbes and treatable with anti microbial drugs. Yet we're still laboring to explain most of our leading scourges -- cancer, heart disease, mental illness, Alzheimer's-- with long lists of risk factors.

In a compelling new book titled "Plague Time" (282 pages. Free Press $25), Amherst College biologist Paul Ewald argues that we're missing an obvious lesson here. Roughly translated: "It's the germs, stupid." (Plague Time is available at Amazon.com)

Though genes and lifestyle are no doubt important, Ewald says, the primary causes of today's "slow-burning plagues" are parasites --viruses, bacteria and other infectious microbes --whose long-term effects we have simply failed to recognize.

Ewald is not a virologist but a bold-minded evolutionist who, in past work, has created a whole new framework for thinking about infectious disease. To understand why microbes behave as they do, he considers their ecological incentives.

Cold viruses can't afford to be too virulent because they require mobile hosts. (A dying cold sufferer wouldn't get around enough to infect other people.)

Parasites that can survive outside their hosts don't have to be so considerate -- especially if they can travel from host to host via mosquitoes or drinking water. A dying malaria sufferer is, if anything, preferable to a healthy one from the parasite's perspective. All the person has to do to spread infection is lie still and get bit.

In "Plague Time" he takes a similar approach. By his reasoning, our genes shouldn't cause much heart disease, Genes that impede our survival tend to die out over time, as their owners fail to reproduce.

By contrast, the parasites with the best tricks for exploiting us are the most likely to stay in the game. THERE IS NO QUESTION THAT VIRUSES AND BACTERIA CAN TAKE UP LONG-TERM RESIDENCE IN OUR BODIES. Some hide deep within our cells to avoid detection by the immune system, while others disguise themselves to resemble our own tissues.

We know the consequences can be serious. Suppose the immune system catches sight of a streptococcal bug that normally evades detection by masking itself as a heart cell. As the body attacks the invader, it may demolish the organ as well.

The question is whether these chronic infections are as pervasive as Ewald suspects. Some experts would scoff at the notion, but the recent findings are impressive. "Until the 1980s," he writes, "it was generally not appreciated that women who were suffering and dying from cervical cancer were the victims of a venereal disease epidemic".

Today it's undeniable. Epidemiologists have puzzled for more than a century over the link between sexual promiscuity and cervical cancer. But over the past 15 years, studies have revealed that human papillomaviruses, America's most common sexually transmitted pathogens, are present in some 93 percent of cervical tumors. Scientists have even identified the proteins that HPVs use to release the brakes on normal cell division.

TIP OF THE ICEBERG

Cervical cancer may be the tip of an iceberg. Less definitive studies have linked childhood strep infection to obsessive-compulsive disorder and Tourette's syndrome.

Traces of a virus that causes mammary cancer in mice have been recovered from human breast tumors.

Researchers in Japan and Germany have linked borna virus --a brain infection seen in horses, sheep and cats-- to schizophrenia and bipolar disorder in people.

A growing body of evidence suggests that Chlamydia pneumoniae, a common respiratory bug, may play a key role in coronary artery disease, the leading cause of death throughout the Western world. Since 1988, researchers have consistently found the bacterium in clogged vessels but not in healthy ones. They've caused arterial lesions in rabbits by infecting them with the germ. They have even found hints that antibiotics can slow the progression of heart disease in infected patients.

As these connections are borne out, they could change medicine as profoundly during the 21st century as germ theory did in the 20th. The question is whether they'll get the attention they deserve.

As Ewald observes, "Those who control access to funding and the channels of scientific communication tend to be believers in the established views."

When Edward Jenner hit upon the notion of a smallpox vaccine in 1797, the Royal Society of London scolded him for risking his reputation on something "so much at variance with established knowledge, and withal so incredible."

When the Hungarian physician Ignaz Semmelweis figured out that physicians' unwashed hands were causing fatal infections among new mothers at the University of Vienna in the 1850s, he lost his own position there.

Though Barry Marshall first reported his findings on the infectious cause of ulcers in 1983, his peers ignored the discovery until 1990, when the National Enquirer got hold of the story and told the world. Let's hope the scientific community is less slow to notice this book. ''

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There seems to be an effort, perhaps encouraged by insurance companies, to limit the availability of antibiotics to patients under the guise of trying to prevent antibiotic resistence. Meanwhile, thousands of tons of antibiotics are used as feed to fatten livestock -- they would die from disease otherwise because of their packed, filthy housing. And, worst of all, hospitals have become the source of much antibiotic resistance because of the indifference of the medical profession.

