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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.

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.

"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.

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."

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

"One of the surprising findings was that when we sequenced all these ... almost half of them fell into the H58 lineage," said first author Dr. Vanessa Wong, an infectious disease specialist with the Wellcome Trust Sanger Institute and University of Cambridge. "That (covered) 21 countries. So we were like, oh no. This is actually kind of everywhere." Typhoid fever is a disease that can be spread by only humans who carry the S. Typhi bacterium in their bloodstreams and intestinal tracts.

The disease is now rare in industrialized countries like Canada - which had 144 reported cases in 2012, probably mostly in travellers - but it is still relatively common in the developing world, especially where hygiene and sanitation are poor. While a typhoid vaccine is available, its efficacy wears off after a few years and many people also can't afford the vaccine in the developing world, where the disease is estimated to cause 21 million cases every year and about 200,000 deaths. Typhoid fever can be treated with antibiotics but the overuse of these drugs has fuelled resistance, as bacteria capable of defeating these drugs survive and proliferate. In a 2013 report, the Public Health Agency of Canada found that S. Typhi infections resistant to the antibiotic ciprofloxacin had increased to 18 per cent from 10 per cent the previous year. When asked if H58 has ever been reported in Canada, the agency said it doesn't routinely analyze the strains of S. Typhi cases since typhoid fever is not endemic here.

In countries where H58 has emerged, the superbug is now crowding out weaker strains, thus dramatically "changing the architecture of the disease," Wong said. She said treating multidrug-resistant strains like H58 also requires intravenous antibiotics - an expensive luxury that many people in the developing world cannot access or afford. Resistance against last-line antibiotics will probably also eventually emerge, she added. "If we carry on and the bug continues to evolve, we'll run out of options pretty quickly." She noted that her study also found H58 in Nepal, where devastating earthquakes have now left the country highly vulnerable to outbreaks of diseases like typhoid fever.

For Virginia Pitzer, a professor of epidemiology with the Yale School of Public Health who was not involved with this study, this "important and interesting" new paper underscores the need to tackle typhoid fever.

Typical components of antimicrobial stewardship programs include education for staff around appropriate antibiotic use, computer-based monitoring of antibiotic use and resistance, and the use of audit and feedback to review antibiotic prescribing patterns. Generally, stewardship programs include the participation of a multidisciplinary group of staff – including infectious disease specialists, nurses, pharmacists and hospitalist physicians.

Andrew Morris, an infectious disease specialist who leads the stewardship program at Mount Sinai and University Health Network says that the biggest barrier to adopting stewardship programs across Canadian hospitals is funding. He notes that hospitals have to find money within their budgets to pay for these programs.

"Often these outbreaks may be occurring and we don’t even know about them," said Dr. Michael Gardam, an infectious disease specialist at Toronto General Hospital.

Jan 30, 2014

The CDC is launching a public education campaign for nursing homes aimed at preventing more bacterial and viral infections from starting and stopping others from spreading. A similar effort was rolled out for hospitals last year.

"One way to keep older people safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes," said CDC Director Tom Frieden in announcing the initiative. Studies have estimated antibiotics are prescribed inappropriately 40 per cent to 75 per cent of the time in nursing homes. Here's why that worries the CDC: Every time someone takes antibiotics, sensitive bacteria are killed but resistant bacteria survive and multiply - and they can spread to other people. Repeated use of antibiotics promotes the growth of antibiotic-resistant bacteria. Taking antibiotics for illnesses the drugs weren't made to treat - such as the flu and common colds - contributes to antibiotic resistance.

Antibiotics also wipe out a body's good infection-fighting bacteria along with the bad. When that occurs, infections like Clostridium difficile can get out of control. C. diff. leads to serious diarrhea that each year puts 250,000 people in the hospital and kills 15,000. If precautions aren't taken, it can spread in hospitals and nursing homes. Health-care facilities already have infection-control procedures in place, such as providing private rooms and toilets for infected individuals. But the CDC is pushing them to do more on the prescribing side, advising nursing homes to track how many and what antibiotics they prescribe monthly and what the outcomes were for patients, including any side-effects.

Other recommendations include placing someone, such as a consulting doctor or a pharmacist, in charge of antibiotics policies and training other staff in following them. Some of the CDC's suggestions could challenge nursing homes' culture and how staffs, residents and their families interact. While nursing home residents and staff are among the people most at risk for the flu, annual shots aren't mandatory. Nor do homes always track who gets them.

That's starting to change at Evangelical Lutheran Good Samaritan Society, a nonprofit that provides a spectrum of senior care services in many states. Starting this year, it will collect data on staff vaccinations at one of its 167 nursing homes and share the pilot project's results with other homes, said Victoria Walker, chief medical officer. But better handling of antibiotics in nursing homes may also require tactful communication with residents' families and nursing home doctors accustomed to treating antibiotics as a default remedy.

