CHICAGO TRIBUNE'S THREE PART EXPOSE' (7/21/2002 ) ON " INVESTIGATION: UNHEALTHY HOSPITALS...PART THREE "



Plus...Nurse leads hospital's war on germs



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Drug Resistant Germs adapt, thrive beyond hospital walls

Unsanitary conditions, heavy reliance on antibiotics create microorganisms that flourish in the community

Last of three part series...By Michael J. Berens,Tribune staff reporter...July 23, 2002

Lapses in infection control and over use of antibiotics are spawning drug resistant germs that are spreading from hospitals into the community at unprecedented rates.

These new super germs stronger, more elusive and deadlier, have multiplied for decades inside thousands of hospitals and now are hitching rides into outside communities on the clothes and skin of patients, workers and visitors.

Until the last few years, most germs quickly died after exposure to the harsher environmental conditions outside hospitals. But, increasingly, microorganisms survive for days, even months. And they have developed the ability to breed most anywhere.

"It was only a matter of time before hospital germs became strong enough to live in the community,"  said Dr. Donald Graham, department chief of infectious diseases at the Springfield Clinic and professor at Southern Illinois University School of Medicine. "We're seeing them pop up everywhere."

In Illinois, the Tribune identified 4,712 cases during 2000 in which individuals contracted hospital born germs without setting foot in a hospital or other medical center --a 1,000 percent increase in the last decade, an analysis of state patient records and public health reports show.

Last year ( 2004 ) at least 200 people in Illinois died after contracting drug resistant germs in their homes,at work or during leisure activities. Victims developed strains of pneumonia, blood poisoning and dozens of other infections rarely identified outside hospitals as recently as five years ago.

The progression of drug resistant germs from hospital to community has taken decades to occur,spurred by a long standing practice to rapidly treat patients with antibiotics but not invest in the more time consuming efforts to locate the sources of germs, federal studies show.

As a result, many hospitals have become reservoirs of micro organisms that continue to adapt to germ fighting drugs.The flow of germs outside the hospital also is aided by cost saving strategies to discharge patients quickly.

In the 1970s, the average stay was about seven days for most patients. Today, stays at most hospitals average three days, according to the American Hospital Association.

Most infections are not detectable during the first three days after exposure, so doctors commonly flood patients with antibiotics, even when they're not sure an infection is present. Health care researchers cite this practice as one of the chief culprits behind the rise in drug resistance.

During longer stays, hospitals had more time to identify infections and provide treatment. Patients were more likely to leave the hospital without a lingering infection. Briefer hospital stays mean that more patients are at home when infections first show symptoms.

Recent federal studies conclude that up to 16 percent of patients' family members carry germs spread by the patient.  In most cases, the germs remain inactive but continue to spread to other people or places, creating a chain of migration that is largely untraceable. Tens of thousands of people now are infected each year as the germs find hosts outside the hospital.

Most victims who are infected are ill or suffer other health problems that weaken their ability to fend off the germs. But Chicago attorney Brad Gershenson, 37, who had not been near a hospital for months when he was infected,  illustrates how even individuals with no discernible medical problems fall prey to hospital germs.

Gershenson, owner of a medical supply company, believed he had a lingering cold weather flu, his wife said. For five weeks, mild fever and nausea flared every few days, then disappeared. By November 2000, symptoms became so constant and severe that he went to the emergency room at Illinois Masonic Medical Center. "He died less than 30 hours later.". From a hospital disease!!!.

Hospital medical records reviewed by the Tribune show Gershenson contracted bacterial pneumonia resistant to the most common and effective antibiotics: penicillin, methicillin and oxacillin.

Doctors traced Gershenson's movements and determined that he had not been inside or near a hospital before falling ill."He thought his symptoms would go away. By the time he came to the hospital, it was too late," said his wife, who asked not to be identified because of privacy concerns. "He was healthy and athletic and so young. It was so sudden and unbelievable."

Tracking the germs



In 1997, two pediatricians at the University of Chicago Hospitals stumbled onto a discovery that cast a national spotlight on hospital germs spreading into communities.


