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Lets Get Realistic about the "Superbug"
- Mark Spigelman (22 July 2004)
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Handwashing & MRSA
- James H MacG Palmer (27 July 2004)
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Cleanliness in hospitals
- Lone Sarosi, Stephen Dalton (31 August 2004)
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Mark Spigelman, Visiting Professor Centre for Infectious Diseases and International
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The Editor BMJ 22nd July 2004 Lets Get Realistic about the "Superbug" The recent publication of National Audit Office (NAO) report on the "rise of superbug infections in hospitals" plus the almost hysterical responses quoted in the press does give rise some interesting thoughts. The basic conclusion appears to be that people do not wash their hands enough!! This means that we should be washing off the causative bacteria and thus ignores the basic question how did they get there in the first place. Why is it that in a place where antisepsis is rigorously paractised, where we are using increasingly more bacterocidal solution to cleanse our hands and increasingly more potent antibiotics to try and overcome the bacteria plaguing our hospitals. Realistically we should be looking for changes to overcome this problem not to intensify the methods that have already been shown to be ineffectual. Statements such as those attributed to Pat Troop chief executive of the Health Protection Agency that "good hand hygiene was essential to prevent cross infection" ignores the nose, clothes and hair of health care workers and postpones the days where the required radical care has to be faced. Resistant bacteria such as MRSA have been with us since the 60's yet amazingly we seem to forget that despite this it has not become a problem outside the hospital environment. Indeed the only antibiotic resistant bacterium that is found in the community is the M.tb bacteria, which is the only one treated long term on an outpatient basis. Thus the treatment of what are basically hospital bacteria is to look at why they are only present in this so called cleanest environment. They do not take root in the environment because they are not genetically advantaged there and the pathogenic islands which give then an ecological niche in the antibiotic rich swamp in a hospital is a positive disadvantage in the outside world. Here their more benign cousins exist and these require less energy to divide and thus quickly become the dominant species (shown by the fact that if you close a ward which has an infection after a few weeks the problem will disappear). I am reminded of what happened to Ignaz Sammellweiss when he in the 1850's first proposed that doctors wash their hands-the medical professions response resulted in one the great of medicine ending his days in a asylum for the Insane. Some years later Lord Listers proposals where taken up with enthusiasm, and certainly the use of soaps and understanding of basic principles of cleanliness have been responsible for a lot of the improvements in infection control and improved longevity of our society since. However we must ask the question have we perhaps gone overboard with this? Has the washing of hands in increasingly more potent bactericidal solutions actually worked or is it the case that what we are killing on our hands our mainly harmless skin commensals thus allowing space for the more lethal bacteria to settle. Should we not be thinking: yes lets keep our hand clean and then have a solution such as some harmless bacteria (probiotic) which we can then dip our hands into to make sure there is no room for the more aggressive hospital bacteria to settle. I have commented on this in at least two publications (Greenblatt and Spigelman 2003 & Greenblatt et al 2003) Articles on the NAO report stress that private hospitals have fewer problems then the NHS one, this is understandable as they treat far less seriously ill patients and we all are aware that many private hospitals send their seriously infected patients to NHS intensive care wards-many of who require long term antibiotics. My personal experience with day care centers confirms that these have even less of a problem and I believe this is in proportion related to the use of antibiotics. Surely nobody suggests that private hospital staff wash their hands better/more often then NHS staff. So the problem is how to isolate surgical and other patients from these nasty hospital residents. My suggestion is we must start treating the cause and not trying to overcome it. If we accept that antibiotics are the cause of the "superbugs" we should try and isolate the people coming in from the community from the superbug. Thus the NHS should have two types of hospital- one in which antibiotics are never used and where post-operative and medical patients are shipped out if they need any type of antibiotics, and another where patients who need antibiotics are admitted. Having separate (isolation) wards in the same hospital will and has not worked. Some such efforts are being made at present but they