The nightmare of hospital-borne infections

Eleanor Rose

We speak to people affected by the infections that ravage hospitals

It was supposed to be the best week of her life. Liza Lindham, 32, had just given birth to her first child in Stockholm in June 2014. The delivery was tough, because the baby’s head had blocked her bladder. Medics drained the urine with a catheter. Finally, with a healthy girl in her arms, Liza returned home, exhausted but exhilarated.

But she grew more and more tired. A few days later, she felt like she’d caught a cold, so she curled up in front of the TV. Her aches and pains got worse. By dinner time, she couldn’t eat, and was shivering violently. “Something’s wrong,” she told her husband.

Liza didn’t know it yet, but she’d picked up a urinary tract infection (UTI), a common complication of catheter use, when bacteria such as E. coli travel from the gut to the bladder. Unnoticed, the UTI progressed. By the time she reached the emergency room, Liza’s temperature was 40.5°C. Sepsis had spread.

Liza Lindham hospital Liza Lindham needed strong antibiotics and a week in hospital to recover from a UTI

It’s anybody’s worst nightmare: going to hospital and winding up sicker. Yet healthcare-associated infections or HAIs—which develop as a direct result of medical or surgical intervention, or after contact with a healthcare facility—are common. A 2018 Europe-wide study by the European Centre for Disease Prevention and Control (ECDC) found that on any given day in 2016 and 2017, one in 15 hospital patients had one or more HAIs. Some 8.9 million are contracted every year across Europe.

The most common are UTIs, pneumonia, surgical site infections, and gastrointestinal illness from bugs such as Clostridium difficile. Bloodstream infections—often introduced by invasive objects such as central-line catheters—are also major killers. Says Dr Carl Suetens, deputy programme coordinator for the ECDC, “The estimated burden of healthcare-associated infections is larger than the combined burden of all other infections under surveillance in Europe.”

"We know from a recent literature review that 30 to 50 per cent of certain types of infections can be prevented"

Liza was given strong antibiotics and monitored as she recovered. She left hospital a week later. Now 37, she’s angry the hospital didn’t inform her of the known risks of catheters, or tell her about UTI symptoms or testing. She now campaigns for the Swedish Sepsisfonden, which raises awareness of sepsis.

Liza children playLiza, shown with her children. She campaigns in Sweden to raise awareness of sepsis

About 65,000 Swedes contract infections in hospital every year. A large proportion of HAIs could be picked up earlier, and many need never happen at all. Dr Diamantis Plachouras, senior expert for the ECDC, says, “We know from a recent literature review that 30 to 50 per cent of certain types of infections can be prevented.” Cracking down on these illnesses is at the core of patient safety. “A patient goes to hospital to get treatment and get better," Dr Plachouras says. "If instead they get an infection, then actually they are harmed. Less infections means better treatment.”

“Things began to go awry”

Following the discovery of the antibiotic penicillin in 1928, doctors began to understand more about how bacteria spread. In 1941, the first-ever infection control officer was appointed at a hospital in the UK. Yet it still wasn’t a priority. Dr Jim Gray, a microbiologist at Birmingham Women's and Children’s Hospitals, says easy availability of antibiotics meant health workers felt relaxed as late as the 1980s. “They thought, Let the infection happen and we’ll treat it” he recalls. “And that’s when things began to go awry.”

consuming bacteria

Doctors began seeing cases of Staphylococcus aureus, a common bug that causes skin and respiratory infections, that no longer responded to the antibiotic methicillin. They called it methicillin-resistant Staphylococcus aureus (MRSA). If it penetrates the skin, it can set off swelling, redness, and blisters. If it burrows deeper, it can cause bloodstream infection. In the early 1990s, two particularly devastating strains began sweeping hospitals in the UK at frightening speed. Yet policymakers struggled to take control. “Nobody did very much about it,” Dr Gray says. Rates of MRSA infection in England rose to 7,700 reports from April 2003 to March 2004. In 2008, a poll by the BBC found that deadly infections such as MRSA were the public’s number one fear about hospital care.

