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C. Diff: Deadly Infection on the Rise in U.S. Hospitals

Consumer Reports' new Ratings show many teaching hospitals fail to prevent this deadly disease

By Hallie Levine
Last updated: March 04, 2016
consumerreports.org

A life-threatening bacterial infection is gaining ground in America’s hospitals, according to a new report from the Centers for Disease Control and Prevention. And a Consumer Reports analysis finds that even some of the nation’s largest and most prestigious medical institutions are having a hard time getting it under control.

The infection, called C. diff (Clostridium difficile) sickened 101,074 hospital patients in 2014, the most recent data available, according to a March report from the CDC. Other research shows that overall about 450,000 people a year, inside and out of hospitals, are sickened by the infection, and it contributes to the death of about 29,000 people.

"New data show that far too many patients are getting infected with dangerous bacteria in healthcare settings,” said CDC director Tom Frieden, M.D. “Doctors and healthcare facilities have the power to protect patients—no one should get sick while trying to get well," he said.

While several serious hospital-acquired infections, such as those caused by central-line catheters, have declined in recent years, C. diff. rates increased by 4 percent between 2013 and 2014, according to the CDC.

And Consumer Reports’ updated Ratings of more than 3,200 hospitals across the country show that many are doing a poor job of reining in the infection. Overall, about a third of them received a low Rating in combating the infection. That means they have C. diff infection rates that are worse than the national benchmark.

That includes 24 of the nation’s largest teaching hospitals, including familiar ones such as Baylor University Medical Center in Dallas, the Cleveland Clinic in Cleveland, Cedars-Sinai Medical Center in Los Angeles, Johns Hopkins Hospital in Baltimore, and Mount Sinai Hospital in New York City. “Teaching hospitals are supposed to be places where we identify the best practices and put them to work,” said Lisa McGiffert, director of Consumer Reports' Safe Patient Project. “But even they seem to be struggling against this infection,” she said.

While about 28 percent of hospitals nationwide earned one of our top two scores in preventing the infection, only four of them were large teaching hospitals: Harris Health System in Houston, Maine Medical Center in Portland, Maimonedes Medical Center in Brooklyn, N.Y., and Mount Sinai St. Luke’s - Mount Sinai West in New York City.

(See the chart below for a complete list of low-scoring large teaching hospitals. And check our free hospital Ratings to see how your local hospitals score on infection prevention for five different types of infections and other key safety measures.)

How C. Diff Spreads

There are two important reasons why C. diff is hard to control in U.S. hospitals.  

First is the misuse of antibiotics in hospitals, said Erik Dubberke, M.D., associate professor of medicine in the Division of Infectious Diseases at Washington University in St. Louis and a spokesman for the Infectious Diseases Society of America. “Those drugs are obviously lifesaving when used appropriately, but they can also make you vulnerable to C. diff,” he said. That’s because those drugs can kill off the “good” bacteria that normally grow in your stomach, allowing bad bacteria, including C. diff, to spread.

About half of all hospitalized patients receive antibiotics during their stay—even though up to 50 percent of such prescriptions are unnecessary or inappropriate, according to the CDC. Particularly worrisome is when patients are given powerful “broad-spectrum” antibiotics, such as ciprofloxacin (Cipro and generic) and levofloxacin (Levaquin and generic), which are meant to act against a variety of disease-causing bacteria at once, instead of drugs that target specific bacteria. That increases the chance of developing C. diff, because those drugs are more likely to kill off the body’s good bacteria along with the bad.

The second reason is poor hygiene. C. diff, which is found in fecal matter, is easily passed from person to person on the hands of healthcare workers—and can survive on door knobs, bed rails, and other surfaces for weeks.

Proper hygiene—including washing hands and, especially, wearing gloves—can cut the spread of the disease. But less than a third of healthcare workers in intensive care units always wash their hands, according to a 2014 University of Iowa study. And a Consumer Reports survey of 1,200 recently hospitalized people found that only about half always saw their doctor or nurse wash their hands.

“Doctors and nurses get busy, and they sometimes simply forget to rewash their hands every time they walk into a new patient’s room,” said Louise-Marie Dembry, M.D., professor of medicine and epidemiology at Yale University and president of the Society for Healthcare Epidemiology of America.

What Hospitals Say

Representatives of some of the low-scoring teaching hospitals in our Ratings say that institutions like theirs face special challenges in combating C. diff.

