Category: Photodisinfection

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!

On Antibiotics and our Responsibility to Question our Doctor about Them

As if being sick isn’t bad enough it now seems we have to do more than just tell our doctor what’s bothering us. In the context of antibiotics, at least, the new rule is that we have a responsibility to make sure our doctor is getting it right, according to highly regarded infectious disease specialist Brad Spellberg, MD.

In this video which runs less than 5 minutes, Dr. Spellberg lays out the issues around antibiotics beginning with what they are: “Antibiotics are just poisons that kill bacteria,” he says. And that fundamental fact – that they’re far from harmless – is what needs to guide our behavior. After the video we’ll discuss Spellberg’s crucial message.

So the point is that since antibiotics can hurt us the trick is to use them only when we have to – which is less often than we think.

Here’s Brad Spellberg on taking an antibiotic: “The key is you only take it when you have a bacterial infection. If you don’t have a bacterial infection and you take an antibiotic all you’re doing is killing off the good bacteria in and on your body and then you’re allowing resistant bacteria to set up shop. Next time you get an infection you now may be infected with the resistant bacteria.” (‘Resistant bacteria’ are those bugs that antibiotics have no effect on thus prolonging your illness, or worse.)

To ensure we take antibiotics only when our illness is bacterial and not viral – viruses cause the flu, most colds, sore throats, earaches, and a lot of bronchitis and pneumonia – Spellberg prescribes 2 rules for us to follow:

(1) “Should you question your doctor? Absolutely. What I would say is the first thing you say is, ‘Jeez Doc do I really need the antibiotic?’” And,

(2) “If the doctor’s clinical judgment is that you have a bacterial infection then you ask a second question, namely ‘Can you give me something that’s narrow? Do you have to give me something that’s so broad?’ Because different antibiotics kill different types of bacteria. You really want to hone in on the most likely bacterial cause.” In other words, you want an antibiotic that works like a laser not a hand grenade.

So when we’re sick and our energy’s down, when we can’t thinking straight and we feel pressure to get back to work and so on, the unfortunate fact is that just getting ourselves to the doctor isn’t enough. Once there we have to get it right, and, says Brad Spellberg, that involves asking his colleagues those two critical questions anytime we find ourselves in antibiotic territory.

And one more thing. As the Harvard School of Public Health cautions us, please stop asking for antibiotics!

The Antibiotic Reflex

Lost in the numerous daily stories about Ebola is this gem: When Thomas Duncan, the first Ebola patient to enter the U.S. undetected, first presented himself to a hospital in Dallas, he and his fiancée told staff more than once that he had been to Liberia. And even though his presenting symptoms were consistent with Ebola, that disease was never considered. Instead, he was diagnosed with a low-grade viral infection, given a prescription and sent home. Three days later he returned to the hospital in worse shape and was diagnosed with Ebola virus disease. The following week Thomas Duncan died.

Subsequent news stories about Mr. Duncan focused largely on two things: How on Earth did hospital workers not consider Ebola when he first appeared there (his family is understandably angry about this). And did he infect other people during that 3 days before he went back to the hospital and was finally admitted (so far, no).

But let’s back up. That prescription he was sent home with when he first went to the hospital – it was for an antibiotic. Never mind that they fumbled the Ebola ball, they also prescribed an antibiotic because they thought he had a low-grade viral infection. Which is like giving a fishing rod to a deer hunter: antibiotics treat bacterial-based infections only, not viral-based ones – so what were they thinking when they prescribed an antibiotic for a viral problem?

Thomas Duncan had the Ebola virus. But he was sent home from the hospital with an antibiotic.

Here’s the thing. Wrongly prescribing antibiotics happens far too often – about 40% of the time according to the US Centers for Disease Control: when presented with illness, the reflex to both seek and prescribe an antibiotic is common to both patient and doctor.

More often than not when you or your child have an ear ache, a sore throat, or cold, flu, or bronchitis-like symptoms, it is some virus that’s doing it to you. Nevertheless, people reflexively seek, and receive, antibiotics.

The physician reflex to over-prescribe is due to patient pressure, the fear patients will go elsewhere, not wanting to bother with lab tests, fear of being sued in the event that an antibiotic should indeed have been described, and, the big catch-all – even if antibiotics aren’t warranted, at least they’ll do no harm.

