Category: Photodisinfection

The Devil and the Angels are in the Details: Healthcare Worker Personal Protective Equipment, Designed to Prevent the Spread of Infection, is Failing Us – And the Problem isn’t With the Equipment

The continuing Ebola outbreak in West Africa has so far infected more than 800 doctors and nurses, killing close to 500 of them, despite the fact that they wore personal protective equipment (PPE) – gowns, gloves, goggles, and masks.

The problem isn’t confined to Africa. Cases where PPE-wearing nurses have contracted Ebola in top notch US and Spanish hospitals reveals an underlying and tricky issue: The equipment isn’t protecting us, it’s because of improper use not the gear itself, and the problem extends to bad bugs in general, not just to Ebola.

PPEJust last week at a medical conference in Orlando, Florida, researchers presented a study which found that contamination occurred almost 50% of the time in PPE-wearing US healthcare workers.

Myreen Tomas, MD, and her colleagues at the Cleveland Veterans Affairs Medical Center, enlisted in their study, nurses, nurses aids, phlebotomists, radiology technicians, physical and occupational therapists, and other healthcare personnel who use PPE and interact with patients.

In 435 simulations they had them remove gowns and gloves that were “contaminated” with a fluorescent lotion. They used black light to identify sites on skin and clothing contaminated with the lotion.

“We were very surprised by what we found,” said Dr. Thomas: Of the 435 PPE removal simulations, there were 200 instances (46%) of contamination, mostly to the hands and neck.

Here’s the good news. If healthcare workers paid attention to the details of using PPE, Dr. Thomas says they could reduce contamination rates to as low as 5%. For example: ensure the gown and gloves are the right size because they come prepackaged so often times they’re too large for most nurses and techs; put the gown on before the gloves; ensure the wrists are completely covered by the gown and that there is no exposed skin; and remove the gown by pulling it away from the body instead of over the head.

This matters because the wearing of PPE is standard practice for dealing with the vast number of people who contract contagious disease. A conservative estimate by the Centers for Disease Control and Prevention says that every year in the US more than two million people are sickened with antibiotic-resistant infections, with at least 23,000 dying as a result. MRSA alone is responsible for almost half of those deaths (p.77). The Canadian rates, population adjusted, are similar.

It’s understood that well-meaning healthcare workers are major conveyers of infectious disease simply because they are so exposed to it.

Thus the question: How much of this harm could we avoid if we paid attention to the details of PPE usage – and thereby reduced worker contamination rates to near 5% – as suggested by Dr. Thomas?

 

 

 

 

 

 

 

What’s For Breakfast?

pancakes 2When we were kids, my sisters and I loved it when our grandmother came by to make us breakfast. Our favorite dish was her pancakes, made from scratch of course, which we smothered in good old fashioned maple syrup. And as it turns out we may have been on to something quite healthy: the maple syrup.

Researchers at McGill University in Montreal say they have discovered an ingredient in 100% pure Canadian maple syrup that helps antibiotics to more easily kill bacteria, and also helps render those bad bugs less toxic in the first place.

They found something else too: the maple syrup extract makes bacteria less able to build biofilms, and it also breaks down biofilms already formed. These are the yucky greasy films you find on various surfaces. One very common example of a biofilm just happens to be — the plaque that forms on your teeth.

See where is this going? If you were to “agree” to have extra pancakes and maple syrup for breakfast — does that mean you wouldn’t have to brush your teeth?

Probably not. But had I ever put that argument to my grandmother I’m pretty sure it would have been met with a smile and something like: “Well, okay … but just this once, mind you!”

Here’s a brief video of the McGill researcher who put in the work on this and gives us a fuller explanation of the science behind it.

Lost and Found: A rediscovered medicine first used 1,000 years ago turns out to be more effective against MRSA than the antibiotics we have today

The scientist: Disease Warrior by day, Viking Warrior by night

The Scientist: Disease Warrior by day, Viking Warrior by night

It’s not often that a woman who dresses up as a Viking Warrior to reenact ancient battles on weekends teams up with a mild-mannered historian to solve one of our great medical problems.

Meet Freya Harrison, PhD, Research Fellow at the University of Nottingham’s Faculty of Medicine & Health Sciences – by day – warrior princess by night.

Of course, if you’re going to act the part of Viking Warrior it only makes sense that you learn to speak the language – Anglo-Saxon – which no one has much bothered to do since about 1066. Which is not a problem, you simply join the University of Nottingham Anglo-Saxon book reading club! And that’s where Ms. Harrison ran into history professor of Viking Studies, Christina Lee.