FEATURE ARTICLE from The Chicago Tribune, 7-21-01, By Michael J. Berens, Tribune staff reporter

See the full article.

``Infection epidemic carves deadly path

CHICAGO -- A hidden epidemic of life-threatening infections is contaminating America's hospitals, needlessly killing tens of thousands of patients each year.

These infections often are characterized by the health-care industry as random and inevitable byproducts of lifesaving care. But a Tribune investigation found that in 2000, nearly three-quarters of the deadly infections--or about 75,000--were preventable, the result of unsanitary facilities, germ-laden instruments, unwashed hands and other lapses ...

Deaths linked to hospital germs represent the fourth leading cause of mortality among Americans, behind heart disease, cancer and strokes, according to the federal Centers for Disease Control and Prevention. These infections kill more people each year than car accidents, fires and drowning combined ...

"The number of people needlessly killed by hospital infections is unbelievable, but the public doesn't know anything about it," said Dr. Barry Farr, a leading infection-control expert and president of the Society for Healthcare Epidemiology of America ...

In a Detroit hospital, as doctors and nurses moved about the pediatric intensive care unit without washing hands, infections killed four babies in the same row of bassinets, according to court records and interviews. But it took three months for administrators to close the nursery for cleaning.

Staphylococcus germs thriving inside a West Palm Beach, Fla., hospital invaded more than 100 cardiac patients, killing 13, according to court records. The survivors underwent painful and debilitating surgery, as rotting bone was cut from their bodies ...

Even a term adopted by the CDC--nosocomial infection--obscures the true source of the germs. Nosocomial, derived from Latin, means hospital-acquired. CDC records show that the term was used to shield hospitals from the "embarrassment" of germ-related deaths and injuries.

To document the rising rate of infection-related deaths, the Tribune analyzed records fragmented among 75 federal and state agencies, as well as internal hospital files, patient databases and court cases around the nation. The result is the first comprehensive analysis of preventable patient deaths linked to infections within 5,810 hospitals nationally.

The Tribune's analysis, which adopted methods commonly used by epidemiologists, found an estimated 103,000 deaths linked to hospital infections in 2000. The CDC, which bases its numbers on extrapolations from 315 hospitals, estimated there were 90,000 that year ...

Government and hospital industry reports analyzed by the Tribune reveal that:

Serious violations of infection-control standards have been found in the vast majority of hospitals nationally. Since 1995, more than 75 percent of all hospitals have been cited for significant cleanliness and sanitation violations.

In thousands of cases observed by federal or state inspectors, surgeons performed operations without washing hands or wearing masks. Investigators discovered fly-infested operating rooms where dust floated in the air during open-heart surgeries in Connecticut. A surgical assistant used his teeth to tear adhesive surgical tape that was placed across an open chest wound during a non-emergency procedure in Florida.

Hospital cleaning and janitorial staffs are overwhelmed and inadequately trained, resulting in unsanitary rooms or wards where germs have grown and multiplied for weeks, sometimes years, on bed rails, telephones, bathroom fixtures--most anywhere ...

Since 1969, when U.S. Surgeon General William Stewart confidently told Congress that the nation could "close the book on infectious diseases," hospital infection rates have quietly pushed higher each year, registering a 36 percent increase in the last 20 years, according to CDC records.

Today, about 2.1 million patients each year, or 6 percent, will contract a hospital-acquired infection among 35 million admissions annually, CDC records show ...

Nurses, in particular, say staffing cutbacks have made the most basic requirements of their jobs difficult to fulfill ...

The national study of 799 hospitals found that patients were more likely to contract urinary tract infections and hospital-acquired pneumonia if nurse staffing was inadequate. The study projected that the widening nursing shortage could create even more problems, such as higher mortality rates.

"When you have less time to save lives, do you take the 30 seconds to wash your hands?" said registered nurse Trande Phillips, who works in San Francisco.

"When you're speeding up you have to cut corners. We don't always wash our hands. I'm not saying it's right, but you've got to deal with reality."

... doctors at Bridgeport Hospital voted on April 21, 1997, against testing all patients for infection because it was not "cost effective," according to minutes of a meeting by the hospital's infection-control committee obtained by the Tribune ...

