Superbugs: Reducing the Serious Threat of Hospital-Acquired Infections

Ask friends, family and colleagues for their list of the most important technological advances of the 20th century, and you’re likely to get answers ranging from powered flight to the computer and telecommunications. But the modern acute-care hospital — while it may not be on many people’s lists —has had as large an impact on our society, and on tens of millions of individual lives, as any of the above important advances.

The development of the modern hospital is so ubiquitous to contemporary life that it is often overlooked, lost in its commonality and taken for granted. From “Dr. Kildare” to “Marcus Welby, MD,” “ER” and “Grey’s Anatomy,” popular culture has enshrined today’s hospital as a kind of secular cathedral — impressive but also often invisible. Until we need it. Before the 1900s, hospitals had a horrible but likely accurate reputation as bastions of filth and disease —as places the poor went to die and the rich avoided (treating their family members at home).¹ Predating many of our discoveries about microbiology, 19th century and earlier hospitals concentrated the sick in wards that lacked modern antiseptic measures, resulting in the unintended effect of creating highly fertile breeding grounds for infectious disease. Even in the 20th century, the Spanish flu killed more young men than the ongoing World War I — mostly from the ability of the flu virus to spread quickly among closely compacted populations in military barracks and hospital wards.

Twentieth-century advances in immunization, antibiotics and disinfectants, and in the education and professionalism of physicians and nurses, helped change both the perceptions and reality of hospitals. At the same time, rapid developments in surgical techniques made treating patients at home impractical — even for the rich — meaning that many life-saving procedures could only be accessed at a centralized facility with specialized equipment and sterile conditions. These factors all combined to turn our modern hospitals into places of hope and healing.

Today, these hard-won advances in the efficacy and reputation of hospitals are being threatened by a troubling, stubborn bubble in the number of infections acquired in hospitals, urgent care centers, long-term care centers and other healthcare facilities. They are all prone to serving as home to an increasing array of hospital-aquired infections (HAIs) that endanger the health and even lives of the patients being treated in them.

The threat of HAIs, also known as superbugs, has become so serious that, in 2008, the U.S. Department of Health and Human Services (HHS) empaneled the multi-agency Federal Steering Committee for the Prevention of HAIs.² The committee is chaired by Dr. Don Wright, MD, deputy assistant secretary for health for HHS’ Office of Disease Prevention and Health Promotion.

How Big a Problem?

According to Wright, about 5 percent of all hospital patients in the U.S. have an HAI at any given time.³ The Centers for Disease Control and Prevention (CDC) estimates that, in 2002, 1.7 million Americans contracted an HAI.⁴ That number is believed to have risen to about two million per year by 2009.⁵ The European Centre for Disease Prevention and Control estimated earlier this year that three million Europeans contract an HAI each year.⁶

And the mortality rate of HAIs is fairly high. In the U.S., CDC estimates that some 99,000 deaths per year are at least partially contributed to by an HAI.⁷ That’s almost 5 percent of those who contract an HAI. The European counterpart estimates some 25,000 deaths per year are due to HAIs. (It is not clear that the U.S. and European centers use the same methods in measuring the culpability of HAI in patient mortality, as the above numbers would result in a European mortality rate less than one-fifth that in the U.S.)

While the numbers alone are staggering—millions of people in Europe and the U.S. acquiring a secondary infection while being treated at a medical facility each year — the economic cost is equally sobering. A study prepared for CDC calculated that HAIs in 2007 cost U.S. hospitals roughly $30 billion to treat.⁸

Considering that the Centers for Medicare and Medicaid has been excluding treatment of preventable HAIs from reimbursement eligibility, and that private insurers are beginning to follow suit,⁹ the financial burden of treating HAIs is likely to increasingly fall on hospitals and other healthcare facilities. And, the above price tag does not factor in the cost of malpractice claims and litigation filed by patients and their families who feel their HAI was preventable — only the immediate cost of treatment.

Gathering Information

Over the past few years, CDC has been tracking HAIs in minute detail, collecting precise information on these infections, including which organisms cause them and how the infection invaded the body.¹⁰ This information gathering has happened under the auspices of two separate but parallel programs: the National Healthcare Safety Network (NHSN)¹¹ and the Emerging Infections Program (EIP).¹² The NHSN tracks HAI reports from more than 11,000 medical facilities in the U.S., while the EIP gathers data from 10 state health departments and academic institutions. Among the microbes most responsible are more than a dozen bacteria and viruses being tracked by CDC’s HAI program:¹³

• Acinetobacter
• Burkholderia cepacia
• Clostridium difficile (C. difficile)
• Clostridium sordellii
• Enterobacteriaceae (carbapenem-resistance)
• Hepatitis
• Human immunodeficiency virus (HIV)
• Influenza
• Klebsiella
• Methicillin-resistant Staphylococcus aureus
• Mycobacterium abscessus
• Norovirus
• Pseudomonas aeruginosa
• Staphylococcus aureus
• Tuberculosis
• Vancomycin-intermediate Staphylococcus aureus and vancomycin-resistant Staphylococcus aureus
• Vancomycin-resistant Enterococci

A number of these (Acinetobacter, Burkholderia cepacia, Pseudomonas aeruginosa) are common in everyday environments (naturally present in soil and water), posing little risk to healthy individuals. But in a hospital setting with patients whose weakened immune systems are unable to respond, these normally benign bacteria can become deadly.