Coincidentally, Professor Lee had her own agenda on the boil: Her belief that the Medieval Era, the so-called Dark Ages, unfairly suffers a bad rap. Her theory is that it was actually a very rational era and one way to prove that would be to look at how they did scientific experiments.

The Historian: The Dark Ages had a Renaissance quality to them and she  would prove it

The Historian: The Dark Ages had a Renaissance quality to them and she needed a scientist to help her prove it

It just so happened that she was in possession of those Medieval Era experiments by way of one of the earliest known medical textbooks ever published, the 9th C Bald’s Leechbook, which Christina had been studying for years. Full of “recipes” for different ailments, she was interested in the one for a lump on the eye which she translated to mean a stye, which her research told her was usually caused by a staph bacteria, often drug resistant ones called MRSA.

Wouldn’t it be a great idea, Christina thought, if she could find someone willing to carry out this 1,000 year old experiment to see if it actually worked – to see if the ancient recipe could function as an antibiotic and kill today’s MRSA. And lo and behold in walks the Viking Warrior who immediately said yes to Christina’s proposed scientific adventure!

The age-old potion called for a precise ratio of garlic + onion or leek + wine + cow bile. “Pound them well together,” strain through a cloth, let stand for 9 days. No, they didn’t have to mash-up a cow; they managed to find the animal bile at a chemist shop. And for the wine, they got it from a vineyard that had been in the area since the 9th C!

Now for the first big test. Throw the recipe into a test tube full of bacteria, let stand for 24 hours, check to see if there’s any effect. There were sleepless nights leading up to that first morning when they looked to see if any of the germ cells were still alive: What Freya Harrison discovered was that the recipe had “a massive, massive killing ability. When we got the first results,” she said, “We were just absolutely dumbfounded. We did not see this coming at all.”

But success in the test tube is one thing, the trick is to make it work in real-life MRSA-infected wounds. So Harrison contacted colleague Dr. Kendra Rumbaugh who was already doing work on MRSA-infected skin wounds in mice at Texas Tech University in the United States.

After using Harrison’s recipe on the MRSA-mice, Dr Rumbaugh reports: “We know that MRSA-infected wounds are exceptionally difficult to treat in people and in mouse models. We have not tested a single antibiotic or experimental therapeutic that is completely effective; however, this ‘ancient remedy’ performed as good if not better than the conventional antibiotics we used.” (My emphasis)

The results matter because antibiotic resistant infections are predicted to cause more deaths than cancer by the year 2050. MRSA, in particular, is particularly deadly (p.77), responsible for about half of all deaths in the U.S. caused by germs resistant to our dwindling supply of antibiotics.

Initially, this was thought to be one of those Friday afternoon just-before-you-head-out-to-the-local-pub kind of experiment. But that’s not at all how it turned out. Dr. Freya Harrison: “The potential of this to work on people as an antibiotic is just beyond my wildest dreams to be honest.”

 

The House Guest

"Bob"

“Bob”

In the 1991 comedy What About Bob? Bill Murray plays Bob Wiley, a psychiatric patient who not only befriends the family of his psychiatrist played by Ricard Dreyfus, Murray turns into that dreaded house guest who just won’t leave. To make matters worse, Murray ends up marrying into the family notwithstanding Dreyfus’s numerous efforts to get him out of there including “death therapy” – placing 20 pounds of explosives in Murray’s backpack on a hiking trip. I’m reminded of the film by research published this week that casts MRSA in the Bill Murray role.

Investigators visited the homes of 350 people in Chicago and Los Angeles who had come to the hospital with skin infections. At these home visits investigators looked at family members’ noses, throats and groins for MRSA colonization. Of the 812 household members studied they found that MRSA colonized one or more of the body sites in 50% (405) of the cases.

Using fancy genome sequencing techniques they also found that: (1) MRSA persisted within the households from 2.3 to 8.3 years before their samples were collected (2) MRSA is transmitted from person to person within households that contain an individual with a skin infection, and (3) MRSA can evolve so that it becomes genetically unique to that particular household. Similar research has found that these newer strains are more drug resistant and dangerous than earlier strains thus making the MRSA harder, or even impossible, to treat.

How MRSA got into those households in the first place was not part of the study. But we know from other research that, ironically, hospitals themselves are implicated. That’s because when hospitals discover a patient is colonized with MRSA they don’t treat it – they don’t “decolonize” that person. Instead, so long as the person isn’t infected (sick) they’ll send them home once their primary illness permits.

