Vaccines against two hospital bugs could be available within a decade, the Government's Chief Medical Officer has said.
A drug to prevent Clostridium difficile (C diff) will be tested on patients having elective surgery later this year, and if it is found to be effective it is likely to be available in three to five years, while a vaccine against MRSA is in development but will not be ready for seven to 10 years.
Launching his annual report, Sir Liam Donaldson also called for a new focus on the health of teenagers.
He highlighted six key factors threatening the health of young people: smoking, alcohol and drugs, accidents and violence, diet, physical activity and sexual health.
Sir Liam said the legal blood alcohol level for drivers under 20 should be reduced to zero.
The report, entitled On The State Of Public Health called for a national summit on health services for teenagers, more involvement of teenagers in the design of health services and the setting up of a young persons' panel on risk taking in teenage years.
Sir Liam said he believed reducing the legal alcohol limit for teenage drivers would save lives.
His report pointed out that alcohol use increases the risk of a crash for a young driver two and a half times more than for an older driver.
Data from the Health Protection Agency (HPA) showed there were 1087 cases of MRSA during October to December 2007, a 0.6% rise compared with July to September 2007.
Figures for C diff showed an 8% drop over the same period.
from the BBC
See cdiff compensation
Monday, July 14, 2008
Saturday, March 29, 2008
Hospitals admit they will miss deadline on superbug 'deep clean'
JAMES CHAPMAN, LUCY BALLINGER and DANIEL BATES
Two out of three hospitals have not completed a "deep clean" of their wards just two days before a deadline set by the Government.
Many are scrambling to complete the task by Monday, the date promised by Gordon Brown last September.
The Prime Minister said all wards would be cleared out and cleaned to industrial standard to try to win the war on superbugs such as MRSA and Clostridium Difficile.
This week the Mail asked Britain's 169 acute hospital trusts if they could meet Mr Brown's party conference pledge.
Of the 127 that responded, 87 said they had not finished and 15 admitted they would not meet the deadline.
One said it did not expect to finish until October.
Alarmingly, 55 trusts admitted they had neither emptied nor "decanted" their wards, suggesting the "deep clean" has been carried out around patients against best practice.
The Mail's survey casts doubt on Health Secretary Alan Johnson's claim last night that 93 per cent of trusts would finish the "deep clean" by Monday and the rest were "well on the way to completion".
Patients' groups expressed concern that many hospitals appeared to be "racing" to finish over this weekend and cast doubt over whether such last-minute efforts would really be effective.
Luton and Dunstable Hospital NHS Foundation Trust, said: "We plan to complete our deep clean by the end of May. It is a challenge to clean a ward and move the patients as our hospital is always full."
Dudley Group of Hospitals NHS Trust said: "A quarter of our programme is completed. It has taken longer than expected and accelerated to achieve earliest completion.
"The programme has taken longer than anticipated to clean each ward area. The trust has taken the decision to concentrate on clinically high risk areas in the first instance."
Dr Jim Stone, director of infection prevention and control at Gloucestershire Hospitals NHS Foundation Trust, said: "We have cleared 17 of our 36 designated areas for the deep clean. We have an ongoing operation which means that by October we will have cleaned all the areas."
But Charles Whitney, of the Royal Free Hampstead NHS Trust, admitted: "I don't think we do decant entire wards to do the deep clean. They pick up furniture, they get chewing gum off seats, they don't empty the whole room out.
"We are not going to finish on March 31 because it is not our programme to give the hospital a clean sweep, it's a rolling programme integrated into our regular cleaning programme."
Caroline Hastie, a spokesman for Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust, one of those which has finished, said: "Patients were really co-operative, so we managed to clean around patients and didn't need to do it ward by ward or bay by bay."
Details released under freedom of information laws suggested that local hospitals are having to pay £22.8million on the programme themselves despite a Government pledge to provide funding.
Shadow health secretary Andrew Lansley said he was "not confident" in the quality of the programme.
"If you are going to do a deep clean, then you should do it when a ward is empty of patients," he said.
"That's going to be extremely difficult for many hospitals - particularly when they're trying to finish over a single weekend."
Funding for the programme, he claimed, was a "shambles".
"It is appalling that Gordon Brown has broken his promise to fund it and the local NHS has ended up footing the bill," he said.
"Every penny spent on this is a penny taken away from local health priorities."
Derek Butler, chairman of the charity MRSA Action UK, said: "We can't be confident the deep cleans have been properly done. They haven't been monitored by the Government.
"The idea all these hospitals are going to rush to get it all finished over one weekend is a joke.
"The Government also made it clear a deep clean should be thorough and top to bottom. Surely that means emptying a ward?"
The Department of Health initially denied that ministers had ever suggested extra money would be provided to cover the £50million cost of deep cleaning.
But Mr Johnson told MPs ten days ago: "We have provided the funding to each strategic health authority to meet the cost of the deep clean. They are not expected to divert money from other resources to it. We provided the money from the centre."
A spokesman later said all NHS money "came from the centre" and trusts had used money "sloshing around" in local surpluses.
Mr Johnson said 22 trusts would not meet the deadline but had started their programmes.
"Patients demanded cleaner hospitals and the NHS has responded," he said.
Source: The Dialy Mail
Two out of three hospitals have not completed a "deep clean" of their wards just two days before a deadline set by the Government.
Many are scrambling to complete the task by Monday, the date promised by Gordon Brown last September.
The Prime Minister said all wards would be cleared out and cleaned to industrial standard to try to win the war on superbugs such as MRSA and Clostridium Difficile.
This week the Mail asked Britain's 169 acute hospital trusts if they could meet Mr Brown's party conference pledge.
Of the 127 that responded, 87 said they had not finished and 15 admitted they would not meet the deadline.
One said it did not expect to finish until October.
Alarmingly, 55 trusts admitted they had neither emptied nor "decanted" their wards, suggesting the "deep clean" has been carried out around patients against best practice.
The Mail's survey casts doubt on Health Secretary Alan Johnson's claim last night that 93 per cent of trusts would finish the "deep clean" by Monday and the rest were "well on the way to completion".
Patients' groups expressed concern that many hospitals appeared to be "racing" to finish over this weekend and cast doubt over whether such last-minute efforts would really be effective.
Luton and Dunstable Hospital NHS Foundation Trust, said: "We plan to complete our deep clean by the end of May. It is a challenge to clean a ward and move the patients as our hospital is always full."
Dudley Group of Hospitals NHS Trust said: "A quarter of our programme is completed. It has taken longer than expected and accelerated to achieve earliest completion.
"The programme has taken longer than anticipated to clean each ward area. The trust has taken the decision to concentrate on clinically high risk areas in the first instance."
Dr Jim Stone, director of infection prevention and control at Gloucestershire Hospitals NHS Foundation Trust, said: "We have cleared 17 of our 36 designated areas for the deep clean. We have an ongoing operation which means that by October we will have cleaned all the areas."
But Charles Whitney, of the Royal Free Hampstead NHS Trust, admitted: "I don't think we do decant entire wards to do the deep clean. They pick up furniture, they get chewing gum off seats, they don't empty the whole room out.
"We are not going to finish on March 31 because it is not our programme to give the hospital a clean sweep, it's a rolling programme integrated into our regular cleaning programme."
Caroline Hastie, a spokesman for Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust, one of those which has finished, said: "Patients were really co-operative, so we managed to clean around patients and didn't need to do it ward by ward or bay by bay."
Details released under freedom of information laws suggested that local hospitals are having to pay £22.8million on the programme themselves despite a Government pledge to provide funding.
Shadow health secretary Andrew Lansley said he was "not confident" in the quality of the programme.
"If you are going to do a deep clean, then you should do it when a ward is empty of patients," he said.
"That's going to be extremely difficult for many hospitals - particularly when they're trying to finish over a single weekend."
Funding for the programme, he claimed, was a "shambles".
"It is appalling that Gordon Brown has broken his promise to fund it and the local NHS has ended up footing the bill," he said.
"Every penny spent on this is a penny taken away from local health priorities."
Derek Butler, chairman of the charity MRSA Action UK, said: "We can't be confident the deep cleans have been properly done. They haven't been monitored by the Government.
"The idea all these hospitals are going to rush to get it all finished over one weekend is a joke.
"The Government also made it clear a deep clean should be thorough and top to bottom. Surely that means emptying a ward?"
The Department of Health initially denied that ministers had ever suggested extra money would be provided to cover the £50million cost of deep cleaning.
But Mr Johnson told MPs ten days ago: "We have provided the funding to each strategic health authority to meet the cost of the deep clean. They are not expected to divert money from other resources to it. We provided the money from the centre."
A spokesman later said all NHS money "came from the centre" and trusts had used money "sloshing around" in local surpluses.
Mr Johnson said 22 trusts would not meet the deadline but had started their programmes.
"Patients demanded cleaner hospitals and the NHS has responded," he said.
Source: The Dialy Mail
Wednesday, March 26, 2008
More than nine people a week die from Superbugs in London alone
More than nine patients a week are dying from hospital superbugs in London, the Standard can reveal.
