Latest Hospital Injury Penalties Include Crackdown On Antibiotic Resistant Germs

Reprinted from KHN / Kaiser Health News

By Jordan Rau December 21, 2016

http://www.khn.org/

The federal government has cut payments to 769 hospitals with high rates of patient injuries, for the first time counting the spread of antibiotic-resistant germs in assessing penalties.

The punishments come in the third year of Medicare penalties for hospitals with patients most frequently suffering from potentially avoidable complications, including various types of infections, blood clots, bed sores and falls. This year the government also examined the prevalence of two types of bacteria impervious to drugs.

Based on rates of all these complications, the hospitals identified by federal officials this week will lose 1 percent of all Medicare payments for a year — with that time frame beginning this past October.  While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In total, hospitals will lose about $430 million, 18 percent more than they lost last year, according to an estimate from the Association of American Medical Colleges.

The reductions apply not only to patient stays but also will reduce the amount of money hospitals get to teach medical residents and care for low-income people.

Forty percent of the hospitals penalized this year escaped punishment in the first two years of the program, a Kaiser Health News analysis shows. Those 306 hospitals include the University of Miami Hospital in Florida, Cambridge Health Alliance in Massachusetts, the University of Michigan Health System in Ann Arbor and Mount Sinai Hospital in New York City.

Nationally, hospital-acquired conditions declined by 21 percent between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The biggest reductions were for bad reactions to medicines, catheter infections and post-surgical blood clots.

Still, hospital harm remains a threat. AHRQ estimates there were 3.8 million hospital injuries last year, which translates to 115 injuries during every 1,000 patient hospital stays during that period.

Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.

Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.

One resistant bacteria that Medicare included into its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause pneumonia and bloodstream and skin infections. MRSA is prevalent outside of hospitals and sometimes people with it show no signs of disease. But these people can bring the germ into a hospital, where it can be spread by health care providers and be especially dangerous for older or sick patients whose immune system cannot fight the infection.

Hospitals have had some success in reducing MRSA infections, which dropped by 13 percent between 2011 and 2014, according to the CDC. AHRQ estimates there were 6,300 cases in hospitals last year.

The second bacteria measured for the penalties is Clostridium difficile, known as C. diff, a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

While it can be treated by antibiotics, C. diff can also become so serious that some patients need to have part of their intestines surgically removed. C. diff can cause diarrhea and can be deadly for the elderly and other vulnerable patients.

C. diff has challenged infection control efforts. While hospital infections dropped 8 percent from 2008 to 2014, there was a “significant increase” in C. diff that final year, the CDC says. AHRQ estimated there were 100,000 hospital cases last year.

“The reality is we don’t know how to prevent all these infections,” said Dr. Louise Dembry, a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America.

The Hospital-Acquired Condition Reduction Program also factors in rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubs. Those infections carry the most weight in determining penalties, but the formula also takes into account the frequency of bed sores, hip fractures, blood clots and four other complications.

Specialized hospitals, such as those that treat psychiatric patients, veterans and children, are exempted from the penalties, as are hospitals with the “critical access” designation for being the only provider in an area. Of the remaining hospitals, the Affordable Care Act requires that Medicare penalize the 25 percent that perform the worst on these measures, even if they have reduced infection rates from previous years.

That inflexible quota is one objection the hospital industry has with the penalties. In addition, many hospitals complain that they are penalized because of their vigilance in detecting infections, even ones that do not cause any symptoms in patients. Academic medical centers in particular have been frequently punished.

“The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior,” said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Federal records show that 347 hospitals penalized last year will not have payments reduced because their performance was better than others. Those include Harbor-UCLA Medical Center in Los Angeles, the Johns Hopkins Hospital in Baltimore and the University of Tennessee Medical Center in Knoxville.

Over the lifetime of the penalty program, 241 hospitals have been punished in all three years, including the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Ronald Reagan UCLA Medical Center in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital in Chicago; and Brigham & Women’s Hospital in Boston.

The penalties come as the Centers for Medicare & Medicaid Services also launches new requirements for hospitals to ensure that the use of antibiotics is limited to cases where they are necessary and be circumspect in determining which of the drugs are most likely to work for a given infection. Hospitals will have to establish these antibiotic stewardship programs as a condition of receiving Medicare funding under a regulation the government drafted last summer.

Lisa McGiffert, who directs Consumers Union’s Safe Patient Project, said that as a result of Medicare’s penalties and other efforts, “more hospitals are thinking more about appropriate use of antibiotics.” However, she said, “I think most hospitals do not have effective antibiotic stewardship programs yet.”

A Brief History Of Antibiotic Resistance

The Grapevine

A Brief History Of Antibiotic Resistance: How A Medical Miracle Turned Into The Biggest Public Health Danger Of Our Time

Feb 17, 2016 09:30 AM By Lecia Bushak

The discovery of penicillin marked the advent of the age of antibiotics, 

an era where previously deadly infectious diseases could be cured in days. Wikimedia

Antibiotics, also known as antibacterials and antimicrobials, revolutionized medicine during the later half of the 20th century. But as time goes on, the success of antibiotics may be completely cancelled out by their combative counterparts: resistant bacteria.