A hidden camera was installed outside Operating Room2, and the tapes revealed that up to half of doctors, primarily surgical residents from Yale University, did not wash their hands before entering the operating room, according to hospital records.

Operating rooms should be secured and sterile during surgeries, but nurses and doctors routinely stepped inside Room2, even while open-heart surgery was under way, to make personal calls on a phone mounted on the wall.

Doctors also are supposed to change from street clothes into clean scrub outfits in a changing room at the hospital, but many doctors wore the scrubs home and back into the hospital the next day--and then directly into the operating room ...

In the 1840s, a Hungarian-born physician, Ignaz Philipp Semmelweis, stood in a Vienna auditorium before his medical peers and proffered a controversial theory: Washing hands saved lives.

When treated by doctors with unwashed hands, pregnant women often developed fatal infections following hospital births, but mothers rarely contracted infections if doctors thoroughly scrubbed their hands with soap and water, his groundbreaking study found.

European doctors ... [after firing Semmelweis, later adopted] the soap-and-water regimen -- the Semmelweis technique. Infection rates plummeted ...

U.S. doctors debated the procedure for an additional two decades.

By the end of the century, however, America developed a hospital system second to none, in part through an obsession with cleanliness. Prevention became a life-or-death necessity because almost any infection could kill.

But by the 1950s, the widespread use of penicillin and other antibiotics allowed doctors to overcome once-lethal infections, and over the decades, prevention gradually became less of a priority. New generations of doctors have grown accustomed to responding to symptoms--wait until the patient is sick, prescribe a drug.

Within the average U.S. hospital today, about half of doctors and nurses do not wash hands between patients, a dozen recent health-care studies show.

The direct observations of federal and state inspectors in recent years underscore the carelessness that threatens patient health. In Baltimore, inspection records show, a doctor placed his stethoscope on the chest of a sweaty patient in the grip of pneumonia, then walked to another room and placed the unwashed, moist device on the chest of a patient. The patient developed pneumonia.

In Loyola University Medical Center in Maywood, a resident physician dropped a surgical glove on a dirty floor, picked it up, put it on his hand and changed the bloody dressing on the open wound of a burn patient ...

Nurses and other health-care workers complain that it's virtually impossible to wash hands between every patient contact, which could number 150 times or more a day in a busy hospital ...

Consequently, most hospitals have begun to use a waterless disinfectant that kills germs and instantly dries on hands. Nurses can squeeze the solution on their hands from wall dispensers and continue to the next patient as their hands are cleaned. Studies show the waterless system kills germs as effectively as soap and water. However, many nurses fail to adopt even this simple measure, hospital inspection reports show ...

The sanitary condition of a hospital also depends on the diligence of its housekeeping staff, but in many facilities those staffs are poorly trained and overburdened.

Since 1995, federal inspectors have cited 31 Chicago hospitals for failure to properly sanitize rooms between patients, mirroring problems found in half of hospitals nationally ...''

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FEATURE ARTICLE from The Chicago Tribune, 7-23-01, By Michael J. Berens, Tribune staff reporter

See the full story.

``Drug-resistant germs adapt, thrive beyond hospital walls

Lapses in infection control and overuse of antibiotics [in hospitals] are spawning drug-resistant germs that are spreading from hospitals into the community at unprecedented rates.

These new super germs -- stronger, more elusive and deadlier -- have multiplied for decades inside thousands of hospitals and now are hitching rides into outside communities on the clothes and skin of patients, workers and visitors.

Until the last few years, most germs quickly died after exposure to the harsher environmental conditions outside hospitals. But, increasingly, microorganisms survive for days, even months. And they have developed the ability to breed most anywhere.

"It was only a matter of time before hospital germs became strong enough to live in the community," said Dr. Donald Graham, department chief of infectious diseases at the Springfield Clinic and professor at Southern Illinois University School of Medicine. "We're seeing them pop up everywhere."

In Illinois, the Tribune identified 4,712 cases during 2000 in which individuals contracted hospital-born germs without setting foot in a hospital or other medical center--a 1,000 percent increase in the last decade, an analysis of state patient records and public health reports show ...

The progression of drug-resistant germs from hospital to community has taken decades to occur, spurred by a long-standing practice to rapidly treat patients with antibiotics but not invest in the more time-consuming efforts to locate the sources of germs, federal studies show.

