Clean-up campaign: the battle against bacteria

Much has been said and written regarding bacteria and healthcare-associated infections, particularly over the past decade with the numbers of MRSA and Clostridium difficile cases peaking; however, when UK Government Chief Medical Officer Sally Davies stated in her annual report that antimicrobial resistance is a bigger threat than terrorism to the UK population, and to countries around the world, it was no exaggeration. She is also correct to state that antimicrobial resistance, if left unchecked, will be a catastrophic threat to future generations and that refusing to face the problem will only create massive problems.

In his book Mirage of Health, French microbiologist Rene Dubos wrote: "Since the days of the cave man, the Earth has never been a garden of Eden, but a valley of decision where resilience is essential to survival. To grow up in the midst of danger is the fate of the human race"; in the face of microbes, it has been one of survival and danger. There are microbiologists and government officials around the world who will say that the threat from microbes and viruses is over-played and that the human race needs a doomsday scenario.

Today, it is easy to forget the threat posed by bacteria that are becoming fitter and stronger as governments lose the resolve to take the tough decisions necessary to win this battle. If any of us have an infection, the answer is to take an antibiotic, but how much longer can this be effective? This remedy has not always been around: in the early to the middle part of the 20th century, over 50% of people did not live past the age of 65, infection was the leading cause of death and people used to live in fear of bacterial infections. There was no cure; the only defence was scrupulous hygiene in the home and hospital.

On the defence

So, how successful have we been in controlling bacteria in our medical facilities? The simple answer is that in the immediate past, we haven't; bacteria has become endemic in UK medical care facilities to such an extent that it is inevitable that patients will contract an infection while receiving care, and that antimicrobials are being relied on to cure infections. But things have changed; the big pharmaceutical companies are no longer developing new antimicrobials, and hygiene is now regarded as the first line of defence.

Policies and performance in healthcare practices have led to stark differences in infection rates. Outside the UK, other countries have stressed the importance of shutting down opportunities for transmission, and have not relied so heavily on aggressive antimicrobials. In the Netherlands, Scandinavia and Western Australia, infections such as MRSA are uncommon, with sporadic outbreaks quickly contained. While 50% of Staphylococcus aureus infections in the US are methicillin-resistant, in the Netherlands, that figure is less than 1%. In Belgium and France, countries that once had a high prevalence, infections such as MRSA have been stabilised and confined.

In the UK, success has been mixed. All the good practice guidelines and legislation that have been implemented over the last decade have still left a situation where some hospital trusts are achieving better success than others. Over the last 13 months, 29 hospital trusts reported no MRSA bloodstream infections, although this does not include surgical site infections or infections in lines and catheters. The new UK Government objective to achieve zero bloodstream infections in all hospitals is admirable, but this is the only benchmark that can be used as it is the only one that is consistently monitored.

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The view is that hospital departments should be hygienic; however, the environment can never be completely devoid of bacteria. Everyone carries forms of bacteria, therefore, even if a room is deep-cleaned, as soon as staff and patients use it, nature will take its course and the room will become 'contaminated'. Everyone who enters a hospital department or healthcare facility either as staff, patient or visitor has a part to play in making sure that bacteria doesn't get the opportunity to cause harm to anyone being treated. Hand hygiene is the superior technology at stopping potentially harmful bacteria being passed from patient to patient, and from fomites to healthcare practitioners.

Health practitioners must maintain good standards when preparing for surgical procedures, with good hand hygiene and aseptic non-touch techniques playing a pivotal role in preventing infection. Their skills must include knowledge of the techniques involved in clinical practice to be able to achieve zero bloodstream infections; if this can be achieved, then more can be done to reduce surgical infections.

Training and education are key for everyone in a healthcare environment. The Francis Inquiry in the UK has shown that care-givers are not always the best they can be. During his report to the Health Select Committee, Robert Francis said it was good that infection rates are published outside of wards, but with ICT, this should be made public. If organisations are open and publish their data, they are more likely to keep on top of the problem and manage it. After all, every infection a patient gets is at its best an insult, and at its worst, deadly.

A 21st-century outlook

So, what approach should care teams and healthcare facilities be taking in the future, and what might the contributing factors be?

Methods and technologies from the 19th century are ineffective at controlling healthcare-associated infections of the 21st century. Other high-risk industries, such as airline, nuclear and car manufacturing, have built-in controls that prevent adverse events that could harm others that come into contact with processes. These could be adapted to healthcare. In the airline and nuclear industries, excellent safety records have been accomplished by learning from mistakes, and ensuring that anything learnt is passed on to others and is free to view at any time. Staff are observed in the process of their work through behavioural safety and human performance tools, and root cause analysis is used to find the underlying cause for failure. Any fault or failure of process is acted on immediately, and within hours this information is passed to other airline carriers and nuclear power operators. Staff are encouraged to raise any concerns regarding safety without fear of intimidation, harassment or bullying, thus improving outcomes for their customers.

These industries also share this information across countries with the agreements of all relevant governments and regulatory bodies. Healthcare should be the same, particularly around antimicrobial resistance and bacterial infections. One example is the New Delhi metallo-ß-lactamase-1 bacteria, which renders the present stock of antimicrobials useless. This particular threat originated in New Delhi, India, and has spread to other countries, leaving a situation where no matter what one country does with bacteria, unless there is a concerted effort to coordinate strategies, patients will still be at risk from bacteria.

To improve patient outcomes and reduce infections in healthcare facilities, those in the medical profession need to work more coherently, not only with their own teams, but also in the wider context of neighbouring facilities and countries. US molecular biologist Joshua Lederberg said that, "the single biggest threat to man's continued dominance on the planet is the virus".

Communal effort

There is no bigger threat to modern human health than bacteria. To stem their domination, countries that have succeeded in controlling outbreaks of infections need to pass on their strategies to those that have yet to tackle this problem. Governments everywhere must understand that modern medicine is based on controlling bacteria.

Healthcare staff are perfectly placed to help to educate the public on the need for better hygiene and healthier lifestyles as part of a treatment regime. Governments should educate the public and pharmaceutical companies need to play their part as well. But to stay one step ahead of the bacteria will take initiative, commitment and political will. It requires governments, the pharmaceutical industry and research establishments to pool their resources in the development of the next generation of drugs and solutions.