Econstudentlog

Antibiotic Policies: Controlling Hospital Acquired Infection

I’ve read about and blogged this topic before, but this is the first academic text on the topic I’ve read. I liked the book and gave it four stars on goodreads. It’s a typical Springer publication, i.e. it’s a collection of relevant studies/papers published on the topic; there are fourteen papers/chapters included in the book. Given the nature of the book there’s some overlap across chapters, but that’s to be expected and it doesn’t really matter much. The book was published in 2011 so it’s reasonably up to date even though things are happening fast in this area.

Some of the authors of the studies included in the book assume that the reader possesses a level of knowledge about microbiology which goes way beyond what you’d get from reading an intro text like Hardy, and although I’ve also previously browsed one of the books you’d actually need to have read in order to understand the details (Brooks, Butel & Morse), I’ve of course long ago forgotten much of that stuff and so occasionally felt a bit lost while reading the book. There’s some good stuff in there though, and many of the chapters I did not find that hard to read although some details eluded me. It’s my impression that you probably will not get much out of the book if you’ve never read a microbiology text before (I actually feel a bit sad having to write that as the topics covered are very important in terms of future public health, and so in a way I’d really wish as many people as possible actually read this book, or at the very least familiarized themselves in some other way with the problems covered in the book).

“This book serves a twin purpose in helping to construct a more informed evidence base for coherent policy making while, at the same time, providing practical advice for health professionals in the prevention and control of HAIs.”

The quote above is from the preface of the book. The papers included in the book cover a wide variety of topics; one chapter deals with the ‘total scale’ of the problem of healthcare associated infections (HAIs), another chapter deals with (among other things) how antibiotic treatment regimes and the development of resistant strains in the community and/or health care institutions are associated, one chapter deals with the epidemiology of drug resistant strains of bacteria and how to properly categorize drug resistance (which can take on many forms), and quite a few chapters focus on specific HAIs (C. difficile, MRSA, VRE, ESBL-producing bacteria, CRE, Acinetobacter baumannii, and MDR (multi-drug resistant) Pseudomonas all get a chapter each). Many intervention studies are covered and the focus is not just on identifying the extent of the problem but also on finding ways to counter the problems; one chapter deals specifically with antibiotic stewardship, which is one of the main ways to try to stop the spread of antibiotic resistance, but many other chapters cover that topic as well in the specific setting. Another key strategic element in any intervention strategy, infection control measures (hand hygiene, patient isolation, etc.), is likewise covered in many of the chapters, and as the studies included have a very ‘evidence-based medicine approach’ to these matters important but potentially embarrasing problems like compliance problems on the part of health care providers [it’s harder to convince doctors to wash their hands than it is to convince nurses..] are not overlooked. The book is not US-centric; countless international studies are included, and a specific chapter is reserved to dealing with MDR infections in low-resource health care settings. The institutional setting is important and is covered in a few chapters, and included in that discussion are observations related to how things like reimbursement methodology may impact health care provider behaviours and how faulty incentive structures on the institutional level may aggravate the problems with resistance development e.g. by failing to address collective action problems in this area.

As might be inferred from the comments above, there’s way too much stuff in there for it to make sense for me to cover it all here. However I have added some observations from the book below, emphasizing some important points and observations along the way and adding a few comments here and there.

“What is required is tackling of the problem at its root cause, namely the gross over use of antibiotics.” […let’s just start out with that one, so that people will not falsely assume that this aspect is not covered in the book.]

“In broad terms, there are two means by which patients can develop multi-resistant infections—they can either develop their own resistant pathogen, or they can acquire someone else’s strain.
Emergence of new resistant pathogens is directly related to antimicrobial selection pressure either via the mutation of new resistance genes or the alteration of bacterial ecology (e.g. in the gut) that facilitates the transfer of naturally occurring or emergent resistance genes from one bacterial class to another […] antibiotic use in food production can have the same effect as direct human antibiotic misuse, since it can select for both resistant pathogens (e.g. fluoroquinolone-resistant Campylobacter in chicken meat) or resistance genes such that food consumption results in either direct fecal colonisation or acquisition of resistance genes by routine gut flora [3,4]. Antibiotic stewardship is therefore not simply a hospital issue.” […]

