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Got Scary Germs?

September 24, 2008
by Mark Hagland
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As health writer JoNel Aleccia reported earlier this year in an article on, Ohio mother of two Amy Warren experienced stomach cramping so severe she felt as though she was still in labor, followed by uncontrollable diarrhea that left her weak and raw. It took four tests to find out the truth: Warren was among growing numbers of Americans sickened by an especially virulent form of the bacterial infection Clostridium difficile, popularly known as C. Diff. “It’s like a science fiction disease,” said Warren, who struggled for six months and three relapses before controlling the infection.

Unfortunately, Amy Warren is far from alone these days. In fact, the latest federal Centers for Disease Control and Prevention figures show that between 2000 and 2005, infections caused by C. diff more than doubled, with 301,200 cases of C. difficile-associated disease (CDAD) logged in by U.S. hospitals, with 28,600 patients dying from it. Federal officials add that when nursing homes and other patient care sites are included, the number of cases nationally is now closer to 500,000. “We’ve been trying to sound the alarm repeatedly since 2004 that the trend is continuing upward,” Cliff McDonald, a CDC epidemiologist told The Wall Street Journal last week.

Here’s the interesting part: many patients acquire C. diff infections as a consequence of taking antibiotics for other illnesses, as the bacteria normally found in a person’s intestines help keep C. diff under control. As a result, hospitals are monitoring and limiting antibiotic use more closely now. What clinicians really need in this context is two things. First, they need the clinical tools associated with the EMR—both the patient record element, and the clinical decision support element—in order to better track infections and better deal with them. On a broader level, the healthcare system as a whole needs more extensive coordination of the kinds of tools and systems that will help public health leaders better track what’s going on in the country with infections, and better alert healthcare provider organizations and the public on emerging and urgent trends.

Hospitals, as everyone already agrees, also need to better crack down on poor hygiene and sanitation habits. “The biggest problem in our hospitals is that they are filthy dirty,” Dr. Alfonso Torress-Cook told earlier this year. Toress-Cook, an epidemiologist, told the media outlet that he had already adopted practices that cut C. diff infections by 90 percent at his acute rehabilitation center in Orange County, California. “If we start cleaning the environment, the infection will take care of itself,” he added.

Hospital and health system CIOs will need to be a part of the discussion both around clinical information systems, obviously, but also the discussion with clinician leaders and facility managers around such topics as purchasing ultraviolet light machines to curb infections, and including building infection control check-ins at appropriate points of care (such as ensuring handwashing prior to inserting central line catheters).

Given the risk to both individual patient and public health, as well as the potential costs involved, infections like C. diff need to be taken seriously, lest we all end up the sicker—and sorrier—for not having acted.



Question for you Mark: when my father was in the hospital with a ruptured aortic aneurysm last year, he wound up getting ventilator-associated pneumonia, specifically a very virulent form of it called Acinetobacter:

Acinetobacter is frequently isolated in nosocomial infections and is especially prevalent in intensive care units, where both sporadic cases as well as epidemic and endemic occurrence is common. A. baumannii is a frequent cause of nosocomial pneumonia, especially of late-onset ventilator associated pneumonia. It can cause various other infections including skin and wound infections, bacteremia, and meningitis, but A. lwoffi is mostly responsible for the latter. A. baumannii can survive on the human skin or dry surfaces for weeks.” — Wikipedia

As far as I could tell, the infection was transmitted from insufficient and inconsistent gowning and gloving by people going in and out of his room (including me). I’m sure most readers have heard about Peter Provonost’s simple checklist strategy which has probably saved thousands of lives, and if implemented consistently, will probably save thousands more.

At the time, I wrote an editorial IT Can't Turn You, emphasizing the human touch in care, regardless of the amount of IT involved.

It seems to me that, especially for smaller institutions with more modest budgets, getting sufficient staffing levels, then implementing low-cost protocols like Provonost’s suggests, would go a long way to reducing these infections, adding IT on top can be the icing on the cake.

Yes, it will need to be a combination of efforts (and technologies), particularly in smaller hospital organizations. It's amazing how poor some of the simple protection protocols are around ventilator and central line catheter care. Innovative hospitals have mandated handwashing/gowning/gloving procedures for everyone involved in caring for patients on ventilators and everyone who s central line catheters. That core checklist-based strategy, augmented by training and certification (simple peer-based certification, not by outside agencies) has worked wonders in reducing infections in the hospitals that have implemented such a strategy. And when it comes to bugs like C. diff, even enforcing the most basic handwashing requirements will become increasingly critical. Fortunately, clinicians and outside organizations alike are becoming more aware.