Their curiosity was aroused when they encountered a Chicago boy hospitalized at the U. of C. for a pneumonia that was resistant to methicillin, the most used and effective antibiotic against the infection. The germ is known as methicillin-resistant staphylococcus aureus.

Hospital-acquired MRSA infections have been common for a decade. But the Chicago doctors had never identified a case in which a healthy person contracted MRSA before entering the hospital.

Drs. Betsy Herold and Robert Daum dug deeper. The boy had not been sick, nor had he recently visited a hospital or any medical center. Likewise, none of the boy's family members had been sick or visited medical centers.

Admission records showed the boy was in the grip of pneumonia before arriving at the hospital, which ruled out the possibility that the germ came from inside the center. A month later, a second boy was admitted to the hospital with pneumonia caused by MRSA. Both boys survived.

Worried they were witnessing a new and dangerous trend, the doctors pored over patient medical files dating to 1993. They discovered 35 previously unknown cases where children appeared to contract MRSA outside the hospital. Herold and Daum published their findings in the Journal of the American Medical Association in early 1998, the first documented proof in this country that MRSA ...a Hospital-acquired infection which have been common for a decade...had spread into communities.

The Chicago discovery was part of a national groundswell of recognition. In 1999, the CDC published a study detailing the cases of four children in two states who were killed by MRSA contracted outside a hospital.


In July 1997, a 7-year-old girl from Minnesota who complained of fever and a pain in her right groin died from MRSA. In January 1998, a 16 month old girl from North Dakota arrived at a local hospital in shock, with a temperature of 105 degrees. She died within two hours of admission. MRSA was found in her lungs. In January 1999, a 13-year-old girl from Minnesota was taken to an emergency room after complaining of fever and spitting up blood. MRSA was found in her blood. "She died seven days later." In February 1999, a feverish 12 month old boy from North Dakota was taken to the emergency room after repeatedly vomiting. MRSA, which was found in the lungs, resulted in pneumonia. "The boy died a day later."

These and many other discoveries stoked renewed interest in infectious diseases as researchers delved into the molecular construction and behavior of germs. Germs that once required moisture now survive on dry fabrics. Germs dependent on a living host can go dormant on inanimate objects for weeks before bursting to life upon contact with human skin. These germs are capable of reproducing in minutes, share their enhanced abilities with other germs upon contact and thrive on surfaces even after smothered with disinfectants.

However, doctors are still not sure what prompts MRSA germs to flare into infections. Staphylococcus is typically a harmless bacterium found on up to one-third of healthy individuals. Resembling clusters of grapes under a microscope, it grows primarily in nasal passages and throats, on hair and skin. But staph germs can sometimes cause nausea, blood infections and pneumonia.

Staph's ability to develop resistance to antibiotics can be traced to practices not only inside hospitals, but also throughout the medical community, playing out over decades in doctor's offices and nursing homes.

Beginning in the 1940s, penicillin was the first line of defense against staph, killing nearly every germ. By 1982, penicillin was effective in less than 10 percent of cases.Doctors have linked the growing resistance to overuse of penicillin, which has been doled out in massive doses for most every ailment, real or imagined. At one time, a brand of toothpaste contained penicillin to meet consumer demand.

As penicillin's effectiveness waned, doctors turned to methicillin, a more powerful antibiotic. In 1974, the replacement drug killed 98 percent of staph germs. By the mid-1990s, it could kill just half of them, and the percentage of staph germs resistant to methicillin is rising.

"We humans can take generations to adapt to stress," said the U. of C.'s Daum. "Bugs can take minutes."

Germs find a home



One measure of the hospital industry's decline in controlling germs and infections is found in hospital inspection reports compiled by state public health agencies and the U.S. Department of Health and Human Services.

Mirroring the national trend, nearly half of Illinois' 305 hospitals have been cited for potentially life threatening breakdowns of infection-control standards since 1995.  Violations range from failure to disinfect rooms, including intensive care units, to unsanitary habits of health-care workers, such as wearing contaminated gloves or clothes or failing to wash hands.