“The global burden of healthcare associated infections (HAI) is currently unknown, despite international efforts to fill this gap in our knowledge. Where the size of the burden of HAI has been quantified, the greatest impact is in those countries with least resources to measure and manage them. […] 3.5–10.5% of hospitalised patients in industrialised countries may experience HAI (E.C.D.C. 2008), while greater than 25% of hospitalised patients in developing world nations may be affected (W.H.O. 2005). […] While in 2000, 70 countries did not screen donated blood for HIV, hepatitis B or hepatitis C, currently the risk of bacterial infection from transfusion is greater than the risk of acquiring these viruses. Reuse of contaminated needles or syringes during injections in limited resource settings poses a major threat for transmission of infection, accounting for an estimated 21 million hepatitis B infections, 2 million hepatitis C infections and over 95,000 HIV infections. […] Of the 8.8 million deaths in children under the age of 5 years, infectious diseases account for 5.5 million (63%) […] clinicians in developing countries tend to diagnose and prescribe medication empirically. People with undetected resistance then receive antibiotics to which their isolate is not susceptible. For example, one study in western Kenya found that more than half of the patients treated empirically for bacterial diarrhea were given ineffective antibiotics. Among patients with shigella, this number exceeded 80% (Shapiro et al. 2001). […] In developing countries, antibiotics are a scarce resource, and most clinics and hospitals can barely afford common first-line agents, much less second and third-line alternatives […] variation in prices of antibiotics is considerable. The wholesale price differential between amoxicillin and co-amoxiclav, for example, is on the order of a factor of 20 (Forster 2010). This means that where resistant bacteria necessitate the use of co-amoxiclav, only 5% of the patients can be treated for the same budget as with amoxicillin. […] In coastal Kenya, resistance to chloramphenicol, amoxicillin, cotrimoxazole, and gentamicin in Gram-negative sepsis is common, and susceptibility remains only to two rarely used drugs, ciprofloxacin and cefotaxime. The cost of treating a 15 kg child with sepsis would be $0.38–2.30 for gentamicin and chloramphenicol versus $73–108 for the effective drugs […] In Thailand, only 9% of antibiotics administered in a teaching hospital were appropriate to the patient’s condition, and 36% of patients were given antibiotics without evidence of an infection […]

“The underused vaccines that could have the biggest effect on antibiotic use in hospitals are against Streptococcus pneumoniae and Haemophilus influenzae type b. To these should be added one of the new vaccines against Rotavirus, the main cause of dehydrating diarrhea, which kills 400,000–500,000 infants and children in developing countries annually. Even though Rotavirus is, in fact, a virus, reducing its incidence will reduce antibiotic use. The most appropriate treatment for rotavirus and other causes of watery diarrhea is oral rehydration therapy, but since antibiotics are used inappropriately in many cases, reducing the number of cases will reduce antibiotic use.” [..vaccines against viruses may help decrease the number of bacteria resistant to antibioticsyep, this stuff is complicated..]

“HAI are recognised as among the most common adverse outcomes from hospitalisation in the US; approximately 1.7 million HAI are reported across the US each year, which are associated with around 99,000 deaths per year. Around a third of HAI are urinary tract infections, one fifth are surgical site infections, 15% are pneumonia and 14% are bloodstream infections (C.D.C. 2010).” […] Estimates in Europe are that approximately 4.1 million patients per year experience HAI, and that attributable deaths are of the order of 37,000 per year (E.C.D.C. 2005–2010).” [These estimates are somewhat uncertain and I’m not sure how much you should read into the fact that they differ in the way that they do, with fewer but more lethal HAIs in the US. Before you read a lot into it, you should certainly note that there is huge regional variation in the data here.] […]

“Surgical prophylaxis is a common area of overuse as shown in many publications. Measured by total DDDs [defined daily doses], it can amount to around one third of a hospital’s total antibiotic use. This illustrates the potential for ecological damage although surgeons often ask whether 24 h or even single dose prophylaxis can really select for resistance. The simple answer is yes, but of course much of the problem is extension of prophylaxis beyond the perioperative period, often for several days in critical patients, perhaps until all lines and drains are removed. There is no evidence base in favour of such practices.” […]