Humans have overused antibiotics simply by harnessing them to treat all sorts of infections from pneumonia to strep throat — but also by sometimes taking too much of them, or infusing them into agricultural systems, animals, and food products, as the CDC illustrates . This overuse has opened the door for bacteria to evolve into resistant strains to beat out drugs. We’re now in a place where changes desperately need to be made in order to prevent millions of deaths from antibiotic resistance in the coming decades. These microscopic microbes seem to be smarter than us.

The authors of a 2010 report on the evolution of resistance note that microbes have “extraordinary genetic capabilities” that benefit “from man’s overuse of antibiotics to exploit every source of resistance genes... to develop [resistance] for each and every antibiotic introduced into practice clinically, agriculturally, or otherwise.” Here’s how antibiotics went from being a revolutionizing medical breakthrough to a massive public health concern.

Which Came First, The Antibiotic Or The Resistance?

The antibiotic era, as it’s called, may not have begun until the 21st century, but antibiotics were still in use in ancient folk medicine. The term “antibiotic” has an extremely broad definition, describing the activity of any compound or chemical that can be applied to kill or inhibit bacteria that cause infectious diseases.

350-550 CE. The earliest traces of antibiotic use date back thousands of years. Tetracycline — a common antibiotic still used today — has been found in skeletons from Sudanese Nubia, an area that included ancient Egypt. Researchers believe that ancient Nubians were actually brewing tetracycline into their beers or otherwise incorporating it into their diets over a long period of time because the compound was found embedded deep in their bones and the population’s documented infectious diseases seem to be quite low. This discovery overturned the commonly-held belief that antibiotics didn’t exist before 1928.

It’s tough to detect other ancient antibiotics aside from tetracyclines, however, as most didn’t settle into bones and tooth enamel in the same way. Only documentation and anecdotes remain to give us insights into the use of other ancient antibiotics. What is now known to be an antimalarial drug, artemisinin, was used in ancient Chinese medicine, and it’s possible that herbalists also used moldy bread to prevent wounds from getting infected. There’s also historical evidence that, in Jordan, red soils rich in antibiotic-producing bacteria were used to treat skin infections like rashes.

And for as long as antibiotics have existed, bacterial resistance has existed alongside them — but never on such a large scale. “The natural history of antibiotic resistance genes can be revealed through the phylogenetic reconstruction,” the authors of one study write, “and this kind of analysis suggests the long-term presence of genes conferring resistance to several classes of antibiotics in nature well before the antibiotic era.” In short, bacteria have always been doing what they’re good at: finding ways to survive.

Alexander Fleming, who discovered penicillin, was also one of the first scientists
to warn about the perils of antibiotic resistance. Wikimedia

1928. Alexander Fleming, a Scottish biologist, took the fight against infections to a new level when he identified penicillin, making this the year that the modern antibiotic era began.

The discovery had apparently been an accident. Fleming had left an uncovered Petri dish of Staphylococcus bacteria near an open window in his basement lab, and in the morning found that mold growth had inhibited the bacteria. Penicillin, which comes from a type of fungi known as Penicillin rubens , became the first compound to be used officially as an antibiotic.

Penicillin was popular in the public during the 1940's and 50's due to its ability to treat a variety
of infectious diseases quickly; this also led to an increased build-up of antimicrobial resistance. Wikimedia

1943. Penicillin was on its way to mass production and was used heavily to treat Allied troops fighting in Europe during World War II. Considered a miracle drug, it was soon available to the public, despite warnings from Alexander Fleming that overuse could lead to mutant bacteria. Because bacteria can transfer genes horizontally — from one bacteria to another immediately — its ability to share resistance was adding to a growing threat unheeded by many scientists and doctors of the day.

1948. Transferring antibiotic use from medicine to agriculture also happened in a rather accidental way. Robert Stokstad, an animal nutritionist, and Thomas Jukes, a biochemist, were working at the company Lederle to develop an “animal protein factor” that could enhance chicken growth and boost poultry profits. The researchers were initially experimenting with vitamin B12, which was believed to boost animal growth, but eventually found that the cellular remains of Streptomyces aureofaciens bacteria — from which tetracyclines are extracted — contained a lot of the vitamin. As the Lederle labs had also discovered the first tetracycline, the researchers had access to plenty of these bacterial remains. Chicks that received supplements including Streptomyces auerofaciens grew 24 percent more than those receiving liver extract, which also contained high levels of B12. The bacteria shells, which still contained traces of the antibiotics, were more effective in making them grow (and much cheaper than liver extract). This discovery jump started the process of routinely injecting antibiotics into animals.

Meanwhile, resistant staph bacteria were growing in hospitals. According to Harvard Magazine, resistant staph infections in hospitals had risen from 14 percent in 1946 to 59 percent in 1948.

1952. By this time, doctors were somewhat aware of the possibility of antibiotic resistance, but overall they remained hopeful and optimistic about the success of these new drugs, which could defeat diseases that had long plagued humanity, like cholera and syphilis. A study on antibiotic resistance published that year concluded that syphilis could be treated “without any indications of an increased incidence of [resistant] infections, and this work gives grounds for hoping that the widespread use of penicillin will equally not result in an increasing incidence of infections resistant to penicillin.”

1950s–1970s. The next couple decades were considered the golden era of antibiotics, due to the sheer number of new drugs that were being developed: streptomycin, to treat serious infections like endocarditis and the plague; ampicillin, which treats respiratory tract infections and meningitis; and dozens of others. In the excitement surrounding the success of these antibiotics, they were made readily available to the public, like penicillin, ultimately paving the way for resistance to develop more easily.