Exclusive figures show for the first time the number of people dying from infections preventable by good hygiene. At least 489 patients died in the capital as a direct result of the stomach bug Clostridium difficile or infection MRSA in 2006.
The bugs were mentioned on a further 456 death certificates, according to figures obtained from the Office for National Statistics.
But a Standard investigation reveals widespread ignorance in hospitals about superbug deaths. Many trusts have no idea how many people with MRSA or C.diff have died in their care and are failing to monitor the problem.
Only 11 London hospital trusts contacted by the Standard were able to produce any data on deaths linked to hospital infections. Of these, just six could produce full figures for the last two years. Only two had information on the more deadly hospital bugs ESBL and GRE - two deaths had been linked to the antibioticresistant bacteria GRE since 2006.
Among the trusts that could not produce figures were Barts and the London and Guy's and St Thomas'.
Barking, Havering and Redbridge NHS Trust produced figures showing at least 101 patients died with or from superbugs between 2006 and last year. Liberal Democrat health spokesman Norman Lamb said it was "astonishing" hospitals were not closely monitoring the figures. He said: "How can trusts expect to know the effectiveness of measures they put in place to tackle these deadly diseases without collecting this data?"
Healthcare charity the Patients' Association said the death rates should be published alongside infection figures, which are released every quarter. Spokesman Michael Summers said: "It is extremely worrying that hospitals are not monitoring death rates properly.
"Patients have the right to know the numbers of deaths from MRSA and C.difficile, not just the numbers contracting an infection. It would be in their best interest to see the full list so they can make an informed choice."
Latest nationwide figures show 6,480 people died in 2006 with C. difficile - a rise of 72 per cent on the year before. At least half of these patients died as a direct result of the stomach bug, but the rise comes after a bid to improve reporting. London's superbug czar Colin Ovington admitted the public would be "surprised" by managers' ignorance of C.difficile and MRSA-linked deaths.
But he added: "They may also be surprised to hear that the problem, although present in London hospitals, is not as serious as in other parts of the UK and that we are determined to keep it under control and further reduce it. The extensive deep cleaning programme across all hospitals supported by £10 million investment is I think testament to our intention to make our hospitals safer places for patients."
The highest number of C. difflinked deaths was in the West Midlands, with 1,115 in 2006.
A spokesman for the Department of Health said: "Most patients with [ hospital infections] such as C.difficile infection recover and figures on deaths would tell us very little about healthcare-associated infections overall. Our surveillance systems concentrate on reported cases using standard definitions so that data collection is consistent."
'MY MOTHER'S C.DIFF DEATH WAS COVERED UP'
Violet Watson was among scores of people who died with C.diff at Barking, Havering and Redbridge NHS Trust in the last two years.
At least 95 deaths at the trust between 2006 and 2007 were linked to the infection - one of the largest totals in London.
The 91-year-old was admitted to hospital after concerns she was dehydrated. But within 11 weeks her organs were failing as she battled with the bug.
Daughter Jacqueline Stanford, 54, says Mrs Watson "lost half her body size" within weeks and claims the hospital covered up her death, saying it was from heart disease. She said: "On the original death notice it said C.difficile was the cause of death but it was crossed out and put as a contributory cause instead."
A spokesman for the trust, where Mrs Watson died in 2006, declined to comment on individual cases but claimed the death figures it had supplied were "misleading".
She said: "This is an extremely large and busy Trust, and the figures need to be looked at as a percentage of cases.
"The Trust ensures that MRSA and C Diff is stated on the death certificate if it were present, not only if it were the direct cause of death."
Source: Amy Iggulden, Health Correspondent - The Standard
Exclusive figures show for the first time the number of people dying from infections preventable by good hygiene. At least 489 patients died in the capital as a direct result of the stomach bug Clostridium difficile or infection MRSA in 2006.
The bugs were mentioned on a further 456 death certificates, according to figures obtained from the Office for National Statistics.
But a Standard investigation reveals widespread ignorance in hospitals about superbug deaths. Many trusts have no idea how many people with MRSA or C.diff have died in their care and are failing to monitor the problem.
Only 11 London hospital trusts contacted by the Standard were able to produce any data on deaths linked to hospital infections. Of these, just six could produce full figures for the last two years. Only two had information on the more deadly hospital bugs ESBL and GRE - two deaths had been linked to the antibioticresistant bacteria GRE since 2006.
Among the trusts that could not produce figures were Barts and the London and Guy's and St Thomas'.
Barking, Havering and Redbridge NHS Trust produced figures showing at least 101 patients died with or from superbugs between 2006 and last year. Liberal Democrat health spokesman Norman Lamb said it was "astonishing" hospitals were not closely monitoring the figures. He said: "How can trusts expect to know the effectiveness of measures they put in place to tackle these deadly diseases without collecting this data?"
Healthcare charity the Patients' Association said the death rates should be published alongside infection figures, which are released every quarter. Spokesman Michael Summers said: "It is extremely worrying that hospitals are not monitoring death rates properly.
"Patients have the right to know the numbers of deaths from MRSA and C.difficile, not just the numbers contracting an infection. It would be in their best interest to see the full list so they can make an informed choice."
Latest nationwide figures show 6,480 people died in 2006 with C. difficile - a rise of 72 per cent on the year before. At least half of these patients died as a direct result of the stomach bug, but the rise comes after a bid to improve reporting. London's superbug czar Colin Ovington admitted the public would be "surprised" by managers' ignorance of C.difficile and MRSA-linked deaths.
But he added: "They may also be surprised to hear that the problem, although present in London hospitals, is not as serious as in other parts of the UK and that we are determined to keep it under control and further reduce it. The extensive deep cleaning programme across all hospitals supported by £10 million investment is I think testament to our intention to make our hospitals safer places for patients."
The highest number of C. difflinked deaths was in the West Midlands, with 1,115 in 2006.
A spokesman for the Department of Health said: "Most patients with [ hospital infections] such as C.difficile infection recover and figures on deaths would tell us very little about healthcare-associated infections overall. Our surveillance systems concentrate on reported cases using standard definitions so that data collection is consistent."
'MY MOTHER'S C.DIFF DEATH WAS COVERED UP'
Violet Watson was among scores of people who died with C.diff at Barking, Havering and Redbridge NHS Trust in the last two years.
At least 95 deaths at the trust between 2006 and 2007 were linked to the infection - one of the largest totals in London.
The 91-year-old was admitted to hospital after concerns she was dehydrated. But within 11 weeks her organs were failing as she battled with the bug.
Daughter Jacqueline Stanford, 54, says Mrs Watson "lost half her body size" within weeks and claims the hospital covered up her death, saying it was from heart disease. She said: "On the original death notice it said C.difficile was the cause of death but it was crossed out and put as a contributory cause instead."
A spokesman for the trust, where Mrs Watson died in 2006, declined to comment on individual cases but claimed the death figures it had supplied were "misleading".
She said: "This is an extremely large and busy Trust, and the figures need to be looked at as a percentage of cases.
"The Trust ensures that MRSA and C Diff is stated on the death certificate if it were present, not only if it were the direct cause of death."
Source: Amy Iggulden, Health Correspondent - The Standard
Superbugs 'cause 10,000 hospital deaths every year
Two superbugs are causing the deaths of more than 10,000 hospital patients every year, an expert has disclosed.
The number of deaths from MRSA and clostridium difficile is being underestimated by about 20 per cent, one of the country's leading authorities on superbugs has said. Official figures put the number of deaths from the two infections at about 8,000 a year.
The Government has insisted that its strategy for
cutting infection rates is bearing fruit
Mark Enright, a professor of molecular epidemiology at London's Imperial College, said the number of deaths from MRSA and c.diff was significantly higher.
"I think it is at least 10,000 a year," he said. "A lot of people are never tested for these infections and their deaths are put down to something else."
Nearly 10 people are dying every day from c.diff, according to official figures, with even more dying from MRSA. In 2006, c.diff was recorded as the underlying cause of death for 3,490 people - a 69 per cent increase on the previous year.
The leap followed a Department of Health order that doctors must note healthcare-acquired infections on death certificates. The edict followed numerous cases in which coroners found that doctors did not record superbugs as the cause of death on death certificates.
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Hugh Pennington, professor emeritus of microbiology at Aberdeen University, said Prof Enright was right to say that figures based on death certificates still underestimated the problem.
He said: "They are very inaccurate evidence at the best of times. They are an underestimate of the problem; they are certainly not an overestimate."
He said there was a "reluctance" to mention MRSA or c.diff because of the pressure to hit targets for reducing hospital-acquired infections, and to avoid potentially costly legal actions.
The Government has insisted that its strategy for cutting infection rates, including a campaign to stop doctors wrongly prescribing antibiotics, and a £50 million "deep clean" of hospitals, is bearing fruit.
The latest quarterly figures from the Health Protection Agency (HPA) showed an 18 per cent fall in MRSA cases in England compared with the previous quarter, and a 21 per cent fall in c.diff cases.