are half measures only (Biant et al 2004) as staff still get exposed to superbug infected areas. This system will only work if we have strict guidelines. Staff and particularly doctors must NEVER enter the other hospital i.e. if you work in a antibiotic free hospital even if your patient is transferred you do not visit them, their doctor any enquiry’s can be made by phone or email. The antibiotic using hospitals would naturally have level of isolation as to day. What this system would be designed for is to make sure surgical patient have the least possible chance of coming into contact with the resistant bacteria that now create such havoc. I realize this upsets the patient/doctor relationship but then that relationship was never meant to put the patient at risk. I am reminded of the writings of Paul Ewald (Ewald in Greenblatt &s Spigelman 2003) when he advised doctors who have the flu not to visit their patients and thus spread the virus. I accept that this may well create its own problems (plague hospitals etc etc) but these can be overcome with proper thought what will not be overcome are the "superbugs" with trying more of the same. If this regime is applied properly then we do have a chance to perhaps start coming to grips with problems created by modern medicine and not let us attack the NHS for trying its best. M Spigelman BSc MB BS FRCS Visiting Professor Centre for Infectious Diseases and International Health, Department of Infection, Windeyer Institute of Medical Sciences,UCL, 46, Cleveland Street, London W1T 4JF Bibliography: Biant L , Teare L, Williams W and Tuite J 2004 Eridication of methicillin resistant Staphloccocus arreus by "ring fencing" of elective orthopaedic beds. British Medical Journal 329: 149-51. Greenblatt C and Spigelman M 2003. Associate Editors Emerging pathogens: Archaeology, ecology and evolution of infectious disease: Greenblatt C and Spigelman M (eds) Oxford University Press Oxford. Greenblatt C, Spigelman M and Vernon K. . 2003. "The Impact of "Ancient Pathogen" Studies on the Practice of Public Health" Public Health Reviews. 31:2: 81-91. Competing interests: None declared |
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James H MacG Palmer, Consultant Anaesthetist Hope Hospital, Salford M6 8HD
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The rise and rise of MRSA (Methicillin resistant Staphylococcus Aureus) is keenly reported not only in the medical journals, but also in the press. An observational audit of handwashing in public washrooms would, I suspect, make very interesting reading. Personal observation (performed, I hasten to add, while washing my own hands!) would suggest that fewer than one in 5 men use washbasins before leaving public washrooms. In addition, no public conveniences seem to have doors opening outwards, in all circumstances they require you to soil your recently washed paws by pulling a handle to open the door. The same applies to almost all hospital washrooms as well! New drugs and procedures may help, but so would changing the hinges on washroom doors. Remember the Broad St Pump! Competing interests: None declared |
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Lone Sarosi, Deputy Director of Infection Prevention and Control Whipps Cross Hospital, Stephen Dalton
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Sir, Noting increasing governmental and public interest around hospital cleanliness(1) and MRSA(2), we thought it would be useful to share our recent experience evaluating a new environmental cleaning concept using microfibre technology, which is being marketed actively in the UK at the moment. While the performance of such systems have been validated extensively using artificially contaminated surfaces, we know of only one other published study which has looked at efficacy in a ward environment. The evaluation involved comparing the new method against our ‘in- house’ 1000ppm hypochlorite / 1% neutral detergent method, using environmental bacterial counts as a marker of efficacy, but was otherwise very similar to a 2003 study performed in Holland(3) where the microfibre method was found to compare very favourably with 1% neutral detergent alone. In addition, we were also interested in the practicalities of introducing a new concept to our contracted cleaning staff. The new method utilises microfibre technology, which improves electrostatic attraction of dust (when dry) and capillary action (when damp). Other recognised advantages of the new method include avoidance of dirty mops with the hazards of spread of gram-negative bacteria in wet environments and, Health and Safety advantages in the form of chemical avoidance and use of heavy buckets of solutions. The evaluation was performed as a double blind crossover and involved the taking of >1500 environmental samples. It was performed within two defined areas within a 16-bedded isolation ward (consisting of 9 side rooms and 2 bays, usually used for cohort isolation of MRSA patients - containing 4 beds and 3 beds respectively) -. Area 1 comprised Bay A, adjacent side rooms 1 and 2, nurses station and main corridor; Area 2 comprised Bay B and adjacent