"There's a real fear of undertreatment and that it is better to err on the safe side, and that means treating with antibiotics but forgetting about all the harms. But giving antibiotics can be just as harmful as not," said Walker. Family members may push for an antibiotic treatment when they visit a loved one in a nursing home who seems sick, even if they don't know precisely what's wrong. Doctors and nurses may go along because they don't know either and it's easier to treat than not. "The family will check in and ask what the doctor did and the nurse will say 'nothing' because they don't see monitoring as doing anything," said David Nace, director of long term care at the University of Pittsburgh, who contributed to the CDC guidelines.

"Practitioners are guilty of saying, 'it's just an antibiotic.' ... We don't appreciate the real threat," he said. Antibiotics are routinely prescribed to treat urinary tract infections, which are common in nursing homes, but too often when a UTI is only suspected, not confirmed, studies have found. The Infectious Disease Society of America is developing guidelines to help institutions implement programs to better manage antibiotics. In addition to fostering antibiotic resistant bacteria and causing C. diff infections, antibiotics also can produce allergic reactions and interfere with other drugs a nursing home resident is taking. Those risks aren't always fully considered, says researcher Christopher Crnich, who has published articles on antibiotic overuse. He is a hospital epidemiologist at William S. Middleton Veterans Hospital in Madison, Wisconsin. "Bad antibiotic effects don't come until weeks or months later, and frankly all we [prescribers] see is the upside when we're dealing with a sick mom or dad," Crnich said.

The Centers for Disease Control in the United States has raised concerns about the use of antibiotics in nursing homes.

The present one is the largest outbreak so far, affecting Guinea, Sierra Leone, Liberia, and Nigeria.

This blood is highly infectious, so those most at risk are health care workers and those in close contact with the patients.

Since the disease is only spread by direct contact with the secretions of those infected, the potential for the widespread EVD infections is considered relatively low.

disease has a mortality rate of between 50 and 90 percent

Early diagnosis and prompt treatment of those infected are essential.

But Canada’s federal government has been silent, declining to post current information about superbugs online or warn the Canadian public about the true extent of the problem, according to critics. The Association of Medical Microbiology and Infectious Disease Canada, a group of respected Infectious Disease specialists, last fall openly accused Ottawa of hiding the data it collects about instances of hospital-acquired infections. The association got a hold of the data and released it in order to inform the public (see sidebar).

The power of cleaning

Frequent door openings can disrupt the positive-pressure airflow system in the OR, "possibly introducing more bacteria into the OR and potentially contributing to contamination of the wound," Bédard and his co-authors write in the Canadian Journal of Surgery. The "bacterial count" in an OR is directly proportional to the number of people in the room, and the more people in the room, the more traffic flowing in and out. "As a surgeon, infection is your worst complication," Bédard said in an email interview. "It is clear that bacteria are brought into the operating room by the OR personnel and can potentially cause surgical wound infections. The best way to monitor traffic is to count door openings."

Some people had valid reasons for leaving the OR - to retrieve an instrument or joint component, for example. But others left to "chat with a friend" in the hallway, ask questions not related to the case or to get personal items, Bédard said. Entering an OR should be viewed as "a privilege and not a right," he said. "Before entering any OR, OR personnel should ask themselves this question: Is my presence really beneficial to the patient?" While the study focused on joint replacements, Bédard believes the findings likely apply to other surgeries as well.

A leading infectious-disease specialist said the volume of surgery traffic startled him. More than 200,000 Canadians get infected in a healthcare institution each year, and surgical site infections account for about a third of all hospitalacquired infections.

"The misery - because I see a lot of these patients - is significant," said Dr. Dick Zoutman, a professor at Queen's University in Kingston and chief of staff at Quinte Health Care in Belleville, Ont. Hip and knee replacements are among the most frequently performed operations in Canada, accounting for more than 104,800 surgeries combined in 2012-13, says the Canadian Institute for Health Information. According to the Quebec researchers, "Infection following total joint arthroplasty remains a disastrous complication for both the patient and surgeon." The cost to treat an infected prosthetic joint can reach $60,000.

"Once the bacteria are in contact with metal, it is very difficult, if not impossible to eradicate with antibiotics alone," Bédard said. Infections require repeat surgeries and, sometimes, temporary removal of the prosthesis in order to sterilize the knee. While the individual risk of infection is low - about one to two per cent - "one per cent times thousands of surgeries per year is not insignificant," Zoutman said.

Patients are frequently given antibiotics before surgeries and airflow systems push air away from the surgical wound to help prevent infections. But, like Pigpen in the Peanuts comic strip, humans "slough off " millions of cells from the skin's surface, Zoutman said. "The staff are gowned and gloved. But the patient is there, giving off their skin cells as we yank and pull and do the surgery ... we all know from the Pigpen theory of infectious diseases, the more people in the room, the greater the risk."

One of the best known superbugs, MRSA, is alone estimated to kill around 19,000 people every year in the United States - far more than HIV and AIDS - and a similar number in Europe.