Critics doubt it will hit one of its key targets, of halving the number of MRSA bloodstream infections recorded in 2004. It may prove impossible to reduce infection rates in Britain to low levels again, they say, because poor hygiene practices have enabled strong strains of MRSA and c.diff to develop over decades.
At least 42 per cent of MRSA strains in Britain are "superstrains", according to a survey published in the journal Eurosurveillance, compared with 20 per cent in other countries.
A Department of Health spokesman said the Chief Medical Officer wrote to the NHS in July 2005 to ensure that infections such as MRSA and c.diff were reported more accurately on death certificates.
"These statistics from 2006 show that this move has worked and our figures are now in line with other developed countries. There is no evidence that the severity of the disease has increased. In fact, c.diff rates are falling."
Source: The Telegraph - Stephen Adams
The number of deaths from MRSA and clostridium difficile is being underestimated by about 20 per cent, one of the country's leading authorities on superbugs has said. Official figures put the number of deaths from the two infections at about 8,000 a year.
The Government has insisted that its strategy for
cutting infection rates is bearing fruit
Mark Enright, a professor of molecular epidemiology at London's Imperial College, said the number of deaths from MRSA and c.diff was significantly higher.
"I think it is at least 10,000 a year," he said. "A lot of people are never tested for these infections and their deaths are put down to something else."
Nearly 10 people are dying every day from c.diff, according to official figures, with even more dying from MRSA. In 2006, c.diff was recorded as the underlying cause of death for 3,490 people - a 69 per cent increase on the previous year.
The leap followed a Department of Health order that doctors must note healthcare-acquired infections on death certificates. The edict followed numerous cases in which coroners found that doctors did not record superbugs as the cause of death on death certificates.
advertisement
Hugh Pennington, professor emeritus of microbiology at Aberdeen University, said Prof Enright was right to say that figures based on death certificates still underestimated the problem.
He said: "They are very inaccurate evidence at the best of times. They are an underestimate of the problem; they are certainly not an overestimate."
He said there was a "reluctance" to mention MRSA or c.diff because of the pressure to hit targets for reducing hospital-acquired infections, and to avoid potentially costly legal actions.
The Government has insisted that its strategy for cutting infection rates, including a campaign to stop doctors wrongly prescribing antibiotics, and a £50 million "deep clean" of hospitals, is bearing fruit.
The latest quarterly figures from the Health Protection Agency (HPA) showed an 18 per cent fall in MRSA cases in England compared with the previous quarter, and a 21 per cent fall in c.diff cases.
Critics doubt it will hit one of its key targets, of halving the number of MRSA bloodstream infections recorded in 2004. It may prove impossible to reduce infection rates in Britain to low levels again, they say, because poor hygiene practices have enabled strong strains of MRSA and c.diff to develop over decades.
At least 42 per cent of MRSA strains in Britain are "superstrains", according to a survey published in the journal Eurosurveillance, compared with 20 per cent in other countries.
A Department of Health spokesman said the Chief Medical Officer wrote to the NHS in July 2005 to ensure that infections such as MRSA and c.diff were reported more accurately on death certificates.
"These statistics from 2006 show that this move has worked and our figures are now in line with other developed countries. There is no evidence that the severity of the disease has increased. In fact, c.diff rates are falling."
Source: The Telegraph - Stephen Adams
Sunday, March 23, 2008
MRSA and C difficile superbug deaths at 10,000 a year
By Lois Rogers
The number of patients in British hospitals dying from superbug infections has reached more than 10,000 every year, according to an expert.
The new figure is about 20% higher than the official toll of 8,000 a year.
Mark Enright, professor of molecular epidemiology at Imperial College London, said that the real number of those succumbing to methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C difficile) in the UK is higher than the government’s records show.
“I think it is at least 10,000 a year,” he said. “A lot of people are never tested for these infections and their deaths are put down to something else.”
Related Links
Superbug deaths soar in England and Wales
Hospital warned over superbug failures
It's back to mops and buckets to beat the superbug
“Antibiotic-resistant bacteria are now so well established here, we will never get rid of them,” said Hugh Pennington, emeritus professor of bacteriology at Aberdeen University and a world expert.
Latest European figures show that Britain’s hospitals are still teeming with treatment-resistant bacteria.
While strict hygiene measures have ensured low infection rates in other countries, microbiologists here are privately admitting that Britain’s problem is so out of control, it will be impossible to prevent the high level of deaths from continuing.
The government’s pledge to reduce rates of MRSA to half the 2004 level is unattainable, they say.
According to figures from Eurosurveillance, at least 42% of MRSA bacteria in British hospitals are “superstrains”, compared with rates of 20% or lower elsewhere.
In the 31-nation European antisuperbug league table, Britain lies close to the bottom, with an infection-control performance better than those of only Malta, Greece, Portugal and Romania.
Source: Times On-Line
The number of patients in British hospitals dying from superbug infections has reached more than 10,000 every year, according to an expert.
The new figure is about 20% higher than the official toll of 8,000 a year.
Mark Enright, professor of molecular epidemiology at Imperial College London, said that the real number of those succumbing to methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C difficile) in the UK is higher than the government’s records show.
“I think it is at least 10,000 a year,” he said. “A lot of people are never tested for these infections and their deaths are put down to something else.”
Related Links
Superbug deaths soar in England and Wales
Hospital warned over superbug failures
It's back to mops and buckets to beat the superbug
“Antibiotic-resistant bacteria are now so well established here, we will never get rid of them,” said Hugh Pennington, emeritus professor of bacteriology at Aberdeen University and a world expert.
Latest European figures show that Britain’s hospitals are still teeming with treatment-resistant bacteria.
While strict hygiene measures have ensured low infection rates in other countries, microbiologists here are privately admitting that Britain’s problem is so out of control, it will be impossible to prevent the high level of deaths from continuing.
The government’s pledge to reduce rates of MRSA to half the 2004 level is unattainable, they say.
According to figures from Eurosurveillance, at least 42% of MRSA bacteria in British hospitals are “superstrains”, compared with rates of 20% or lower elsewhere.
In the 31-nation European antisuperbug league table, Britain lies close to the bottom, with an infection-control performance better than those of only Malta, Greece, Portugal and Romania.
Source: Times On-Line
Superbugs and NHS failings
Superbugs kill at least 10,000 people in Britain each year — 20 times the number who die of Aids. Why isn’t the government spending more on finding out why?Lois Rogers
Like many, Brian Clinch was under the impression that, despite the failures of the past, the British health service was tackling the frightening epidemic of antibiotic-resistant superbugs. That was before a visit to Norway made him realise that this record-breaking tide of resistant infections is far from under control and is also a problem of our own making.
Clinch, a former RAF pilot from Dorset, has kidney failure and needs dialysis three times a week. It was only when he went for dialysis treatment in the Norwegian city of Stavanger three months ago that he discovered he was one of the tens of thousands of Britons unwittingly infected with the deadly superbug methicillin-resistant Staphylococcus aureus (MRSA).
The day after arriving in the oil-refining port on Norway’s Atlantic coast, he went to the city’s university hospital. Dialysis had been arranged on the understanding that he had been tested for MRSA in the UK. But a routine throat swab in Stavanger showed Clinch was carrying MRSA. “All hell broke loose,” he says. “The results of the MRSA tests arrived after they’d given me one session of dialysis. They were angry and deeply unimpressed with the dialysis centre in England.
“I felt like a complete pariah. I was taken into an isolation room and everyone put on gowns, masks and bootees before they came anywhere near me. It’s obvious they are frightened to death of getting these infections in Norway, and are doing everything they can to keep them out.”
He is right. Norway, with its population of 4.7m, had only 332 cases of MRSA in 2006, and has the lowest rate of antibiotic-resistant bacteria in Europe. About 1 in 200 of the infections found in patients’ bloodstreams in Norway is caused by a treatment-resistant “superbug”, while in Britain, getting on for half of all infected patients have been colonised by strains of bacteria that normal antibiotics cannot treat.
Norway, which, like Britain, runs a publicly funded health service free at the point of delivery, prides itself on its “search and destroy” policy for killer infections. But the contrast between its health services and our chaotic hospital system is a stark reflection of a difference in approach that has much more to do with attitude than money.
The public area of Stavanger’s 950-bed hospital resembles nothing so much as an up-market hotel. Leather armchairs are arranged around a virtual log fire; seemingly relaxed visitors sip coffee and nibble pastries. The town is comparable to Ipswich in size and affluence, but first impressions of the hospital suggest it is wealthier. But beyond the reception, the 1970s-built wards tell a different story. Norway’s cash-limited national health service is suffering exactly the same colossal pressure as our own NHS.
In the infectious-diseases unit there are 19 people on trolleys in the corridor. At least 11 more lie in the corridors of other departments. The wait may be long, and patients may end up temporarily in the wrong department as staff struggle to allocate beds. It is a sight familiar to anyone who has observed the treatment lottery of the British NHS, and the enormous battle between restricted supply and limitless demand for healthcare. But even under the pressure of winter infections, Stavanger’s problems with capacity are not reflected in infection rates.
The atmosphere is busy but calm. The gleaming corridors are populated with cheery cleaners; there is a sense of belonging among the workforce that is often absent among the clock-watching agency workers who increasingly maintain large chunks of our own hospitals.