side rooms 3 and 4. The ‘in-house’ cleaning method for floors involved initial dry wiping with colour coded ‘J-Cloths’ followed by wet mopping using a freshly prepared warm 1000ppm hypochlorite / 1% neutral detergent solution (Actichlor Tablets ‘Adams Healthcare’ / ‘Taski 300’ 1% neutral detergent ‘JohnsonDiversey’). Other surfaces are also cleaned with same strength hypochlorite / detergent solution. Local policy requires mop heads to be laundered daily and disposal of ‘J-Cloths’ daily. In practice we are aware that this does not always happen. An initial proposal was submitted to the local Research and Development Committee, which included approval from the local Ethics Committee. The evaluation commenced following a scoping exercise after which the protocol was agreed by the Infection Control Department and the study sponsor ‘JohnsonDiversey’. Training sessions for the new system were provided by ‘JohnsonDiversey’ prior to start of study for the regular ward cleaner, their supervisor and training manager to enable domestics to become familiar with its use and to ensure correct system continued over weekend periods. For the first 2 weeks Area 1 was cleaned with the in-house method and Area 2 with Microfibre method. At the two-week point, methods were switched over. Microbiological swabs and one hour settle plates at predefined points were taken ‘pre’ and ‘post’ cleaning on 2 consecutive days in both Areas during each of the 4 weeks of the evaluation. The range of surfaces sampled included a) floors; b) laminar surfaces: lockers, windowsills, curtain rails, patient tables; c) contoured surfaces: towel dispensers, bed heads, handrails and taps. All samples were taken by one individual throughout, using standardised methodology. Inoculated swabs were placed into sterile ¼ strength Ringer’s solution (with halogen neutraliser) during transport, coded and despatched immediately to an independent laboratory (Industrial Microbiological Services Limited, UK) which supplied all consumables and undertook culture (spiral plating onto Trypcase Soy Agar -aerobic count and Baird Parker - Staphylococcus aureus count) and statistical analysis of results while blinded to the code – known to them only as method A and method B. In terms of microbiological efficacy, overall results showed both systems were able to impact favourably on environmental bacterial load. However, neither method completely and consistently removed the microbiological population. Method B (hypochlorite/detergent) did show a statistically significant greater reduction in the numbers of aerobic bacteria on both floors and laminar surfaces than Method A (Jonmaster). No statistical difference was found between the two methods when used on contoured surfaces and no statistical difference on levels of S. aureus on any surface although there was a trend generally in favour of Method B. It should be recognised that this comparison was against a hypochlorite/detergent containing cleaning solution rather than standard 1% neutral detergent, more commonly used for general hospital environmental cleaning. Full data and analysis available on request. The operators were unanimously positive and reported a more user friendly, speedier system and visually cleaner appearance where the Jonmaster Microfibre system had been used and which left more time available to do high cleaning due to the additional accessories (e.g. extension rods and moulded tools) the system offers. Accepting that this was a relatively small study that could have been affected by, the nature of the patients’ conditions in the study rooms, e.g. heavy dispersers and minor infractions of the original protocol, results suggest that the ‘in-house’ cleaning method employing 1000ppm hypochlorite / 1% detergent may have the edge over the new Jonmaster Microfibre system in terms of bacteriological efficacy. However, it may be argued that, providing a robust training programme is produced for all grades of domestic staff and managers, the benefits of the Jonmaster Microfibre system in terms of user friendliness, Health and Safety issues and operator efficiency could outweigh this slight advantage from the traditional cleaning system particularly, when hypochlorite is not employed, as in other areas of the hospital. Lastly, as the Jonmaster Microfibre system is a completely new concept in cleaning, the authors suggest a staged implementation and further pilots to be carried out in a variety of locations within the healthcare environment before widespread implementation is considered. Thanks to ‘JohnsonDiversey’ for sponsoring this evaluation. Sarosi L Goodbourn C Cameron-Watson C Finn-Davies E 1 Department of Health Guidance ‘ Towards cleaner hospitals and lower rates of infection’. Gateway Reference 3502, July 2004. 2 White C. MRSA infections rose by 5% between 2003 and 2004(BMJ News). BMJ 2004;329:131. 3 Ballemans CAJM, Blok HEM, Swennenhuis J, Troelstra A, Mascini EM. Dry cleaning or wet mopping: comparison of bacterial colony counts in the hospital environment. J Hosp Infect 2003; 53:150-52. Competing interests: None declared |
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