#SurfacesMatter in Pathogen Transmission
Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc has dutifully served on the Board of Directors for the Healthcare Surfaces Summit since its inception because the mission of finding solutions to the spread of infections via surfaces completely aligns with both his personal and professional life. His extensive education and certifications in microbiology, molecular biology and virology is reinforced with a Ph.D. in Education (public health). He currently serves as Chair and Professor of the Clinical Laboratory Science Program at Texas State, as well as Associate Dean for Research in the College of Health Professions. Dr. Rohde is Past President of TACLS, a TEDx speaker, Global Fellow, and Honorary Professor of International Studies. Follow him on Twitter @RodneyRohde & Linkedin at https://www.linkedin.com/in/rodneyerohde/
Dr. Rohde’s professional website: http://rodneyerohde.wp.txstate.edu/
This past week, I received my weekly phone call from my parents. My dad is a retired railroad conductor who is from the #GreatestGeneration. He is one of the strongest people I know. My brother, sister and I grew up hearing him often say to us, “I don’t have time to be sick,” as he headed out on another train trip. Like many of us, our parents are our heroes.
We think of them as being invincible – until they are not.
Being a railroad conductor was a great career for my father. In my hometown of Smithville, Texas, most men wanted the job because it provided a strong and steady income for a family. It allowed my mom to be a stay at home mother who raised the three of us – also a full-time job! A railroad conductor is the boss of the train, not the engineer. Dad worked when there was still a caboose at the back of the train and I still remember the vivid stories of him telling us about “jumping on and off” of the caboose to walk the train for inspection. Unfortunately, those long walks past hundreds of railway cars meant that he was often walking at odd angles in hard rock. Well, thirty plus years of doing that wore out his knees and his ankles.
Finally, it became too much to bear and he received a medical retirement in his late 50’s. A great career, yet, one that took a terrible toll on his body. Last night, dad called to let me know that one of his feet had been bothering him again. What started as a small “corn” on one of his feet, opened up, and started draining blood. For my father, he knows what this means as he has had one knee replacement and multiple surgeries on both ankles to fuse bones with screws and pins.
He has become my student with respect to trying to understand what the difference is between “regular staph infections versus #MRSA.” Dad has been in and out of the hospital the past several years receiving everything from incision and drainage procedures to full-blown surgery to remove an infected toe, tissue and bone. Likewise, he has become all too familiar with oral versus IV antibiotics from multiple classes of antimicrobials. Finally, he and mom have had long discussions with me about infection control and prevention in the healthcare and home / community setting because all #SurfacesMatter in the new post-antibiotic world of #superbugs and #antibioticresistance (#amr). It saddens me to see the confusion and sometimes surrender on their faces due to “another infection.” While I cannot prove it, my professional opinion as an infectious disease microbiologist and medical laboratory professional leads me to believe that his problems started with the various metal components inserted into my dad’s knee and/or feet years ago – you see, ALL surfaces matter ALL the time.
Surfaces – the Real Battlefront!
What most people do not understand about the environment is that there is an entire world of unseen microbes hiding on all surfaces. Bacteria, viruses, fungi and other microbial life can exist, at least for some time, on almost any surface known to humankind. Likewise, many of us do not realize that “clean does not necessarily mean microbial clean.” In other words, the cleaning and disinfection of surfaces has complex scientific nuances. One must understand the type of surface with respect to the proper choice of disinfectant. In the fight against infections, material compatibility is critically important. The healthcare environment uses any number of materials (e.g. plastics, vinyl, metals, etc.) for equipment, surfaces, and devices that are regularly cleaned with disinfectants. Harsh disinfectants may cause equipment damage, unnecessary costs, and contribute to poor clinical outcomes. We must work to develop standards, resources, and education to overcome key challenges in surface cleaning and disinfection. Our call to action must be a new paradigm on the upstream challenges (design and choice of surfaces) as well as the downstream options (cleaning and disinfection of surfaces) for overall patient safety and health.