Susan Fallon’s daughter Sammie was 17 when she was admitted to University Hospital of North Staffordshire in April that same year, suffering flu-like symptoms. Doctors eventually took a bone-marrow sample, which showed she had an auto-immune condition. Susan, 53, now knows from hospital notes that there were three patients diagnosed with MRSA on the general ward that Sammie shared.

Susan Fallon with a photo of her daughter Sammie, who was diagnosed with MRSA 

Within a week, the teen noticed swelling on her hip from the needle, but doctors dismissed it as bruising. Then she developed severe back pain. She was diagnosed with MRSA.

Doctors raced to treat the superbug with different types of antibiotic. But a week later, as Sammie’s condition deteriorated and doctors transferred her to intensive care.

Sammie died in her mother’s arms from multiple organ failure. The family was heartbroken. “Within a year, my dad died—he just couldn't cope,” says Susan. Sammie's death was preventable, she says.

Susan joined campaign group MRSA Action UK, throwing herself into conferences and press interviews to raise awareness, which she continues today. It was grieving relatives-turned-activists like Susan who led the drive for government action in the UK. In 2000, then Prime Minister Tony Blair declared HAIs a “top priority” and ordered a programme of deep cleaning in hospitals.

Health workers in countries across Europe were fighting similar battles as the world awoke to the dangers of HAIs. The first case of MRSA was confirmed in Latvia in 2002. By 2004, it was endemic. Professor Uga Dumpis, a doctor who specialised in infectious disease, was charged with investigating. In 2007 he asked Agita Melbarde-Kelmere, a nurse at Pauls Stradins Clinical University Hospital in Riga, to help, and she became one of Latvia’s first infection control nurses.

When Melbarde-Kelmere visited ICU and neonatal wards, she saw medics make basic mistakes such as using gloves to touch patients rather than washing their hands. Gloves can be contaminated, she warned. She set out to teach them. “It wasn’t easy. When I walked into the ICU, staff would leave for 20 minutes,” she says. One hospital official complained that handwash solution was costly.

"Superbugs were unusual 15 years ago, but today Dr Gray sees as many as 250 new cases a year in his hospital"

Melbarde-Kelmere pushed on, holding training sessions about the pitfalls of poor hand hygiene. Little by little, she noticed improvements. Staff began to ask questions. “It’s only when you have discussions with staff and step-by-step training to understand why they make mistakes that improvement is possible,” she says.

The impact was huge. In just six months, Melbarde-Kelmere and her team lowered infection rates by as much as 50 per cent. The World Health Organisation (WHO) celebrated her work on its website.

Melbarde-Kelmere now trains doctors and nurses around the country. “We’re the pioneers of infection control in Latvia,” she says. She now wants to see more infection control nurses in Latvia’s smaller regional hospitals, to push HAI rates down further.

 

What keeps microbiologists awake at night

Widespread MRSA outbreaks showed country leaders that they could no longer ignore hospital infections. Special measures in England cut the number of cases to 846 during the period from April 2017 to March 2018. Meanwhile, the ECDC began monitoring all types of healthcare-acquired infections in 2011-12 using a special Europe-wide snapshot called a point prevalence survey.

Data from its second point prevalence survey in 2016 to 2017 showed that, for some countries, rates remained roughly the same between the studies. Dr Petra Gastmeier, director of the Institute of Hygiene and Environmental Medicine at Charite, Berlin, says that’s partly because gains made from improvements to infection control methods such as hand hygiene and screening have been countered by the growing complexity of the healthcare environment. “The patients we see are becoming older and more severely ill, and they are being treated using more devices, which are entrance-ways for pathogens,” she says.

Although still a danger, MRSA never became quite as drug-resistant as doctors feared. Meanwhile, there are new threats on the horizon, says Dr Gray. “Quietly across the world, we started to see gram-negative bacteria such as E. coli, Klebsiella and enterobacter, which everybody carries as part of the normal gut flora, becoming more drug resistant," he says.