“Since 2002, increasing rates of CDI [Clostridium difficile Infection] with a more severe course, higher mortality (from 4.7 to 13.8%) and more complications (from 7.1 to 18.2%) have been reported in Canada […] Of all patients who develop CDI in the hospital setting, approximately 80–90% have used antibiotics in the previous 3 months. […] MRSA can survive for months in hospital environment […] and it can be isolated on clinical equipment, as well as on general surfaces especially close to patient’s area, such as curtains, beds, lockers and over-bed tables […] Before contact precautions are implemented, MRSA carriers may have already contaminated their environment with MRSA. […] Cross-transmission between patients may occur via HCWs [health care workers’] hands after touching contaminated environmental surfaces […] One study showed that 10% of HCWs fingertips were contaminated with MRSA after contact with MRSA positive patient’s environment […] There is now reasonable evidence that rates of MRSA, C.difficile, VRE and multi resistant Gram-negatives can be reversed by modulating use of key agents such as cephalosporins and quinolones […] The real problem for the future, of course, is how to do this without “squeezing the balloon”, transferring the resistance selection pressure to other classes of agents. This highlights another paradox, that of current antibiotic policies which tend to lead to a lack of diversity of use of different classes of antibiotics. Diversity of use is probably one of the best strategies to delay emergence of resistance, although a lack of choice of truly different drug classes makes its implementation problematic. Moreover, the holy grail, and the most difficult thing is to achieve total reduction in prescribing while not compromising patient outcomes. Again, this isn’t something current strategies are good at achieving.” […]

“ESBL-producing bacteria are not only present in hospitals from endemic nosocomial sources but are introduced into the hospital from other health care facilities (particularly high rates occur in care of the elderly homes […] but also from individuals coming
from the community (Ben-Ami et al. 2006). […] This community carriage is an important facet of ESBL control [Again, what happens outside the hospitals matter a great deal…] […]

“Carbapenems have the broadest antimicrobial spectrum of any beta-lactam antibiotic and are frequently used as first-line agents for the treatment of severe infections caused by multiresistant Gram-negative bacteria […] The emergence and spread of carbapenem-resistant Enterobacteriaceae (CRE) are therefore a major concern for patient safety and public health. Infections due to CRE may lead to increased likelihood of treatment failure and growing reliance on third-line agents and combination therapy, with doubtful therapeutic efficacy and increased potential for toxic side-effects […] It also increases the cost of treatment […] CRE differ from most other multidrug-resistant bacterial pathogens in that there is no reliable treatment available (Schwaber and Carmeli 2008). […] two cases of panresistant CRE were recently reported from a hospital in New York […panresistant strains are basically untreatable, US.] […] Patients with CRE infection are at high risk of treatment failure and adverse outcomes, including increased mortality and morbidity, longer length of hospital stay, and higher treatment costs when compared to infections caused by susceptible strains. Several studies have reported high percentages of crude in-hospital mortality— some over 50%—among patients infected with CRE […] the magnitude of the excess mortality directly attributable to CRE is difficult to quantify […] Overall, uncertainties persist in individual patient-level analyses regarding which prior antibiotic exposures are most important as risk factors for acquisition of, transmission of and infection with CRE. Similarly, ecologic studies using aggregate datalevel analyses do not show a clear-cut picture.” […]

“Antibiotic policies are crucial but they cannot be effective without active infection control program[s]. A hospital with a strong infection control program without an antibiotic stewardship component would tackle transmission of multi-resistant organisms such as VRE but would not prevent individual patients from getting colonised or infected with resistant microbes. On the other hand, strong antibiotic stewardship would be expected to control the menace of multi-resistant organism but in absence of an infection control program, transmission of organisms (even if not multiply resistant) would be easy and would adversely affect patient care.” […]

“A retrospective, risk-adjusted, cohort study of 80 patients with Acinetobacter bacteraemia conducted in Korea demonstrated that those infected with imipenemresistant strains had a significantly higher 30-day cumulative mortality rate than those infected with imipenem-susceptible strains (57.5% versus 27.5%) […] This was mainly due to a higher rate of inappropriate antimicrobial therapy. […] Carbapenems are the mainstay of treatment for severe infections. However, carbapenem-resistant A. baumannii strains have emerged worldwide. […] A considerable proportion of multi-drug resistant A. baumannii strains are susceptible only to polymyxins, which prompted the use of an old antibiotic in recent years. […] Polymyxins are polypeptide antibiotics that act as detergents on the bacterial cell wall. They were introduced in 1940 but they were abandoned in the 1980s due to the occurrence of nephrotoxicity and neurotoxicity. […] Reported nephrotoxicity ranges between 8 and 36%. […] Reported neurotoxicity ranges between 7 and 29%, with oral and perioral paresthesias, visual disturbances and polyneuropathy […] [So basically what has happened is that doctors have been forced to restart using drugs they threw away 30 years ago because those drugs caused kidney failure and severe nerve damage. These old drugs are currently the only drugs that work against some MDR infections, and no new drugs are even close to being developed at this point]. […]