But given that MRSA colonization is the greatest risk factor for MRSA infection, and because the researchers involved in today’s study conclude: “Decolonization of household members may be a critical component of prevention programs to control MRSA spread in the United States,” it seems time to reconsider the wisdom of sending MRSA-colonized patients home untreated.

The good news is you don’t need 20 pounds of explosives to it. We have the technology.

“The longer they stay, the longer they stay”

If you think people are being pushed out of hospitals sooner than they used to be you’d be right, but not necessarily because of long wait times and bed shortages. Rather, it’s because hospitals can do something to you that’s utterly counterintuitive – they can make you sicker. The chief concern is that you’ll pick up a serious infection.

mrsa 4For example, a recent study found that 1 in 12 adults in hospitals across Canada are either colonized or infected with a “superbug.” And that’s an underestimate because the researchers only looked at 3 superbugs: MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant Enterococci), and Clostridium difficile.

Dr. Brad Spellberg, an infectious disease specialist and the Chief Medical Officer for Los Angeles County-University of Southern California, explains the issue.

To begin with, Spellberg says, understand that hospitals are a place where the sickest people in society are gathered together. Therefore, there’s lots of antibiotics being used and so you’re breeding superbugs that become resistant to the antibiotics. And so the bacteria you encounter in the hospital are a lot nastier than the stuff you’re going to pick up at home.

In other words, patients come into the hospital for whatever ails them and while there they pick up an infection, and the next thing you know that 1 or 2 day hospital stay turns into a week or a month. Hence the saying among physicians, “The longer the stay, the longer they stay.” Hence the new thinking, “get people out of the hospital before they get a complication of being in the hospital.”

There’s two interesting sidebars to this.

One, these nasty hospital superbugs are seen more in developed countries than in underdeveloped countries. These superbugs and the infections you get in the hospital are side effects of modern medical therapy. For example, all those lines and tubes that permit various medicines to get into your body also give bacteria easy access to your body. Before they had to fight through your skin. Now they have a direct route into your bloodstream through these “super-highways.”

Two, your lifestyle matters. For example, wear a seat belt so if you’re in a car accident you don’t end up in the ICU with a head injury, but in the ER with minor cuts and bruises.

Dr. Spellberg’s remarks can be found in the following interview. Most of the good stuff is explained in just the first 3 minutes. Aside from being a leading world authority on the subject, Spellberg is a compelling speaker and writer. Anything from this guy is well worth checking out.

How did drug-resistant E Coli end up on the lettuce in Vancouver famers’ markets? The answer my friend is blowing in the wind

Jayde Wood

University of British Columbia land and food systems researcher Jayde Wood noticed something unusual: a spate of outbreaks of food-borne illness associated with fresh produce. “Ten to 20 years ago,” she says, outbreaks were mostly related to beef and animal products. Things have changed. The proportion of foodborne disease related to fresh produce has experienced a drastic increase in the past 10 years.”

So her team trotted over to the nearby farmers markets in Vancouver to collect produce samples from 14 vendors at 5 different, unidentified markets, and test them for a range of different bacteria.

They found bacteria in 72 % of their samples, of which 13% harbored E. coli.  What Wood found “shocking,” however, was that almost all the E.coli were resistant to one or more antibiotics. And then there was the yuck factor: 20% of the E. coli in the samples were fecal contaminated.

It wasn’t within the mandate of Wood’s research to explain these findings, however recent studies in the US give us a pretty good idea about what’s going on. The trick is to look at 3 facts in combination in the Wood’s research: (1) E coli is found in the gut of animals (2) antibiotic resistant E coli – which was 97% of them in the Vancouver samples – means the bacteria had previously been exposed to antibiotics, and (3) the evidence of fecal contamination. This all points in one direction – to industrial farms as a source.

It works like this. About 80% of antibiotics used in the US (where we have more complete data) aren’t for people; rather, they’re for food animals – cows, pigs, and chickens – to make them grow faster and to prevent them from getting sick. Scientists have also figured out how much antibiotics we throw at these animals each year and it’s a whopping 13 tons, which raises the question: where does it all go?

How resistant bacteria go from these farms to people was looked into by Brian Schwartz, MD, of the Johns Hopkins School of Public Health. His team was interested in the escalating MRSA rates in rural Pennyslvania and wanted to know if they were related to the numerous nearby industrial-scale pig farms. Schwartz concludes there is a connection and explains:

“Every year in this area [rural PA], there’s about 600 million gallons of animal manure spread onto crop fields.