The Tide Turns, The Superbugs Arrive

1955. As Fleming had predicted, resistance to penicillin gradually built up due to the accessibility of the drug. By 1955, many countries had attempted to slow this resistance by limiting penicillin use to prescription only, but it was too little too late: many bacterial strains had already defeated the antibiotic, including staphylococci.

1960. In an attempt to defeat penicillin-resistant strains, scientists developed methicillin, a different antibiotic in the penicillin class that could work against resistance. But within a year, bacterial strains developed resistance to methicillin too — eventually called MRSA , methicillin-resistant Staphylococcus aureus , or S. aureus . Now, MRSA can resist most antibiotics, and infections are common in hospitals — making it one of the biggest forerunners of multiple-drug resistant (MDR) bacteria.

For decades, poultry and other animal farms utilized antibiotics
freely in feed to promote growth. Reuters

1976. At Tufts University, a physician and researcher named Stuart Levy became one of the first to identify antibiotic resistance due to their use in animals, and to clamor for greater awareness of the problem. He worked on a study that year that examined how small amounts of antibiotics in animal feed could cause resistance in humans. On a farm in Massachusetts, Levy fed tetracycline to chickens, and found that tetracycline-resistant bacteria began to populate the chickens’ gut flora within a week. Despite this, rampant use of antibiotics like vancomycin (which had previously been considered a “last resort” drug) throughout the 1980’s led to an epidemic of resistant strains on farms and among humans.

1990s. A stronger resistant strain of MRSA began sickening normal, healthy people in the 1990s. This perhaps created a greater public awareness of the danger of antimicrobial resistance.

In the midst of emerging superbugs and MDR bacteria, the CDC and other
public health organizations began issuing public service announcements
to curb the liberal use of antibiotics. CDC / Wikimedia

By 2002 , up to 60 percent of S. aureus cases in hospitals were resistant to methicillin. In 2005, over 100,000 Americans were stricken with MRSA infections and some 20,000 died, more than the amount of people who were dying from HIV and tuberculosis combined, according to Harvard Magazine.

2012. As more researchers began working on the impending antibiotic-resistant epidemic, they had to tackle the classification of multidrug-resistant bacteria, which were multiplying by the minute. In a 2012 study, a team of scientists proposed adding the terms extensively drug-resistant (XDR) and pandrug-resistant (PDR) to multidrug-resistant (MDR) bacteria to better help them classify and potentially defeat these superbugs. It was the first time that researchers had a unified set of definitions for MDR bacteria to better understand them.

2013. After decades of certain researchers calling for action, the FDA finally implemented aplan to phase out certain antibiotic use in animals. But the extent to which this plan is effective at reducing the massive damage already done is difficult to identify.

2014. In response to major superbug outbreaks like Klebsiella pneumoniae (which causes pneumonia and bloodstream infections in the hospital) and gonorrhea strains all over the world, the World Health Organization (WHO) released a statement noting that “this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country.”

2015. McDonald's announced that it would phase out all meat sources that contained antibiotics, marking the first step of a major fast food company to heed the public health warnings and take action.

Since the 70s, very few new antimicrobial agents have been discovered, and the only way for researchers to combat resistant bacteria has been to modify already existing antibiotics. This has led to a standstill of sorts between current antibiotics and the rapidly adjusting “superbugs.”

Today, from farms to hospitals to everyday workplaces, animals and humans are likely teeming with different forms of resistant bacteria. In 2013, a Consumer Reports investigation showed that over half of ground turkey meat sold in the U.S. contained strains of drug-resistant bacteria. According to the CDC , some 2 million people in the U.S. are infected with drug-resistant bugs every year, and 23,000 of them die from these infections. Those numbers are likely to get worse in the coming decades, according to recent reports.

The danger of the situation is mainly in its complexity, Rustav Aminov writes in a 2010 report on antibiotic resistance: “It is not a single grand challenge; it is rather a complex problem requiring concerted efforts of microbiologists, ecologists, health care specialists, educationalists, policy makers, legislative bodies, agricultural and pharmaceutical industry workers, and the public to deal with. In fact, this should be of everyone's concern, because, in the end, there is always a probability for any of us at some stage to get infected with a pathogen that is resistant to antibiotic treatment.”

12 Hospitals You Might Want to Avoid

Posted from consumerreports.org

They have high rates of MRSA, C. diff, 
and other dangerous infections

By Joel Keehn

Last updated: September 30, 2015

Every year, an estimated 648,000 people in the U.S. develop infections during a hospital stay, and about 75,000 die with one of those infections, according to the Centers for Disease Control and Prevention. That’s more than twice the number of people who die each year in car crashes.

To highlight the growing problem of dangerous hospital infections, Consumer Reports recently rated hospitals based on their infection rates for two of the most common and deadly bacterial infections in hospitals, MRSA and C. diff. And we identified the 12 hospitals in the country that earned low scores not only against those hospital infections but also three other infections in our Ratings. Those include infections following surgery as well as infections associated with urinary catheters and central-line catheters (large tubes that provide medicine and nutrition to patients).

Those 12 low-scoring hospitals performed poorly across all five types of hospital infections, based on data they provided to federal government agencies, between October 2013 and September 2014. "Getting a low score across all five infection categories is a red flag that the hospital is not focusing proper resources on infection control," says Doris Peter, Ph.D. director of the Consumer Reports Health Ratings Center.