For example, they may see sicker patients than non-teaching hospitals, said Craig Civale, a spokesman for Baylor University Medical Center. “As a major academic hospital in an urban setting, BUMC routinely admits very complex patients with multiple conditions,” he said. A spokeswoman for Cedars-Sinai Medical Center offered a similar explanation for its hospital's C. diff infection rate, and also notes that it sees an unusually large number of older patients, who are at increased risk of the infection.

Another factor may simply be that teaching hospitals detect more cases of the disease than do other hospitals, because they test and report more carefully, said Lisa Maragakis, M.D., senior director of health care epidemiology and infection control for the Johns Hopkins Health System.

Still, hospital officials acknowledge that C. diff. is a serious problem, and that they are responding by changing their practices. “The results reported by Consumer Reports are disappointing to us,” said a spokeswoman for Mount Sinai Hospital in a statement. Mount Sinai also said that it has recently established a task force to look into the hospital’s infection rates, and is investigating “evidence-based practices targeted to reduce all healthcare-associated infections.”

At Baylor, the hospital is developing new protocols to ensure that antibiotics are prescribed appropriately, Civale said. Johns Hopkins is taking similar steps, and is also instituting “rigorous hand hygiene and environmental cleaning initiatives,” Maragakis said. In addition to to those steps, Cedars-Sinai now tests all patients with diarrhea for C. diff, a spokeswoman for the hospital said. And in a statement to Consumer Reports, the Cleveland Clinic noted that the hospital is “committed to continuous improvement in quality and safety.”

What You Can Do

If you (or family members or friends) are in the hospital, here’s what you can do to reduce your risk of developing a C. diff infection:

• Make sure you really need that antibiotic. If your doctor wants to give you an antibiotic, ask why. If he suspects an infection, he should do a rapid culture, if possible, to quickly pinpoint the possible bacteria so that he can prescribe the most effective antibiotic at the lowest dose. 
• Watch out for heartburn drugs. Hospital patients are sometimes prescribed heartburn drugs called proton-pump inhibitors such as omeprazole (Prilosec and generic) and esomeprazole (Nexium and generic) to ease stomach pain. But those medications can also increase the risk of C. diff infections taking hold in your stomach. So if your doctor suggests you take one of those drugs while in the hospital, ask why. 
• Insist on hand-washing and gloves. Ask everyone who walks into your room whether they’ve washed their hands—if they’re doing it at your sink, make sure they scrub for 40 to 60 seconds. Also check that they are wearing gloves. Rubbing on alcohol-based hand sanitizer is not strong enough to destroy C. diff, Dembry said. 
• Ask about the hospital’s protective measure: Hospitals should order a C. diff test for any patient who has diarrhea (three loose stools within 24 hours), said the CDC. Anyone with diagnosed C. diff should be put in a single room, and healthcare providers should wear gloves and gowns when treating that patient.

Consumer Report's Hospital Ratings Receive National Attention

Consumer Reports released their most recent analysis of hospital infection data last week showing that many well-known teaching hospitals are performing poorly in CR's Ratings and putting patients at risk. (Their hospital Ratings are now free to all consumers.) CR released the story in conjunction with a CDC press conference about antibiotic resistance, which included Tom Frieden, M.D., CDC director, and Peter Pronovost, M.D., from Johns Hopkins Hospital. CR's timely and relevant content was referenced in the first question from the media when an NBC News reporter asked about Johns Hopkins' low score in preventing the hospital-acquired infection, C. diff. This story is part of CR's ongoing hospital safety coverage.

Fluoroquinolones Are Too Risky for Common Infections

An FDA panel says popular antibiotics such as Cipro are overprescribed and should have stronger warnings about dangerous side effects

By Teresa Carr / Consumer Reports / Last updated: March 07, 2016

Last November, Rachel Brummert, 45, of Charlotte, North Carolina, stood before a panel of experts and described the ever-worsening series of health problems, including 10 ruptured tendons and progressive nerve damage, she’s suffered as side effects of taking the antibiotic Levaquin, a type of fluoroquinolone, for a suspected sinus infection in 2006.

The Food and Drug Administration convened the panel to consider whether the official drug labels for fluoroquinolones, a group of antibiotics that includes drugs such as Cipro and Levaquin, should be changed to more clearly spell out their risks and discourage overuse. Brummert, the executive director of the Quinolone Vigilance Foundation, was one of more than 30 people who spoke during the open public hearing portion of the meeting about how the drugs had an impact on their lives.