Stavanger has a policy of not moving infected patients around; if they have several conditions, doctors from different specialities come to them, not the other way round. And isolation rooms are available, complete with negative air pressure to prevent infections from being wafted outside. Barrier nursing methods involving gloves, aprons and scrupulous hand-washing are strictly applied with infectious patients.
Jon Sundal, the head of infectious diseases at Stavanger, complains of a relentless battle to keep his unit under control. “There is a shortage of nurses – the five new single rooms cannot be staffed,” he says. Nevertheless, even with bed occupancy running at over 100%, conditions in his hospital offered a stark contrast to the grime of most of Britain’s healthcare facilities.
“We saw the writing on the wall early on with antibiotic resistance,” says Olav Nataas, head of medical microbiology at Stavanger. “We had one serious outbreak in the 1980s, and since then we just haven’t allowed it to happen, except when we sent some waiting-list patients to Britain for hip replacements and they came back infected.
“I don’t think hospital cleaning has much to do with it. What works is screening. You test everyone, and you isolate and treat everyone you find with it. In England you can’t do that now because you have too many cases.”
It is legitimate to ask if Britain’s NHS has lurched into a ruinously expensive crisis that may yet see the entire service implode. It is also legitimate to ask how our microbial surveillance system, let alone our hospital cleaning services, has failed us so badly: why did scientists not warn us of this disaster in the making, and is it too late to do anything about it?
The global use of antibiotics since the 1940s has achieved a simple Darwinian consequence: the fittest bacteria survive. Antibiotics work by disrupting the production of components needed to create new bacterial cells. Penicillin, for example, selectively interferes with the construction of bacterial cell walls, which have a different structure to the cell tissue of humans and other mammals. By the end of the 1940s, about half of the Staphylococcus aureus strains tested in hospitals had adapted to produce an anti-penicillin toxin called penicillinase. Within months of the launch of the antibiotic methicillin in 1960, the first resistant strains of Staphylococcus aureus were emerging. Shortly after that, bacteriologists began finding strains impervious to up to four common antibiotics.
Warnings about the dangers of antibiotic overuse started to emerge from laboratories, but because relatively few patients were affected and nobody knew what to do about it, the situation was ignored. Antibiotics continued to be consumed in ever-growing quantities by sick humans and farm animals alike.
The problem took off in 1991, when Britain contributed its own supercharged strain to the world lexicon of multi-drug-resistant superbugs. MRSA-16 first appeared in Northamptonshire, rapidly infecting 400 patients and 27 staff in three hospitals. Within 18 months it had been reported in 135 more hospitals. Nobody knows how it spread. Along with another British strain, MRSA-15, it went on to infect patients around the world, a pattern that continues. A meticulous Health Protection Agency study, mapping how the new strains popped up unexpectedly in new hospitals, was published in the Journal of Clinical Microbiology in 2004. But it was too long after the event to shed any light on how the infection had carried. Now research funding is focused on firefighting – casting around for ways to damp down the effects of the pathogens.
It is not just MRSA that is sweeping across Britain like a plague. Streptococcus, enterococcus and Escherichia coli (E coli) are among a host of bugs emerging in resistant forms and causing everything from pneumonia to tuberculosis, bone destruction and lethal damage to the heart. In addition, we are facing “hyper-virulent” new strains of the bacteria Clostridium difficile (C diff), which have colonised the sites left free by the effect of antibiotics, which kill off many harmless bacterial colonies in their path.
Although C diff is not resistant to treatment, its spores linger indefinitely and, until recently, NHS staff were largely unaware of how to kill them. Consequently, it is the biggest killer of the current superbugs. In 2006 it was mentioned
on the death certificates of 6,480 people, against 1,652 deaths officially attributed to MRSA. However, these figures are recognised to be underestimates, as many superbug deaths are never identified. Mandatory surveillance of MRSA bloodstream infections is a recent innovation, the number of people carrying it with no symptoms is not recorded, and the formal collection of figures for death and disease associated with C diff (which causes unstoppable diarrhoea or gut perforation) only began in April 2007. The government estimates the annual cost of treatment for such cases to be over £1 billion.
Officially, the total number of MRSA infections is 7,000-8,000 a year, while C diff is running at an annual 55,600 cases. Many experts believe the real total for all superbug infections is nearer 300,000 – how many are fatal is believed to be vastly higher than the official figures suggest. There is no way of knowing the true figure, as relatively few people are tested.
Meanwhile, a variety of new resistant pathogens are waiting in the wings. In September 2006, a variation of Staphylococcus aureus that produces a toxin called Panton-Valentine leukocidin (PVL) claimed its first British victims. Since then, anxiety over this threat has escalated. The pathogen selectively attacks the young rather than the old; it gets into bones and joints, causing crippling damage.
A multi-drug-resistant version of a common food-poisoning bug, ESBL (extended-spectrum beta-lactamase) E coli, is also causing anxiety. First identified in the 1980s, it has spread steadily to cause an average of 30,000 cases of blood poisoning and urinary-tract infections a year. Although it has officially been blamed for 57 deaths so far, the true total is believed to be many thousands. Government scientists think the source is meat and milk, colonised by superbugs as a result of overuse of agricultural antibiotics.
Jodi Lindsay, a senior expert at St George’s hospital, London, and a world authority on superbugs, says: “It is inevitable things will get much worse. We don’t know enough about how these bacteria behave, because not enough research is being done. We have increasing numbers of surgical operations, elderly people with long-term serious disease, and diabetics. All these patients have compromised immune systems and are at risk. Not only that, there is potential for new, really virulent strains of bacteria, capable of attacking healthy people.”
Mark Enright, professor of molecular epidemiology at Imperial College London, says the real number of deaths in the UK from MRSA and C diff is “easily more than 10,000”. He shares the concern that reservoirs of superbug infection in hospitals will increasingly spill out to attack otherwise healthy people: “You could be carrying a resistant form of MRSA and it could then get in through a superficial injury.”
There is evidence that such a problem is already occurring in other parts of the world. A new form of MRSA, USA300, has emerged not in hospitals but in the wider community in America. It is killing 18,000 a year – considerably more than the number killed by HIV/Aids, and, most worryingly, the victims include a number of otherwise healthy children. The latest flurry of anxiety was in Brooklyn, New York, in October, when Omar Rivera, a previously fit 12-year-old, suffered the telltale crop of pus-filled spots associated with USA300. Within days he was dead. In other parts of America, three other children, aged 4, 11 and 17, died the same month.
A team at the University of California in San Francisco has been tracking the infection. Last month they published a study showing that a variant of USA300 was spreading in gay communities on the East and West Coasts. And a new “community” strain of C diff in the US has targeted children, pregnant women and new mothers, with fatal results. There has been at least one similar death in the UK, but testing was not available to confirm if it was the same pathogen.
Europe also has a “community” MRSA: ST80. Officially it is considered less of a threat because, it is argued, levels of poverty in western Europe are not as severe as in the US. Without the immune-system damage caused by malnutrition, the infection is less likely to cause an epidemic.
All that is known about USA300, and other virulent community-acquired strains of staphylococcus, is that they generally include Panton-Valentine leukocidin, and that this lethal toxin can jump between different types of bacteria. If a PVL-carrying bacterium infects someone already carrying a cold virus, it can spur the onset of a deadly form of necrotising or tissue-killing pneumonia, which kills 60% of those who develop it. Although guidelines for GPs to alert them to this new threat to public health are being issued later this spring, Lindsay and other scientists complain that Britain persists in spending too little on basic research to tell us more about the nature of these brand-new infectious agents.
Many scientists have also attacked our slow and patchy response to the problem of antibiotic resistance. “In the early 1990s, microbiologists were divided,” says Hugh Pennington, emeritus professor of bacteriology at Aberdeen University. “For everyone who argued the case for containment, there’d be many more who maintained that Staph aureus had been with us for ever, and it did not make much difference if strains were methicillin-resistant or not.”
As a result, investigating how microbes developed their resistance, how infections spread, why particular resistant strains appeared in some areas but not in others, did not seem that important to healthcare planners. Microbiology began to feature less and less in medical training. According to the Royal College of Pathologists, there are now only 645 fully qualified hospital microbiologists in Britain, of whom only 387 are working in the NHS in England. Up to 10% of hospital microbiology posts are unfilled because of a shortage of qualified applicants.
At the same time that the superbugs were taking hold, those with the expertise to tackle them were keen to work instead in Aids research, with its support from glamorous figures such as Princess Diana and Elizabeth Taylor. The pattern inexplicably continues. According to the Department of Health, £3.8m has been spent by the government since 2002 under the umbrella of “clinical microbial research”, while £14m a year is spent on Aids, which kills fewer than 500 here annually. And it has become clear that a recently allocated £16.5m that microbiologists believed was for research into antibiotic resistance will be shared with research projects on sexually transmitted diseases and hepatitis.
“Asking why we put so much money into Aids research is a very good question,” said Brian Duerden, government inspector of microbiology and infection control. “Medical research is highly political and highly fashion-driven.”
Dr Peter Dukes, programme manager of the Infections and Immunity Research Board at the Medical Research Council (MRC), blamed the paucity of research proposals and the shortage of researchers in the field of antibiotic resistance: “When the MRC offered to fund a research project six years ago, 20 proposals were received and only one was good enough to sponsor.” Given America’s sinister new USA300 infection, our persistent preoccupation with Aids may soon look very misguided indeed.
Microbiologists who have remained in the NHS are dismayed that their warnings of disaster from antibiotic resistance have been ignored by hospital managers focused on performance indicators and productivity targets, which concentrated on waiting times. “We needed to do more screening, but there were never the resources. Even now they are cutting back,” said a consultant intensive-care specialist at a large provincial hospital. “There used to be two consultant microbiologists here, but one left and was not replaced. So we had no expert on intensive-care ward rounds to advise on appropriate antibiotics and infection control.”
New government directives require hospitals to carry out MRSA screening on patients being admitted – though not those having outpatient or day-surgery procedures. The consultant said the extra testing burden, without any extra staff to do it, had meant that vital surveillance for other new infections was not happening.
In addition, as pressure has been ratcheted up to channel funds into meeting a range of “patient episode” productivity targets, basic hospital cleaning has been scaled back and contracted out. Those working in healthcare seem increasingly ignorant of the basics of hygiene. Healthcare workers increasingly fail to wash their hands as they race between beds, which are meant to be kept 100% occupied. Increasing numbers of patients are unnecessarily admitted to wards from accident-and-emergency departments, simply to avoid breaking the maximum four-hour permitted A&E wait. In December it was reported that the hotel costs of caring for extra patients who were not actually sick enough to need treatment had wasted £2 billion over the past five years.
Many microbiologists point to the decline of attention to hygiene as a basic function of healthcare as nurse training has become increasingly academic and classroom-based. “The only infection-control procedure proven to work is scrupulous hand-washing, a basic approach explained by Florence Nightingale during the Crimean war and seemingly lost in the intervening 150 years,” said Richard Wise, former chairman of the government’s specialist advisory committee on antimicrobial resistance, and adviser to the Health Protection Agency Board. “Not washing the hands between patients should be made a disciplinary offence.”
Most hospitals have bottles of alcohol-based hand disinfectant by their doors, but Duerden says that until recently their inefficacy against C diff spores was “not common knowledge” outside microbiology circles – an unacceptable level of ignorance, insists Wise, who said it had been known about “for donkey’s years”.
Olav Nataas, however, insists the search-and-destroy process is key: “We know hand-washing is never 100%,” he says. “This preoccupation with cleaning is not the main issue. It is identifying the infection as rapidly as possible and treating it in a way that does not risk others.”
It is this uncertainty among Britain’s scientists, healthcare administrators and politicians that has led to the latest disagreement about hospital cleaning. This month, every hospital in Britain is meant to have completed a special “deep clean”, for which an extra £57m has been allocated. How exactly a deep clean is performed is less clear. There are no prescriptions for cleaning materials, training for cleaners, or methods of checking whether things are actually clean.
A helpful list of Department of Health ideas has been published, including suggestions such as washing curtains, walls and beds. Many will be dismayed to discover these are not already part of routine procedures. A government rapid-review panel has also been established to examine the efficacy of cleaning products, but it is down to individual hospital trusts to decide what they need to do, and which wards to deep-clean. While, for example, the West Midlands region is spending almost £10m on the exercise, only £3m is being spent in the northeast. Some hospitals are emptying entire wards to allow hydrogen peroxide “fogging”, which uses a vapour to destroy the cell walls of all organisms, or ultrasound vibration, to produce a similar effect.
Nobody is keen to define what “clean” means in hospital terms and, according to Andrew Large, the director-general of the Cleaning and Support Services Association, some hospitals are doing nothing at all. “There is no specification about whether hospitals are clean or not, but there is plenty of academic evidence that a greater presence of people doing routine cleaning on wards is what makes a difference,” he says. “After all, you could do a deep clean, but if the person inspecting it goes in and sneezes when they happen to be carrying one of these infections, you are back to square one.”
Annual spot checks for cleanliness are being introduced by the Healthcare Commission from next month. Those not complying may be issued with lists of improvement needed, and if, for example, they still leave bedpans lying around, “special measures” will be imposed. It is not possible to find out what these special measures might be; according to a Department of Health spokesman, “it will be decided at a local level”.
Many patients have paid a high price for our confused health policies. In Britain’s worst outbreak of superbug infection, there were 90 deaths and 1,170 C diff infections across three hospital sites in Maidstone, Kent, between April 2004 and September 2006. A report on the disaster by the Healthcare Commission in October described patients being left to lie in their own infection-laden excrement, a shortage of nurses and an ignorance of the risks of moving infected patients between wards.
There were a further 33 avoidable deaths from C diff between 2003 and 2005 at Stoke Mandeville hospital in Buckinghamshire. An inquiry found that managers ignored advice to isolate those infected and instead concentrated on shutting down more beds to cut costs.
The cost of compensating superbug victims is also soaring. The NHS Litigation Authority has paid out £12.5m for 287 cases, plus a record-breaking £5m in January to the actress Leslie Ash, 49, whose career has been ruined. An anticipated £1m will go to Shaun Franks, 39, who underwent surgery for a broken ankle. His leg was taken over by an immovable colony of MRSA, which could only be eradicated from his body by amputation of the leg. During his treatment, staff at Northampton general hospital unwittingly used an antibiotic that accelerated the growth of the MRSA. “It has been a nightmare,” said Franks. “I lost my job, my relationship – everything. Every time I thought I was getting better, it would come back again.”
There is no question that ignorance of good practice has played a significant part in the spread of superbugs in Britain. A study in the late 1990s by Otto Cars, an expert in infectious diseases at Uppsala University, Sweden, compared antibiotic use across Europe. British doctors were administering over 18 daily doses per 1,000 people, compared with 13 in Germany and Sweden and 11 in Denmark. Most of the prescriptions were for coughs and colds – 90% of which are caused by viruses, not bacteria.
Duerden admits that the first comprehensive campaign to educate GPs and the public about the overuse of antibiotics only got off the ground eight years ago with the launch of a cartoon character, Andybiotic. But a survey of almost 11,000 adults published in the British Medical Journal last year indicated that most people still did not understand the risks.
Hajo Grundmann, now a senior infection-control adviser to the Dutch government, worked for seven years in Britain’s NHS before returning home in 2001. He runs the Eurosurveillance database, monitoring levels of antibiotic-resistant infections in 31 countries. Britain has the highest rate in western Europe. “It is connected with the high workload,” he says.
“I worked in Nottingham. We were able to isolate MRSA cases at first, but when the waiting-list initiative came in, there was huge pressure on beds. As soon as the pressure goes up, hand-washing goes down. But the British problem is also due to people’s attitudes. It just has not been taken seriously enough.”
So where do we go from here? Plans remain vague to introduce the sort of routine pre-treatment screening for superbugs that exists in Norway, but there is hope. Lewisham hospital in south London has seized the initiative and, since 2005, has been screening all patients admitted through A&E. They take swabs from mouths, noses, armpits and groins of everyone, and swirl them around in a proprietary bacteriological “broth” that is cooked overnight. If the broth changes colour, MRSA is definitely not there. If it does not, the patient might be infected. Precautions are taken for “might be” cases while they receive further testing. Dr Gopal Rao, the consultant microbiologist leading this blindingly obvious initiative, which has halved the rate of MRSA from 12% to 6% in the hospital, says: “If you know someone is infected, you treat them differently, even if you don’t have the facilities to isolate them.”
Other hospitals, including Guy’s and St Thomas’ in London, are trying out similar initiatives, but it is expensive, and it is difficult to introduce new practices in the NHS without producing years of evidence demonstrating the cost benefit. Wolverhampton hospital estimates it has saved 212 lives and £6.8m with better infection-control measures, such as giving consultants targets for infection rates among patients. Why can’t other hospitals do the same?
The government says it can reduce MRSA to half its 2004 rate by the end of the summer and cut levels of C diff by 30% within three years, though the starting points for this claim are unclear. Health Protection Agency (HPA) data for the latest quarter, during the summer of 2007, show MRSA bloodstream-only infections have fallen from 1,304 to 1,072; C diff infections were 10,334, compared with 13,669 for the previous quarter. The HPA admits the data is unreliable owing to changes in collection methods. Cynics might simply conclude there are fewer patients in hospital in summer.
There are, however, measures being launched by the government: to increase the number of hospital matrons to 5,000 to oversee hygiene by May, and make available £270m a year for hygiene campaigns, extra infection-control nurses and pharmacists to tackle over-reliance on antibiotics.
But that does not explain why we continue to invest in areas such as Aids research, or the hypothetical risk of pandemic flu, yet hope that drugs developed in the middle of the last century will protect us against new infections that are killing thousands each year.