The same is true of bacteria associated with the human digestive tract (escherichia coli [E. coli], Klebsiella, Enteroccocci), where they normally do their job without causing us any health problems. Remove them from our intestines and put them near patients with compromised immune systems, and they are a serious danger.¹³

For the most part, these particular bacteria can still be effectively treated by current antibiotics. The resistant strains on the list are the ones garnering the alarming headlines in the popular media — for the very sobering reason that our ability to fight them is limited. And, these strains exist almost exclusively in healthcare facilities.

The major entry points tracked by CDC are catheters, surgical incisions and ventilators.¹⁴ The infection types designated by CDC are based on both the entry point and the part of the body that becomes infected:¹⁵

• Surgical site infection
• Central line-associated bloodstream infection
• Catheter-associated urinary tract infection
• Ventilator-associated pneumonia

Looking more closely at HAIs, certain agents are associated with certain designated infections. For instance, cather-associated urinary tract infections are most commonly caused by Enterobacteriaceae (carbapenem-resistance), Klebsiella or vancomycin-resistant Staphylococcus aureus.¹⁴

Not Just Hospitals

One of the byproducts of the dramatic rise in healthcare costs of the past few decades has been the growth in the number of alternatives to a traditional acute-treatment hospital. From urgent-care clinics offering a lower-cost option to the emergency room to outpatient surgical facilities, long-term residential nursing care and dialysis centers, there are numerous examples of nonhospital medical facilities that serve the same role as a ward in a full-service hospital.

Not surprisingly, these medical facilities are seeing the same challenge from HAIs as are the hospitals they complement and compete with. In fact, CDC’s HAI-prevention program even includes dental facilities.¹⁶ Any place where invasive procedures compromise the body’s defense against hostile organisms is capable of spreading HAIs.

Fighting Back

Using the solid body of statistics it has compiled on HAIs, CDC and other health organizations and professionals have already begun devising strategies to prevent these infections — and develop more effective treatments for those patients who are infected.

With more than 11,000 medical facilities being tracked for HAIs in this country alone, CDC admits that a 100 percent eradication is not a realistic goal at this time. But even the government’s 2009 target goal of a 40 percent reduction by the end of September 2013 (compared with 2010 infection rates) would mean tens of thousands fewer premature deaths each year in the United States alone.

The government-led HAI task force issued its National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination in 2009, which included the above target goal. That plan provides detailed and multipronged plans that are geared specifically to the types of facilities, the bacteria or viruses causing the infection, and the most common methods of transmission. It is organized into three main sections: acute-care hospitals, outpatient facilities and long-term care facilities.¹⁷ Many of the recommendations are surprisingly low-tech and common-sense: Are your staff members washing their hands as often as they should? Are instruments being properly sterilized?¹⁸

Consistency in following both legal guidelines and proven best practices remains the most effective method in preventing HAIs. Properly trained medical professionals know how to disinfect an examination or operating room, and how to follow established parameters to reduce infection risk. It’s doing it properly over and over again, for every patient every day without ever growing lax or careless, that is the greatest challenge — the weakest link in the prevention chain.

To help administrators follow through on meeting this difficult human challenge of consistently following protocols to prevent HAIs, CDC has numerous materials available in a centralized online location: www.cdc.gov/HAI/prevent/prevention.html. There are brochures and one sheets, flyers and posters, almost all available in PDF format that can be downloaded and printed out.While these are no substitute for professional training materials and curriculum, they are a good starting point to ensure staff are clear on their obligations and the best methods for meeting them.

Making Progress

CDC reports that some transmission methods are already seeing lowering rates of infection. By 2010, central line-associated bloodstream (CLAB) infection rates had dropped 18 percent from two years earlier.19 CDC attributed the drop to better and more consistent implementation of best practices by staff at the 1,500 hospitals that took part in the study the results were based on. A year later, the rate of CLAB infections had dropped even further.²⁰

A smaller program involving just seven hospitals from around the U.S. that focused on reducing surgical site infections during colorectal surgeries managed to achieve a 32 percent reduction over an 18-month period.²¹ Another benefit of avoiding infections is that the patients needed shorter hospital stays before going home to continue their recovery.

A promising front in the battle against HAIs is the use of copper in more surfaces in hospital equipment. The May issue of the journal Infection Control and Hospital Epidemiology included a study on copper in hospital settings, showing HAI infection rate reductions of up to 58 percent when copper is used in place of other metals and existing preventive techniques are followed.²²

One of the challenges facing public health officials trying to both encourage improvements in HAI prevention while also accurately measuring them is that hospital and other healthcare facilities are only all too human — and there have been several studies showing both wide discrepancies in reported infection rates among similar facilities23 and suggestions that reported rates of some HAIs may be artificially lowered due to expectations of success.²⁴

Looking Ahead

As the lead agency in the effort to reduce the human cost of HAIs, CDC continues to invest in research in multiple disciplines to try to improve technology and techniques in battling HAIs. Among the current research efforts:

• Working on new tests to make detection of HAI-linked microorganisms quicker and more accurate
• Investigating the biology of vancomycin-resistant Staphylococcus aureus
• Studying new methods of ensuring the sanitation of water supplies in healthcare facilities²⁵

CDC and its partners, both private and public, are continuing their efforts to accurately measure HAIs, improve the training and performance of healthcare professionals to lower the incidence of secondary infections acquired at healthcare facilities, and develop new treatments to cure those patients who do become infected.

The results so far are promising, if incomplete. But the attention brought to bear on the issue should ensure that preventable infections become rarer in the years to come.