P. aeruginosa is the second most common cause of health-care associated pneumonia, of hospital-acquired pneumonia and of ventilator-associated pneumonia (VAP). It is also reported as the cause of 9% of hospital-acquired urinary tract infections (UTIs). […] It is estimated that the rate of colonization and/or infection by MDR P. aeruginosa is 0.5 episodes/1,000 patient-days in the general ward and 29.9 to 36.7/100 patients in the ICU (Agodi et al. 2007; Peňa et al. 2009). […] infections by MDR P. aeruginosa have a significant impact on mortality. A retrospective study of our group in non-neutropenic hosts in the general ward disclosed 22.2% mortality of infections by MDR P. aeruginosa compared to 0% of infections by susceptible isolates […]. For ICU infections caused by MDR P. aeruginosa mortality ranges between 22% and 77%; this ranges between 12% and 23% when ICU infections are caused by susceptible isolates (Shorr 2009).” […]

Antibiotic effectiveness can be viewed as a shared resource in which current use depletes future value and imposes costs on society in the form of longer hospitalization, higher mortality rates, and the diversion of resources into the provision of newer and more expensive drugs. In making treatment decisions, prescribers should weigh the favorable effects of applying antibiotics to improve a patient’s health against the negative consequences for the public and future drug effectiveness (Laxminarayan 2003b). However, clinicians usually ignore the future therapeutic risks to society associated with antibiotic use and instead focus on the direct benefits of antibiotic treatment to their patients. […] In the absence of a good pipeline of new drugs, it is the balance between the individual patient and society as a whole, otherwise known as the ecological perspective, that has to be clearly established and debated. We need to get clever, quickly. […] In the long term, new antibiotics are needed […] However, as a gap of 10–15 years has been identified (European Centre for Disease Prevention and Control and European Medicines Agency 2009), immediate action is needed to conserve the power of the available arsenal.”

November 27, 2013 - Posted by | books, health, health care, medicine

13 Comments »

  1. A lot of good info – I will probably have to reread at some time to get it all. But one question burns, so please forgive me if the answer is somewhere in the text.

    I’m quite shocked to see the mention that doctors not washing hands should be a factor in this day and time. Perhaps a hundred years ago, but there is absolutely no excuse today. As I myself have experieced a few HAIs, which has totally changed my habits concerning hand hygiene eventhere’s no special need any more, I would probably get real angry if I ever experienced a doctor not taking this serious. (It was a great pleasure recently to experience a dental surgeon who really was a total hygiene nazi haggling the nurse with procedures – it made me feel safe.)

    So when you mention that, I have to ask if it is a universal problem or a problem related to places of questionable standards only?

    Thanks for the post.

    Comment by info2 | November 28, 2013 | Reply

    • I understand very well why your experience might have changed your habits permanently, and I really don’t mind answering this question; this was one of several topics I decided not to cover in the post not because I didn’t think it was interesting but rather because I couldn’t really blog the entire book, and I could easily see myself end up doing that if I went into all these sorts of details.

      So, to answer your question let’s start out with the observation that hundreds of millions of people ‘in this day and time’ are quite poor. So let’s start out with those people:

      “Overcrowding in hospital wards, inadequate staffing, and insufficient supplies hinder infection control practices [in low-resource health care settings], creating an environment where bacteria can easily spread within the hospital and eventually from hospital patients and staff to the community. The absence of (or lack of adherence to) infection control guidelines in clinical settings also means that hospital staff may not follow basic procedures, such as hand washing and equipment sterilization. […]

      In most low and middle-income countries no studies have been conducted on the effectiveness of infection control measures to reduce the spread of antibiotic resistance. Studies from wealthy countries are limited, but certain practices are considered effective. Increased hand washing and the use of alcohol rubs show consistent reductions in bacterial contamination (Thompson et al. 1982; Pittet et al. 2006; Lennell et al. 2008). The difficulty comes in getting hospital personnel to maintain the practice (Pittet et al. 2000). For hospitals in developing countries, the challenges are many. For example, in an Indonesian pediatric intensive care unit, literal adoption of CDC guidelines was impossible because of several factors. They are: (1) poor physical environment such as absence of hand-washing basins and presence of contaminated tap water, (2) budgetary constraints, (3) unreliable and inappropriate supply of equipment and supplies, including reuse of single-use items, poor storage of reprocessed items, and overuse of expensive disinfection agents, (4) limited microbiologic diagnostic facilities, (5) lack of health care worker knowledge, particularly regarding transmission risks associated with poor practice, (6) local customs and culture, including the hierarchical relationship between physicians and nurses, (7) lack of institutional support from the hospital administration and infection control infrastructure, and (8) poor sterilization capabilities (Rhinehart et al. 1991 in Zimmerman 2007). […]

