Originally from hospitalinfection.org
By Lucette Lagnado
Nov. 2, 2015
As the infection-control czar of the Mount Sinai Health System in New York, Brian Koll often turns to federal and state health authorities, as well as researchers and colleagues, for the latest on controlling antibiotic-resistant germs.
Dr. Koll has an additional resource in his quest to eradicate superbugs in his seven-hospital system: his grandmother Dora. Although she has been dead 28 years, Dr. Koll says he relies on her advice every day.
Antibiotic-resistant bugs have made hospital stays risky, with 75,000 patient deaths a year due to infections acquired in health facilities that doctors were unable to control. Infectious-disease specialists are working feverishly to tackle the scourge, trying to reduce antibiotic usage, which experts say is critical, and implementing rigorous cleaning methods.
Dr. Koll, 55 years old, believes some of the most effective cleaning techniques are those favored by his grandmother, who raised him in the 1960s in Edison, N.J. “My grandmother never left a crumb anywhere,” Dr. Koll says, recalling how she would get down on her knees to scrub floors. There was a vigor to her cleaning-elbow grease, he says-and she relied on one product above others: bleach. To this day, when Dr. Koll goes on rounds at Mount Sinai, he says he is delighted by the scent of bleach. “You can smell it, so you know that it is being used,” he says.
When visiting loved ones in the hospital, says Betsy McCaughey, founder of the Committee to Reduce Infection Deaths, a nonprofit patient advocacy and education group, “forget flowers and candy; bring bleachwipes instead,” she says. “It could save their life.”
Bleach is one of a handful of products that actually kills spores of Clostridium difficile left on tray tables, bed rails and other surfaces. C. diff, as it is commonly known, is a virulent bug that causes severe diarrhea and nausea and can be fatal. Dr. Koll says last spring he issued what came to be known at Mount Sinai as a “bleach edict”-a systemwide executive memo in which he said bleachmust be used for cleaning in most units.
Still, the bleach edict hasn’t been easy to implement, Dr. Koll says. The substance can be corrosive, shortening the life span of equipment such as gurneys. Housekeeping staff don’t like it because it leaves a dull film; in hospitals, there is a premium placed on shiny floors. Dr. Koll used to tinker with the cleaning-solution formula when patients or staff couldn’t tolerate the smell. These days, standard bleach wipes or spray is often used.
Most hospitals in New York State use bleach to clean isolation rooms where C. diff patients are housed, according to a 2014 report from the state health department. But only 22% of the hospitals use bleach for daily cleaning of regular rooms. The majority still rely on so-called quaternary ammonium-based cleaners or other disinfectants, even though these products “are not effective in killing C. difficile spores,” the report said.
A spokesman for the Greater New York Hospital Association said: “Hospitals are deeply committed to reducing hospital-acquired infections, and use a number of proven disinfectants as part of that battle, but whenever the presence of C. diff is suspected or confirmed, they use bleach.”
There were an estimated 722,000 cases of hospital-acquired infections in the U.S. in 2011, the latest year available, according to the Centers for Disease Control and Prevention. On any given day, 1 in 25 hospital patients in the U.S. becomes infected, the CDC says. “What other industry would tolerate that?” Dr. Koll asks.
A 2011 study, published in the journal Infection Control and Hospital Epidemiology, found an 85% reduction in C. diff cases when environmental-service workers at two high-risk hospital units at Mayo Clinic switched to Clorox bleach wipes from another disinfectant for daily cleanings of patient rooms and at discharge.
Many experts, while agreeing a clean hospital environment is important, maintain acquired infections can be stopped only with strict limits on how antibiotics are prescribed.
“I don’t think the major issue is to scrub and scrub the floors. I think the major issue is to have judicious use of antibiotics,” says Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Dr. Fauci, who rose to prominence during the AIDS epidemic, thinks the public underestimates the threat of antibiotic resistance. He worries some antibiotics will stop working, leaving doctors without weapons to care for the sick.
In New York’s Montefiore Health System, Belinda Ostrowsky, known as the hospital’s antibiotic steward, has made reducing the use of powerful antibiotics her priority. Dr. Ostrowsky, who helps oversee a 64-hospital effort to reform antibiotic use sponsored by the United Hospital Fund, a nonprofit health research organization, and the Greater New York Hospital Association, says while “cleaning is very important, you can’t only clean the environment and not do the antibiotics.”
Powerful, broad-spectrum antibiotics kill the “bad” bacteria that make a person sick as well as the “good” bacteria in the patients’ systems, leaving them vulnerable. A doctor at Montefiore who wants to prescribe one of several strong antibiotics must get the case reviewed and seek permission, Dr. Ostrowsky says.
Dr. Koll says he is also grappling with antibiotic overuse at the Mount Sinai system. He recommends a “time out,” reassessing patients a couple of days after they start antibiotics to see if a more targeted drug could be used. And he urges a return in some cases to “older, cheaper, narrower spectrum antibiotics,” whose use has at times faded as powerful, broad-spectrum antibiotics came on the market. The old workhorse penicillin, for instance, won’t work on many severe infections common in hospitals, but there are times it could be used effectively, including for meningitis and pneumococcal pneumonia , Dr. Koll says. He also favors an older antibiotic from the 1970s called Bactrim. “Newer is not better. You don’t need to use these super, super drugs,” he says.
Dr. Fauci, of the National Institute of Allergy and Infectious Diseases, agrees older drugs might be very useful in the fight against antibiotic-resistant bugs, though he has doubts about penicillin. It is important “to go back to antibiotics we haven’t used to try to repurpose them again,” he says.
In another initiative, Dr. Koll installed “secret shoppers,” similar to the people stores use to spot shoplifters, who roamed hospitals checking if workers and doctors were cleaning their hands. But there was pushback, and they were renamed “anonymous observers,” which he says is less “gotcha.” He and his team also use a product called Glo Germ. To demonstrate its use, Dr. Koll applies some to a table, scrubs it and shines a special light to look for the presence of germs.
Dr. Koll, named executive director of infection control and prevention over the Mount Sinai system about a year and a half ago, says he is seeing some results. C. diff-infection rates at three hospitals are below the state level. Rates of surgical-site infections are also down, particularly in cardiac surgery.
Sinai’s flagship hospital, with its complex patient population, poses some of the toughest challenges. On a recent October afternoon, Dr. Koll toured Mount Sinai’s neurosurgical intensive care unit, which had an outbreak of C. diff last spring. Alarmed, staff sprang to action. Patients were moved to other units while crews engaged in “terminal cleaning,” scrubbing rooms from top to bottom.
Desktops and shelves were stripped of books and papers, which are a draw for germs, leaving only patient charts. Bleach was used liberally.
The measures appear to be working. C. diff cases plunged to zero in the past couple of months. Dr. Koll smiled as he walked around the unit. He could smell the bleach.