It is not just my dad either. Much like my friend and colleague’s story, my dad is now all too familiar about the role surfaces play in pathogen transmission in healthcare and community settings. Since I first started conducting research on Methicillin Resistant Staphylococcus aureus (MRSA) and lecturing on the dangers of antibiotic resistant superbugs that cause healthcare associated infections (HAIs), it seems like my circle of friends, family, colleagues and total strangers have crossed paths with at least one person tormented by these nasty microbes. #HAIs have no bias – they do not care if you are rich or poor; conservative or liberal; male or female, what ethnicity you are – they have just one purpose. That purpose is to reproduce and harm you. In addition, many times that purpose is to kill you.
After talking with dad last night, it got me to thinking about this post / blog. A thought has been crossing my mind for a while now.
Have we reached an era where elective medical procedures should not be performed?
There are always risks when having surgery. As I often say to others, “there is no true ‘minor’ surgical or medical procedure.” On top of the usual concerns, antibiotic resistant infections from HAIs have made me start to ask myself, “is that surgery or procedure truly necessary?” I mean, we all understand that trauma and life-threatening illnesses may require surgery. However, what about elective surgeries or procedures - things like knee or hip replacements? I cannot tell you how many consultations I have done on post-operative complications from an HAI like MRSA with a surgery involving a replacement of a knee, shoulder, or hip. I have begun to inform people that they truly need to have a serious discussion with their healthcare team and themselves about just how badly they need that replacement. Certainly, many times it is necessary. I mean, my father is one of the toughest men I know, and the pain had just become too unbearable. I am just saying that maybe we all need to ask ourselves these difficult questions. If nothing else, there needs to be an open conversation with your healthcare team about the dangers that surfaces play in a patient’s environment, as well as with implants and other devices.
A risk analysis should become part of your medical consideration.
As a researcher, whenever I begin a new project involving humans (and animals), I am asked to analyze and explain the risk/benefit of my work to an Institutional Review Board. Perhaps, this type of discussion needs to happen with our doctor and healthcare team.
In light of the ongoing issue of medical device sterilization / reprocessing problems, I even have concerns about things like a colonoscopy or other invasive diagnostic procedures. I am not saying these procedures are not lifesaving or necessary. I am just asking the question. If you do not really need it (elective plastic surgery, a colonoscopy very late in your life, endoscopy, etc.), maybe you should not have it due to the real risk of acquiring an HAI.
HAIs are Real!
The World Bank projects that without intervention more than 10 million people will be killed by superbug infections by 2050[i] and over the same time period healthcare costs will increase from $300 billion per year to $1 trillion per year. In their report[ii], the World Bank notes, “humans live in a permanent arms race with harmful microbes.”
Former World Health Organization (WHO) Director-General Margaret Chan has said the rise of antibiotic resistance could lead “to the end of modern medicine as we know it,” [iii] where things as common as strep throat or a child’s scratched knee could once again kill. A BBC report notes that while Chan’s comment may sound alarmist, “it may not be alarmist enough.”[iv] Practically, what this means if the current epidemiology continues is that there will be one new antibiotic resistant infection every three seconds. Although significant progress has made in preventing some infection types, there is much more work to be done. On any given day, about one in 25 hospital patients has at least one healthcare-associated infection. Unfortunately, HAIs affect 5 to 10 percent of hospitalized patients in the U.S. per year. Approximately 1.7 million HAIs occur in U.S. hospitals each year, resulting in 99,000 deaths and an estimated $20 billion in healthcare costs.
Plainly, this is not theory; it is real. Recently, the Centers for Disease Control and Prevention (CDC) reported[v] an incident where a woman in Nevada died of an incurable infection caused by a strain of the bacteria Klebsiella pneumoniae resistant to all 26 antibiotics available in the United States to treat infection.