“I am living proof that the risks in using a fluorquinolone to treat a routine infection far outweighs the benefits,” Brummert says.

After reviewing the evidence, the 21-member FDA panel agreed. They voted overwhelmingly that, in most cases, the benefit of fluoroquinolones to treat three common illnesses—bacterial sinus infections, urinary tract infections, and some forms of bronchitis in people with chronic lung disease—was outweighed by the risk of rare, but serious side effects, including irregular heartbeats, depression, nerve damage, ruptured tendons, and seizures.

Currently, those three illnesses account for nearly one-third of all fluoroquinolones prescribed outside of hospitals in the U.S. according to data presented by Janssen Pharmaceuticals, makers of Levaquin, at the FDA meeting.

While the fluroquinolones are essential for treating serious infections such as anthrax, the FDA panel members noted that they are overprescribed for common infections where other treatments would work just as well with less risk. They called on the FDA to strengthen labeled warnings and clarify when the drugs—should—and should not—be used.

Rampant Overprescribing

Over the last 30 years, the FDA has approved five fluroquinolone antibiotics to treat one or more of three illnesses considered by the panel: ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox), ofloxacin (Floxin), and gemifloxacin (Factive). All are also available as generics.

Much of the evidence on the risks of the drugs emerged after the drugs were on the market and used by millions of patients. While medical organizations such as the Infectious Diseases Society of America have updated their guidelines to advise against prescribing fluoroquinolones for milder garden-variety infections—including most cases of bronchitis, sinus infections, and urinary tract infections—many doctors haven’t gotten the message. That's likely because these powerful antibiotics work against a wide variety of bacteria, says Lindsey R. Baden, M.D., an infectious disease physician at Brigham and Women’s Hospital in Boston, Massachusetts, an associate professor at Harvard Medical School, and a member of the FDA panel. That can lead to overprescribing.

“Fluoroquinolones play an important role in treating serious infections such as those caused by bacteria that are resistant to other types of antibiotics,” says Baden. But in the case of less severe illnesses such as a mild bacterial sinus infection or uncomplicated bladder infection, the drugs “should typically be reserved for second-line or even third-line treatment after other antibiotics have failed,” says Baden.

When to Say 'No' to Cipro and Similar Drugs

Below we’ve listed three types of infections where fluoroquinolones are often not the best first choice for treatment along with our medical advisers’ advice about what to do instead.

• Sinus infections. “The vast majority of sinus infections are caused by a virus, not a bacteria and antibiotics don’t work against viruses,” says Baden. Even if bacteria are responsible, the infection will typically clear up on it’s own in a week or so. An antibiotic such as amoxicillin may be warranted if your symptoms last longer than a week, start to improve and then worsen, or are very severe—accompanied by a fever of 101.5 or higher, for example, or extreme pain and tenderness over your sinuses. For more information see Choosing Wisely recommendations from the American Academy of Allergy, Asthma, and Immunology. 
• Urinary tract infections (UTIs). If you have symptoms of a urinary tract infection such as having to urinate frequently, pain or burning when you go, cloudy or bloody urine, and a fever, you may need an antibiotic to treat the infection. Several types of antibiotics are effective against uncomplicated bladder infections; fluoroquinolones are typically only necessary if the infection is resistant to other antibiotics or has spread to the kidneys. Note that people aged 65 and older often have bacteria in their urine, but do not need to be tested or treated for a UTI unless they have symptoms. For more information see Choosing Wisely recommendations from the American Geriatric Society. 
• Bronchitis. As with sinus infections, most cases of bronchitis, or chest colds, are caused by a virus and are not helped by taking an antibiotic. (Read our advice on what to do ease symptoms while your body fights the infection.) One exception: patients with chronic obstructive pulmonary disease (COPD), a condition that causes difficulty breathing, may benefit from antibiotics if they develop symptoms severe enough to require hospitalization. In that case, the best choice of drug depends on the several factors, including which bacteria are prevalent in your area. For more information on using antibiotics to treat respiratory illness in children see Choosing Wisely recommendations from the American Academy of Pediatrics.

All Antibiotics Have Risk

Brummert says she hopes that the FDA will act on the advisory panel’s recommendations. “Curbing unnecessary prescribing of fluoroquinolones could save thousands of Americans from needless suffering,” she says.