Though carelessness is a big part of the problem, so too is the harsh calculus of hospital administrators who don't want to pay the cost of searching for the reservoirs of germs, said Dr. Victor Yu, a professor of medicine at the University of Pittsburgh who specializes in hospital- acquired germ research.

Although infection control can be as simple as thorough cleaning and strict attention to hand- washing, some methods--such as updating air filtration systems or periodically flushing water pipes--are effective but costly. "Too many administrators don't want to necessarily find germs inside their facility because repairs to equipment or extensive cleaning can mean shutting down a department or floor. Even a few hours is a significant loss of revenue," Yu said.


Yu and a growing body of infection-control experts are critical of the CDC-endorsed policy known as selective surveillance, in which hospitals don't screen all patients for infections, but target only the sickest or most vulnerable ones. Hospital officials argue that testing every patient is too costly.

Though selective testing identifies many hospital-acquired infections, it allows a significant number of germs and infections to go undetected, leaving colonies in the hospital that eventually can spread into communities, many of the nation's leading hospital epidemiologists say.

Hospitals, with their warm, constant temperature and immune compromised patients, are ideal incubators for germs and prime hosts for outbreaks. Germs can find dozens of spots to multiply and wait for a person to infect.Federal and state health-care studies document hundreds of cases where resistant germs have pooled for years inside hospitals.

Lawsuits filed this year on behalf of 110 patients against Palm Beach Gardens Medical Center near West Palm Beach, Fla., allege that drug-resistant germs thrived inside the medical center for more than five years.


Infections killed 13 cardiac patients and left most of the others with injuries that caused permanent crippling, said attorney Calvin Warriner, who represents the patients and their survivors.


Heart patient Michael Lebedecker, 61, became concerned after health-care workers examined his surgical chest incision without wearing gloves, said his wife, Janet. She said she witnessed a surgical resident use his teeth to tear surgical tape that was placed across a chest bandage.

"My husband was worried about infections, but doctors said not to worry because there were no problems," she said.Lebedecker, who underwent bypass surgery in 1999, contracted an antibiotic-resistant germ in the hospital and died five weeks after the operation. Hospital records show that he was infected by MRSA.

Lorraine Lydon, 57, survived a similar infection following cardiac bypass surgery, but she now lives a life tethered to oxygen tanks and dozens of expensive medicines. She said she saw instances where health care workers failed to wash hands between patients, but she did not think the lapses were potentially dangerous at the time .MRSA was detected in her sternum within a week after the September 2000 surgery. Doctors told her they never determined the source of the germ.

Doctors have tried so many times to remove infection-ridden bones from Lydon that further surgeries could prove fatal to her weakened body. "I've already had 18 surgeries, but the germ is still inside me. It will never go away," she said."Besides, they've already removed virtually every bone in my chest. There's nothing else to take."



Investigative records from Florida's Agency for Health Care Administration show 23 complaints have been filed by patients or employees relating to infections or unsanitary conditions at Palm Beach Gardens from 1997 through 2001.A Palm Beach Gardens spokeswoman declined to discuss specific patient cases or inspection reports. But she said patient safety is its top priority and the hospital has a long record of quality care.

The Tribune visited the facility twice--in April 2001 and a year later--and found many noticeable improvements in the one-year period, from freshly painted walls to redesigned waiting rooms. However, infection-control breakdowns still existed, from nurses observed failing to wash hands between patients, construction dust floating in the air near the emergency and operating rooms, and employees who left the hospital in scrubs and returned to restricted operating room areas.

At lunchtime, for example, nearly a dozen nurses and other health-care employees streamed outside, carrying cafeteria trays of food to picnic tables on small grassy strips shaded by trees.

As the employees sat at picnic tables, ducks and other fowl darted about their legs in search of fallen crumbs. The birds frequently brushed feathers against the scrub uniforms of the nurses. Birds are considered major carriers of germs, particularly salmonella, which can cause lethal blood poisoning. Birds also can be carriers for staphylococcus germs.

Many employees wore protective slipcovers over their shoes as they trooped into the grass littered with bird feces. They did not remove the contaminated slipcovers before re-entering the hospital.