In Texas, researchers at the Houston Methodist Research Institute are trying to deal with the thousands of infections that are increasingly showing up in their hospital system and apparently caused by another strain of the K. pneumoniae.[vi]
And seven states (New York, New Jersey, Illinois, Indiana, Maryland, Massachusetts and Oklahoma) have become flashpoints for infections from a superbug-like, multi-drug-resistant fungus called Candida auris that is emerging in U.S. hospitals and has grown from seven to 122 cases in the past nine months as of the end of May.[vii]
Dr. James Johnson, a professor of infectious diseases medicine at the University of Minnesota and a specialist at the Minnesota VA Medical Center, has said of the superbug threat: “People have asked me many times ‘How scared should we be? … How close are we to the edge of the cliff?’ And I tell them: ‘We’re already falling off the cliff.’”[viii] I agree. In fact, I spend more and more of my time consulting with family, friends, colleagues and total strangers regarding this topic.
I have been on a mission to increase awareness of the unheralded professions that are so critical in the battle against HAIs and the antibiotic resistant superbugs that cause one in every seven HAI[ix] (one in four in long-term acute care hospitals). In 2016, at a TEDx Talk[x] whose theme was “Everyday Heroes,” I shined a spotlight of my own on two such professions – the medical laboratory professional and the Environmental Services (EVS) hygiene specialist. Recently, I also have been talking about how important your pharmacist is to this issue.
I have a special affinity for the medical laboratory professional since I teach clinical laboratory science. Similarly, I firmly believe EVS comprises first-line-of-defense specialists whose training has included learning best practices for effective infection prevention, on-going in-service education and effective hygiene management in patient rooms and all other areas of the hospital.
To me, the hygiene specialist is a “secret weapon” [xi] in preventing HAIs. This is especially true when they are included as a component of a multimodal, collaborative intervention-type solution.
However, everyone in healthcare needs to step up their vigilance in preventing HAIs. We have reached a new era. One in which our great-grandparents and grandparents dealt. A post-antibiotic era is on our doorsteps if not walking through our door already. We still believe that it is an easy thing to “take an antibiotic” and everything will be fine.
Ladies and gentlemen, I believe those days may be over. Truly, every Surface Matters!
To learn more about the work of the Healthcare Surfaces Summit and find out how you can help, visit: https://www.healthcaresurfacessummit.org/
[i] “Drug-Resistant Infections: A Threat to Our Economic Future,” World Bank. 2017. Washington, DC: World Bank. License: Creative Commons Attribution CC BY 3.0 IGO
[iii] “Who Director-General Briefs UN on Antimicrobial Resistance,” remarks, Dr. Margaret Chan, Director-General of the World Health Organization, April 18, 2016
[iv] “How We Can Stop Antibiotic Resistance,” Erin Biba, BBC, June 8, 2017
[v] “Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae – Washoe County, Nevada, 2016,” Morbidity and Mortality Weekly Report, CDC, January 13, 2017/66(1); 33
[vi] “Scientists Find a Rare Superbug in Houston,” Alexandra Sifferlin, Time Health, May 16, 2017
[vii] “Superbug C. auris Grows to 122 Cases in 7 States, CDC Says,” Susan Scutti, CNN, May 31, 2017
[viii] “A Nevada Woman Dies of a Superbug Resistant to Every Available Antibiotic in the U.S.,” Helen Branswell, STAT, Jan. 12, 2017
[ix] “Vital Signs: Preventing Antibiotic-Resistant Infections in Hospitals – United States, 2014,” Morbidity and Mortality Weekly Report, CDC, March 11, 2016/65(9); 235-241
[x] “Saving Lives in the Shadows of Healthcare,” Rodney E. Rohde, TEDx Texas State University, Nov. 5, 2016
[xi] “A Secret Weapon for Preventing HAIs: A Scientist’s Message to Hospitals Trying to Rid Themselves of Healthcare-Associated Infections,” Rodney E. Rohde, Elsevier, July 15, 2014