Growing numbers of patients are picking up infections in hospital. How is it happening and what can we do to stop it, asks Eithne Donnellan, Health Correspondent
Every year hundreds of patients pick up bugs in Irish hospitals, coming down with infections they probably wouldn't have contracted had they been treated at home. For a small number the consequences are fatal.
Yet most people seem unaware of the prevalence of hospital-acquired infections and of what they can do to stop them, according to Prof Martin Cormican, consultant microbiologist at University College Hospital in Galway. Patients who know the risks, he says, are more likely to help hospitals beat the bugs.
One organism that is a significant problem for hospitals is methicillin- resistant Staphylococcus aureus, or MRSA. Many people suffer no ill effects after being "colonised" by the bug, but if it gets into your bloodstream there can be a "pretty substantial" chance that it will kill you, according to Prof Cormican. "MRSA does result in the death of people who might otherwise have been expected to recover," he says.
We don't know how many people are infected with the bug each year, as the statistics are not published. Last year, however, the National MRSA Reference Laboratory, at St James's Hospital in Dublin, found MRSA in blood samples from more than 400 patients.
Hospitals keep their own figures but are reluctant to disclose them. Prof Cormican suspects the total is significant. "If lists were published for all hospitals I think patients would be concerned," he says.
A lot of MRSA is spread on the hands of doctors, nurses and other healthcare staff, so frequent and thorough hand-washing is considered crucial to prevent contamination.
Unfortunately, a study at Prof Cormican's hospital recently found that 49 per cent of doctors did not wash their hands after each consultation.
Dr Edmond Smyth, a consultant microbiologist at Beaumont Hospital in Dublin, points out that busy staff may not always be as hygienic as they need to be to prevent infections spreading. "In an emergency somebody could rush from one bed to another without washing their hands," he says.
This may partly explain the increase in hospital-acquired infections, he says. Another big factor, he suggests, is overcrowding, with many hospital wards now dealing with more patients than they have places. "Within 24 hours you could have more than two people in the same bed," he says.
Dr Margaret Hannan, consultant microbiologist at the Mater Misericordiae Hospital in Dublin, also attributes it to understaffing, which she says many studies have shown contributes to the problem.
"We have already seen higher infection rates in the last year on wards where the nursing staff has been reduced due to budget constraints. If this were to continue for a longer period cross-infection in hospitals would certainly increase further," she says.
Dr Hannan points out that part of the rise might be explained by improved surveillance, diagnosis and reporting of hospital-acquired infections; she says, however, that another, more likely factor is a lack of isolation facilities. As there is no way to keep the first patients on their own, the bug is able to spread.
And there is also, ironically, the problem of medical advances: as seriously ill or injured patients are more likely to survive than they were in the past, hospitals now house more vulnerable, infection-prone patients.
They also have to cope with bacteria that are becoming more resistant to common antibiotics and with changing or entirely new viruses.
Severe acute respiratory syndrome, or SARS, for example, which spread rapidly among the Canadian and South-East Asian healthcare staff who were the first to treat it, was a new illness. The winter vomiting virus that affected Irish hospitals this year seemed to be a new form of an existing infection.
"We have had winter vomiting for years but it has become more of a problem over the last two," says Dr Smyth. "It may be that the virus has undergone change and none of us are now immune to it. The other possibility is that in the couple of years preceding the last 18 months the incidence of it declined, so our immunity to it went down, and when it came back we succumbed."
Prof Corcoran says that, although the outbreak passed, he can't be sure the vomiting bug has gone away. It is often picked up in the community, he says, then brought into hospitals, where containing it can be extremely difficult.
With the SARS virus returning to Singapore last week, it is the time to put isolation facilities in place, according to Dr Hannan. "We were lucky the last time. We may not be so lucky the next," she says. The Republic had just one probable case of SARS during the global epidemic of the past year.
The cost to the healthcare system of hospital-acquired infections is enormous. A 1997 study found that one in 10 patients was at risk of infection in Irish hospitals; at that time, it said, the problem was using almost €30 million of health-service resources a year. The money goes on drugs and lost bed days, as a result of the extra time patients have to spend in hospital.
Data from the Department of Health and Children indicates that during the first nine months of last year about 3,200 bed days were lost "due to isolation measures being implemented in acute hospitals mainly as a result of the winter vomiting virus".
When, for example, St James's Hospital in Dublin closed its bone-marrow transplant unit in 2001 for several months, after an outbreak of vancomycin-resistant enterococci, it had to send patients abroad, at considerable cost, for transplants .
Another less common but life-threatening bug that patients can pick up in hospital is Clostridium difficile. An infection that arises in the bowel after exposure to antibiotics, it has caused deaths here, according to Dr Smyth - although recent reports that it and MRSA had been found on the white coats, pens, stethoscopes and notebooks of hospital doctors in Galway turned out to be inaccurate.
Even so, says Prof Cormican, all hospitals need to get better at controlling infection. As figures are unavailable for Ireland, some from Britain might indicate the potential problem. According to a report there in 2000, hospital-acquired infections could be killing up to 5,000 people a year and costing the NHS more than €1.4 billion. The study, by the National Audit Office, also said the infections could contribute to a further 15,000 deaths.
According to Prof Cormican, the risk of catching an infection in hospital depends on patients' circumstances. "If they are coming in for a short time the risk is very low. If they are coming in for intensive anti-cancer therapy, which will destroy their immune system, then they are more likely to get an infection. Most hospitals have processes in train to try and protect you. Patients can help by being aware of the risks."
And so could the State, he believes, by investing more in infection control.
Dr Smyth agrees. He says a strategy to control antimicrobial resistance drawn up in 2001 has been implemented slower than he would have liked, "largely due to the unavailability of funds". He also says hospitals need more single rooms, so they can isolate patients.
Investing in infection control will save money in the long run, according to Prof Cormican. But with increasing pressures on the health budget it may be that it won't be a priority.
Methicillin-resistant Staphylococcus aureus
Many of us have Staphylococcus aureus on our skin or in our noses. Occasionally the bacterium causes minor skin infections, such as pimples and boils. It can be more serious, however, and even deadly. The form resistant to the antibiotic methicillin is more common among elderly or very sick hospital patients, or those with open wounds, such as bedsores, or tubes going into their bodies. It can be treated with other antibiotics. MRSA almost always spreads by contact, not through the air.
Winter vomiting bug
The small round structured virus, or SRVS, is a particularly resistant microbe spread through the air and by personal contact. Symptoms include severe, often projectile vomiting - giving the infection its popular name - diarrhoea, abdominal pain and mild fever. Most vanish in 48 to 72 hours, leaving sufferers able to cope without medical help. The bug can be serious for the elderly and those with weak immune systems, however; these patients may require intravenous fluids.
Clostridium difficile
This bacterium is commonly found in the intestinal tract; during or after a course of antibiotics, and in some other circumstances, it can inflame the colon. It is thought to cause several million cases of diarrhoea and colitis around the world each year. The primary treatment is to stop using the antibiotic. Using a particular group of antibiotics is also a therapy. Patients may need to be rehydrated intravenously to replace fluids lost through diarrhoea. Very rarely surgery is required.
Vancomycin-resistant enterococci
Enterococci are bacteria found in the faeces of most humans and many animals. Occasionally they cause human disease. The commonest are urinary-tract and wound infections. The type of the bacterium that has become resistant to vancomycin is common only in patients who have been in hospital for long periods, those on certain antibiotics and those fed by nasogastric tube. Most outbreaks have been in kidney- dialysis, transplant, haema- tology and intensive-care units.
The range of effective antibiotics is very limited.