Saturday, December 19, 2015

Infection Control in a Small Hospital

Today I want to continue talking about what its like to work in infection control in a small hospital.  About 70% of all hospitals in the US are under 200 beds and 55% are under 100 beds. I carry out infection control work on a volunteer basis for a hospital near my home with an average census of around 40-50 patients. Since I began working there about four years ago, the hospital has undergone receivership, was purchased by a larger hospital in the area, and our system is now about to merge with another huge health care system in our region. This constant series of administrative earthquakes has challenged our infection control efforts.

We have made enormous progress on a number of fronts. Our hand hygiene program has had huge success with compliance rates now approaching 100%. We have revamped our microbiology procedures to better diagnose patients with pneumonia and to better identify resistant bacteria. Our antibiotic resistance rates among key pathogens remain low. We are revamping our surgical wound infection prevention program in a way that I believe will further reduce our already low rates of infection. And we have made great strides in assuring that patients requiring isolation remain isolated during all their sojourns around the hospital for diagnostic testing and procedures.

Our hospital is one of the highest rated medical centers in our area based a number of criteria including patient safety and infection control.  We do very well on all our external audits including those by the Joint Commission on Accreditation of Hospitals. And I agree that the hospital provides high quality care. I just know that we could do even better.

We do have a number of challenges that I think are directly related to our small size.  Our digital medical records system is badly in need of overhaul. It cannot perform any of the key infection control functions such as microbiology lab surveillance, diagnostic code surveillance for hospital-acquired infection nor can it provide reporting to the National Healthcare Safety Network of CDC.  All of this must be done by hand by our infection control nurse.  Our nurse also carries out daily rounds on all the hospital inpatient units, screens the OR schedule and peruses the emergency room patient and diagnosis list in pursuit of infections that might have been acquired at the hospital and of patients in need of some sort of isolation for colonization or infection by multiply-resistant organisms. She struggles to get all this done without computer support.

Our computer systems also are unable to support our antimicrobial stewardship efforts.  We are unable to determine antibiotic dosing in standard format such as defined daily doses. This makes it almost impossible to follow antibiotic usage trends. The pharmacy staff has been cut continually since I joined such that it is difficult for them to keep up with basic stewardship functions such as assuring that patients are getting the correct doses of the antibiotics that the physician has ordered.  Other functions, like trying to get patients off of unnecessary antibiotics, have fallen by the wayside.

Every time we attempt to bring on new functionality to our system or bring in a new computer system for infection control, we are about to merge and are told that we have to wait for the merger to occur.

My hospital has a small intensive care unit.  It exists to back up our surgeons who refuse to operate (understandably) in a hospital without such a unit.  In fact, our ICU maintains a census of 3-5 patients and there is almost always at least one or two on a ventilator. The problem is that we have only one intensivist.  Obviously, he cannot be there 24/7.  Although this may work well, the reliance on trained physicians assistants, ICU nurses and frequent telephone contact makes me nervous. I would prefer to have enough intensivist coverage such that some trained physician was easily available on a 24/7 basis. To resolve this would require systematic changes that might be forthcoming with the latest merger – but in the meantime, we are still on hold. 

Some might say that we should close the hospital altogether.  But those people do not live in this community.  To the community, the hospital is very important and extremely well liked and, as I noted in the beginning, we provide high quality care for our patients.  

Having worked in a very large hospital system (I was at a university-affiliated VA for 16 years), I now understand the issues confronting both types of systems, large and small. Small hospitals have unique problems that are not appreciated by insurers and key payers like Medicare and Medicaid.  Yet small hospitals comprise the bulk of hospital-based healthcare in the US. We need to start paying more attention to them.

Tuesday, December 8, 2015

The Endgame

Is this how it will end for us? We use our absolutely last line antibiotic to attempt to put fat on a pig more quickly and select for a plasmid-mediated resistance gene capable of spreading worldwide? Even more galling is that China is not the only country to do this – count the US in as well.

I guess I should start at the beginning of this story. We are now living in an era where, according to Jim O’Neill in the UK, 700,000 people globally die of resistant infections every year. The most resistant bacterial pathogens we deal with today are the Gram-negative bacteria like those resistant to our next-to-last line antibiotics, the carbapenems (CRE). Currently, we can treat CRE with tigecycline (sometimes) and most often, with colistin.  Colistin is an old antibiotic discovered around 1947  and marketed in the 1950s.  It was almost never used systemically since it is  neurotoxic and nephrotoxic (causes nerve and kidney damage).  Given that colistin, at least until the emergence of CRE, was never used – no one knew how to use it or even if it actually was effective when given systemically. Since physicians are having to use colistin more and more frequently to treat CRE infections, we are now learning that it can be effective and that there are a few things we can do to lessen its toxic effects. But, no matter what, it is still not a very effective treatment and it remains toxic. On the other hand, until now, we have had nothing else to offer.

Luckily, for some CRE, we now have a new antibiotic, ceftazidime-avibactam, that should work.  The antibiotic was approved last year in the US and will be approved (I presume) in Europe very soon. But it does not cover all CRE – only some of them. Another antibiotic, wending its way through clinical trials at a tectonic pace is aztreonam-avibactam.  This will address another group of CRE. Finally, there is eravacycline – a tetracycline similar to tigecycline with fewer side-effects and the potential for oral use.  But it recently failed a key phase III trial in urinary tract infection and its future is in doubt. Further, most tigecycline-resistant bacteria will also be resistant to eravacycline. Is there resistance to these new antibiotics? Yes.  Will we still need other options including colistin?  Probably.

This brings us back to fattening pigs. A month or so ago, the Lancet reported the emergence of colistin-resistance caused by a gene, mcr-1, found in samples from animals and some human patients in hospitals in China.  This gene is carried on plasmids and can readily spread from one bacterium to another.  It has already been reported outside of China- in Malaysia and now in Europe. The origin of the gene?  Feeding colistin to pigs to promote growth. Who besides China allows this practice?  The United States – that’s who.

Do we even need to use antibiotics to cause more rapid growth of animals?  Probably not.  A raft of studies has shown that with more advanced farming techniques, antibiotics as growth promoters add little (less than 5%) to the value of meat produced. True – that with poor technique like overcrowding and unsanitary conditions, antibiotics seem to be more important – but why don’t we work on bettering conditions for raising animals rather than relying on antibiotics.  Also – if we have to rely on antibiotics to promote growth of animals, it is the height of stupidity to use the one that is our absolute last hope for highly resistant human pathogens.

Unfortunately, even if we could do better in the US – and if we had an effective FDA we could – we also need to address this problem globally, including in China and other Asian countries with whom we have signed a new trade agreement. If we don’t address this now, at home and abroad, we will lose our ability to stay ahead of bacterial resistance altogether.

– and this might just be how it all ends.