Hospitals Have Hope in Dutch ‘Search and Destroy’ Strategy

Combating Deadly Bacteria

An electron micrograph image of clumps of methicillin-resistant Staphylococcus aureus bacteria, commonly referred to by its acronym, MRSA. The “killer bug” has become commonplace in German hospitals, where it infects one in 70 patients in the average intensive care unit. So-called “multiresistant pathogens” are a serious problem in Germany and other countries

Every day, several people die in German hospitals after being infected with bacteria resistant to most antibiotics. Though the threat is growing, a strategy long-used in the Netherlands is catching on and raising hopes.

When Germans are admitted into Dutch hospitals, they are usually surprised to learn that they will be placed under quarantine. Doctors and nurses will only approach them after donning protective gowns, gloves and surgical masks.

In the Netherlands, Germans are considered an infection risk because their hospitals, nursing homes, rehabilitation centers and dialysis stations back home are full of so-called “multiresistant pathogens” — in other words, bacteria that have grown resistant to almost all antibiotics.

One Dangerous Bacterium

In particular, the “killer bug” MRSA — short for methicillin-resistant Staphylococcus aureus — has become almost commonplace in German hospitals, where it infects one in 70 patients in the average intensive care unit (ICU). Likewise, although MRSA infections are starting to level off — albeit at a high level — there has been a marked increase in so-called ESBL-producing intestinal bacteria (with ESBL being an abbreviation of “extended spectrum beta-lactamase”). These bacteria produce an enzyme that can destroy penicillins, cephalosporins and other antibiotics. Indeed, the Robert Koch Institute, Germany’s leading institution for disease control and prevention, estimates that the country sees at least four unnecessary deaths every day as a result of infections acquired in hospitals.

A Life-Threatening Scratch

“At first it was only a little scratch, here, on my lower leg,” says Emma P., 83, who lives near the northwestern German city of Münster. But that seemingly harmless injury was just the beginning of an ordeal that would last for months.

After being admitted to the hospital with a broken leg, P. scraped her ankle on her hospital roommate’s walker. Initially, it didn’t seem like anything serious. “The nurse just stuck a bandage on it,” P. explains.

But the open wound refused to close. Instead, it continued to grow until it had eaten its way deeper into the tissue and halfway around her leg. “At a certain point,” P. says, “it had become a real hole.”

A swab test eventually revealed that MRSA had gotten into the wound. Emma P.’s scratch could now mean death as a result of blood poisoning.

Fears of a ‘Post-Antibiotic Era’

These days, standard antibiotics are almost completely ineffective against pathogens like MRSA. And, to make matters worse, pharmaceutical companies don’t even have any new ones in development. Since new antibiotics must be used in moderation so as to slow the emergence of resistant strains, drug makers have few incentives to develop them. Likewise, the World Health Organization (WHO) is already warning that, if we don’t come up with new ways to fight these kinds of infectious diseases, we might just enter into a “post-antibiotic era” in which they can’t be treated at all.

Although this is an admittedly nightmarish scenario, there have been some studies and projects suggesting that these bacteria can be successfully combatted. But, to get there, we have to develop the right strategy.

“First, we have to create an awareness of the problem,” says Petra Gastmeier, who heads the Institute of Hygiene and Environmental Medicine at Berlin’s Charité Hospital. “Otherwise, a doctor who has worked at a hospital for five years will just think the infection level at that hospital is normal.”

For years, regular and thorough hand disinfection has been regarded as a miracle weapon against every type of hospital infection. But this practice is no longer enough by itself. Indeed, the daily hospital routine has become so complex that an ICU nurse caring for three patients would have to wash his or her hands an unfeasible 150 times a day just to have a good chance of preventing the transmission of multiresistant bacteria.

And then there are other issues. As Matthias Schrappe, director of the University of Bonn’s Institute for Patient Safety, explains, “multiresistant bacteria are also transmitted outside the hospital and brought back into the clinical setting from there. Anyone who hopes to successfully combat these pathogens has to take this into account.”

Holland’s ‘Search and Destroy’ Technique

Holland’s “search and destroy” strategy for specifically fighting MRSA bacteria has precisely this in mind. Every at-risk patient — for example, anyone who has recently been in a hospital — is first placed in quarantine until the results of a nasal swab test indicate that he or she is MRSA-free. Those found carrying the dangerous bacterium, on the other hand, are kept in isolation and treated until the pathogen can no longer be detected.

Emma P. was also quarantined as soon as she tested positive for the bacterium. “I was allowed to have visitors,” she says, “but they all had to wear masks.” And, she adds, most of the time she was alone, “without a soul in sight.”

As P. explains, her recovery was not a pleasant one. Every day, her wound would undergo a cleaning that involved scraping it out with a sharp-edged spoon and using a vacuum dressing to draw out the fluids in her wound. Every day, an ointment containing one of the last few antibiotics to be effective against MRSA was applied inside her nose, where the bacteria tend to accumulate. And, every day, she had to wash her body and her hair with disinfectant soap.

Still, the effort paid off. After a long three weeks, the MRSA pathogen could no longer be found in P.’s wound. Doctors then removed a piece of skin from her upper leg and grafted it onto the gaping hole in her lower leg. Now the wound is starting to heal.

‘Our Only Chance’

“Actively searching for the bacteria and then targeting and destroying them is our only chance,” says Alexander Friedrich, a senior physician at the Institute for Hygiene at UKM hospital in Münster, Germany. Friedrich believes that the search-and-destroy strategy used in the Netherlands should serve as a model for others. With it, the Dutch have managed to keep their MRSA rates extremely low over the last two decades. 

