NOVA examines the medical community's alarm as the spread of antibiotic-resistant infection increases, and studies how one hospital fights its own dramatic epidemic.
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00:00Melbourne, Australia. In this city's busy and modern hospitals, patients are waging
00:15a life and death struggle against a virulent infection outbreak. Undetected by human eyes
00:22and carried by patients, nurses and doctors, it spreads like wildfire. But only 40 years
00:29ago, scientists believed that they had conquered infection. The development of penicillin had
00:34ushered in a golden age of antibiotics, effective against a variety of deadly diseases. What
00:40went wrong? How could infection have again seized the upper hand? How could a hospital
00:46control a runaway infection outbreak when its best weapon, the wonder drugs, are being
00:50rendered useless? Tonight, NOVA explores when wonder drugs don't work.
01:06Major funding for NOVA is provided by this station and other public television stations
01:10nationwide. Additional funding was provided by the Johnson & Johnson family of companies,
01:17supplying health care products worldwide. And by Allied Signal, a technology leader
01:24in aerospace, electronics, automotive products, and engineered materials.
01:47The men driving this ambulance do not normally dress this way, but a virulent organism is
02:07sweeping through eastern Australia's large hospitals, and it seems nothing can block
02:12its progress. The health minister, Mr. Roper, and his senior officers are examining reports
02:20that the golden staph infection has reached epidemic proportions in major Victorian hospitals.
02:26The germ, which is reported to have affected thousands of patients, has developed resistance
02:30to all but one antibiotic. The Australians call this germ MRSA, which stands for multiply
02:38resistant staphylococcus aureus. They've been fighting it since 1977. Draconian measures
02:47had to be taken to get the outbreak under control. In Melbourne, by 1980, 36 hospitals
02:54were affected. The focal point for much of the concern was the city's most prestigious
03:02teaching hospital, the Royal Melbourne. Any patient admitted during the height of the
03:09epidemic stood a one in six chance of picking up the infection during his stay. People coming
03:15in for routine surgery could be delayed for months. Nursing homes and smaller hospitals
03:20refuse to accept their patients. The organism responsible for the outbreak is called staphylococcus
03:30aureus. In the last 40 years, it has undergone a dramatic change. When Alexander Fleming
03:40first spread it on his culture dish, he made the classic observation that it was killed
03:44by the penicillin mold. But today, that same staphylococcus can resist the effects of not
03:51just penicillin, but other antibiotics as well. Staphylococcus aureus, a bacterium sometimes
03:58known as the golden staph, normally lives harmlessly on our skin or in our nasal passages.
04:04But if it entered into the wrong place, into the blood or bone, it can cause serious and
04:09sometimes fatal infections in people whose defense mechanisms have been weakened. Back
04:14in the 40s, scientists thought they had the answer to infectious disease. A new source
04:19of wonder drugs had been unearthed. Secrets hidden in the soil for countless ages have
04:24been revealed in one of the greatest scientific detective hunts of all time. Scientists had
04:31discovered that naturally occurring germ-killing chemicals could be harvested from organisms
04:35that lived in the soil. What new discoveries still lie locked in the soil? What possible
04:43cures for diseases as yet untouched? From the tedious developmental years of penicillin
04:49has emerged a specialized industry accomplishing feats impossible a decade ago. Pressing steadily
04:55forward, scientists and physicians of vision and experience may soon make the next great
05:01contribution to the age of antibiotics.
05:11The discoveries of new and stronger antibiotics continued. A handful of drug companies recognized
05:17their healing and profit potential. For the researchers, the pressure was on to produce
05:21more antibiotics. But by the 50s, the heady optimism was evaporating. The organisms which
05:30antibiotics were designed to destroy were fighting back. Many hospitals around the world
05:38were plagued with a new strain of Staphylococcus, resistant to every available antibiotic. It
05:43attacked not only frail patients, but staff members as well. The panic was disguised by
05:52the sober language of this training film.
05:54Beware of any staff, male or female, with a boil or septic spot. They may be a cross-infection
06:00menace. It must always be remembered that sufferers from boils are almost certainly
06:06nasal carriers of pathogenic Staphylococci, so the nose should be treated as well.
06:12They hopefully massaged noses with antiseptics, but the problem was not controlled until a
06:17new group of semi-synthetic antibiotics called the methicillins were developed. Throughout
06:22the 60s, it looked as though the chemists had the upper hand again. But the more these
06:26antibiotics were used, the more likely it became that resistant strains would emerge.