Baden points out that all antibiotics—not just fluoroquinolones—should be used more thoughtfully.

“Really, I think the labels for all antibiotics should be strengthened to remind doctors and patients that when the drug is unwarranted, prescribing it has no benefit and exposes patients to needless risk, however small that risk may be,” says Baden. “Antibiotics are overused; as a community we need to be having these conversations about better prescribing based on the balance of benefits to harms.”

Editor's Note: This article and related materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

What your friends with cancer want you to know (but are afraid to say)

Copied from FB, March 4, 2016

Kim Helminski Keller is a Dallas-based mom, wife, teacher and journalist. She is currently receiving treatment for thyroid cancer.

People with cancer are supposed to be heroic.

We fight a disease that terrifies everyone.

We are strong because we endure treatments that can feel worse than the actual malignancies.

We are brave because our lab tests come back with news we don’t want to hear.

The reality of life with cancer is very different from the image we try to portray.

Our fight is simply a willingness to go through treatment because, frankly, the alternative sucks. Strength? We endure pain and sickness for the chance to feel normal down the road. Brave? We build up an emotional tolerance and acceptance of things we can’t change. Faith kicks in to take care of the rest.

The truth is that if someone you love has cancer, they probably won’t be completely open about what they’re going through because they’re trying so hard to be strong.

For you. However, if they could be truly honest and vulnerable, they would tell you:

1. Don’t wait on me to call you if I need anything. Please call me every once in a while and set up a date and time to come over. I know you told me to call if I ever needed anything, but it’s weird asking others to spend time with me or help me with stuff I used to be able to do on my own. It makes me feel weak and needy, and I’m also afraid you’ll say “no.”

2. Let me experience real emotions. Even though cancer and its treatments can sometimes influence my outlook, I still have normal moods and feelings in response to life events. If I’m angry or upset, accept that something made me mad and don’t write it off as the disease. I need to experience and express real emotions and not have them minimized or brushed off.

3. Ask me “what’s up” rather than “how do you feel.” Let’s talk about life and what’s been happening rather than focusing on my illness.

4. Forgive me. There will be times when the illness and its treatment make me “not myself.” I may be forgetful, abrupt or hurtful. None of this is deliberate. Please don’t take it personally, and please forgive me.

5. Just listen. I’m doing my very best to be brave and strong, but I have moments when I need to fall apart. Just listen and don’t offer solutions. A good cry releases a lot of stress and pressure for me.

6. Take pictures of us. I may fuss about a photo, but a snapshot of us can help get me through tough times. A photo is a reminder that someone thinks I’m important and worth remembering. Don’t let me say “I don’t want you to remember me like this” when treatment leaves me bald or scarred. This is me, who I am RIGHT NOW. Embrace the now with me.

7. I need a little time alone. A few points ago I was talking about how much I need to spend time with you, and now I’m telling you to go away. I love you, but sometimes I need a little solitude. It gives me the chance to take off the brave face I’ve been wearing too long, and the sil1ence can be soothing.

8. My family needs friends. Parenting is hard enough when your body is healthy; it becomes even more challenging when you’re managing a cancer diagnosis with the day-to-day needs of your family. My children, who aren’t mature enough to understand what I’m going through, still need to go to school, do homework, play sports, and hang out with friends. Car-pooling and play dates are sanity-savers for me. Take my kids. Please.

My spouse could also benefit from a little time with friends. Grab lunch or play a round of golf together. I take comfort in knowing you care about the people I love.

9. I want you to reduce your cancer risk. I don’t want you to go through this. While some cancers strike out of the blue, many can be prevented with just a few lifestyle changes – stop smoking, lose extra weight, protect your skin from sun damage, and watch what you eat. Please go see a doctor for regular check-ups and demand follow-up whenever pain, bleeding or unusual lumps show up. Many people can live long and fulfilling lives if this disease is discovered in its early stages. I want you to have a long and fulfilling life.

10. Take nothing for granted. Enjoy the life you have right now. Take time to jump in puddles, hug the kids, and feel the wind on your face. Marvel at this amazing world God created, and thank Him for bringing us together.

While we may not be thankful for my cancer, we need to be grateful for the physicians and treatments that give me the chance to fight this thing. And if there ever comes a time when the treatments no longer work, please know that I will always be grateful for having lived my life with you in it. I hope you feel the same about me.