When you have antibiotics in animal feeds, the manure is loaded with undigested antibiotics. It’s loaded with antibiotic-resistant bacteria. And it’s loaded with the genes that the bacteria can transfer back and forth to each other that allow them to become resistant.

So you put the manure on that crop field, and it doesn’t rain for a month. And the soil gets dusty, and a big wind comes by. It goes airborne. It can travel by air. Or conversely, a big rainstorm comes by and all the MRSA gets washed off into the drainage, off of the field and into the local streets and onto the neighbors’ lawns.”

There’s a way to independently verify Schwartz’s study. Find yourself an industrial farm and check for samples of antibiotic resistant bacteria and antibiotics both upwind and downwind of the farm. If Schwartz is right then the downwind collection should contain significantly more bacteria and antibiotics.

Would you like a boiled salad with that?

Scientists at Texas Tech did just that and their findings were exactly as the Schwartz study predicts. Lead researcher Phil Smith, PhD, explains: “Bacteria are quite resilient beings and can survive on … feedlot dust as they travel in the wind. And because the antibiotics travel with them, this puts them under selective pressure to retain their resistance as they multiply – the non-resistant ones just don’t finish the journey…The particles travel far from their starting point at the feedlot. (My emphasis.)

For those fortunate enough to live in Vancouver the question becomes, what can you do to protect yourself from foodborne pathogens? UBC’s Jayde Wood offers this: “You can probably wash away a lot of bacteria, but it only takes a tiny amount of pathogen to get you sick. Chances are not that great that washing will completely eliminate all of the virulent bacteria.”

“There’s not too much else you can do as a consumer,” she says. “Cooking is effective at eliminating bacteria, but you don’t really boil your salad before you eat it.”

It’s All In The Delivery

As legendary comedian Jack Benny used to say, it’s not so much the joke but how you deliver it that makes all the difference. As it turns out there may be a similar rule at work in the delivery of antibiotics.

The question is this: When you take an antibiotic, whether orally or by IV, how does it know where to go? The infection could be anywhere in your body; in your lungs, your nose, your knee, your ankle, etc. So when you take the antibiotic, does it go directly to the trouble spot as if it were riding in a taxi, or does it behave more like a bus, stopping at several places along the way?

The answer is bus, apparently.

“When you give antibiotics by mouth or IV, it goes through your entire body. Everywhere in the body sees it and all the bacteria that’s already in your body see it,” says Fred Sweet, MD, co-founder of the Rockford, Illinois Spine Center.

This made Sweet curious. He wanted to know if direct versus indirect delivery of the antibiotic made a difference in the ability to treat infection. His theory was that each time the antibiotic bus stopped, it off-loaded some of its potency, therefore by the time it got to the trouble spot it wouldn’t be as effective.

So he brought in the rats and loaded them up with disease-causing bacteria. One group was administered the antibiotic vancomycin (the last resort antibiotic for MRSA) through an IV. The other group was given the same amount of vancomycin that was in the IV, but all of it was applied directly to the area of infection in powder form via a patch.

The result? For the rats that got the IV, 100 percent became infected. For the vancomycin powder, none became infected.

Dr. Sweet says there are two important implications. One, by changing how antibiotics are administered, physicians could possibly reduce the rates of infection after surgery nearly tenfold. Two, lessening the antibiotic load through direct application would mean having fewer antibiotic-resistant strains of bacteria thus slowing the rising plague of antibiotic resistance – which is predicted to cause more deaths than cancer by 2050..

Sweet thinks it’ll be 15 to 20 years before the technique could become the status quo, but added that from what he could tell, “If we can reduce these systemic antibiotics, I think within just a few years after that the number of resistant organisms will fall off the charts.”

So the next time your doctor prescribes an antibiotic be sure to ask her if there’s any way it can be delivered by “taxi”!

A “smart” watch designed to promote better hand hygiene in hospital workers was voted the second most important medical advance of 2014. But should it have been?

The heat is on to deal with the rising global plague of antibiotic resistance (ABR). A problem so severe that a report just released, commissioned by UK Prime Minister David Cameron, predicted it will cause more deaths than cancer by 2050. This past September, President Obama issued an Executive Order giving the full force of law to a National Strategy on Combating ABR. And the people that oversee the prestigious Longitude Prize in science have made available all of its US $15 million prize fund to come up with solutions.

So given the worldwide push to address ABR it perhaps shouldn’t surprise us that readers of the online medical journal Medscape – doctors, nurses, and scientists – voted a smart watch, designed to encourage better in-hospital hand hygiene, to be the second most important medical advance of 2014.