Low-Scoring Hospitals for Infection Prevention
Here are the 12 low-scoring hospitals, listed alphabetically:

Brooklyn Hospital Center, Brooklyn, N.Y.
Decatur Memorial Hospital, Decatur, Ill.
Floyd Memorial Hospital and Health Services, New Albany, Ind.
Fremont-Rideout Health Group, Marysville, Calif.
Little Company of Mary Hospital and Health Care Centers., Evergreen Park, Ill.
Mercy St. Anne Hospital, Toledo, Ohio
Riverview Medical Center, Red Bank, N.J.
Rockdale Medical Center, Conyers, Ga.
St. Petersburg General Hospital, Saint Petersburg, Fla.
The Charlotte Hungerford Hospital, Torrington, Conn.
UF Health Jacksonville, Jacksonville, Fla.
Venice Regional Bayfront Health, Venice, Fla.

Note that the data our hospital Ratings are based on are released ​periodically throughout the year by the CDC. The CDC adjusts that data to account for factors such as the health of a hospital’s patients, its size, and whether it’s a teaching hospital. See our complete and the most current hospital Ratings as well as more about how we rate hospitals.

We’ve asked these hospitals what they are doing to improve, and why their infection rates were higher than average during the reporting time period of October 2013 to September 2014. To date, we have received written responses from the following hospitals:

Brooklyn Hospital Center
Floyd Memorial Hospital and Health Services
Fremont-Rideout Health Group
Little Company of Mary Hospital and Health Care Centers
Rockdale Medical Center
St. Petersburg General Hospital
UF Health Jacksonville
Venice Regional Bayfront Health

Decatur Memorial Hospital called us after we published our Ratings to discuss our findings but has not yet submitted a written response. We will add that response and any other as we receive them.

How Hospitals Can Improve
Our report, "How Your Hospital Can Make You Sick," revealed how hospitals and doctors contribute to hospital-acquired infections and antibiotic resistance and what hospitals and patients can do to protect against the problems.

Specifically, hospitals must do these things to prevent infections:
Follow infection control protocol, such as using protections including gowns, masks, and gloves by all staff.
Reduce overuse of antibiotics.
Have an antibiotic stewardship program. That should include mandatory reporting of antibiotic use to the CDC.
Accurately report how many infections patients get in the hospital.
Promptly report outbreaks to patients, as well as to state and federal health authorities.

Join our efforts to stop hospital infections and support our work in stopping the spread of antibiotic-resistant bacteria.

How your hospital can make you sick

Consumer Reports’ new Ratings of more than 3,000 U.S. hospitals show which do a good job of avoiding MRSA, C.diff, and other deadly infections

www.consumerreports.org / Published: July 29, 2015

In the ongoing war of humans vs. disease-causing bacteria, the bugs are gaining the upper hand. Deadly and unrelenting, they’re becoming more and more difficult to kill. You might think of hospitals as sterile safety zones in that battle. But in truth, they are ground zero for the invasion.

Though infections are just one measure of a hospital’s safety record, they’re an important one. Every year an estimated 648,000 people in the U.S. develop infections during a hospital stay, and about 75,000 die with them, according to the Centers for Disease Control and Prevention (CDC). That’s more than twice the number of people who die each year in car crashes. And many of those illnesses and deaths can be traced back to the use of antibiotics, the very drugs that are supposed to fight the infections.

Terry Otey appears to be one casualty in that ongoing battle. Three years ago, a few weeks after an overnight stay for back surgery at Providence Regional Medical Center in Everett, Wash., he went to the emergency room vomiting, dizzy, and with excruciating back pain. Bacteria known as MRSA (methicillin-resistant staphylococcus aureus) had taken hold in his surgical incision and quickly spread to his heart. He died in the hospital about three months later, following a cascade of serious health problems. “He just wanted to ease his back pain enough to play golf,” says his sister, Deborah Bussell.

Kellie Pearson, 49, a farmer in northern California, says she encountered a different kind of bug after having heart surgery last April. Her doctors prescribed an antibiotic in the hopes that it would prevent a postsurgical infection. Instead the drug killed off healthy bacteria in her body, and another germ, C. diff (clostridium difficile), swooped in, causing diarrhea so severe that she had to stay in the hospital an additional five days until doctors could rein in the potentially deadly infection.

She recovered but soon realized that she wasn’t the only patient suffering. “When I was able to walk down the hall in the hospital,” she says, “I was horrified to see room after room with C. diff caution signs on their doors warning that the patients inside, like me, had been infected.”

In the danger zone

“Hospitals can be hot spots for infections and can sometimes amplify spread,” says Tom Frieden, M.D., director of the CDC. “Patients with serious infections are near sick and vulnerable patients—all cared for by the same health care workers sometimes using shared equipment.”

Making the situation even more dangerous is the widespread, inappropriate use of antibiotics that’s common in hospitals, which encourages the growth of “superbugs” that are immune to the drugs and kills off patients’ protective bacteria.

It’s “the perfect storm” for infections to develop and spread, says Arjun Srinivasan, M.D., who oversees the CDC’s efforts to prevent hospital-acquired infections. “We’ve reached the point where patients are dying of infections in hospitals that we have no antibiotics to treat.”

But there’s hopeful news: Some hospitals are taking steps to reduce infections and end inappropriate antibiotic use. “But others have made little effort,” Srinivasan says.