Into the community


Though most infections can be treated with drugs, the arsenal of available antibiotics for more stubborn infections is rapidly shrinking. In labs throughout the world, pharmaceutical companies are racing to develop more powerful infection-fighting drugs.

Staphylococcus germs are among the most common in a hospital. For more than a decade, as the germ grew resistant to methicillin, doctors have battled it with vancomycin. The antibiotic is commonly referred to as medicine's last line of defense against staph infection.

CDC studies show that up to half of patients who received vancomycin to prevent infections were treated unnecessarily, a practice that contributes to drug-resistant infections.

In 1999, the CDC issued a warning to the nation's health-care professionals that a Chicago-area woman who lived in a nursing home had developed an infection partially resistant to vancomycin. Other cases have been reported nationally.

Last year, the American Association for the Advancement of Science warned that some forms of staph infection, such as bacterial pneumonia, could become untreatable by vancomycin if germs grow stronger.Those fears are proving true.

On July 5, the world's first fully vancomycin-resistant staphylococcus germ was discovered in Michigan. A 40 year old patient, a diabetic with chronic kidney problems, contracted a staph infection in a gangrenous toe. Diabetics often suffer poor blood circulation, which can cause the eventual loss of toes, feet and legs. This patient apparently didn't pick up the germ in a hospital, and CDC tests did not turn up the germ in an outpatient clinic where he received dialysis. Where he was infected has not been pinpointed.

The infection marks an important first. Vancomycin's failure to treat it is seen as a warning that there will be future cases of antibiotic resistant staph.  In this case, doctors were able to control the infection by removing infected tissue and keeping symptoms such as fever in check with other drugs.

The CDC encourages hospitals to follow 12 steps to stem infections and prevent the spread of germs.



This strategy includes "washing hands more often and thoroughly, even for health care workers who wear gloves,which can become contaminated while they are being put on."  Also recommended by the CDC: selecting antibiotics and doses with increased care and precision; using catheters, which can provide an entry way for germs, only when absolutely necessary; and immediately stopping treatment when the infection is cured or unlikely.

Borrowing a theme from anti crime efforts, the CDC has adopted the phrase "Just say no to vanco" to remind doctors not to prescribe vancomycin unless absolutely necessary. The CDC also is finishing an eight-year study on the impact of antibiotic use on germ resistance in 41 hospitals.

The study targets 12 common germs, such as staphylococcus aureus, and has found that resistant germs can thrive anywhere in hospitals.

In one case study, coordinated for the CDC by the Rollins School of Public Health of Emory University in Atlanta, 4,303 samples of staph germs taken from intensive care units were studied. Nearly 36 percent were resistant to the most common and effective antibiotics.

For Buffalo Grove resident Debra Shore, the race to find new antibiotics could become an issue of life or death. Last year, a staph germ resistant to methicillin infected her right foot, which had suffered complications related to her diabetes. She already had lost three toes to amputation, and the infection caused swelling and intense pain in her foot.

Because she had not been in a hospital or doctor's office for weeks before the infection, Shore and her doctor are convinced that the germ was contracted somewhere in her home. Shore received a new antibiotic that won FDA approval in 2000. The new drug, Zyvox, is marketed by Pharmacia Corp. as an alternative to vancomycin. Medical studies show Zyvox is as effective as vancomycin.

Drug company officials and doctors hope introduction of new drugs will stunt or delay germs' ability to develop resistance. Although there have been no reported cases of staph germs developing resistance to Zyvox, other germs have already developed resistance to the new drug.

In July, infected by staph again, Shore began a new round of antibiotics to try to save her right foot. Doctors decided to alternate antibiotics to reduce the chances of staph germs developing a resistance, and this time they chose vancomycin. It seems to be working.

"I fear there will be a day when there are no more drugs to help me," Shore said. "My doctor said this germ only was found in hospitals years ago. Now it's everywhere. "If this germ gets any stronger, I may not be able to survive the next round."