06:32At the end of the 70s, reports started coming in of new strains of Staphylococcus, resistant
06:36to methicillin, and up to eight other antibiotics as well. The worst reports came from Australia.
06:43Dr. Stuart Levy is professor of medicine and microbiology at Tufts University School of
06:50Medicine in Boston. He is chairing an international task force to examine the problem of antibiotic
06:56resistance.
06:57A very dramatic and important example of how a resistant bacteria can change the ways of
07:05a complete hospital, and even a city, occurred in Melbourne, Australia. In the late 70s,
07:10a single hospital began to have a problem with this multiple resistance in Staphylococcus,
07:15and they couldn't treat it. And soon, other hospitals in Melbourne developed the same
07:20problem.
07:21The outbreak began in 1977, when the first cases appeared on the burns and surgical wards.
07:26It's closing up really well. Getting much, much better. Give it about three or four more
07:33days and get a skin graft on top of that.
07:36Surgery patients with deep wounds were particularly vulnerable. When the wounds became infected,
07:41skin grafts and, worse still, bone grafts were destroyed. It is thought that a patient
07:50with an infected foot may have spread more than just a few friendly words around the
07:54ward. Once released in the environment, the bacteria from his foot spread insidiously,
07:59lingering everywhere and exposing patients to the risk of infection.
08:09From the bedclothes, the tiny germ-laden skin flakes of a carrier could be wafted into the
08:13air to land on a neighbor's bed. It was further spread by nurses and doctors as they passed
08:23from bed to bed, carrying it from the skin of one patient onto the skin of another.
08:33Noses became potential reservoirs. Every sneeze and sniffle could release a cloud of the resistant
08:39germ. The organism's ability to colonize people and places so readily was particularly
08:45dangerous in areas like intensive care. Here, critically ill people, whose natural defenses
08:54are down, are often put on intravenous fluids and tubes, providing a direct route for the
08:59organism to enter their bloodstream and cause infection.
09:04Outside, the public and the press knew little. But by the middle of 1981, the hospital's
09:10infection control team had pieced together an alarming picture of how this multiply-resistant
09:14organism spread through the hospital. After the first cases appeared in burns and surgical
09:20wards, it spread to the intensive care unit. Patients from here carried it to the rest
09:25of the hospital as they were transferred to other wards. Gradually, the infection spread
09:30from bed to bed, from ward to ward, from floor to floor. Surgical, medical, renal, and cardiothoracic
09:38wards were all affected. But the doctors, who only saw their own patients, were unaware
09:44of the wider picture. The full scale of the problem was only apparent to the microbiology
09:53team, headed by Dr. Ken Harvey.
09:56The problem seemed to us to be immense. No one seemed to be particularly interested.
10:01The clinicians felt that the organism wasn't causing any harm to patients, whereas we at
10:07the center, seeing all the cases of infection, had a different view. And we were just incredibly
10:13frustrated as an infection control team at that point in time. Nothing seemed to be happening.
10:18My brief today is to inform you about the nature of this superbug, the problems that
10:24it's caused, our attempts at control, and the current state of the battle.
10:30Ken Harvey felt that the best way of getting the message across to the skeptical physicians
10:34was to give an impassioned lecture.
10:36Well, in 1977, the organism was only isolated occasionally from Melbourne. But by 1979,
10:4336 hospitals had reported problems in this city. In the 12 months from 1980 to 81, MRSA
10:52was isolated from 545 patients in this hospital. It was judged to have caused a significant
10:58clinical infection in 50%. Of those 254 patients, 30% died.
11:06It wasn't just the large number of new cases that concerned Ken Harvey. It was also the
11:12disturbing pattern of antibiotic resistance that was emerging.
11:16Recently, resistance had developed to two more antibiotics, gentamicin and chloramphenicol.
11:23This meant that Staphylococcus was sensitive to only one, vancomycin.
11:29Vancomycin has always been a last resort antibiotic since its first use in the 50s. It has to
11:34be closely monitored because of its serious side effects, which can include deafness and
11:38kidney damage. It also costs as much as $800 a day per patient.
11:45So far, resistance to vancomycin hasn't emerged. Its rare use in the past may be one reason
11:50why it still works today.