'Be your own advocate'

Kellie Pearson recovered from a life-threatening case of C. diff caused by antibiotics she got in the hospital. But shortly after, she says, her doctor wanted to prescribe a broad-­spectrum antibiotic to prevent infection in her incision. “I was shocked because that could trigger the C. diff all over again,” she says. Her takeaway: “You have to be your own advocate.”

Red flags for bad bacteria

Methicillin-resistant staphylococcus aureus (MRSA)

We are focusing on C. diff and MRSA for two important reasons.

First, the infections are common and deadly. More than 8,000 patients each year are killed by MRSA; almost 60,000 are sickened by the infections. The bacteria often find their way into patients’ bodies through the lines and tubes that doctors use to deliver medication and nutrition to patients, or via surgical incisions, as happened to Terry Otey.

C. diff is an even bigger concern. Kellie Pearson is one of the 290,000 Americans sickened by the bacteria in a hospital or other health care facility each year. She was lucky: At least 27,000 people in the U.S. die with those infections annually.

Second, poor MRSA or C. diff rates can be a red flag that a hospital isn’t following best practices in preventing infections and prescribing antibiotics. That could not only allow C. diff and MRSA to spread but also turn the hospital into a breeding ground for other resistant infections that are even more difficult to treat.

For example, as dangerous as MRSA is, an infection can be cured if it is treated promptly with vancomycin, long held out as an “antibiotic of last resort.” But, in part because that drug is now so often used in hospitals, another resistant strain of bacteria—vancomycin-resistant staphylococcus aureus, or VRSA—is emerging. “VRSA infections pose special challenges; they can be even more difficult to treat than MRSA,” Srinivasan says.

Hospitals that rate well

Clostridium difficile (C. diff)

To earn our very top rating in preventing MRSA or C. diff, a hospital has to report zero infections—an admittedly high bar. Still, 322 hospitals across the country were able to achieve that level in our MRSA ratings, and 357 accomplished it for C. diff, showing that it is possible. (Experts say some hospitals might game the system. Read more about how hospitals fudge the numbers, and help us identify those that might not accurately report infections.)

More hospitals were able to earn either of our two highest ratings—indicating that they reported either zero infections or did much better than predicted compared with similar hospitals: more than 623 hospitals received high marks for MRSA, and 917 did so for C. diff.

Hospitals really begin to distinguish themselves when they earn high ratings against both infections: 105 hospitals succeeded in that. Even better, some hospitals excel against not only MRSA and C. diff but also other infections that the CDC tracks and that are in our hospital Ratings. Those include surgical-site infections and infections linked to urinary catheters or central-line catheters, large tubes that provide medication and nutrition.

“Hospitals that do well against infections across the board have figured something out and deserve special mention,” Peter says. Only nine hospitals in the country—those featured in the “Highest-Rated in Infection Prevention” chart earned that high honor. (Note that some of hospitals listed in that chart differ from those in the September 2015 issue of Consumer Reports magazine because new data was released by the federal government after the magazine went to press.)


And hospitals that don't

You won’t find any familiar, big-name hospitals on that top-performing list. In fact, several high-profile hospitals got lower ratings against MRSA, C. diff, or both, including the Cleveland Clinic in Cleveland, Johns Hopkins Hospital in Baltimore, Mount Sinai Hospital in New York City, and Ronald Reagan University of California Los Angeles Medical Center.

Those are all large teaching hospitals in urban areas, which in our analysis did not do as well as nonteaching hospitals of similar sizes in similar settings. That could be because teaching hospitals may do a better job of reporting infections. Or, as a representative for Ronald Reagan UCLA Medical Center told us, they may see sicker patients or have more patients undergoing complex procedures.

Although the CDC adjusts the data to account for some of those factors, teaching hospitals tend to perform worse. For example, only 6 percent of teaching hospitals received one of our two top scores against C. diff, compared with 14 percent of similar nonteaching hospitals.

“Yes, teaching hospitals face special challenges. But they are also supposed to be places where we identify best practices and put them to work,” says Lisa McGiffert, director of the Consumer Reports Safe Patient Project. “Obviously, that is not happening as well as it should.”

Larger hospitals also tended to do worse in our Ratings. That could be because patients in smaller hospitals are less likely to be exposed to infections. But some larger hospitals managed to do a good job avoiding infections. Case in point: Harlem Hospital Center in New York City earned high ratings against MRSA and C. diff. Or consider Northwest Texas Healthcare System in Amarillo, Texas. It made it onto our list of top hospitals in the prevention of all of the infections included in our Ratings.

What safe hospitals do

Good hospitals focus on the basics:

Use antibiotics wisely

Almost half of hospital patients are prescribed at least one antibiotic, Srinivasan says, but “up to half the time the drug is inappropriate.” To combat antibiotic misuse, many good hospitals have “antibiotic stewardship” programs, often headed by a pharmacist trained in infectious disease, to make sure that patients get the right drug, at the right time, in the right dose.

Such programs often monitor the use of broad-spectrum antibiotics. Doctors at some hospitals use three times more of those all-purpose bug killers than others. Reducing broad-spectrum prescriptions by 30 percent would “cut hospital rates of C. diff by more than 25 percent, plus reduce antibiotic resistance,” says Clifford McDonald, M.D., a CDC epidemiologist.