Despite repeated requests, no minister was available to answer the questions raised in this article. A written statement explained that investment in Aids was vital as part of Britain’s contribution to world public health. The statement also referred to the (unsuccessful) infection-control policies introduced up to a decade ago; offered guidance on the need to isolate infectious patients in single rooms; and highlighted the aspiration to offer more patients single rooms in several new hospitals currently being planned.
A Department of Health spokesman explained that despite the fact that Brian Duerden had been unable to answer many of my questions, it was not government policy to offer more than one spokesman on the same issue. According to Richard Wise, it is impossible to avoid the conclusion that until superbugs become – as they surely will – impossible to ignore, we can expect to see our governments concentrate on headlines rather than detail.
Source: Times on-line
Like many, Brian Clinch was under the impression that, despite the failures of the past, the British health service was tackling the frightening epidemic of antibiotic-resistant superbugs. That was before a visit to Norway made him realise that this record-breaking tide of resistant infections is far from under control and is also a problem of our own making.
Clinch, a former RAF pilot from Dorset, has kidney failure and needs dialysis three times a week. It was only when he went for dialysis treatment in the Norwegian city of Stavanger three months ago that he discovered he was one of the tens of thousands of Britons unwittingly infected with the deadly superbug methicillin-resistant Staphylococcus aureus (MRSA).
The day after arriving in the oil-refining port on Norway’s Atlantic coast, he went to the city’s university hospital. Dialysis had been arranged on the understanding that he had been tested for MRSA in the UK. But a routine throat swab in Stavanger showed Clinch was carrying MRSA. “All hell broke loose,” he says. “The results of the MRSA tests arrived after they’d given me one session of dialysis. They were angry and deeply unimpressed with the dialysis centre in England.
“I felt like a complete pariah. I was taken into an isolation room and everyone put on gowns, masks and bootees before they came anywhere near me. It’s obvious they are frightened to death of getting these infections in Norway, and are doing everything they can to keep them out.”
He is right. Norway, with its population of 4.7m, had only 332 cases of MRSA in 2006, and has the lowest rate of antibiotic-resistant bacteria in Europe. About 1 in 200 of the infections found in patients’ bloodstreams in Norway is caused by a treatment-resistant “superbug”, while in Britain, getting on for half of all infected patients have been colonised by strains of bacteria that normal antibiotics cannot treat.
Norway, which, like Britain, runs a publicly funded health service free at the point of delivery, prides itself on its “search and destroy” policy for killer infections. But the contrast between its health services and our chaotic hospital system is a stark reflection of a difference in approach that has much more to do with attitude than money.
The public area of Stavanger’s 950-bed hospital resembles nothing so much as an up-market hotel. Leather armchairs are arranged around a virtual log fire; seemingly relaxed visitors sip coffee and nibble pastries. The town is comparable to Ipswich in size and affluence, but first impressions of the hospital suggest it is wealthier. But beyond the reception, the 1970s-built wards tell a different story. Norway’s cash-limited national health service is suffering exactly the same colossal pressure as our own NHS.
In the infectious-diseases unit there are 19 people on trolleys in the corridor. At least 11 more lie in the corridors of other departments. The wait may be long, and patients may end up temporarily in the wrong department as staff struggle to allocate beds. It is a sight familiar to anyone who has observed the treatment lottery of the British NHS, and the enormous battle between restricted supply and limitless demand for healthcare. But even under the pressure of winter infections, Stavanger’s problems with capacity are not reflected in infection rates.
The atmosphere is busy but calm. The gleaming corridors are populated with cheery cleaners; there is a sense of belonging among the workforce that is often absent among the clock-watching agency workers who increasingly maintain large chunks of our own hospitals.
Stavanger has a policy of not moving infected patients around; if they have several conditions, doctors from different specialities come to them, not the other way round. And isolation rooms are available, complete with negative air pressure to prevent infections from being wafted outside. Barrier nursing methods involving gloves, aprons and scrupulous hand-washing are strictly applied with infectious patients.
Jon Sundal, the head of infectious diseases at Stavanger, complains of a relentless battle to keep his unit under control. “There is a shortage of nurses – the five new single rooms cannot be staffed,” he says. Nevertheless, even with bed occupancy running at over 100%, conditions in his hospital offered a stark contrast to the grime of most of Britain’s healthcare facilities.
“We saw the writing on the wall early on with antibiotic resistance,” says Olav Nataas, head of medical microbiology at Stavanger. “We had one serious outbreak in the 1980s, and since then we just haven’t allowed it to happen, except when we sent some waiting-list patients to Britain for hip replacements and they came back infected.
“I don’t think hospital cleaning has much to do with it. What works is screening. You test everyone, and you isolate and treat everyone you find with it. In England you can’t do that now because you have too many cases.”
It is legitimate to ask if Britain’s NHS has lurched into a ruinously expensive crisis that may yet see the entire service implode. It is also legitimate to ask how our microbial surveillance system, let alone our hospital cleaning services, has failed us so badly: why did scientists not warn us of this disaster in the making, and is it too late to do anything about it?
The global use of antibiotics since the 1940s has achieved a simple Darwinian consequence: the fittest bacteria survive. Antibiotics work by disrupting the production of components needed to create new bacterial cells. Penicillin, for example, selectively interferes with the construction of bacterial cell walls, which have a different structure to the cell tissue of humans and other mammals. By the end of the 1940s, about half of the Staphylococcus aureus strains tested in hospitals had adapted to produce an anti-penicillin toxin called penicillinase. Within months of the launch of the antibiotic methicillin in 1960, the first resistant strains of Staphylococcus aureus were emerging. Shortly after that, bacteriologists began finding strains impervious to up to four common antibiotics.
Warnings about the dangers of antibiotic overuse started to emerge from laboratories, but because relatively few patients were affected and nobody knew what to do about it, the situation was ignored. Antibiotics continued to be consumed in ever-growing quantities by sick humans and farm animals alike.
The problem took off in 1991, when Britain contributed its own supercharged strain to the world lexicon of multi-drug-resistant superbugs. MRSA-16 first appeared in Northamptonshire, rapidly infecting 400 patients and 27 staff in three hospitals. Within 18 months it had been reported in 135 more hospitals. Nobody knows how it spread. Along with another British strain, MRSA-15, it went on to infect patients around the world, a pattern that continues. A meticulous Health Protection Agency study, mapping how the new strains popped up unexpectedly in new hospitals, was published in the Journal of Clinical Microbiology in 2004. But it was too long after the event to shed any light on how the infection had carried. Now research funding is focused on firefighting – casting around for ways to damp down the effects of the pathogens.
It is not just MRSA that is sweeping across Britain like a plague. Streptococcus, enterococcus and Escherichia coli (E coli) are among a host of bugs emerging in resistant forms and causing everything from pneumonia to tuberculosis, bone destruction and lethal damage to the heart. In addition, we are facing “hyper-virulent” new strains of the bacteria Clostridium difficile (C diff), which have colonised the sites left free by the effect of antibiotics, which kill off many harmless bacterial colonies in their path.
Although C diff is not resistant to treatment, its spores linger indefinitely and, until recently, NHS staff were largely unaware of how to kill them. Consequently, it is the biggest killer of the current superbugs. In 2006 it was mentioned
on the death certificates of 6,480 people, against 1,652 deaths officially attributed to MRSA. However, these figures are recognised to be underestimates, as many superbug deaths are never identified. Mandatory surveillance of MRSA bloodstream infections is a recent innovation, the number of people carrying it with no symptoms is not recorded, and the formal collection of figures for death and disease associated with C diff (which causes unstoppable diarrhoea or gut perforation) only began in April 2007. The government estimates the annual cost of treatment for such cases to be over £1 billion.
Officially, the total number of MRSA infections is 7,000-8,000 a year, while C diff is running at an annual 55,600 cases. Many experts believe the real total for all superbug infections is nearer 300,000 – how many are fatal is believed to be vastly higher than the official figures suggest. There is no way of knowing the true figure, as relatively few people are tested.
Meanwhile, a variety of new resistant pathogens are waiting in the wings. In September 2006, a variation of Staphylococcus aureus that produces a toxin called Panton-Valentine leukocidin (PVL) claimed its first British victims. Since then, anxiety over this threat has escalated. The pathogen selectively attacks the young rather than the old; it gets into bones and joints, causing crippling damage.
A multi-drug-resistant version of a common food-poisoning bug, ESBL (extended-spectrum beta-lactamase) E coli, is also causing anxiety. First identified in the 1980s, it has spread steadily to cause an average of 30,000 cases of blood poisoning and urinary-tract infections a year. Although it has officially been blamed for 57 deaths so far, the true total is believed to be many thousands. Government scientists think the source is meat and milk, colonised by superbugs as a result of overuse of agricultural antibiotics.
Jodi Lindsay, a senior expert at St George’s hospital, London, and a world authority on superbugs, says: “It is inevitable things will get much worse. We don’t know enough about how these bacteria behave, because not enough research is being done. We have increasing numbers of surgical operations, elderly people with long-term serious disease, and diabetics. All these patients have compromised immune systems and are at risk. Not only that, there is potential for new, really virulent strains of bacteria, capable of attacking healthy people.”
