When hospitals want to make a name for themselves, they spend on reputations and technology—on the esteemed surgeon or the top-of-the-line gamma knife and the star radiologist to operate it. Such investments attract publicity as well as patients seeking the best available health care. Lately, though, some hospitals have been making an unexpected discovery. The kinds of expenditures that truly improve patient care are often not directed at the top of their pay scale, with the famous specialists, but rather at the bottom, with the anonymous janitors.
Hospitals have reached this realization while trying to cope with an alarming trend. Over the past decade the organisms that cause most infections in hospitalized patients have become more difficult to treat. One reason is increasing drug resistance; some infections now respond to only one or two drugs in the vast armamentarium of antibiotics. But the problem also arises because the cast of organisms has changed.
Just a few years ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA, or methicillin-resistant Staphylococcus aureus. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.
“Hand hygiene is very, very important,” says Michael Phillips, a hospital epidemiologist at New York University Langone Medical Center who has been studying this problem. “But we are coming to understand that it is one of just several important interventions necessary to break the chain of infection that threatens our patients.”
The infectious organisms that require all this extra effort became a serious problem around 10 years ago. The first outbreaks were caused by vancomycin-resistant Enterococcus, or VRE, and Clostridium difficile, known as C. diff, followed by a group of bacteria collectively referred to as highly resistant gram-negative organisms: Escherichia coli, Klebsiella, Pseudomonas and Acinetobacter.
This varied lot enters hospital rooms via multiple avenues. Acinetobacter and Pseudomonas prefer to live in the soil and water, but they are carried into hospitals from the outside world on people's shoes and clothes. In contrast, VRE, E. coli, Klebsiella and C. diff thrive inside human beings. These bacteria enter hospitals in patients' intestines and escape when bedbound patients suffer from diarrhea, contaminating the air and equipment around them.
The new scourges are particularly tough to clear away for several reasons. The gram negatives, for instance, have a double wall that gives them extra defenses against antibiotics and shields them from damage by other compounds, including cleaning chemicals. Many of the bugs can survive in low-nutrient environments, such as glass, plastic, metal and other materials that make up a hospital room. Consider VRE. One strain that caused an outbreak at the University Medical Center Utrecht in the Netherlands grew in a lab dish for 1,400 days after being dried in a test that mimicked what might happen in a patient's room. (MRSA also survives on surfaces, but for much shorter duration.)
Because of such abilities, the latest bacterial threats create an infection risk at least as great as health care workers' contaminated hands. “It forces us to raise the cleanliness of the hospital as a clinical issue, just as washing our hands is a clinical issue,” says Cliff McDonald, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention.