The war against superbugs

The Sunday Herald has discovered that, in the past two years alone, hygiene inspectors have discovered more than 400 instances of hospitals failing to meet infection control standards.

A leading infection expert also told the Sunday Herald that Scotland is "nowhere near" seeing the end of the superbug scourge in hospitals.

Meanwhile, nearly 1500 cases of superbugs picked up outwith hospitals - such as in care homes - have been recorded by health boards in the past 12 months.

A raft of measures have recently been introduced to improve hygiene in hospitals, including the setting up of the Healthcare Environment Inspectorate (HEI).

The HEI sends superbug "hit squads" into hospitals to check that standards are being adhered to, with both announced and unannounced inspections taking place in each acute hospital at least once every three years. These hit squads have discovered an increasing number of cases year on year.

In its first year of operation, in 2009-10, 36 inspections were carried out, resulting in 172 "requirements" being issued to hospitals for failing to meet Healthcare Associated Infection (HAI) standards, during 36 inspections. The following year 210 requirements were issued during 38 inspections.

Some of Scotland's leading hospitals have performed poorly in the spot checks, with inspectors uncovering dirty toilets, dusty floors and badly stained walls at Edinburgh Royal Infirmary. In October, a report raised "significant concerns" over cleanliness after finding dirty equipment, including a heart defibrillator, and dusty floors at Glasgow's Southern General.

Margaret Watt, chair of Scotland Patients Association, said while she believed standards were improving, patients were still complaining about hygiene in hospitals.

"We did hear of a hospital visitor that tried to get some gel for hand washing and the canisters were empty," she said. "Four of them were empty and they had to go to a fifth one before they got any gel and could go and visit the person they were visiting. These are things that shouldn't happen."

She added: "We also passed on a complaint to the HEI the other week about a cleaner who thought it was appropriate to use the same cloth for everything, and wiped a patients' tray with the cloth she wiped the floor with."

Watt said the work of the HEI was vital, but she believed it should have more staff and all inspections should be carried out without prior notice.

"I would like to see more staff and more people being taken to task," she said. "Unannounced visits are what you are looking for, as it keeps people on their toes."

But it is not all bad news. Latest annual figures from Health Protection Scotland show 351 cases of MRSA were reported by hospital laboratories in 2010, a year-on-year drop of around 17%. In addition, 1492 cases of MSSA, which is related to the same bug which causes MRSA, were also found, representing an annual drop of 1.5%.

In 2010, the number of new cases of C diff was 2219, down 39% on 2009.

However, last month health workers were warned to be vigilant for outbreaks of C diff after figures showed a 4% rise in cases between July and September, compared with the previous quarter.

Professor Hugh Pennington, emeritus professor of bacteriology at Aberdeen University, cautioned that the official figures did not reveal the "whole picture".

He said cases of MRSA were measured by recording infections in the bloodstream, but other cases such as wound infections are not included in those statistics.

Pennington said that improvements in the care of intravenous lines – a common route for bloodstream infections – could explain the decrease, rather than measures such as hospital cleaning and handwashing.

"It is entirely right and proper that a lot more attention to that issue [bloodstream infections] has been paid to over the past few years. But it is only part of the picture and there is still a lot of MRSA about.

"Bloodstream infections are good as a general indicator. It is giving a general picture, although one has to be aware it is attacking it through a particular route which might give a false sense of optimism."

He added: "We are nowhere near saying we have seen the back of the bug. There is a long way to go yet until we are at the [low] levels they have been at in Denmark, Norway, Sweden and Holland for example, where they really never had a big problem to start with."

The Scottish Government's budget for tackling superbugs will be £25m in 2012-13 and 2013-14 for each year. The funding will be given to health boards to use for ongoing initiatives such as rolling out a national programme to screen patients for MRSA in hospitals and employing infection control managers.

A Government spokesman said cases of MRSA and MSSA in Scotland were at the lowest ever level since records began in 2005 and cases of C diff had dropped by nearly 80% since 2007.

He added: "But we need to maintain the pace of improvement to keep bringing the number of infections down."