The assumption of no harm, however, has proven flat-out wrong. Because when you’re improperly prescribed an antibiotic two things happen: your bugs, not wanting to die, fight back and evolve into “superbugs” that are able to resist antibiotics in the future. So the next time you get a bacterial infection and really do need that prescription it won’t help you. Second, you don’t keep those superbugs to yourself. Instead, you spread them to the people closest to you, like family and friends. And like you – and because of you – should these people eventually need an antibiotic the chance of it not working has now increased.

We don’t know whether or not Mr. Duncan asked for an antibiotic. What we do know is that when he first went to the hospital the world in general and health care workers in particular were on notice (2d para below the Gov. Perry video) that a deadly viral outbreak in West Africa was just one flight away from our doorstep. Despite that, and despite having all the evidence it needed to treat Mr. Duncan as a possible Ebola case, the Dallas hospital antibiotic reflex sprang into action with dire consequences: Thomas Duncan died, his family are mourning, the hospital staff who got it wrong are surely not feeling good about themselves, and the nation is scared.

Preventing Infections With Universal Decolonization is the Smart Way to Extend the Useful Lifetime of Antibiotics

Eight days ago, the United States government rolled out its National Strategy to fight the growing crisis of antibiotic resistant bacteria. It is a crisis because at least 2 million Americans are severely wounded and at least 23,000 are left dead (about half are due to MRSA alone), every year, by infections that antibiotics no longer cure. As antibiotics continue to lose their usefulness, these numbers will grow.

MRSA (red) growing in the fibers of a wound bandage.

A key component of the White House Strategy is to try and extend the useful lifetimes of the antibiotics we have now by restricting their use – this is called “stewardship.” We’re familiar with the principle from our own lives.

For example, antibiotics are just like a community car: the more everybody uses it the more run down it gets until eventually it’s no good to anybody. So to extend the useful lifetime of the car restrict its use to necessary things like going to work, but no more drag racing and trips to the beach. With antibiotics, continue to use them to treat serious infections but stop prescribing them for things they don’t work on like the common cold and the flu, or because patients pressure you for them.

Back in July, when the president’s science advisors tabled their report that became the basis of the National Strategy, it received unanimous and enthusiastic approval. There was, however, one elegant and very subtle partial dissent from Christine Cassel, MD, a member of the President’s Council of Advisors on Science and Technology (PCAST).

Dr. Christine Cassel: Recognized by the NIH as one of the leading women leaders in science, and was the first woman to be President of the American College of Physicians and to be Chair of the American Board of Internal Medicine.

She began : “… [M]y congratulations … on a masterful and really thorough look at the original literature about this. I just wanted to – and this is not really I think in the report yet … – add to the definition of stewardship in two ways.  One is we think of stewardship as not prescribing antibiotics unnecessarily. But there’s another kind of stewardship which is reducing the risk of infection so the person doesn’t need the antibiotic … if you think about American hospitals … Medicare & Medicaid, and in particular the innovation center programs have incentives in place … to reduce HAIs, which is where some of the more dangerous ones are.

And we learned just in the last year that’s down 10%. You may say 10% is not a lot, 10% is half a million adverse events and 15,000 lives. Not to mention lots of dollars, but also lots of avoided need for antibiotics in the first place, and for exposing those bacteria to more antibiotics. So I think there’s a way in which looking at prevention is an important thing.” (My emphasis.) (Webcast, Antibiotic Resistance Report Discussion, 39 minute mark.)

Dr. Elizabeth Bryce: Her work embodies the philosophy of Dr. Cassel, and is supported by the latest research.

In other words – less elegantly – we need to double down on prevention. A prime example of prevention in action was just reported in The Journal of Hospital Infection. In a study led by Elizabeth Bryce, MD, the Vancouver General Hospital, concerned about the overuse of antibiotics yet needing to reduce infections that arise during surgery, replaced the standard antibiotic ointment with a universal decolonization method using a novel light-based disinfection therapy. They found a “significant reduction” in the overall surgical site infection rate and the greatest decreases were a 42% drop in orthopedic and spinal patients. (This work received an international innovation award.)

Given that one of the controls was the 12,387 surgery patients over the 4 years prior to the study who received the standard antibiotic therapy, the reduced infection numbers would have translated, over those years, into a lot of saved lives, needles trauma, and antibiotics that needn’t have been dispensed.

Indeed, as The Lancet reported yesterday, “findings from large randomised trials show that decolonisation of nasal carriers of S aureus, irrespective of sensitivity to meticillin, can reduce postoperative wound infections, and that universal decolonisation is more effective than targeted decolonisation on intensive care units.” (My emphasis.)

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