Deadly germ invades area hospitals
Medical infection reporting system stalls as new superstrain of bacteria is confirmed

Sunday, November 06, 2005
Harlan Spector
Plain Dealer Reporter

Test results last week confirm suspicions that a deadly intestinal superbug has invaded Greater Cleveland, but the news comes as a plan to track cases in hospitals and nursing homes is stalled.

Local health authorities devised the plan as concerns mounted that Clostridium difficile was growing more virulent. They predicted in August that a reporting system relying on hospital cooperation would begin within a month.

Ohio hospitals are not required to report infections that patients acquire at their facilities. Infectious-disease specialists say they are committed to reporting cases of Clostridium difficile -- C. diff for short -- because of the growing threat. But attention has turned to a debate among hospitals about how to collect and report infection data, a concern that some say is more about public relations than public health.

The debate is churning as molecular tests of bacteria from the Stokes Cleveland VA Medical Center and another Cleveland hospital showed they are the same antibiotic-resistant superstrain that has caused outbreaks in Canada, Europe and other parts of the United States.

Testing for the superstrain has been expanded to other Cleveland-area hospitals.

The virulent bacteria is blamed for as many as 2,000 deaths in Quebec in 2003 and 2004. The death toll, reported in a recent Canadian study, is far higher than previous estimates.

C. diff until recently typically caused nothing more than diarrhea - more an unpleasant episode than a life-threatening condition. But the new strain is difficult to treat and highly toxic. British researchers reported in September that it produces up to 23 times more toxins than older strains.

The VA has seen C. diff infections double nationally in the past four years, said Dr. Curtis Donskey, an infectious disease specialist at the Cleveland VA. Doctors at other local hospitals have also alerted Cuyahoga County health authorities to increases in cases, resulting in longer hospital stays, more complications and deaths.

Cuyahoga County Coroner Dr. Elizabeth Balraj has documented 10 deaths related to C. diff since 2003, though it's not known whether the deadly strain was present. Balraj, who reviews only a sliver of hospital deaths, said they were the first fatalities from C. diff she has seen in 18 years on the job.

Despite signs of the growing problem, health authorities are trying to mount a defense with little intelligence. Hospitals are reluctant to divulge infection data that may put them in a harsh light. The subject is so sensitive that the Cleveland Clinic declined even to say whether it supports voluntary reporting to health authorities.

Tracking cases is fundamental to the public health mission of preventing disease. It's difficult to control infectious diseases without knowing where the infections are.

"How in the world do you know you have a problem unless you're counting?" said Marc Volavka, who heads a Pennsylvania agency that oversees hospital infection reporting.

The C. diff threat has brought Northeast Ohio into a national debate over whether hospitals should be compelled to report infections acquired during patient stays. Infectious bacteria lurk in all health-care settings, causing pneumonia, surgical and urinary tract infections and other complications that lengthen hospital stays and cause an estimated 90,000 patient deaths a year.

Reporting infection rates is the newest frontier in a movement for better quality. Consumers, insurers and businesses are demanding accountability for hospital performance. Since 2003, six states have passed laws requiring hospitals to publicly report infections.

Advocates say mandatory reporting forces hospitals to improve. But hospitals oppose efforts they characterize as inadequate and unfair. They say there is no standard way to measure infection rates, taking into account risks of different patient populations.

Hospitals say that with C. diff infections, numbers can be misleading because patients transferring between hospitals and long-term-care institutions can pick up the bug anywhere. Private hospitals don't want to be blamed for infections that patients catch somewhere else.

"Obviously, hospitals need to worry about the perception of the public," said Dr. Jennifer Hanrahan, an infectious disease specialist at MetroHealth Medical Center.

The dilemma is that the C. diff bug can live in the gut for months, but it typically does not sicken patients until they take antibiotics for surgery or other reasons. Certain antibiotics trigger infection because they wipe out natural bacterial defenses.

"It's a Catch-22 for clinicians," said Barbara Bradley, chief of infection control at the state health department. "They have to treat an infection and they don't know whether that treatment is going to cause C. diff."

The germ is transmitted through contact with feces found on surfaces and on the hands of health-care workers. Handwashing by hospital employees and careful selection of antibiotics are among the most effective defenses.

