Hospital Microbiome Project

To all of my blog friends: Except where absolutely required, please stay out of hospitals - as patient or as visitor. The following excerpts from Hospital Microbiome explain why I make the request. If you find the subject of interest, I recommend clicking on the link to read the whole article. (I post only the references used within the excerpts.)

Overview

What is the research question and why is it important?

Contrary to public expectation, the potential for contracting a microbial pathogen is highest within a hospital environment, and these infections are much more likely to be fatal.  The Centers for Disease Control and Prevention identified 1.5 million cases of environmentally-contracted notifiable diseases in the United States for 2002 [1], 15,743 of which resulted in death (1 %) [2]. In comparison, during the same year, estimates of healthcare associated infections (HAI) in the United States was 1.7 million, a rate of 4.5 infections per 100 hospital admissions, which contributed to an astonishing 99,000 deaths (6%) [3]. This sobering statistic places HAIs as the 6th leading cause of death, ahead of diabetes, influenza/pneumonia, and Alzheimer’s [4]. Circumstantial evidence suggests that agent transfer between surfaces and humans is the most important transmission route, and therefore, hospitals are likely to be the foremost ecosystem for studying the transfer of microorganisms between humans and a built environment.

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Currently there is a lot of misinformation about the whole idea of where infection comes from in the hospital setting, i.e. infected instruments, water supply, keyboards, human hands, noses, sheets, etc. The real question to ask is geo-spatially how does the microbiome of a hospital organize? The only way to know that is to study it before patients and personnel are there, and then to track how the structure (and key elements that it houses) become colonized, and from where the infection originates. Or if such colonization does not occur, what the potential mode of transmission might be. The new knowledge to be gained is that humans infect the structure, but the infected structure itself does not cause the infections (hypothesis to be tested). Sick patients enter the hospital with lots of pathogens (they have received antibiotics, chemotherapy, etc), they are then likely to leave a microbial/viral footprint in the locations they have been, whether by air or physical transmission. We then identify these microbes on objects like keyboards and personnel like nurses’ fingers, leading to misleading blame on the mode of transmission, when these most often, causally, represent rare events. There is circumstantial evidence that hands are the most common vehicle for the transmission of HAIs within a hospital, which has led to the assumption that hand-washing is the leading measure for preventing the spread of antimicrobial resistant infections [32]. Unpublished data suggests that hand washing reduces infection only by about 3-5%, and while this helps, infection rates are going up not down. The most compelling evidence we have of the association between environmental contamination and patient infection comes from unpublished studies that demonstrate circumstantial evidence of an increased risk for multi-drug resistant organism infections among hospital patients occupying a bed space that was previously occupied by an infected or colonized patient. However, these analyses are somewhat limited, even when multiple confounders are considered in the analysis. The need for education is highlighted by unpublished studies that explore aggregated hand hygiene performance, which typically only examines a limited number of hand hygiene opportunities, yet suggest that studies where hand-washing is reported may be woefully overestimating of rates.

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References 

1. Groseclose SL, Brathwaite WS, Hall PA, Connor FJ, Sharp P, et al. (2004) Summary of Notifiable Diseases — United States, 2002. MMWR Morb Mortal Wkly Rep 51: 1–84.
2. Hall-Baker PA, Nieves E, Jajosky RA, Adams DA, Sharp P, et al. (2010) Summary of Notifiable Diseases — United States, 2008. MMWR Morb Mortal Wkly Rep 57: 1–100.
3. Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, et al. (2007) Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 122: 160–166.

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32. Allegranzi B, Pittet D (2009) Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection 73: 305–315.doi:10.1016/ j.jhin.2009.04.019.

Comments

[buffy]

My sister had gall bladder surgery last Friday. I was astonished to learn that it was an out patient surgery! She went in around 1:00 and was home by 5:00. I thought it was inappropriate that they sent her home so soon, but she didn't want to be in the hospital any longer than necessary, and now I can see why. Thanks for the post. Dear Husband seems to have come through his visit without any serious problems.

[Cop Car]

Buffy--So happy to hear that your DH is doing OK. I meant to ask on your blog - but didn't! You really, really, really want to have any surgery that is possible to do as outpatient surgery.

Of course, our use/misuse of antibiotic soaps and medicinal antibiotics sets the whole population up for devastation by multiple-drug-resistant strains.

[Joared]

Professionally, I've repeatedly observed the extreme cleaning measures taken in hospital and skilled nursing facility rooms, and with objects there, after someone who has had any of the various drug-resistant strains, colonized or not. The cleaning seems to have been quite thorough, but I may have been fortunate to have been in some of the better settings.

I do know that numerous times I have gone into rooms posted with signs to gown, glove and/or even mask (if airborne) only to discover family members who have totally disregarded the signs, and apparel items at the door. They'll sometimes sit on the edge of the bed, laugh and say, "Oh well, it's all in the family" when I inform them of the situation. I have no authority in such situations, so at best I can only alert Nursing, but it's after the fact.

Too many people seem not to realize the danger in microbes they cannot see, or which have not yet specifically subjected them to illness (and may not, like MRSA, until they become ill in the future.)

On a personal level, I've also had acquaintances stories related to me of individuals needing isolation who have been sent home with strict instruction. How well precautions are followed varies for numerous reasons.

Good that you're alerting any readers here as lots of education to the public on the matter is needed.

[Cop Car]

Joared--Just recently, I read the discouraging news that good hand-washing emphasis makes only a 3% difference in the spread of influenza. I don't think they were addressing hospitals, though. Although I know they are not following protocol, I have seen too many health care workers use poor (or no) handwashing proceedures in skilled nursing homes - mostly, when I was an ombudsman. I have even observed (outside the nursing home) a nursing home nurse change her baby's diapers and then handle food - without hand washing or sanitizing. Gross out!