Five years ago, Friedrich launched EurSafety Health-Net, a joint German-Dutch project that fosters close cooperation in fighting the hospital bacteria between regions along and on both sides of the border. Though the collaboration project might teach the Germans a lot, it could also benefit the Dutch. Ron Hendrix, a microbiologist and project coordinator, lives in Enschede, five kilometers (three miles) from the German border and knows what such proximity can mean. “When there’s a fire in Germany,” he says, “we also have a problem.”

Across the border, in the northwestern German region participating in the project, all hospitals are now required to screen at-risk patients for MRSA. As a result, it is only now possible to get a detailed view of what happens when the medical community tries to sweep a problem under the rug for too long. “Here,” says Friedrich, pointing to a map of the region. “In 2004, two patients with an MRSA strain that was new to the region were transferred from southern Germany to here.” By 2008, he recounts, the same strain of the bacterium was found in hospitals in five different regional districts. It had become uncontrollable — but it halted at the Dutch border.

“Here in Germany, patients are often transferred from one hospital to another,” Friedrich explains. “It was only after we began to closely examine this transfer network that we could finally grasp that all hospitals in the German part of the project region actually make up a more-or-less single entity.”

In addition to hospitals, Friedrich has also brought into his network nursing homes, rehabilitation clinics and, most importantly, the offices of physicians in private practice. “The whole thing can only work,” Friedrich explains, “if they continue to perform swab tests in patients after they have been treated for MRSA in the hospital and to complete the treatment that was started there.”

The Hygiene Officer

Friedrich can already report the new strategy’s initial successes. In the project region surrounding Münster, there has been a sharp drop in the number of cases of MRSA-related blood poisoning. Now, he says, the important thing is to transfer responsibility for fighting MRSA from the level of coordinators and public health departments to deep within the hospitals themselves.

“For example,” Friedrich says, “the public health departments need to occasionally send people to the hospitals to check on whether they really have a hygiene officer, whether this person isn’t also the mobile-phone, radiation and genetic-engineering manager who is also standing in the operating room from morning to night, and whether the only reason he was even appointed as the hygiene officer was because he didn’t say ‘no’ fast enough.”

Ulrich Hartenauer is the chief of anesthesiology at Münster’s EVK hospital — and the perfect example of a hygiene officer who takes his job seriously. “As the chief of anesthesiology,” he says, “I play an important role. Anyone who falls out of my good graces is going to have a rough time. I can quickly make them aware of just how limited their options are.”

To provide hospitals with incentives and a structure for implementing a successful strategy against multiresistant bacteria, Friedrich has created five seals of quality that hospitals can earn in the same way that hotels can earn one to five stars.

The first (and lowest) seal, which is awarded for instituting thorough MRSA-screening processes, is already hanging in the lobby of Hartenauer’s hospital. Now he is doing what he needs to do to earn the second seal: expanding its screening for ESBL-producing pathogens. (The three other seals — for the training of hygiene personnel, the follow-up treatment of infected patients and the development of care networks — will only start being awarded over the next five years.)

A Different Bacteria, a Different Beast

Unfortunately, earning that second seal will be much harder than the first. “It’s now becoming clear,” says Wolfgang Witte, a division head at the Robert Koch Institute, “that the measures taken against MRSA cannot prevent the occurrence of ESBL-producing bacteria.”

Unlike MRSA, ESBL-producing bacteria do not form colonies in the nose and on the skin, but deeper within the body. And when they are in the intestine, for example, they become practically beyond the reach of doctors. What’s more, a wider range of bacteria might be involved, and ones that can pass resistance genes among themselves.

As Witte warns, it’s “critical that we start doing something about ESBL-forming bacteria.” The most important measure will be changing the way antibiotics are used in hospitals so as to make it harder for bacteria to develop resistance to them.

Breaking Old Habits

For his part, Hartenauer is already attending a seminar called “Antibiotic Stewardship” to learn how to advise all the doctors in his hospital on how to use antibiotics in a more logical way. But many more people need to follow suit. “There are far too few experts in this field,” says Winfried Kern, head of the Center of Infectious Diseases and Travel Medicine at the University of Freiburg in the southern German city, who launched the seminar. “Doctors just keep using antibiotics in the same way they were first taught to.”

According to Hartenauer, a typical thing he needs to educate doctors about is “perioperative antibiotic prophylaxis.” The surgical practice is used to make sure that all skin bacteria entering a surgical wound are immediately killed off. “But surgeons have a different way of thinking about it,” Hartenauer says. “They say to themselves: ‘Hmm, this was a difficult operation. I removed necrotic tissue, and it took a long time. I don’t want this wound to get infected later on. So let’s just extend the prophylaxis by three days.’ Then, of course, I have to get involved and say: ‘We don’t do this anymore.'”

Still, Hartenauer knows he is fighting an uphill battle. “When it comes to antibiotic therapy, I’m interfering directly with the treatment prerogatives of a fellow physician,” he says. “That’s when I might find myself resorting to psychological tricks.”

Getting hospital management on his side can also be helpful, Hartenauer adds: “I tell them: ‘I’ll help you reduce your annual budget for antibiotics by €20,000 ($28,000).'”

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Full article and photos: http://www.spiegel.de/international/germany/0,1518,726781,00.html