These new superbugs are called "extended spectrum beta-lactamase (ESBL) producers." They cause UTIs, among other infections, and produce enzymes that break down penicillin, cyclosporine, and other former mainstays of antibiotic treatment. Such superbugs were unusual 15 years ago, but today Dr Gray sees as many as 250 new cases a year in his hospital. They can still be treated with a group of powerful last-line antibiotics: colistin and the carbapenems.

“In some parts of the world we are seeing the emergence of gram-negative bacteria resistant to colistin and the carbapenems as well,” says Dr Gray. About 33,000 people die in Europe each year from superbugs, 39 per cent of which are colistin and carbapenems-resistant (CCR). High infection rates in Greece, Italy, and Cyprus—where about half of samples of the pneumonia-causing bug Klebsiella pneumoniae examined in a 2016 study were found to be CCR—have raised concerns that it could spread throughout Europe. “It’s the thing that keeps us awake at night,” says Dr Gray. But, he reassures, “It’s a threat at the moment rather than a reality.”

 

Don't fall victim

If it all sounds frightening, don’t panic. There are things you can do to protect yourself when you are in hospital. The first is to ask your doctor or nurse if they’ve washed their hands. A study of German hospitals found that hand-washing isn’t guaranteed. “If you observe 100 procedures where hand hygiene should be performed, it’s being done properly in 75 of them,” Dr Gastmeier says. “Patients are often reluctant to ask, but it’s really important.”

Be mindful about how bacteria spreads. “Any surface near a patient will have the patient’s bacteria on it, no matter how well it’s been cleaned,” says Dr Gray. If you touch that surface then go to a communal area such as the toilet, you can transfer pathogens, so you and your visitors need to wash your hands, too.

What's more, he warns “You should only use the handbasins on wards for handwashing.” If you pour sugary liquids or dirty water down the sink, it provides a nutrient source for bacteria in the drain, which then multiply. “When you turn the tap on, water sprays back, and that can spread bacteria,” Dr Gray says.

"While experts work to solve the problem, don’t avoid medical treatment. Hospitals are, overall, getting better, even if the challenges are tough"

Not all HAIs are preventable, says Dr Gastmeier, particularly ones from bacteria in the patient’s own body. It’s hard to stop a catheter to the bladder from transferring bugs from the gut that could cause a UTI. But it’s useful to be cautious of procedures themselves. “Patients should be aware that catheters may be dangerous and should ask their doctors if it’s really necessary, or could be eliminated,” she says.

Retired teacher Christian K*, 77, was sent for heart catherisation—an invasive test to explore the coronary arteries—at a German clinic in Bad Berleburg after feeling tightness in his throat. Afterwards, he noticed a swelling on his left arm where a cannula had been. He quickly developed MRSA, then sepsis.

Christian spent two months in hospital and was left with urinary and fecal incontinence as well as impaired mobility. “My confidence in healthcare has been seriously disturbed,” he says. Meanwhile, the heart check itself came back clear—he’s not convinced he needed it.

Meanwhile, Liza Lindham in Sweden urges patients who undergo invasive tests and treatments to know the symptoms of UTIs—pain passing urine, cloudy urine, aches and pains—as well as signs of sepsis—high fever, rapid breathing, and nausea or diarrhea. If feeling ill, tell staff—and insist they listen. “Patients need to speak up for themselves,” she says.

The European Council issued recommendations to help member states fight HAIs back in 2009, and the ECDC regularly issues extra guidance. It is ultimately up to Europe’s governments and hospitals to implement it, say experts. Dr Suetens of the ECDC concludes,“It is about ensuring every hospital has an infection control nurse and sufficient isolation capacity; that is, enough single rooms to isolate patients with highly drug resistant microorganisms. It’s about ensuring the proper hand hygiene is done, with proper infrastructure such as handwash dispensers next to beds.”

While experts work to solve the problem, don’t avoid medical treatment. Hospitals are, overall, getting better, even if the challenges are tough. Dr Gray says, “Healthcare is safer now than it has been for a very long time."


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