Focusing first

on prevention

County Health Commissioner Terry Allan said hospitals have not delayed efforts to report cases. Authorities decided first to review infection-control practices at hospitals and nursing homes, he said.

"After discussing this with some of our local specialists, I am not sure that simply setting up a database to collect numbers in the community is the best first step," Allan said in an e-mail.

Behind the scenes, hospitals are grappling with a voluntary reporting system that local infectious disease specialists from the major hospitals recommended in August.

"This is a process that we initiated, and we are committed to doing this," Dr. Robert Salata of University Hospitals of Cleveland said in an e-mail.

Hospitals say they are doing more to stop the spread of C. diff. Some isolate infected patients, though experts don't agree whether that is necessary. Some also are steering away from antibiotics most likely to trigger C. diff infections. Cases at the Cleveland VA have dropped since the hospital adopted new measures, such as using a bleach solution to clean patient rooms, Donskey said.

A more difficult task is compelling workers to take simple precautions such as washing hands before touching patients. Research shows that doctors, for instance, only wash their hands about half the time.

Clare Becker of Olmsted Falls said her 74-year-old husband, Paul, was sickened by C. diff for the second time this year at Southwest General Health Center in Middleburg Heights. She complained to medical staff when she saw that some health-care workers did not wash their hands or wear gloves around her infected husband.

"It's very interesting how casual they are about something that can be a killer," Becker said.

A Southwest spokeswoman said the hospital requires workers to wear gloves when in contact with C. diff patients, and to wash hands afterward.

In the case of Angela Azzarello, an 83-year-old woman who died in September after contracting C. diff, complaints about unsanitary conditions at the nursing home where she lived surfaced after her death. Azzarello's daughter, Loretta DeGaetano, complained to the state Health Department that dirty latex gloves littered her mother's room, and feces stained the curtain surrounding her bed.

"My mother died a horrible, agonizing death," DeGaetano wrote in the formal complaint. "None of this was necessary."

Officials at the nursing home, Stratford Commons in Glenwillow, did not respond to requests for comment. The Ohio Health Department told DeGaetano recently that it could not substantiate her complaint.

Azzarello died at South Pointe Hospital in Warrensville Heights, but neither the hospital nor the nursing home was required to report the infection.

Ohio law requires health providers to report dozens of infectious diseases such as hepatitis to public health agencies. Hospitals have to report infections contracted in their institutions only in the case of outbreaks. But even health authorities aren't clear what constitutes a hospital outbreak.

"We haven't had any reports," said Allan, the health commissioner. "But we don't know what the threshold is."

Legislature considering

infection-reporting law

More than 30 states, including Ohio, have considered mandatory reporting of hospital infections, though bills have failed in many of the states. In Ohio, two bills are in the House health committee. Tensions between public health and hospital interests have surfaced.

The Ohio Hospital Association opposes mandatory reporting. In a February letter, the hospital group said there are no accepted standards to report hospital-acquired infections. It also argued that legislation would duplicate other hospital quality initiatives.

Whether an infection was acquired in a hospital or elsewhere is a public relations issue, Mary Yost of the hospital association acknowledged. But she added, "If the data is out there, it should be meaningful and properly understood."

The hospital group may have an ally in the Ohio Department of Health. The Health Department objected to one of the bills, saying that it would cost too much for hospitals to comply with reporting requirements. The department also cited concerns about hospitals' ability to accurately report infection data.

Nobody said it would be easy. The first states to require reporting have faced difficulties. Pennsylvania is the furthest along.

In the state's initial report in July, Pennsylvania hospitals noted 11,668 infections, accounting for nearly 1,800 deaths and $2 billion in additional hospital charges.

However, the Pennsylvania Health Care Cost Containment Council estimated from billing data that there actually were about 10 times as many infections. Many hospitals did not report all their cases, said Marc Volavka, the agency chief.

"We've had some of the hospitals acknowledge to us privately - they would never say it publicly - when we read back the billing data to them, they were shocked to learn how many infections their [practitioners] weren't reporting," Volavka said.

"It's far from perfect. But we're going to get there because it's the right thing to do."

To reach this Plain Dealer reporter:

hspector@plaind.com, 216-999-4543


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