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Nurse leads hospital's war on germs


By Michael J. Berens...Tribune staff reporter...Published July 22, 2002

The success of Children's Hospital in Birmingham, Ala., underscores how any hospital can virtually eradicate infections, even among the sickest children.The hospital operates under the philosophy that every dollar spent on infection control saves farmore in costs measured by extended hospital stays and lawsuits.

At the heart of this strategy is registered nurse Mary Gould, who calls herself a bug detective. Among hospital staff, she's affectionately known as the "infection-control Nazi" because no detail escapes her corrective glare.

Clearly surprised to see Gould during a recent tour of the pediatric intensive care unit, a nurse clutching a soda-pop can blurted out, "I didn't set it down."

Nurses are not allowed to eat or drink near patients.  Germ carrying hands easily contaminate the slick, aluminum surfaces of soda cans. If a can is set on a bed stand, germs could travel from the can to the stand and eventually to one or more patients. Although the chances of this happening are remote, the nurse tossed her drink in the trash.

"Doing pretty well isn't good enough," Gould later explained. Nurses seem to genuinely welcome Gould in their departments. Gould, who began as an emergency room nurse in 1973, understands the pressures. "In nursing you give away so many pieces of yourself. After so many years, you just don't have any left," she said.

Every Monday at 8 a.m. she sits in front of a desktop computer to analyze weekend results of blood and culture tests at the 230-bed facility. She probes the spreadsheet looking for patterns of germs. "There's a salmonella case," she said, but quickly dismissed the incident because it involved an emergency room patient. The patient had the germ before entering the hospital. Such cases are labeled community-acquired germs.

For two tense months last year, Gould said she was baffled by a cluster of similar infections ravaging children who suffered respiratory ailments and breathed through tracheotomy tubes. She looked at the first usual suspect: dirty hands.

Earlier, she eliminated the need for water to wash hands, and banned a hand-softening lotion that reacted with latex gloves, resulting in small holes or fissures on the gloves. The waterless system, adopted by most large hospitals, uses an anti-bacterial solution that doesn't leave a sticky film and kills germs more effectively and quickly than vigorous scrubbing at a sink, according to numerous studies. Containers of solution are hung on walls outside every patients room. Nurses at Children's embrace the new system because they can sterilize their hands while on the run.

But dirty hands were not the problem this time,  she determined. For two months she interrogated dozens of nurses and doctors, conducted surveillance of work patterns and practices, and pored over medical charts. She found no explanation for the outbreak until overhearing a respiratory therapist comment that a group of children was ready for physical therapy session in a small playroom. The sessions, designed for social interaction with other children, were not documented in medical charts.

In the end, she discovered that a plastic ball tossed among the children was covered with the germ ancylobacter, which causes blood poisoning. Every child who touched the ball became a candidate for infection. On a recent tour of the playroom, Gould made sure each toy was cleaned after a child was through with it. "This is one place where we encourage kids not to share their toys," Gould said.

The hospital also uses silver-alloy catheters, which cost more but can prevent infections. "I think it only costs a couple thousand dollars extra a month to buy these catheters. I can't imagine why any hospital would not want to use them."



In fact, most hospitals remain unconvinced that silver-alloy catheters repel enough infections to be worth the cost, according to the federal Centers for Disease Control and Prevention. The CDC and other federal agencies are working on studies to prove the efficacy of the catheters, in use at most European hospitals for a decade.

Gould acknowledged that some infections are beyond any hospital's control, and no hospital--even hers--can have a perfect record.


At Children's, one potential weak point is that critically ill infants are kept in large intensive care units along with newborns suffering infections. On a recent tour of the intensive care unit, a newborn boy who contracted a life-threatening infection from his parents was connected to a ventilator at the end of a row of five patients. Signs were hung around the bed warning nurses to take extra contact precautions. Gould said there is no risk to the other children unless a health-care worker fails to wash hands.

Gould takes pride that the hospital's overall infection rate hovers close to zero most months, an achievement confirmed by CDC and state public health records. The hospital shares specific infection rates with patients before they face surgery, she said. She wishes more hospitals would disclose such risks.

"I just don't see how we couldn't tell patients," she said. "We're talking about their lives."
Copyright © 2002, Chicago Tribune


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