      When the necessary elements of proper hygiene are in place, hand washing can work. In Argentina, an intervention combining staff education, performance feedback, and proper hand hygiene initiatives resulted in a decrease from 45.94 to 11.10 bloodstream infections per 1,000 intravascular device-days and from 47.55 to 27.93 HAI per 1,000 bed-days. Even though this initiative was in a well funded urban facility, barriers to implementation still existed, including lack of resources, infection control programs, awareness, and support (Rosenthal et al. 2003, 2005). […] Small scale projects have shown implementation successes of interventions in infection control in resource-poor settings (Duerink et al. 2006).”

      Problems like the fact that the local tap-water is contaminated can cause trouble in some parts of the world and may potentially change what will constitute optimal hand hygiene practices. I assume you were mostly thinking about Western countries when asking your question, but infectious diseases tend to spread from person to person and the next pandemic isn’t going to start out in a university hospital in Switzerland, so I figured I should cover this aspect as well in my reply. But on to the Western setting…

      “of major importance are behavioral aspects. Is hand hygiene before and after patient contact a routine? Do the doctors as well as nurses practice it? (Doctors are notoriously non-compliant in this respect) A systematic review on observed or selfreported compliance rates showed an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30–40%) than in other settings (50–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved (Erasmus et al. 2010). Hand hygiene is not the only measure to avoid the spread of resistant microorganisms. Clean protective clothing, isolation routines for patients colonized or infected, avoidance of non-essential indwelling urinary and intravascular catheters, and meticulous care of wounds and intravascular devices all contribute strongly to optimal infection control. […] the distance from beds to hand-washing facilities may be [an] important determinant […]

      One of the evidence-based changes that have successfully promoted hand hygiene is the systematic switch from hand washing to alcohol-based hand rub as the “gold standard” practice (Johnson et al. 2005). The WHO recommends making the use of alcohol-based hand rubs preferable to hand washing in most situations (World Health Organization (WHO) 2009). […] Although only limited data is available on the actual transmission of resistant microorganisms following failure to respect primary hygienic measures, it is clear that wearing hand/wrist jewelry and long sleeved coats and shirts hamper the application of proper hand and forearm hygiene. In a recent French study, the risk factors linked to the wearing of jewelry in multivariate analysis were the type of medical center, the professional category (doctors wore more jewels than nurses), and older age (Vandenbos et al. 2011).”

      It’s incidentally not just in the area of infection control that doctors tend not to comply with guidelines (where they exist), there are (naturally) also problems when trying to implement antibiotic stewardship:

      “EARS-net, is a European-wide network of national surveillance systems, providing European reference data on antimicrobial resistance (European Centre for Disease Prevention and Control (ECDC 2010)). The recent ESAC point prevalence survey of antibiotic use in 20 hospitals in Europe has provided lessons about improvement targets. Overall, 30% of patients were prescribed antimicrobials; prophylaxis for surgery was continued for >24 h in 40% (Ansari et al. 2009). [24h+ continuation of prophylaxis is against recommendations] […] [In Scotland] Only 57.9% of antimicrobials used were noted by investigators as being compliant with local guidelines.”

      They note in the book that:

      “In some US hospitals, antibiotics may “substitute” for infection control and it is unlikely to be of the highest standard (Laxminarayan and Malani 2007). There is substantial scope for improvement in both public and private hospitals.”

      An important aspect of this discussion is that we used to live in an age where antibiotics could pretty much cure everything; where you’d almost always have a relatively cheap drug that could deal with a potential infection. This is quite likely to have affected a large number of current doctors’ perceptions of the importance of infection control measures. Now that we’re running out of drugs, some doctors need to change their habits. And it is not easy to get them to do that. There are many reasons why this may be harder than it looks. It certainly doesn’t help that the link between any given HAI and a doctor’s behaviour is unclear in the specific case; you can very rarely (never?) say if a patient got sick because the doctor didn’t wash his hands, we just know that if doctors don’t wash their hands more patients will get sick. Nor does it help that implementation of infection control measures through things like guidelines etc. don’t always show impressive results on their own, at least in part because compliance rates tend to be low (i.e., the fact that many health care workers don’t do as they’re told means that the guidelines don’t work particularly well, which means that they may get to be perceived of as bothersome and worthless, even though if more health care workers followed them results might be a lot more impressive).

      Comment by US | November 28, 2013 | Reply

    • “I have to ask if it is a universal problem” – actually the Erasmus review provides a very clear answer:

      Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring.” (my bold)

      They based the review on 96 empirical studies of patient populations living in industrialized countries.

      Comment by US | November 28, 2013 | Reply

      • A really important aspect in the context of this specific discussion is incidentally a related aspect I do not cover in the post; what we mean by the words ‘hospital-acquired’. This is a topic they cover in quite a bit of detail in the book and I don’t really want to cover all the things they have to say about that stuff here, but when having this discussion it’s very important to have in mind that not all hospital-acquired infections are the result of faulty hygiene etc. People who are admitted to a hospital tend to be sick, they’re often immunocompromised, sometimes their organs are failing. Sometimes it takes very little to push them over the edge, and sometimes the methods that are used to keep them alive end up killing them through complications; a person who can’t breathe on his own gets put on a mechanical ventilator, and three weeks later he dies from VAP. That’s not necessarily the doctor’s fault, and the patient would have died sooner if he hadn’t been put on a ventilator.

        There are a variety of forms of HAIs, and differents HAIs may respond to different types of interventions. There’s a lively debate about which forms of HAIs [or at least what we in this discussion call HAIs; Medicare uses the term HAC – hospital-acquired infection – when discussing these matters, a terminology the application of which the authors criticize in the text] should be considered to some extent ‘permissible’ and which shouldn’t and about who should get to decide that question, and the book goes into some details about that stuff, but two main points here are that ‘hospital-associated’ doesn’t always mean ‘hospital-caused’ (the bacterial colonization in question might have happened to the sick individual even if he’d stayed at home; colonization might be the result of him being very ill rather than him being very ill at the hospital – most very sick individuals are to be found at the hospital.. Some infections which are termed HAIs are to a significant extent community-acquired, e.g. the ESBL-producing strains talked about in the post) and that far from all HAIs are realistically preventable.

        Comment by US | November 28, 2013

  2. Thanks a lot for the very detailed answer(s). I have read them with great interest.

    And no, of course you can’t prevent all infections picked up at a hospital. Other than the explanations you already mentioned, I would suspect that the fact alone, that any hospital is a point of a lot of human activity would raise the risk of catching an infection even if it were healthy persons with normal immune systems and no surgical sutures. (For my own experience, which of course proves nothing at all, but still – I gained several infections while being hospitalized, but none while I myself tended to my wounds at home. I don’t believe my home was more safe than the hospital in any other way but the fact that only a handful of people visited my home during this time, while thousands probably passed through the hospital.)

    But the fact that a lot of persons are especially vulnerable to infections, and that the risk for different reasons is higher than in normal situtation, and that this have been known for a long time, is precisely the reason why it shocked me, when you hinted (and now confirmed) that it is still a universal problem. Doctors that work in conditions with no clean water and limited supply of alternative methods of cleaning are of course excused, but any doctor in a sanitized hospital has no excuse. If I saw one enter a patient ward without alcohol rubbing hands I would report a ‘utilsigtet hændelse’ (they did that at the hospital I was admitted to).

    Somehow it seems understandable to me, that it is easier to bring down these problems with nurses. Besides the fact that they probably have a lot more interaction with patients, their job is to a high degree to follow procedure, which makes it relatively easy to tighten procedures. While the doctors job is more autonomous and to a high degree consists of taking judgement and choosing which procedures should be followed, and always weighing the pros against the cons and cutting corners when it makes sense. I just can’t wrap my head around why you wouldn’t choose hand hygiene procedures – it’s easy to maintain (in non-stressed situations, at least), and not doing so could kill your patient.

    Well, noone would argue against this, I guess. Thanks for the answer again.

    Comment by info2 | November 28, 2013 | Reply

    • “While the doctors job is more autonomous and to a high degree consists of taking judgement and choosing which procedures should be followed, and always weighing the pros against the cons and cutting corners when it makes sense”. That’s one way to put it. One might also say that ‘they’re arrogant people who think they know everything and who don’t like to be told what to do.’ Remember this illustrative quote: “although surgeons often ask whether 24 h or even single dose prophylaxis can really select for resistance. The simple answer is yes.” Yet surgeons think they know better and so they keep doing things which they are advised against doing. I would be very surprised if surgeons are unique in this respect, although they may be ‘worse than average’ because surgery is, as far as I’ve gathered, considered most places to be a high-status specialty within the medical field. But we’re probably saying close to the same thing and yes, this stuff probably accounts for part of the reason why adherence rates are lower for doctors than for nurses.

