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Within hours of emergency surgery to drain "brown, foul-smelling liquid" and excise dead tissue, and four days after her 45th birthday, Ms. Smith was dead. "She kept yelling at me, 'I know my body, I know there's something wrong in my stomach and nobody wants to listen to me. And I'm going to end up dying here,' " said Kym Dyck, her sister-in-law. "She died the most horrible, painful death anybody could suffer, and nobody would listen to her and reach out to her." Ms. Smith's tragic demise was more dramatic than many cases of hospitalacquired infection (HAI). Necrotizing fasciitis is a frightening, but rare, complication. Still, about 8,000 Canadians a year die from bugs they contract in facilities meant to make them better, while many more see their hospital stay prolonged by such illness.

She likely did not know that most surgical-wound infections arise from bacteria patients carry into hospital on their skin, which can then sneak inside through incisions, especially when infection-control safeguards are not optimum. As early as the day after her operation, the Métis woman began to complain of pain in her abdomen, only to be told by nurses that she simply needed to walk about, Ms. Dyck recalls. Some of that suffering is reflected in her patient charts, obtained by the family and provided to the National Post. On Oct. 1, she complained of gastrointestinal bloating and discomfort; the following day, heartburn, bloating and slight nausea, the records note.

Yet after years of well-intentioned work and millions of dollars spent on combating the scourge, the details and extent of the problem remain murky. No national statistics, for instance, document the number of surgicalwound infections like Ms. Smith's, one of the most common types of hospitalacquired pathogens. A federal agency now publishes rates of sepsis, or blood infection, at individual hospitals, but their methodological value is a matter of debate. Government tracking of worrisome, drug-resistant bacteria is patchy and of questionable practical use, say infectious-disease physicians. "There is no question that at a national level, both our surveillance for hospital-acquired infection and our surveillance for anti-microbial resistance is not serving our needs," said Allison McGeer, an infectious-disease specialist at Toronto's Mount Sinai Hospital. "[And] we know, very substantially, that you can't fix what you're not measuring."

"You could sit and call every hospital in the country, and ask them when was the last time they cleaned the sink in the [neonatal intensive care unit] and how they cleaned it, and you'd get nothing but blank stares." Health care is paying much more attention, at least, to the HAI problem than it did a decade ago, said Dr. Michael Gardam, infection-control director at Toronto's University Health Network. After heavy media coverage of the mostly hospital-based severe acute respiratory syndrome (SARS) outbreak and deadly hospital infestations of Clostridium difficile, said Dr. Michael Gardam, infection-control director at Toronto's University Health Network. As health-care-related infection became a very public affair, hospitals started hiring more experts, encouraging hand-washing and generally striving to prevent infection, rather than just treating it after the fact as an unavoidable cost of doing medical business. Dr. Gardam's hospitals have even begun characterizing hospital-acquired infections as adverse events, akin to more traditional medical error. Whether because of such measures or not, Ms. Smith had few fears when she entered St. Boniface on Sept. 30, 2013, for an operation for uterine fibroids, her family says.

Meanwhile, important lessons about how diseases spread inadvertently within health facilities often come to light in fits and starts. Two hospitals in Toronto and one in Quebec, for instance, announced independently in the late 2000s that they had discovered contaminated sinks were the source of separate, deadly outbreaks of infection. Some word of the episodes got out through specialized medical journal articles, academic conferences and sporadic news stories. But there is no systematic way of disseminating such information across the system, said Darrell Horn, a former patient-safety investigator for the Winnipeg Region Health Authority. "It's just totally loosey-goosey," he said.

The program's focus is drug-resistant bacteria, the increasingly familiar methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and C. difficile. It is based, though, on a sampling of just 57 teaching hospitals, a fraction of the country's 250 or so acute-care hospitals. The SARS outbreak, for instance, erupted at a community hospital that is not part of that network. Infectious-disease doctors have long complained that it takes too long for the data those hospitals submit to the Agency to be posted. "If I want to know what's happening with MRSA, I call my friends," said Dr. McGeer. More complete, and easier to access, is the system developed by the European Centre for Disease Control, says Lynora Saxinger, an infectiousdisease specialist at the University of Alberta. It not only tracks drug-resistant bugs, but matches those stats with the use - or possible over-use - of antibiotics, considered the main cause of the problem. The latest concern of infectiousdisease specialists is a class of antibiotic-defeating organisms known as carbapenem-resistant Enterobacteriacaeae (CRE), a "game-changer," said Dr. Saxinger. The death rate is as high as 50%. CRE is part of the public health agency's surveillance system, meaning those 57 hospitals submit their numbers, but Dr. McGeer said all acutecare hospitals in Canada should have to report them. Meanwhile, "the last CRE outbreak ... I heard about it on the news," said Dr. Saxinger.