Mark Enright, professor of molecular epidemiology at Imperial College London, says the real number of deaths in the UK from MRSA and C diff is “easily more than 10,000”. He shares the concern that reservoirs of superbug infection in hospitals will increasingly spill out to attack otherwise healthy people: “You could be carrying a resistant form of MRSA and it could then get in through a superficial injury.”
There is evidence that such a problem is already occurring in other parts of the world. A new form of MRSA, USA300, has emerged not in hospitals but in the wider community in America. It is killing 18,000 a year – considerably more than the number killed by HIV/Aids, and, most worryingly, the victims include a number of otherwise healthy children. The latest flurry of anxiety was in Brooklyn, New York, in October, when Omar Rivera, a previously fit 12-year-old, suffered the telltale crop of pus-filled spots associated with USA300. Within days he was dead. In other parts of America, three other children, aged 4, 11 and 17, died the same month.
A team at the University of California in San Francisco has been tracking the infection. Last month they published a study showing that a variant of USA300 was spreading in gay communities on the East and West Coasts. And a new “community” strain of C diff in the US has targeted children, pregnant women and new mothers, with fatal results. There has been at least one similar death in the UK, but testing was not available to confirm if it was the same pathogen.
Europe also has a “community” MRSA: ST80. Officially it is considered less of a threat because, it is argued, levels of poverty in western Europe are not as severe as in the US. Without the immune-system damage caused by malnutrition, the infection is less likely to cause an epidemic.
All that is known about USA300, and other virulent community-acquired strains of staphylococcus, is that they generally include Panton-Valentine leukocidin, and that this lethal toxin can jump between different types of bacteria. If a PVL-carrying bacterium infects someone already carrying a cold virus, it can spur the onset of a deadly form of necrotising or tissue-killing pneumonia, which kills 60% of those who develop it. Although guidelines for GPs to alert them to this new threat to public health are being issued later this spring, Lindsay and other scientists complain that Britain persists in spending too little on basic research to tell us more about the nature of these brand-new infectious agents.
Many scientists have also attacked our slow and patchy response to the problem of antibiotic resistance. “In the early 1990s, microbiologists were divided,” says Hugh Pennington, emeritus professor of bacteriology at Aberdeen University. “For everyone who argued the case for containment, there’d be many more who maintained that Staph aureus had been with us for ever, and it did not make much difference if strains were methicillin-resistant or not.”
As a result, investigating how microbes developed their resistance, how infections spread, why particular resistant strains appeared in some areas but not in others, did not seem that important to healthcare planners. Microbiology began to feature less and less in medical training. According to the Royal College of Pathologists, there are now only 645 fully qualified hospital microbiologists in Britain, of whom only 387 are working in the NHS in England. Up to 10% of hospital microbiology posts are unfilled because of a shortage of qualified applicants.
At the same time that the superbugs were taking hold, those with the expertise to tackle them were keen to work instead in Aids research, with its support from glamorous figures such as Princess Diana and Elizabeth Taylor. The pattern inexplicably continues. According to the Department of Health, £3.8m has been spent by the government since 2002 under the umbrella of “clinical microbial research”, while £14m a year is spent on Aids, which kills fewer than 500 here annually. And it has become clear that a recently allocated £16.5m that microbiologists believed was for research into antibiotic resistance will be shared with research projects on sexually transmitted diseases and hepatitis.
“Asking why we put so much money into Aids research is a very good question,” said Brian Duerden, government inspector of microbiology and infection control. “Medical research is highly political and highly fashion-driven.”
Dr Peter Dukes, programme manager of the Infections and Immunity Research Board at the Medical Research Council (MRC), blamed the paucity of research proposals and the shortage of researchers in the field of antibiotic resistance: “When the MRC offered to fund a research project six years ago, 20 proposals were received and only one was good enough to sponsor.” Given America’s sinister new USA300 infection, our persistent preoccupation with Aids may soon look very misguided indeed.
Microbiologists who have remained in the NHS are dismayed that their warnings of disaster from antibiotic resistance have been ignored by hospital managers focused on performance indicators and productivity targets, which concentrated on waiting times. “We needed to do more screening, but there were never the resources. Even now they are cutting back,” said a consultant intensive-care specialist at a large provincial hospital. “There used to be two consultant microbiologists here, but one left and was not replaced. So we had no expert on intensive-care ward rounds to advise on appropriate antibiotics and infection control.”
New government directives require hospitals to carry out MRSA screening on patients being admitted – though not those having outpatient or day-surgery procedures. The consultant said the extra testing burden, without any extra staff to do it, had meant that vital surveillance for other new infections was not happening.
In addition, as pressure has been ratcheted up to channel funds into meeting a range of “patient episode” productivity targets, basic hospital cleaning has been scaled back and contracted out. Those working in healthcare seem increasingly ignorant of the basics of hygiene. Healthcare workers increasingly fail to wash their hands as they race between beds, which are meant to be kept 100% occupied. Increasing numbers of patients are unnecessarily admitted to wards from accident-and-emergency departments, simply to avoid breaking the maximum four-hour permitted A&E wait. In December it was reported that the hotel costs of caring for extra patients who were not actually sick enough to need treatment had wasted £2 billion over the past five years.
Many microbiologists point to the decline of attention to hygiene as a basic function of healthcare as nurse training has become increasingly academic and classroom-based. “The only infection-control procedure proven to work is scrupulous hand-washing, a basic approach explained by Florence Nightingale during the Crimean war and seemingly lost in the intervening 150 years,” said Richard Wise, former chairman of the government’s specialist advisory committee on antimicrobial resistance, and adviser to the Health Protection Agency Board. “Not washing the hands between patients should be made a disciplinary offence.”
Most hospitals have bottles of alcohol-based hand disinfectant by their doors, but Duerden says that until recently their inefficacy against C diff spores was “not common knowledge” outside microbiology circles – an unacceptable level of ignorance, insists Wise, who said it had been known about “for donkey’s years”.
Olav Nataas, however, insists the search-and-destroy process is key: “We know hand-washing is never 100%,” he says. “This preoccupation with cleaning is not the main issue. It is identifying the infection as rapidly as possible and treating it in a way that does not risk others.”
It is this uncertainty among Britain’s scientists, healthcare administrators and politicians that has led to the latest disagreement about hospital cleaning. This month, every hospital in Britain is meant to have completed a special “deep clean”, for which an extra £57m has been allocated. How exactly a deep clean is performed is less clear. There are no prescriptions for cleaning materials, training for cleaners, or methods of checking whether things are actually clean.
A helpful list of Department of Health ideas has been published, including suggestions such as washing curtains, walls and beds. Many will be dismayed to discover these are not already part of routine procedures. A government rapid-review panel has also been established to examine the efficacy of cleaning products, but it is down to individual hospital trusts to decide what they need to do, and which wards to deep-clean. While, for example, the West Midlands region is spending almost £10m on the exercise, only £3m is being spent in the northeast. Some hospitals are emptying entire wards to allow hydrogen peroxide “fogging”, which uses a vapour to destroy the cell walls of all organisms, or ultrasound vibration, to produce a similar effect.
Nobody is keen to define what “clean” means in hospital terms and, according to Andrew Large, the director-general of the Cleaning and Support Services Association, some hospitals are doing nothing at all. “There is no specification about whether hospitals are clean or not, but there is plenty of academic evidence that a greater presence of people doing routine cleaning on wards is what makes a difference,” he says. “After all, you could do a deep clean, but if the person inspecting it goes in and sneezes when they happen to be carrying one of these infections, you are back to square one.”
Annual spot checks for cleanliness are being introduced by the Healthcare Commission from next month. Those not complying may be issued with lists of improvement needed, and if, for example, they still leave bedpans lying around, “special measures” will be imposed. It is not possible to find out what these special measures might be; according to a Department of Health spokesman, “it will be decided at a local level”.
Many patients have paid a high price for our confused health policies. In Britain’s worst outbreak of superbug infection, there were 90 deaths and 1,170 C diff infections across three hospital sites in Maidstone, Kent, between April 2004 and September 2006. A report on the disaster by the Healthcare Commission in October described patients being left to lie in their own infection-laden excrement, a shortage of nurses and an ignorance of the risks of moving infected patients between wards.
There were a further 33 avoidable deaths from C diff between 2003 and 2005 at Stoke Mandeville hospital in Buckinghamshire. An inquiry found that managers ignored advice to isolate those infected and instead concentrated on shutting down more beds to cut costs.
The cost of compensating superbug victims is also soaring. The NHS Litigation Authority has paid out £12.5m for 287 cases, plus a record-breaking £5m in January to the actress Leslie Ash, 49, whose career has been ruined. An anticipated £1m will go to Shaun Franks, 39, who underwent surgery for a broken ankle. His leg was taken over by an immovable colony of MRSA, which could only be eradicated from his body by amputation of the leg. During his treatment, staff at Northampton general hospital unwittingly used an antibiotic that accelerated the growth of the MRSA. “It has been a nightmare,” said Franks. “I lost my job, my relationship – everything. Every time I thought I was getting better, it would come back again.”