      ‘Doctors vs nurses’ doesn’t explain everything though, and the reasons why behaviours differ across these groups will not give you ‘the full answer’. There is a large variety of cultural and institutional factors that may play a role. There’s the classical ‘old doctors’ (who during their education might not have focused a lot on infection control measures, or they may have forgotten what they learned) vs ‘young doctors’ (more focus on this aspect during their education, at least some places). Different methods of information gathering may lead to different behaviours, and some types of information systems (the key distinction here is probably ‘mandatory’ vs ‘optional’, but included information sources matter as well) may be more likely to lead to health care workers hiding problematic behaviours than others. The consequences related to problematic findings and behaviours is also a potential area where implementation may go wrong, or right. Established feed-back mechanisms is probably important. Coordination mechanisms related to e.g. interdepartmental setup or the wider institutional context (e.g. cross-hospital coordination – some types of this sort of coordination is at this point basically banned in the US due to antitrust laws, a very problematic aspect of the current regulatory setup in terms of infection control more generally, as well as in terms of antibiotic stewardship – they talk about this aspect in one chapter of the book but I decided not to cover that stuff here)) play a role. Is it a one-off initiative, or are they making it permanent? Often interventions work well in the beginning, but then compliance rates drop over time – this problem needs to be addressed when implementing the scheme. Completely different factors may matter as well, e.g. ones associated with the wider socioeconomic contexts in which the intervention takes place. To take one example, different cultures have different medical cultures. This is not from the book, but a classic observation is that an ”Asian doctor’ is different from a ‘European doctor’ in a variety of ways (e.g., nurses may be more likely to point out problematic behaviours of doctors in a European context than in a South-East Asian context). Just as the successful practical implementation will be different in Uganda and in Norway, the optimal approach to infection control in New York may not be optimal in Singapore even though the latter’s health care systems are in many ways much more alike than are the former’s. As illustrated above, even the simple physical setting and simple stuff like the distance from the bed to the hand-washing facilities may be important! Stress is important. There’s a lot of stuff that matters here, both in terms of why doctors behave the way they do and in terms of how to set up a good intervention with a high likelihood of successful implementation.

      You might say that talking about these kinds of factors and coming up with the best ways to implement intervention mechanisms is a waste of time because, ‘dammit, doctors should just wash their hands and there really is no excuse!’, but it’s a lot easier to say that doctors should wash their hands than it is to actually get them to do it; the latter requires a lot more work and a greater understanding of the reasons why they don’t. ‘Explaining’ doesn’t need to mean ‘explaining away’, and/but of course the main focus should be on intervention-related angles of attack that have the highest likelihood of actually leading to changes in the decisionmaking processes of health care workers (…and hopefully ultimately also patient outcomes). You say that you “just can’t wrap my head around why you wouldn’t choose hand hygiene procedures – it’s easy to maintain (in non-stressed situations, at least)”, but if it were actually that easy all doctors (and nurses! Although nurses’ compliance rates are higher than doctors, they’re far from impressive…) would follow the guidelines, and they don’t. Doctors’ behaviours tell us that it’s not actually that easy. Doctors don’t always wash their hands, so there’s a need here for people to figure out why they don’t and what can be done to make them start washing their hands more often. Habits die hard, and as long as bad habits persists patients die.

      On a minor note, I don’t really care much about moral judgments (…except perhaps to the extent that shame may work as a useful motivator in an intervention scheme…🙂 ) – finding out how best to kill the bad habits is what’s important, and although the authors of the book don’t actually talk much about the specifics (handwashing is a very small part of the big picture and some of the stuff above is speculation on my part rather than stuff based on the book’s coverage), doing that requires precisely the kind of evidence-based approaches that these authors apply throughout the book. I’m glad these people are doing the stuff they do.

      Comment by US | November 28, 2013 | Reply

      • I think ‘arrogance’ is a somewhat useable trait for a person, who might find himself in a spot, where he need to take a fast decision regarding someones else life with the risk of being wrong. If he doesn’t believe in his own decisions he might kill someone due to lack of decisiveness – if he can’t shrug of taking the wrong decision he’ll end up killing himself. This can of course lead to being stubborn when you shouldn’t be and such. But it is no wonder, I believe, that the trade favors such mentality, even without it being high status.