As a result, many hospitals have become reservoirs of microorganisms that continue to adapt to germ-fighting drugs.

The flow of germs outside the hospital also is aided by cost-saving strategies to discharge patients quickly. In the 1970s, the average stay was about seven days for most patients. Today, stays at most hospitals average three days, according to the American Hospital Association.

Most infections are not detectable during the first three days after exposure, so doctors commonly flood patients with antibiotics, even when they're not sure an infection is present. Health-care researchers cite this practice as one of the chief culprits behind the rise in drug resistance.

During longer stays, hospitals had more time to identify infections and provide treatment. Patients were more likely to leave the hospital without a lingering infection. Briefer hospital stays mean that more patients are at home when infections first show symptoms.

Recent federal studies conclude that up to 16 percent of patients' family members carry germs spread by the patient. In most cases, the germs remain inactive but continue to spread to other people or places, creating a chain of migration that is largely untraceable. Tens of thousands of people now are infected each year as the germs find hosts outside the hospital ...

In 1997, two pediatricians at the University of Chicago Hospitals stumbled onto a discovery that cast a national spotlight on hospital germs spreading into communities.

Their curiosity was aroused when they encountered a Chicago boy hospitalized at the U. of C. for a pneumonia that was resistant to methicillin, the most used and effective antibiotic against the infection. The germ is known as methicillin-resistant staphylococcus aureus ...

Drs. Betsy Herold and Robert Daum dug deeper. The boy had not been sick, nor had he recently visited a hospital or any medical center. Likewise, none of the boy's family members had been sick or visited medical centers ...

Worried they were witnessing a new and dangerous trend, the doctors pored over patient medical files dating to 1993. They discovered 35 previously unknown cases where children appeared to contract MRSA (methicillin-resistant staphylococcus aureus) outside the hospital.

Herold and Daum published their findings in the Journal of the American Medical Association in early 1998, the first documented proof in this country that MRSA (methicillin-resistant staphylococcus aureus) had spread into communities.

The Chicago discovery was part of a national groundswell of recognition ...

In July 1997, a 7-year-old girl from Minnesota who complained of fever and a pain in her right groin died from MRSA (methicillin-resistant staphylococcus aureus).

In January 1998, a 16-month-old girl from North Dakota arrived at a local hospital in shock, with a temperature of 105 degrees. She died within two hours of admission. MRSA (methicillin-resistant staphylococcus aureus) was found in her lungs.

In January 1999, a 13-year-old girl from Minnesota was taken to an emergency room after complaining of fever and spitting up blood. MRSA (methicillin-resistant staphylococcus aureus) was found in her blood. She died seven days later.

In February 1999, a feverish 12-month-old boy from North Dakota was taken to the emergency room after repeatedly vomiting. MRSA (methicillin-resistant staphylococcus aureus), which was found in the lungs, resulted in pneumonia. The boy died a day later.

These and many other discoveries stoked renewed interest in infectious diseases as researchers delved into the molecular construction and behavior of germs.

Germs that once required moisture now survive on dry fabrics. Germs dependent on a living host can go dormant on inanimate objects for weeks before bursting to life upon contact with human skin. These germs are capable of reproducing in minutes, share their enhanced abilities with other germs upon contact and thrive on surfaces even after smothered with disinfectants ...

Staph's ability to develop resistance ... Beginning in the 1940s, penicillin was the first line of defense against staph, killing nearly every germ. By 1982, penicillin was effective in less than 10 percent of cases ...

As penicillin's effectiveness waned, doctors turned to methicillin, a more powerful antibiotic. In 1974, the replacement drug killed 98 percent of staph germs. By the mid-1990s, it could kill just half of them, and the percentage of staph germs resistant to methicillin is rising.

The problem facing the medical community is that germs, which multiply into millions of one-cell organisms every few minutes, can undergo spontaneous mutations that result in resistance. Every time an antibiotic is used, it presents another opportunity for the germs' genetic material, their DNA, to mutate and be passed on to the next generations of germs.

"We humans can take generations to adapt to stress," said the U. of C.'s Daum. "Bugs can take minutes."

One measure of the hospital industry's decline in controlling germs and infections is found in hospital inspection reports compiled by state public health agencies and the U.S. Department of Health and Human Services.

Mirroring the national trend, nearly half of Illinois' 305 hospitals have been cited for potentially life-threatening breakdowns of infection-control standards since 1995. Violations range from failure to disinfect rooms, including intensive care units, to unsanitary habits of health-care workers, such as wearing contaminated gloves or clothes or failing to wash hands.

Though carelessness is a big part of the problem, so too is the harsh calculus of hospital administrators who don't want to pay the cost of searching for the reservoirs of germs, said Dr. Victor Yu, a professor of medicine at the University of Pittsburgh who specializes in hospital-acquired germ research ...

"Too many administrators don't want to necessarily find germs inside their facility because repairs to equipment or extensive cleaning can mean shutting down a department or floor. Even a few hours is a significant loss of revenue," Yu said.

Yu and a growing body of infection-control experts are critical of the CDC-endorsed policy known as selective surveillance, in which hospitals don't screen all patients for infections, but target only the sickest or most vulnerable ones. Hospital officials argue that testing every patient is too costly.

Though selective testing identifies many hospital-acquired infections, it allows a significant number of germs and infections to go undetected, leaving colonies in the hospital that eventually can spread into communities, many of the nation's leading hospital epidemiologists say.

Hospitals, with their warm, constant temperature and immune-compromised patients, are ideal incubators for germs and prime hosts for outbreaks. Germs can find dozens of spots to multiply and wait for a person to infect ...

Heart patient Michael Lebedecker, 61, became concerned after health-care workers examined his surgical chest incision without wearing gloves, said his wife, Janet. She said she witnessed a surgical resident use his teeth to tear surgical tape that was placed across a chest bandage.

"My husband was worried about infections, but doctors said not to worry because there were no problems," she said.

Lebedecker, who underwent bypass surgery in 1999, contracted an antibiotic-resistant germ in the hospital and died five weeks after the operation. Hospital records show that he was infected by MRSA (methicillin-resistant staphylococcus aureus).

Lorraine Lydon, 57, survived a similar infection following cardiac bypass surgery, but she now lives a life tethered to oxygen tanks and dozens of expensive medicines. She said she saw instances where health-care workers failed to wash hands between patients, but she did not think the lapses were potentially dangerous at the time.

MRSA (methicillin-resistant staphylococcus aureus) was detected in her sternum within a week after the September 2000 surgery. Doctors told her they never determined the source of the germ.

Doctors have tried so many times to remove infection-ridden bones from Lydon that further surgeries could prove fatal to her weakened body.

"I've already had 18 surgeries, but the germ is still inside me. It will never go away," she said. "Besides, they've already removed virtually every bone in my chest. There's nothing else to take."

Investigative records from Florida's Agency for Health Care Administration show 23 complaints have been filed by patients or employees relating to infections or unsanitary conditions at Palm Beach Gardens from 1997 through 2001 ...

At lunchtime, for example, nearly a dozen nurses and other health-care employees streamed outside, carrying cafeteria trays of food to picnic tables on small grassy strips shaded by trees.

As the employees sat at picnic tables, ducks and other fowl darted about their legs in search of fallen crumbs. The birds frequently brushed feathers against the scrub uniforms of the nurses. Birds are considered major carriers of germs, particularly salmonella, which can cause lethal blood poisoning. Birds also can be carriers for staphylococcus germs.

Many employees wore protective slipcovers over their shoes as they trooped into the grass littered with bird feces. They did not remove the contaminated slipcovers before re-entering the hospital ...

In one case study, coordinated for the CDC by the Rollins School of Public Health of Emory University in Atlanta, 4,303 samples of staph germs taken from intensive care units were studied. Nearly 36 percent were resistant to the most common and effective antibiotics.

For Buffalo Grove resident Debra Shore, the race to find new antibiotics could become an issue of life or death.

Last year, a staph germ resistant to methicillin infected her right foot, which had suffered complications related to her diabetes. She already had lost three toes to amputation, and the infection caused swelling and intense pain in her foot ...

Shore received a new antibiotic that won FDA approval in 2000. The new drug, Zyvox, is marketed by Pharmacia Corp. as an alternative to vancomycin. Medical studies show Zyvox is as effective as vancomycin ...

In July, infected by staph again, Shore began a new round of antibiotics to try to save her right foot ...

"I fear there will be a day when there are no more drugs to help me," Shore said. "My doctor said this germ only was found in hospitals years ago. Now it's everywhere.

"If this germ gets any stronger, I may not be able to survive the next round."''

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