There is no evidence Ms. Smith was infected with a drug-resistant organism, but by the time she went in for emergency surgery, it appears little could have saved her. Indeed, once begun, necrotizing fasciitis has a 70% death rate. Early the next morning, her blood pressure had sunk, the telltale black of more dead tissue had spread around her side to her back and she went into cardiac arrest, dying minutes later. The hospital investigated the incident and assured the family that lessons learned from it would be passed on to staff - and help future patients, says Ms. Dyck. Mr. Horn says his experience across Canada suggests it is unlikely those lessons will be shared with anyone else in the health-care system, or the public. Meanwhile, Ms. Dyck says the sight of doctors and nurses fruitlessly attempting to revive her sister-in-law - her abdomen left open as part of the flesh-eating treatment - remains etched in her mind, as is the thought it might all have been prevented. "What I witnessed, I was traumatized by for months and months," she said. "It was just a terrible, terrible, painful death. And she knew she was going to die, that's the worst thing." National Post tblackwell@nationalpost.com

To see the first part of the series, Inside Canada's world of medical errors, go to nationalpost.com

To register for the conference or for more information, please visit the OCHU website: http://www.ochu.on.ca/conferences_conventions.html.

speakers and contributors will be discussing possible next steps to be taken in the healthcare community

the conference will address issues such as for-profit care and factory medicine, staffing ratios, under reporting, shiftwork and working conditions, bullying in the workplace

William Charney, is a nine-time published author of healthcare safety books. He has also published more than 30 peer-reviewed articles in the field. For five years, Mr. Charney was a safety officer at the Jewish General Hospital in Montreal, Quebec. For ten years, he was the director of environmental health at the Department of Public Health in San Francisco. Then for five years, he was a safety coordinator for the Washington Hospital Association. For the last ten years, he has been a consultant in the field of occupational health.

Then, in the late 2000s, a new "indestructible" germ emerged from India, an E. coli gut bacterium modified by a gene called NDM-1 (New Delhi Metallo-betalactamase-1). Worryingly, the DNA responsible for the mutation has been found to be capable of being transmitted easily to other species of bacteria.

Most strains of MRSA are almost impossible to treat and the only line of defence (as hospital managers have belatedly realized) is better hygiene.

In the late 1990s, Methicillin-resistant Staphylococcus aureus, a germ resistant to both the penicillin-based and cephalosporin antibiotics, emerged.

And while antibiotic overuse has declined in the West, it has exploded in India and China, where the drugs are usually sold prescription-free.

Another major cause is the massive quantity of antibiotics fed to livestock.

Finally, we have not seen a new class of antibiotics since 1987

Global co-operation is also needed. Countries where antibiotics are available over the counter need to change their laws. Antibiotic resistance is exacerbated by international travel, so we need more screening at airports. We need new ways to encourage drug firms to invest in antibiotics

Unless action is taken to curb the rising incidence of drug resistance, Weir and others in the medical community say, there is good reason to believe the day will come when antibiotics will be powerless against many once-treatable infections.

Patients “are getting sicker than they used to from bacterial infections that have been treatable for many decades,” the OMA report says,

One of the major underlying causes is the overuse of antibiotics.

Andrew Simor, head of microbiology and infectious diseases at the Sunnybrook Health Sciences Centre in Toronto, added that there is a “tremendous” amount of evidence showing a relationship between antibiotic use in animals and the risk of drug-resistant bacteria.

The report, titled "When Antibiotics Stop Working," finds antibiotics are not as effective as they once were because bacteria are adapting to them.

The Government of Ontario must develop a system for farm industry surveillance to keep track of the identities and quantities of antibiotics being purchased, and those being moved into or out of Ontario. Currently, surveillance of antibiotic movement does not exist in the province. Surveillance should be established in areas where it does not exist (agriculture) and strengthened in areas where it does exist (medicine) in order to collect data and gain a firmer understanding about antibiotic resistance in both humans and animals

An independent institution should be established in conjunction with one of Ontario's medical schools to use currently available data to develop and maintain optimal antibiotic use guidelines that physicians in Ontario can use

to guide their practice,

The federal government should provide funding for research, strengthened surveillance, and educational campaigns focused on antibiotic resistance. There is a dearth of community-based surveillance of organisms and resistance patterns, and this must be rectified.

Many hospitals in other provinces publish their infection rates on their websites, and in Ontario it's required by law.

the accepted Canadian standard.

Daneman and his team investigated antibiotic use among 66,901 people aged 66 and older living at long-term care facilities in Ontario. They found nearly 78 per cent or 50,061 patients received a course of antibiotics in 2010.

The antibiotics were most commonly prescribed for seven days. But nearly 45 per cent of the treatments, 21,136 courses, exceeded a week, the researchers found.

"I think these are a real bonus to our units," said Worthington of the specialized teams made of housekeeping and infection control staff.

The risk of developing the infection in hospital is about 1%, he said.