Squash the Bug
Europe is killing off hospital infections. Why isn't the United States following suit?
If you are an American admitted to a hospital in Amsterdam, Toronto, or Copenhagen these days, you'll be considered a biohazard. Doctors and nurses will likely put you into quarantine while they determine whether you're carrying methicillin-resistant Staphylococcus aureus, a deadly organism that is increasingly common stateside, especially in our hospitals. And if you test positive for methicillin-resistant staph, or MRSA, these European and Canadian hospital workers will don protective gloves, masks, and gowns each time they approach you, and then strip off the gear and scrub down vigorously when they leave your room. The process is known as "search and destroy"—a combat mission that hospitals abroad are undertaking to prevent the spread of germs that resist antibiotics. Our own health authorities, meanwhile, have been strangely reluctant to join the assault.
In the United States, MRSA kills an estimated 13,000 people every year, which means that a hospital patient is 10 times as likely to die of MRSA as an inmate is to be murdered in prison. The latest survey by the Centers for Disease Control and Prevention found that 64 percent of the Staphylococcus-aureus strains in American hospitals were MRSA—that is, resistant to the powerful antibiotic methicillin and other antibiotics—which makes them difficult to treat. MRSA has also spread to the general public, afflicting football teams and schools in the last three years. I know a healthy 5-year-old who got a staph infection recently after she skinned her knee on the playground. She ended up requiring two full months of antibiotic treatment, while her mother scoured the house with bleach on doctor's orders. And she may not be rid of the bug yet.
Given the dimensions of the threat, you'd think that the CDC would be making a priority of fighting it. After all, federal health agencies have spent billions to fight anthrax (which caused five deaths in 2001), smallpox (last U.S. death: 1949), and pandemic flu (yet to appear in the United States). And there is reason to think that search and destroy works, since health-care authorities abroad have kept rates of antibiotic-resistant bugs in their countries much lower than ours. In Dutch hospitals, the rate of MRSA is less than 1 percent. Canada's rate is 10 percent. And more than 100 studies have shown the effectiveness of search and destroy, including work released in the last month in the United States.
Yet the CDC refuses to endorse search and destroy. It is sticking to the mantra that hospital workers should wash their hands more carefully and frequently, and that in most cases patients should be isolated only after symptoms of infection with MRSA appear. Routine surveillance to find patients who may not be symptomatic, but are still contagious, is rarely practiced, and not recommended in the CDC's new hospital infection-fighting guidelines, which were released last week after five years of deliberations. The guidelines do not include a routine recommendation for search and destroy.
This is a bitter pill for many infectious-disease experts, who have been joined by the relatives of dead patients, Consumers Union, and even a few Congress members in pressing the CDC. "Why are we spending millions if not billions on bird flu, a ghost that might not happen, when you have thousands being colonized by MRSA and dying of it?" asks Dr. William Jarvis, a top CDC hospital-infection expert until he resigned in 2003. At a March 29 hearing on hospital infections—which, all told, kill an estimated 90,000 patients each year—Rep. Bart Stupak, D-Mich., charged that the CDC had stood by, despite a steady rise in infections since the early 1970s. "During that time, hospital stays have grown dramatically shorter yet infection rates continue to go up," Stupak said. "What do we have to do to motivate CDC?"
Of course, many who succumb to hospital infections are already old, weak, and sick. And fighting such infections is a complicated, laborious business. Bacteria are everywhere, and each type of medical intervention, whether it be open-heart surgery, hip replacement, or traumatic wound care, carries specific risks of infection and methods for avoiding them. The Dutch approach is to test all high-risk patients before they are admitted. High risk, in practice, means diabetics, kidney-dialysis patients, and anyone who has been in a high-risk environment, such as a nursing home—or, from the point of view of the Dutch, the United States.
It's far more effective to isolate carriers, who may not yet be sick with the resistant microbes, than to wait until you have a confirmed infection, says Dr. Jan Kluytmans, a leading Dutch combatant in the resistance wars. Kluytmans' hospital in Breda, Netherlands, has had only one hospital-acquired MRSA infection since 2001, out of perhaps 40,000 patients. He estimates that the technique has prevented about 150 deaths. The University of Virginia Hospital in Charlottesville imposed the same system in 1980, and has maintained lower rates of MRSA than hospitals of comparable size. In late 2002, Rhode Island Hospital in Providence began search and destroy, and the MRSA infection rate at the hospital has dropped 43 percent, says chief epidemiologist Dr. Leonard Mermel, while it has continued to rise at most other hospitals in New England.
The counterargument is made by Dr. Robert Weinstein, a hospital-infection expert at Cook County Hospital in Chicago, and a leader on the CDC advisory committee that issued last week's guidelines. Weinstein argues that isolated patients generally get lousier care. And while aggressive action against MRSA may lower rates of that infection, he says, it doesn't necessarily reduce the incidence of deadly infections overall. Weinstein isn't against hospitals trying search and destroy. But he doesn't think it should become the standard of care until more studies prove its efficacy.
With a few exceptions, American hospitals, for their part, have been leery of the short-term expense and staff burden posed by search and destroy. A quick nasal swab of an admitted patient may cost only $20, but the nursing staff has to carefully monitor isolated patients, and find room to house them. The hospitals' reluctance may be shortsighted, however: A recent study showed that the average hospital infection adds $20,000 to a patient's bill. And while hospitals have traditionally passed on their costs to other payers, Medicare—which sets reimbursement standards—is starting to curtail payments to cover hospital errors, and may eventually stop paying to treat infections that could have been prevented.
The biggest push for search and destroy may come, sadly, from the threat of lawsuits. Several large ones have been settled with hospitals where patients died of infections. Fifteen states have passed laws that require hospitals to report infection rates, and another 28 are considering such legislation. An infectious-disease specialist I know offers a much simpler prescription: Whatever you do, he says, stay out of hospitals.