Keep it clean

C. diff and MRSA can live on surfaces for days and can be passed from person to person on hospital equipment or the hands of health care workers. To prevent that, hospitals must be kept scrupulously clean. “Infection control is all about the basics, starting with hand hygiene,” says Christine Candio, president and CEO of St. Luke’s Hospital in Chesterfield, Mo., which earned higher Ratings against both MRSA and C. diff.

She reminds patients, “it’s your right to ask” staff to wash up. In fact, fastidious hand washing slashes rates of C. diff, MRSA, and other infections. St. Luke’s also “prioritizes cleanliness,” in some cases exceeding infection-control guidelines—cleaning the rooms of C. diff patients twice daily, for example, and replacing curtains between patients.

What more needs to be done

Steps such as those, plus federal mandates for some public reporting of infections data, have already led to reduced rates of certain infections. Still, McGiffert says hospitals need to do more:

• Consistently follow the established protocols for managing superbug infections, such as using protections including gowns, masks, and gloves by all staff.
• Be held financially accountable. Already, hospitals in the bottom 25 percent of the government’s data at preventing certain complications now have Medicare payments docked 1 percent. But they should also have to cover all costs of treating infections patients pick up during their stay.
• Have an antibiotic stewardship program. That should include mandatory reporting of antibiotic use to the CDC.
• Accurately report how many infections patients get in the hospital. And the government should validate those reports.
• Be transparent about infection rates. For instance, Cleveland Clinic acknowledges its below-average performance in C. diff prevention on its website. “That’s refreshingly candid,” Peter says.
• Promptly report outbreaks to patients, as well as to state and federal health authorities. Those agencies should inform the public so that patients can know the risks before they check into the hospital.

Germ warfare: Protect yourself against superbugs

First step: Check our Ratings to see how hospitals in your community compare in preventing infections and other measures of hospital safety. 

But bad things can happen even in good hospitals. For example, Terry Otey developed his infection after a 2012 surgery in a hospital that now gets one of our higher ratings against MRSA. Our experts say there are several things you can do when you’re in the hospital and after you’re discharged to minimize your risk and spot symptoms of possible infection early:

In the hospital

Consider MRSA testing. A nasal swab can detect low levels of MRSA and allow medical staff to take precautions, such as having you wash with a special soap before your procedure.

Insist on cleanliness. Ask to have your room cleaned if it looks dirty.

Take bleach wipes for bed rails, doorknobs, and the TV remote. Insist that everyone who enters your room wash his or her hands.

Keep your own hands clean, washing regularly with soap and water.

Question antibiotics. Make sure that any anti­biotics prescribed to you in the hospital are needed and appropriate for your infection.

Watch out for heartburn drugs. Medications such as Nexium and Prilosec increase the risk of developing C. diff symptoms by reducing stomach acid that appears to help keep the bug in check. So ask whether the drug is needed and request the lowest dose for the shortest possible time.

Ask every day whether ‘tubes’ can be removed. The risk of infection increases the longer items such as catheters and ventilators are left in place. If you’re not able to ask, be sure a friend or family member does.

Say no to razors. If you need to be shaved, use an electric hair remover, not a razor, because any nick can provide an opening for infection.

At home

If you’ve been in the hospital, “assume you’ve been exposed to potentially dangerous bacteria,” says Lisa McGiffert, director of the Consumer Reports Safe Patient Project. Here’s what to do when you get home to keep yourself and your family safe:

Watch for warning signs. They include fever, diarrhea, worsening pain, or an incision site that becomes warm, red, and swollen. People at particular risk include adults older than 65 as well as infants, anyone on antibiotics, and people with a compromised immune system.

Practice good hygiene. If you or someone you live with receives a diagnosis of a hospital-acquired infection after being discharged from the hospital, take extra precautions to make sure that it doesn’t spread. Steps you should consider take include cleaning frequently touched surfaces with 1 part bleach mixed with 10 parts water and reserving a bathroom for the infected person. If that’s not possible, use the bleach solution to disinfect surfaces between uses. And don't share toiletries or towels; use paper towels rather than cloth hand towels.

Editor's Note:
This article also appeared in the September 2015 issue of Consumer Reports magazine.

Note that there are some differences between the print and online versions of the story because new data was released by the federal government after the issue went to press.

Dangerous infections...

Dangerous infections that are resistant to antibiotics are spreading and growing stronger, with dire consequences

CONSUMER REPORTS

Jul. 2, 2015, 4:42 PM

The next time you’re offered a prescription for antibiotics and ask yourself, “What harm could it do?” think about Peggy Lillis.

Five years ago, the 56-year-old kindergarten teacher from Brooklyn, N.Y., was given the antibiotic clindamycin, which was supposed to prevent a dental infection.

Instead, the drug wiped out much of the “good” bacteria in her gut that normally keeps “bad” bacteria in check.

Without that protection, harmful bacteria in her belly ran rampant, triggering an intestinal infection so severe that doctors had to perform emergency surgery to remove her colon.

Despite that desperate, last-ditch effort, “within 10 days of taking those pills, my mother was dead,” says Lillis’ son, Christian.

Or consider Zachary Doubek, a rambunctious 12-year-old from New Brunswick, N.J. After a baseball game, Zachary came home complaining of knee pain that worsened overnight and quickly escalated.

