Concerns about antibiotic-resistant bacteria have become a staple feature of news and documentaries. An April 2008 Panorama special How safe is your hospital? looked at the alarming rise of Clostridium difficile (C. diff) in UK hospitals. Showing the programme as a whole with a group of students would be inappropriate; it lasts for a full hour and the pace is often cumbersome. In addition, I fear that much of the discussion of old ladies and diarrhoea runs the risk of generating inappropriate responses from classes of teenagers.
Having said that, there are some real nuggets here which, appropriately selected, can raise some of the scientific and ethical issues associated with antibiotic usage. The opening 3 minutes of the programme, available as an iPlayer clip on the BBC website, has general potential as a scene-setter. The full episode is also being streamed on the Panorama website (in the BBC’s older RealPlayer-based format). The most useful section of the episode starts about 14 minutes in (14:20 on the streamed video), beginning with the interview of Prof Richard James from Nottingham University and showing the following 5 minutes (through to the section on the outbreak at the Stoke Mandeville hospital, although there are some other natural end-points in between if this is too long).
C.diff is not a new organism, and occurs normally in the intestines of about 3% of the population. These individuals are usually completely well, the C.diff is held in check by other ‘good’ bacteria in the gut. Problems arise when people, e.g. the elderly, have a weakened immune system. Importantly, the use of ‘broad-spectrum’ antibiotics, given in good faith to treat bacterial infections, can actually generate an environment in which C.diff can proliferate. The term ‘broad-spectrum’ is used because these compounds can have an effect on the growth of a wide range of bacteria, including both Gram negative and Gram positive organisms. As the voiceover puts it, “in a normal gut C.diff will get nowhere, it’s kept at bay by all the healthy bacteria. But broad-spectrum antibiotics have a scatter-gun effect, they destroy the bad guys but they also kill off the good ones. With the defences down, C. difficile can now proliferate”. Prof James explains that C.diff is able to survive when so many other bacteria succumb to the antibiotic treatment because it forms very stable spores which are able to stay dormant until circumstances improve and allow them to break out and form normal cells again.
Presenter Sally Magnusson then moves on to interview Prof Brendan Wren at the London School of Tropical Medicine. He demonstrates that C. diff spores can also survive when the bacteria are exposed to disinfectant products such as those used to clean hospitals. The strain that has been causing problems, called O27, is particularly robust, as well as being more virulent and easier to spread – a combination that has, literally, proven deadly.
Much of the video focuses on the circumstances surrounding particular outbreaks of C. difficile at a cluster of hospitals run by the Maidstone and Tunbridge Wells NHS Trust, which grabbed headlines in 2007 (e.g. Ward bug errors cause 90 deaths and linked stories). A number of policy and institutional issues that contributed to the spread of C.diff are discussed, issues which are echoed at other hospitals too.
One problem stems from the high rates of bed occupancy – often 95% or more. Whilst it may make economic sense not to have empty beds in a hospital, it is a disaster-in-waiting from an infection control point of view since there is insufficient time to clean properly between patients. Experts suggest that bed occupancy needs to be 85% or less to reduce this particular risk-factor.
Secondly, a shortage of nurses can leave staff overstretched and unable to deal adequately with the care and hygiene issues of their patients; the Kent and Sussex hospital is said in the video to have had a 17% shortfall in staff compared with the national average.
Thirdly, the physical proximity of patients can allow for easy spread of infection; at the Kent and Sussex beds were so close together that patients could literally reach out and touch the person in the next bed. The ‘open plan’ wards of most UK hospitals have also contributed to this problem.
Fourthly, hospitals have felt it necessary to prioritise their resources into meeting Government-generated initiatives and performance targets, such as reducing waiting times in A&E, to the neglect of more medically-justified priorities. A focus on “strategic initiatives” has been to the detriment of day-to-day running of the wards. Changes elsewhere in the NHS, notably reduced access to GP services, have led to an increase in people turning up at casualty seeking treatment.
What is being done, and what else could be done, to challenge the rise of infections such as Clostridium difficile? Interestingly, the fact that C.diff goes through a highly-resistant spore phase means that some of the strategies such as increased use of alcohol hand-wash and the Government’s much vaunted drive for steam cleaning of hospitals can actually exacerbate the problem. This organism may be triggered into more spore production by exposure to alcohol or extreme temperature and thus spread more easily. Use of alcohol handscrubs therefore needs to be interspersed with soap and water hand cleaning (in one hospital shown in the video alcohol washes are used on entry to the ward, and between patients, and soap and water on the way out).
Better cleanliness certainly has a part to play, and it is important that doctors, patients and their relatives recognise that we are all involved in this. Other interventions need to be at the hospital level or via government. Positioning beds further apart, and ideally having separate isolation wards for patients known to be infected are key. Visitors and nurses attending the isolation ward need disposable gloves and aprons at all times. A shift to only making up the beds that are needed, rather than having empty beds pre-made, reduces the opportunity for infection to spread via soft furnishings such as blankets and pillows. Ideally hospitals will be re-designed to have more individual rooms with en suite facilities (ironically a focus on the future development of one such facility at Pembury was one of the distractions that led the Maidstone and Tunbridge Wells NHS Trust to neglect the day-to-day care of the current patients.
There is also a call for more fundamental scientific research on the biology of infective agents. There are presently only 2 antibiotics – vancomycin and metronidizol – that are effective against C. difficile. More antibiotics, but also more non-antibiotic strategies such as vaccines, need to be developed. The budget for this kind of basic research is minute compared to the funds poured into the ostentatious steam cleaning programme (these points are picked up at 53:20 into the video).
Possible questions that might be asked in conjunction with this video:
1. Why does treating a person with antibiotics sometimes lead to greater risk that they will become infected with Clostridium difficile? (hint: think about the Yakult probiotic drink adverts)
2. Clostridium difficile is a nasty bacterium that causes diarrhoea and death. What is it about the biology of this microorganism that allows it to survive treatments (e.g. antibiotics, steam cleaning) that would kill other bacteria?
3. Clostridium difficile is known as a “hospital-acquired infection”. Think of three reasons why being in hospital might contribute to somebody catching this bacterium?
4. Suggest two strategies (either scientific or policy-related) that might help in the battle against infection with C. difficile.
This programme can be available via a variety of routes. As mentioned above, the introductory 3 minutes are available on iPlayer (UK C. diff deaths ‘rise sharply’). The complete programme is currently available via the Panorama website in BBC player/Real Media format – scroll down to the 27th April and click the “Watch:How Safe is Your Hospital?” link NOT the “How safe is your hospital?” title which takes you to the iPlayer clip). Members of the BUFVC can also order copies quoting TRILT identifier 008F6BA0.