The Year in Medicine 2014: News That Made a Difference. Medscape, Dec. 15, 2014

It’s a smart idea to address the issue of healthcare worker hand hygiene: “The critical thing that all of us as healthcare providers can do is clean our hands between patient contact: and that is the number one, two, and three action to keep our patient safe,” says Dr. John Embil, Director of Infection Prevention and Control at Winnipeg’s Health Sciences Centre. That’s because the contaminated hands of healthcare workers are the most common vehicles of transmission in most settings.

But we may have a problem. As we said at the time of the smart watch announcement, it’s not just that it might not solve the problem of hospital-acquired infections — it could well make it worse. A sharp-eyed microbiologist pointed out to Medscape: “You know what I never see is a comment about the watch itself (any watch). You can’t sterilize a watch, you can’t even clean most very well. You could clean and sterilize the watch band, if you want to take the time to remove the watch from it. That watch sees many patients a month. That watch can catch all types of particles [germs] …”

Indeed, earlier in the year Medscape published the recommendations of The Society for Healthcare Epidemiology of America (SHEA) regarding what healthcare professionals should wear. Chief among the recommendations is what SHEA calls the Bare Below the Elbows (BBE) policy, something the Brits, for one, have long endorsed.

BBE means just that: nothing on the arms below the elbow, thus healthcare workers should wear short sleeves versus the traditional white lab coat, no wristwatch, and no jewelry. This ensures better hand and wrist hygiene, thereby minimizing the transfer of bacteria that might be contaminating HCWs attire.

Apparently BBE was a success in Britain as instances of MRSA cited on death certificates fell by 77 per cent after the policy was implemented.

So the right policy – or device – will make a difference. That makes sense. But we also have to be careful. Just because we call something “smart” doesn’t mean it is.

If only it were that easy.

A minute of your time: Here’s a 70 second video on how to stop the spread of infection in your home

In Wednesday’s blog we wrote about the disquieting fact that if you contract MRSA in the community – your home, say – it will return 40% of the time, either to the patient or to someone in their household. The main reason for this is that the bad bugs will remain on you, someone you share your home with, or on certain household surfaces.

The good news is that health authorities unanimously agree on the best way to prevent a recurrence: wash your hands – that’s the Golden Rule of infection prevention.

But there’s a problem. We mortals don’t know how to do it properly. For example, a study conducted in 2012 found that fecal strains were present on 26% of hands, with 11% of hands being comparable to a dirty toilet bowl in terms of the number of germs – yikes!

So here’s a video from our friends in Britain that shows us the right way to wash. I don’t know about you but I scored an F!

Handwashing best practice from Royal Society for Public Health on Vimeo.

MRSA – the house guest that just won’t leave

Doctors have long noticed something disquieting that happens after they successfully treat someone who contracted MRSA in the community – in their home, for example – it comes back about 40% of the time. Either to the patient or to someone in the patient’s household.

So researchers at the Harbor UCLA Medical Center looked into why MRSA is a repeat offender. They found a number of things that you’d expect and something that you wouldn’t.

The basic fact is this: in a home where someone had MRSA, and even though that person may now be better, MRSA bugs will remain in the house for 3 months or more, 50% of the time. So even though you’re now cured there’s still a coin flips chance that more of the little buggers will continue to hide out in your home for months.

Where in your home? On you, anyone that lives there, and certain household surfaces more than others.

Let’s begin with you. Let’s say a MRSA skin infection on your hand is successfully treated. Nonetheless, you may still carry MRSA elsewhere on your body, your nose in particular, and elsewhere on your skin.

You also shed the bug as you go about your business in the house. The most common off-loading places are the bathroom door handle, bathroom sink handle, toilet seat in the bathroom used most frequently by the patient, the patient’s hairbrush, kitchen counter top, kitchen sink handle, landline telephone, refrigerator door handle, television remote, and the favorite nonplush toy of any child, if it was your child that had MRSA.

The researchers found that when MRSA remained in the home at the 3 month mark it was most prevalent on the child’s favorite toy (ouch), bathroom door handles, and toilets.

The other people in the house will pick up the MRSA from these surfaces or from direct contact with the sick person.

So a good scrubbing of the house seems like the obvious answer but here’s where we run into a problem: the households that did the most cleaning were the same ones that had the most MRSA after 3 months!

So what can you do? You adapt the cop rule which says always watch the hands – no weapon can hurt you unless the bad guy has it in his hands. Similarly, medical authorities agree that a person’s hands are what most often carries and transmits the bad bugs – so always wash the hands.

As for how you get rid of your sick child’s favorite toy – well, proceed with caution!

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