His doctor initially prescribed an antibiotic that failed to bring the problem under control. Zachary had the bad luck of running into a strain of bacteria that, after repeated exposure to antibiotics, had evolved, developing defenses against the drugs. Zachary’s infection raced through his body, forcing doctors to put him in a medically induced coma until they could rein it in with vancomycin, a powerful antibiotic that, luckily, still worked against the germ.

Zachary survived, but a year and six surgeries later, he still walks with a limp from the ordeal. “We may never know how he got infected,” says his mother, Marnie Doubek, M.D., a family physician, “but we know that the antibiotic that should have first helped him didn’t work.”

Scary new superbugs

Peggy Lillis’ and Zachary Doubek’s stories are all too common. Though antibiotics have saved millions of lives since penicillin was first prescribed almost 75 years ago, it’s now clear that unrestrained use of the drugs also has unexpected and dangerous consequences, sickening at least 2.25 million Americans each year and killing 37,000.

That harm comes in two main ways. First, as in Lillis’ case, antibiotics can disrupt the body’s natural balance of good and bad bacteria, which research shows is surprisingly important to human health. Lillis was killed by one such bad bug, the bacteria C. difficile. At least 250,000 people per year now develop C. diff infections linked to antibiotic use, and 14,000 die as a result.

Second, overuse of antibiotics breeds “superbugs”—bacteria that often can’t be controlled even with multiple drugs. Doubek was a victim of MRSA (methicillin-resistant staphylococcus aureus), a bacteria once confined to hospitals that has now spread into the community, including nail salons, locker rooms, and playgrounds—where Doubek may have picked up his infection. MRSA and other resistant bacteria infect at least 2 million people in the US annually, killing at least 23,000.

As alarming as those numbers are, experts say things could get much worse, and fast. The Centers for Disease Control and Prevention has sounded the alarm about two threats: CRE (carbapenem-resistant enterobacteriaceae), which—when it gets into the bloodstream—kills almost 50 percent of hospital patients who are infected; and shigella, a highly contagious bacteria that overseas travelers often bring home and that is now resistant to several common antibiotics, raising fears of an outbreak in the U.S.

The World Health Organization and the European Union call the rise of resistant bacteria one of the world’s most serious health crises, putting us on the verge of a “post-antibiotic era.” In June, President Obama convened a forum on the crisis at the White House attended by 150 organizations, including Consumer Reports. And his 2016 proposed budget included $1.2 billion for combatting resistant infections.

Miracle Drugs Gone Awry


The CDC estimates that up to half of all antibiotics used in this country are prescribed unnecessarily or used inappropriately.

“We have to act now to reverse this problem,” says Thomas R. Frieden, M.D., director of the CDC. “If we lose the ability to treat infection, we lose the ability to safely do much of what we take for granted in modern medicine.”

Part of the solution may come from developing new antibiotics. But experts say it’s even more important that doctors, hospitals, and consumers develop a new attitude to the drugs, learning when antibiotics should—and shouldn’t—be used.

That applies even to how the drugs are employed on farms: 80 percent of the antibiotics in the U.S. are actually fed to chickens, cows, and other food animals, mostly to speed their growth and to prevent disease.

Frieden and others say the problem, although complex, is fixable—if we act now. Here, what you need to know about antibiotic overuse and its consequences, and how to protect yourself and your family.

“Antibiotics really are miracle drugs. Patients believe that. I believe that,” says Lauri Hicks, D.O., head of the CDC’s program Get Smart: Know When Antibiotics Work.

Ask anyone who has had a brush with bacterial meningitis. About 85 percent of people treated with antibiotics for that infection survive; without the drugs, almost all die. In fact, many of the advances of modern medicine—organ transplants, invasive surgery, cancer therapy, among others—depend on antibiotics. For example, without the drugs up to 40 percent of people undergoing total hip-replacement would develop an infection and almost one-third of those would die.

But antibiotics have become a victim of their own success. The drugs seemed so effective that we started using them even in cases when they shouldn’t be,” Hicks says. Overall, in fact, the CDC estimates that up to half of all antibiotics used in this country are prescribed unnecessarily or used inappropriately.

How doctors misuse antibiotics



One recent study of 204 doctors suggested some physicians may be more likely to prescribe antibiotics for viral infections toward the end of their office hours—a sign they may be taking the easy route to handling patients’ complaints.

Antibiotic misuse happens in many ways:

Using the drugs to treat illnesses caused by viruses, not bacteria. Doctors know, of course, that antibiotics don’t work against viruses, like those that cause the common cold or the flu. But in some cases tests can’t help distinguish between the two. Or doctors may feel that they just don’t have the time to determine the cause, and figure “it’s better to be safe than sorry.” One recent study of 204 doctors suggested some physicians may be more likely to prescribe antibiotics for viral infections toward the end of their office hours—a sign they may be taking the easy route to handling patients’ complaints.

Prescribing the drugs just to satisfy patient demand. Doctors may also just want to make their patients happy—and patients often want antibiotics. For example, in a recent Consumer Reports poll of 1,000 adults, one in five people who got an antibiotic had asked for the drug. “I often have patients who ask for antibiotics,” says Marnie Doubek, who sees many sick children in her practice. “So I understand the pressure to just say OK. But now, especially with Zachary’s experience, no way.”