The additional cost of treating and caring for each patient with a healthcare-associated infection (HAI) estimated to be between £4000 and £15,000. Health boards have been set strict new targets to meet by 2013. They will be expected to achieve a C diff infection rate of 0.39 or below per 1000 total occupied bed days, in patients aged over 65. The rates currently range from 0.15 in NHS Forth Valley to 0.64 in NHS Ayrshire and Arran.

For MRSA and MSSA, which are included in a general category of staphylococcus aureus bacterium, the target is 0.26 cases per 1000 bed days. NHS Highland currently has the lowest rate at 0.21, with NHS Forth Valley recording the highest at 0.45.

Dr Charles Saunders, deputy chair of the British Medical Association Scotland and a consultant in public health medicine, claimed huge improvements had been made in reducing HAI rates, although he also raised concerns over whether progress can continue to be made as quickly in the future.

"There are things which are countering those improvements, one of which is the bed occupancy rates," he said. "There is pretty good evidence that once you get high bed occupancy rates then it is very difficult to stop a lot of HAI.

"Part of that is because you don't have time to get things properly cleaned and partly it is because once you get to those high rates, you tend to move people around hospitals a lot. So they get admitted to one ward and maybe go through three or four different wards in the next few days.

"If they have anything when they come in, they have an opportunity to spread it quite widely and they also obviously increase the opportunity they have to pick up stuff by being in different wards."

He also warned financial constraints on health boards could have an impact on tackling the problem in the coming years.

"Pressure on budgets is probably going to put more stress on hospital systems in terms of turnover and pushing more people through perhaps than can be done so safely," he said. "I think we are likely to maintain where we have got to, but it will make continuing improvements more difficult."

The issue of hospital superbugs is in the spotlight with the ongoing Vale of Leven Hospital inquiry, which is investigating an outbreak of C diff at the Dunbartonshire hospital between January 2007 and June 2008, which claimed at least 18 lives.

Theresa Fyffe, director of the Royal College of Nursing Scotland, said the inquiry was a "constant reminder" of the tragic consequences of an outbreak.

"I look forward to the findings of the inquiry being published so that health boards and staff across the country can take these into account," she added.

"While a lot of work has been carried out in recent years and dramatic improvements in infection rates and cleanliness have been seen, there is always more to be done."

In the wake of the Vale of Leven outbreak, each NHS board has been required to publish a "snapshot" picture of the number of HAIs recorded at each hospital, on a bi-monthly basis.

The figures show that nearly 700 cases of MSSA, 700 of C diff and more than 100 cases of MRSA have been recorded outwith hospitals over the past 12 months – infections which patients may have picked up in places such as care homes or in the general community.

And experts last week warned of the threat of potentially deadly strains of MRSA which are easily passed between people outside of hospitals and can cause serious illness even in healthy individuals.

Cases of what is known as "PVL-positive community acquired" MRSA strains have been recorded in the UK – including the variety known as USA 300, which can lead to a flesh-eating form of pneumonia, and passes easily through skin-to-skin contact.

Derek Butler, chair of charity MRSA Action UK, said: "The PVL strain can cause very serious infection, especially in the lungs or the skin. It is becoming harder to treat.

"The fear is if that strain gets into the hospitals and mixes with the hospital-acquired strains, then we could have a "super" superbug, which will be virtually impossible to treat."

THE pioneer of antiseptic surgery Joseph Lister would be "disturbed" at a lack of attention to hygiene practices in the NHS today, according to a leading surgeon.

John MacFie, the president of the Association of Surgeons of Great Britain and Ireland, said Lister, who studied and practised medicine in Edinburgh and Glasgow, was a perfectionist who demanded high standards of all his staff.

But he added: "I suspect he might look at modern care in the NHS and be disturbed at the lack of attention to hygiene by both individuals and organisations. I fear he would be shocked by the overcrowding of modern hospitals and the commonplace finding of bed occupancies of greater than 100%".

MacFie made his comments ahead of a talk he will be delivering at a major conference being held by the Royal College of Surgeons of Edinburgh (RCSEd) this week, to mark the 100th anniversary of Lister's death.

The event in Edinburgh will feature lectures on Lister's work and modern surgical techniques and is expected to attract around 400 surgeons and health experts from across the UK, Europe and the US.