There is no question that ignorance of good practice has played a significant part in the spread of superbugs in Britain. A study in the late 1990s by Otto Cars, an expert in infectious diseases at Uppsala University, Sweden, compared antibiotic use across Europe. British doctors were administering over 18 daily doses per 1,000 people, compared with 13 in Germany and Sweden and 11 in Denmark. Most of the prescriptions were for coughs and colds – 90% of which are caused by viruses, not bacteria.
Duerden admits that the first comprehensive campaign to educate GPs and the public about the overuse of antibiotics only got off the ground eight years ago with the launch of a cartoon character, Andybiotic. But a survey of almost 11,000 adults published in the British Medical Journal last year indicated that most people still did not understand the risks.
Hajo Grundmann, now a senior infection-control adviser to the Dutch government, worked for seven years in Britain’s NHS before returning home in 2001. He runs the Eurosurveillance database, monitoring levels of antibiotic-resistant infections in 31 countries. Britain has the highest rate in western Europe. “It is connected with the high workload,” he says.
“I worked in Nottingham. We were able to isolate MRSA cases at first, but when the waiting-list initiative came in, there was huge pressure on beds. As soon as the pressure goes up, hand-washing goes down. But the British problem is also due to people’s attitudes. It just has not been taken seriously enough.”
So where do we go from here? Plans remain vague to introduce the sort of routine pre-treatment screening for superbugs that exists in Norway, but there is hope. Lewisham hospital in south London has seized the initiative and, since 2005, has been screening all patients admitted through A&E. They take swabs from mouths, noses, armpits and groins of everyone, and swirl them around in a proprietary bacteriological “broth” that is cooked overnight. If the broth changes colour, MRSA is definitely not there. If it does not, the patient might be infected. Precautions are taken for “might be” cases while they receive further testing. Dr Gopal Rao, the consultant microbiologist leading this blindingly obvious initiative, which has halved the rate of MRSA from 12% to 6% in the hospital, says: “If you know someone is infected, you treat them differently, even if you don’t have the facilities to isolate them.”
Other hospitals, including Guy’s and St Thomas’ in London, are trying out similar initiatives, but it is expensive, and it is difficult to introduce new practices in the NHS without producing years of evidence demonstrating the cost benefit. Wolverhampton hospital estimates it has saved 212 lives and £6.8m with better infection-control measures, such as giving consultants targets for infection rates among patients. Why can’t other hospitals do the same?
The government says it can reduce MRSA to half its 2004 rate by the end of the summer and cut levels of C diff by 30% within three years, though the starting points for this claim are unclear. Health Protection Agency (HPA) data for the latest quarter, during the summer of 2007, show MRSA bloodstream-only infections have fallen from 1,304 to 1,072; C diff infections were 10,334, compared with 13,669 for the previous quarter. The HPA admits the data is unreliable owing to changes in collection methods. Cynics might simply conclude there are fewer patients in hospital in summer.
There are, however, measures being launched by the government: to increase the number of hospital matrons to 5,000 to oversee hygiene by May, and make available £270m a year for hygiene campaigns, extra infection-control nurses and pharmacists to tackle over-reliance on antibiotics.
But that does not explain why we continue to invest in areas such as Aids research, or the hypothetical risk of pandemic flu, yet hope that drugs developed in the middle of the last century will protect us against new infections that are killing thousands each year.
Despite repeated requests, no minister was available to answer the questions raised in this article. A written statement explained that investment in Aids was vital as part of Britain’s contribution to world public health. The statement also referred to the (unsuccessful) infection-control policies introduced up to a decade ago; offered guidance on the need to isolate infectious patients in single rooms; and highlighted the aspiration to offer more patients single rooms in several new hospitals currently being planned.
A Department of Health spokesman explained that despite the fact that Brian Duerden had been unable to answer many of my questions, it was not government policy to offer more than one spokesman on the same issue. According to Richard Wise, it is impossible to avoid the conclusion that until superbugs become – as they surely will – impossible to ignore, we can expect to see our governments concentrate on headlines rather than detail.
Source: Times on-line
Sunday, March 16, 2008
Dust, Debris And Disease
Mar 16 2008 By Marion Scott
Exclusive Mrsa Gran Uncovers Secret Report Exposing Filthy Ward
A PATIENT has uncovered a secret document exposing filthy conditions in the ward where she caught MRSA.
The damning report uncovers a catalogue of disease risks in one of Scotland's busiest operating theatres.
Gran Elizabeth Miller caught the superbug in 2001 while being treated in Glasgow Royal Infirmary's ward 65.
The leaked minutes highlight medics' fears about dust and debris falling through missing ceiling tiles, on to sterile equipment.
Consultant cardiothoracic surgeons Alan Faichney and Ian Colquhoun and microbiologist John Hood discussed the issue at a meeting about problems at ward 65.
The report, from November 2001, states: "The Infection Control Team are very short staffed. Some hand wash basins were lacking in soap and some equipment was very dusty and dirty.
"Dust levels on the ward were high and shower areas had not been cleaned appropriately...the theatre environment is very poor.
"There are several ceiling tiles missing from just outside the single rooms and directly in front of the clinical area where sterile equipment is stored. There is a risk of dust and debris falling from the open ceiling and thereafter accumulating on the floor, furnitire and equipment.
"High levels of dust may harbour MRSA which survives well in dust.
"Dr Faichey raised concerns that Infection Control Nurses have not investigated the links with theatres more thoroughly as there have been a number of deep-seated infections.
"The cardiothoracic theatres are, in his opinion, in a poor state of repair and very dirty."
The meeting took place just over a week after gran Elizabeth, 71, of Kilsyth, was diagnosed with MRSA following a heart valve op. She is suing in a case which could open the floodgates to similar claims - costing the NHS millions.
Her lawyer Cameron Fyfe said: "These damning reports clearly show the most senior doctors and infection experts expressing grave concerns and it is clear the situation had been ongoing for some time. The NHS should make minutes such as this public as an incentive to ensure hospital managers enforce infection control policy."
An NHS Greater Glasgow & Clyde spokeswoman said: "We can't comment due to ongoing legal action."
The government has pledged to spend £53million in the next three years to try to wipe out MRSA. In 2001, 830 cases were recorded in Scotland's hospitals.
Last year there were 1162 cases and MRSA contributed to 422 deaths and was recorded as the main cause in 51 others, a 30 per cent rise from 2006.
Richard Stern, of campaign group MRSA Support, said: "True figures of hospital infection may be as high as four out of every 10 patients.
"We applaud Mrs Miller because the NHS will be forced to explain in court how they have allowed this level of carnage to continue."
Source: SUNDAY EMAIL
Exclusive Mrsa Gran Uncovers Secret Report Exposing Filthy Ward
A PATIENT has uncovered a secret document exposing filthy conditions in the ward where she caught MRSA.
The damning report uncovers a catalogue of disease risks in one of Scotland's busiest operating theatres.
Gran Elizabeth Miller caught the superbug in 2001 while being treated in Glasgow Royal Infirmary's ward 65.
The leaked minutes highlight medics' fears about dust and debris falling through missing ceiling tiles, on to sterile equipment.
Consultant cardiothoracic surgeons Alan Faichney and Ian Colquhoun and microbiologist John Hood discussed the issue at a meeting about problems at ward 65.
The report, from November 2001, states: "The Infection Control Team are very short staffed. Some hand wash basins were lacking in soap and some equipment was very dusty and dirty.
"Dust levels on the ward were high and shower areas had not been cleaned appropriately...the theatre environment is very poor.
"There are several ceiling tiles missing from just outside the single rooms and directly in front of the clinical area where sterile equipment is stored. There is a risk of dust and debris falling from the open ceiling and thereafter accumulating on the floor, furnitire and equipment.
"High levels of dust may harbour MRSA which survives well in dust.
"Dr Faichey raised concerns that Infection Control Nurses have not investigated the links with theatres more thoroughly as there have been a number of deep-seated infections.
"The cardiothoracic theatres are, in his opinion, in a poor state of repair and very dirty."
The meeting took place just over a week after gran Elizabeth, 71, of Kilsyth, was diagnosed with MRSA following a heart valve op. She is suing in a case which could open the floodgates to similar claims - costing the NHS millions.
Her lawyer Cameron Fyfe said: "These damning reports clearly show the most senior doctors and infection experts expressing grave concerns and it is clear the situation had been ongoing for some time. The NHS should make minutes such as this public as an incentive to ensure hospital managers enforce infection control policy."
An NHS Greater Glasgow & Clyde spokeswoman said: "We can't comment due to ongoing legal action."
The government has pledged to spend £53million in the next three years to try to wipe out MRSA. In 2001, 830 cases were recorded in Scotland's hospitals.
Last year there were 1162 cases and MRSA contributed to 422 deaths and was recorded as the main cause in 51 others, a 30 per cent rise from 2006.
Richard Stern, of campaign group MRSA Support, said: "True figures of hospital infection may be as high as four out of every 10 patients.
"We applaud Mrs Miller because the NHS will be forced to explain in court how they have allowed this level of carnage to continue."
Source: SUNDAY EMAIL
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