Rushing to drugs too quickly. Even when infections are caused by bacteria, doctors sometimes prescribe antibiotics when it might be wise to wait a few days to see whether mild symptoms clear up on their own. One example: ear infections in children older than 6 months. When mild, those infections often improve untreated. But as many parents know, a crying child can be a powerful motivator to seek a quick fix even if, in the long run, repeated use of antibiotics may be more likely to cause problems than solve them.

Abusing broad-spectrum drugs. When antibiotics are called for, doctors often reach too quickly for “broad spectrum” ones that attack multiple bacteria types at once. That shotgun approach is not only more likely to breed resistance but also to wipe out protective bacteria. The drug that triggered Lillis’ C. diff infection, clindamycin, is one such drug.

Those drugs were developed with the thought that “killing as many bugs as you possibly can in every patient” was a good idea, says John Powers, M.D., former lead medical officer of Antimicrobial Drug Development and Resistance Initiatives at the Food and Drug Administration.

Doctors loved the broad-spectrum antibiotics and, spurred by aggressive marketing from drug companies, began using them for common problems such as ear and sinus infections. Given that widespread use, “it’s hardly a shock that we now have a problem with resistance and C. diff,” Powers says.

The danger of new drugs

Many of those broad-spectrum drugs were introduced 30 years ago, when antibiotic development was in its heyday. More than 50 antibiotics were introduced in the 1980s and 1990s. But that once-steady drug pipeline has slowed to a trickle, for several reasons.

One is that coming up with new classes of antibiotics that target superbugs is proving to be a tough scientific puzzle. Most of the new antibiotics introduced since 2000 have been minor tweaks to existing drugs, not major breakthroughs.

The other big reason? Money. “Developing antibiotics is not that profitable,” says Henry Chambers, M.D., an infectious disease specialist at the University of California San Francisco School of Medicine. Drug companies would rather focus on medications that many people take for a long time, he explains, because the market, and profit potential, is larger.

The government is trying to sweeten the economic incentive. In 2012, the FDA began to fast-track certain antibiotics and told drugmakers that patent protection on the drugs would last an additional five years. Since then, 49 new drugs have entered the pipeline’s fast lane and six have been approved.

The FDA has proposed further streamlining—allowing companies to test drugs using smaller, shorter, or fewer studies—for antibiotics that are meant to treat serious infections in patients with no other options. Legislation now with Congress would also lower the requirements needed to get new antibiotics on the market.

When Big Pharma pushes drugs

That approach means the FDA “is willing to accept less safety and efficacy data,” acknowledges Edward Cox, M.D., director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research. But he says that’s a trade-off that many doctors are willing to make.

Still, some researchers and patient advocates worry about fast-tracking drugs. “We absolutely need new antibiotics,” says Lisa McGiffert, director of Consumer Reports’ Safe Patient Project. “But that doesn’t justify lowering the bar on the standards for drug approval. These can be dangerous drugs, so they should be thoroughly tested for safety and efficacy before we unleash them on the public.”

Perhaps the biggest concern is that even if effective new antibiotics make it to market, they may not provide much long-term help if health care professionals and patients continue to misuse the drugs. And, Chambers says, there may be pressure on doctors to use the drugs widely, despite the growing threat of antibiotic resistance.

Some pressure may come from drug companies, which have a history of marketing new drugs aggressively, and even illegally. Pfizer agreed to pay $1 billion in 2009 to settle allegations that the company illegally promoted four drugs, including the antibiotic linezolid (Zyvox), which was pushed to treat forms of MRSA for which it was not approved.

The real antibiotic solution


Avoid infections in the first place by staying up to date on vaccinations.

With education and a little prodding, doctors have shown that they can do better.

One study, in the Journal of the American Medical Association, found that doctors who attended a 1-hour session on guidelines for treating common upper-respiratory tract infections and then received feedback on their prescribing habits, cut their use of broad-spectrum antibiotics almost in half. Inappropriate prescriptions for sinus infections and pneumonia were cut by 50 to 75 percent.

Several medical organizations, such as the American Academy of Family Physicians and the American Academy of Pediatrics, have distributed guidelines on appropriate antibiotic use to their members. In some cases, that advice is incorporated into electronic medical records, so doctors are alerted if they prescribe a drug inappropriately.

Still, patients play a key role, too, by helping to make sure those drugs are used only when necessary, and by avoiding infections in the first place. Here are a few guidelines to follow:

Don’t push for antibiotics. If your doctor says you don’t have a bacterial infection, don’t insist. Ask about other treatments that can help you feel better, such as a pain reliever, throat soother, antihistamine, or decongestant.

Ask whether you can fight it off on your own. If bacteria are the cause but your symptoms are mild, ask about trying to fight off the infection without drugs.

Request targeted drugs. When possible, your doctor should order cultures to identify the bacteria that caused your infection and prescribe a drug that targets that bug.

Use antibiotic creams sparingly. Even antibiotics applied to the skin can lead to resistant bacteria. So use over-the-counter ointments containing bacitracin and neomycin only if dirt remains after cleaning with soap and water.

Avoid infections in the first place. That means staying up to date on vaccinations. And it means washing your hands thoroughly and regularly, especially before preparing or eating food, before and after treating a cut or wound, and after using the bathroom, sneezing, coughing, and handling garbage. Plain soap and water is best. Avoid antibacterial hand soaps and cleaners, which may promote resistance.

Read more: http://www.consumerreports.org/cro/health/the-rise-of-superbugs/index.htm#ixzz3fQgA6mIC