        You could say that eg. paramedics probably would be in such a situation more often, so that would be the same thing, but the key to the patients survival probably depends more on the paramedics training than his knowledge. He is keeping the patient alive with standard techniques long enough for the doctor to take charge of the situation to make the decisions that determine the long term outcome for the patient.

        You mention the distance from bed to basin which remind me of stories I have read more than once, that buildings can impose problems as medicinal traditions evolve. For example that the once clever thougt out design for travelling through the hospital become bottle necks as trends go from bed wards to ambulatory care. Yet placing alcohol dispensers in key locations should seem a lesser task comparing to changing the infrastructure of a giant building. But obviously thats not enough, or we could have ended this conversation some thousands words ago.

        Comment by info2 | November 28, 2013

      • I see your, “if he can’t shrug of taking the wrong decision he’ll end up killing himself” and add: “physicians have higher rates of suicide than the general population…” (Actually you may also have picked the wrong gender for your hypothetical doctor; female doctors have a much higher suicide-related excess mortality than do male doctors).

        “placing alcohol dispensers in key locations should seem a lesser task comparing to changing the infrastructure of a giant building. But obviously thats not enough…” Nope, sadly it isn’t. I’d really wish it were that easy. But even if it were, implementing proper hand hygiene habits would of course be but one of many things that would need to be taken care of before the goal of minimizing HAIs would be achieved. A lot of other infection control measures would have to be implemented as well, and infection control is but one aspect of this problem – “What is required is tackling of the problem at its root cause, namely the gross over use of antibiotics.” Nope, no simple solutions there either.

        Sometimes looking at all those onion layers can be rather frustrating.

        Comment by US | November 28, 2013

      • I can’t really make out how those doctor suicide numbers are made. Is it male doctors that have 40 percent higher chance than the general male population and female doctors 130 percent higher than the general female population? Or is it male doctors having 40 percent higher chance than the general population with no regards to sex and female doctors having 130 percent higher chance than the general population in total? There is already a large gender gap in most populations with male suicide rates about 5 times as high as women, so there is a large difference.

        It would probably be the first which actually still would make it most likely, that the suicidal doctor is male (probably around three times a high suicide rate for male doctors compared to female doctors). If it were the latter the suicide rate for female doctors would be around seven times as high as compared to other women. It seems like quite a lot.

        On the other hand – females generally don’t attempt suicide less frequently than men (on the contrary), it just so happens that males are much more succesful. I suspect that a doctor would have no problems in planning a succesful suicide and getting the means to do it (medicine). That could to some extent explain a significant raise among men (who are already quite succesfully killing themselves) and a huge raise among women (who usually aren’t that succesful). Well, of course, it’s purely speculation.

        Sorry for going off topic.

        Comment by info2 | November 30, 2013

      • It’s the former.

        Medicine overdose is a much less reliable and in general more reversible suicide method than are more violent methods like hanging or gun suicide. The fact that males are more likely to use such methods is part of the reason why they’re more likely to die from suicide. If doctors are more likely to overdose and less likely to eat a bullet than are people in the general population, they may actually be less likely to die from their suicide attempts. Though I highly doubt there’s good data on this kind of stuff.

        Comment by US | December 1, 2013

      • In general you are right, but a doctor would definitely know better than to try and kill herself with paracetamol and other stupid stuff, that people actually do. I don’t think it would that hard to improve the general succes rate for suicide by drugs by adding some knowledge.

        Comment by info2 | December 1, 2013

      • “a doctor would definitely know better than to try and kill herself” – some people would surely pull a full stop there…🙂

        Anyway I got curious about the methods so I did a brief google. Here are some US data from last year:

        “For physicians, firearms were the most common method (48%), followed by poisoning (23.5%), blunt trauma (14.5%), and asphyxia which included hanging (14%). Non physicians also used firearms as the most common method (54%), but asphyxia was the second most common cause of death (22%) followed by poisoning (18%) and then blunt trauma (6%).

        Differences don’t seem to be that big though there are slightly more poisonings among doctors. You can read the study here:

        http://www.ghpjournal.com/article/S0163-8343%2812%2900268-X/fulltext

        I’ve only just skimmed it briefly – I may decide to blog it in more detail later.

        Comment by US | December 1, 2013

    • The numbers aren’t that different, but the study also mentions that doctors are also more likely to die from overdoses, some of which may be suicides but never categorized as such. And there sure is a very distinct difference in the choice of drugs.

      Comment by info2 | December 2, 2013 | Reply


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