When superbugs invade

PHOTO: When superbugs invade

WE get admitted into hospitals in order to make us well. But ironically, hospital stays can sometimes be the cause of further illness.

After all, when you have so many sick people in one place, not only are harmful microorganisms being concentrated in one area, but those who would be the most vulnerable to such infections are also located in the same surroundings.

So what? you might say. After all, the hospital is ideally equipped to deal with illnesses, with all the different healthcare professionals, facilities and medications available under its roof.

If you're going to get sick, the best place would be at the hospital, wouldn't it?

The problem with that assumption is that the infections you pick up while in the hospital - known as healthcare-associated infections (HAIs) - are a breed of their own.

Due to their exposure to many medications in the hospital environment, these microorganisms have evolved immunity or resistance to many of the standard antibiotics used to kill off their more commonplace brothers.

Some, in fact, have already evolved to outsmart all but the latest generation of antibiotics, meaning that there are only one or two treatment options available if you should be so unfortunate as to be infected by these microorganisms.

Even then, these last-choice drugs are highly toxic in themselves, which can lead to severe side effects in the patient.

With such limited treatment options, the main line of defence against these HAIs can only be prevention. And this is where the infection control team of the hospital comes into play.

Infection control team

Usually consisting of nurses and overseen by a physician, a hospital's infection control team has the dual roles of surveillance and education.

At Universiti Malaya Medical Centre (UMMC), a team of nurses (including one matron and one sister) and two medical lab technicians make up the infection control department, overseen by infection control consultant and clinical microbiologist Assoc Prof Dr Mohd Yasim Yusof.

However, they are backed up by infection control-linked nurses in each ward of the hospital.

These nurses, who work full-time in their wards, look out for patients with drug resistant infections, and report them to the infection control department. They also help monitor infection control practices in their wards.

The set-up is similar in Pantai Hospital Kuala Lumpur (PHKL), although the number of full-time infection control team members differ.

In PHKL, nurse Kalai Selvi Kumaresen is the sole staff member involved in infection control on a full-time basis.

However, she explains that there are around 30 other staff members who are also involved in infection control. These include link nurses in the wards and members of non-clinical departments like housekeeping, engineering, and food and beverages.

They are overseen by a committee of physicians, chaired by consultant physician Dr P. Ravindran Menon.

Says Dr Ravindran: "We're really serious about the problem (of HAIs), especially after the last outbreaks of SARS (severe acute respiratory syndrome) and bird flu.

"As public awareness of the outbreaks was so high, hospital management also became very aware of the precautions that needed to be taken, and supportive of infection control measures."

Kalai adds that while they did have infection control measures previously, the area only started garnering serious attention in recent years.

At UMMC, the infection control department was founded in the early 1980s, around the time MRSA (Methicillin-resistant Staphylococcus aureus) started to become a major problem.

Says Assoc Prof Mohd Yasim: "Our team has been around for a long time, but I think more hospitals are becoming more concerned (about this area) because of accreditation, which is a factor in medical tourism."

Both international healthcare accreditation bodies like the Joint Commission International, and local ones like the Malaysian Society for Quality in Health, include infection control standards as part of their accreditation process.

Reporting trends

In Malaysia, the Health Ministry (MoH) requires all teaching hospitals and government hospitals to submit statistics on HAIs every month.

They also have these hospitals do a point prevalence study twice a year for HAIs.

"All teaching hospitals and MoH hospitals check all the infection cases present in the hospital on those two designated days," explains Assoc Prof Mohd Yasim.

"We have a team of around 10 nurses who go through the case notes of all the patients in all the wards - except for certain ones like accident and emergency, and the labour ward - to check for healthcare-acquired infections," he says.

The results are then sent to the ministry for compilation and comparison.

Private hospitals like PHKL are not required to take part in this exercise.

However, Dr Ravindran says that cases of HAIs are reported to the ministry when they occur under the mandatory reporting of communicable diseases.

He adds: "We compile our own antibiogram for PHKL every three months, and disseminate the information to all our staff.

"We collect all the bacteria cultures taken from different parts of the body to find out which bacteria are resistant to which antibiotics.

"This is how we become aware of the emergence of superbugs within the hospital, and are able to guide our doctors in prescribing the appropriate antibiotics."

Causes and conditions

According to Dr Ravindran, HAIs cover a wide spectrum of conditions.

These include infections unique to the hospital environment, which are associated with certain medical equipment or surgical wounds. For example, surgical site infections, ventilator-acquired pneumonia, urinary catheter infections and central line infections.

At UMMC, Assoc Prof Mohd Yasim says that as the hospital receives many serious cases that require many intravenous lines and/or have serious wounds, they have quite a high rate of bloodstream HAIs.

"Our HAI rate is 3.3%, which is not too good, but not too bad either. And if you look at HAIs alone, around 30% are bloodstream infections; the rest are mainly from hospital-acquired pneumonia, surgical site infections and urinary catheter infections."

The microorganisms that hospitals look out for in particular may vary from institution to institution.

For example, PHKL pays particular attention to MRSA, ESBL-producing organisms (extended spectrum beta-lactamase), Acinetobacter baumanii and Stenotrophomonas maltophilla.

"These are other than the multi-drug resistant organisms seen in patients, who have been in hospital for a long time, or transferred from other hospitals," he says.

Assoc Prof Mohd Yasim says that the most frequent drug-resistant organisms in UMMC are A. baumanii, MRSA, EBSL-producing organisms, Escherichia coli and Pseudomonas aeruginosa.

He adds: "One of our main worries is vancomycin-resistant organisms, because the drug of choice now for drug-resistant organisms is vancomycin."

In addition, they monitor for unusual infectious microorganisms like Vibrio cholerae and Salmonella typhi.