11:52The increasing infection rate caused by MRSA has necessitated an escalating use of vancomycin,
11:59raising the real possibility that vancomycin resistance may also emerge, leaving us with
12:04nothing with which to treat hospital-acquired staphylococcal infection.
12:10Despite continued searching, there have been no new discoveries of an anti-staphylococcal
12:15agent since 1964, merely chemical modifications of drugs we already have.
12:23The pessimists would say that we may have found all the antibiotics there are to find,
12:29but in 40 years hence, we may look back on the antibiotic era as just a passing phase
12:34in the long history of medicine, an era in which a great natural resource was squandered,
12:41the bugs proved smarter than the biochemists, with the consequence that doctors once again
12:46could only deal with sepsis by draining pus and excising devitalized tissue.
12:53Faced with this scenario, it does seem prudent to attempt the control of antibiotic-resistant
12:59organisms.
13:01That task fell to the infection control sister, the nurse who occupied the delicate middle
13:06ground between the medical staff and the microbiologists. Armed only with lab reports, Val Humphrey's
13:12mandate was to banish this bacterium from the wards.
13:15It was almost impossible to try and pinpoint where it had started and how it was getting
13:24around the hospital.
13:27Fighting this germ wasn't going to be easy. It can survive for months in dry, dusty places
13:31which are difficult to clean.
13:33We did embark on a search and destroy effort to locate areas where MRSA might be a problem.
13:40How long has that equipment been up there?
13:44And we found it in many, many places and particularly on things like the beds and the bedside lockers
13:49and the chairs that patients sat up in during the day.
13:55This is one of the rooms she surveyed. She found MRSA on the blind, on the windowsill,
14:02on the lamp, on the chair, and all over the floor. And this was after the room had been
14:09cleaned.
14:11The germ wasn't confined to the wards. The hospital laundry had to handle an influx of
14:16infected linen. To their horror, they discovered that the infected linen had somehow contaminated
14:21the clean linen store. This was potentially disastrous because the laundry supplied not
14:26only the Royal Melbourne, but 75 other hospitals in the area.
14:32It began to look as though the laundry could be a major reservoir of Staphylococcus. With
14:37an emergency fund of around $2 million, laundry manager Noel Brown set out to stop the spread.
14:46This is the area which we hold our clean linen prior to dispatch, and this is the area that
14:50we concentrated most heavily in. We pulled our shelving apart. We pulled the bottom shelves
14:56off, cleaned underneath. We replaced the flooring. We disinfected all the walls. We repainted
15:03them. The windows you see up there, we welded them closed so none of the people who work
15:09here could possibly open them. And it's been something like four years now since we've
15:13found any MRSA in this area.
15:17Meanwhile, back on the wards, Val Humphrey was trying to identify which of the staff
15:22members were carrying it.
15:23The other thing we'd like to do is to do your nose swab. If you want to do it yourself,
15:29that's okay.
15:30No, I'll trust you.
15:31Do you want to do it?
15:32It took a lot of charm and diplomacy to carry out this policing operation.
15:36It was very difficult to approach staff and say, can we take cultures of your hands as
15:42part of an epidemiological investigation.
15:46But Val Humphrey got her way and invariably found that staff members were carrying the
15:51organism on their hands. Surprisingly, she found that the oldest and simplest aseptic
15:57precaution, washing hands, was being neglected. The doctors, she found, were the worst offenders.
16:08Medical staff don't wash their hands before and after touching patients. And one particular
16:17surgeon once said to me, Val, you tell me how to wash my hands and I'll do it. And
16:22I said, you know, if you have to be told how to wash your hands, then you shouldn't be
16:25here as far as I'm concerned. The concept, I think, with most medical staff is that they
16:32only wash their hands when the patient's dirty. And that is that they can see something like
16:38feces or pus and they've touched it. So they're really thinking of themselves, and I don't
16:44want that on my hands, but not thinking of the concept of what I've got on my hands I'm
16:48taking to the next patient.
16:50But one central issue caused Val Humphrey's relationship with the medical staff to deteriorate.
16:55Hi, Greg. Have you heard of Golden Staph? No. It's a type of an organism that spreads
17:02infection. And I'm just going to do a routine screen just to test to see if you have it.
17:07The question was whether a patient who carried the organism but was not infected by it represented
17:12a risk to others in the ward. Val Humphrey believed in checking as many patients as possible.
17:19When she found carriers, she had them removed from the ward to a separate isolation unit.
17:23And this is when the trouble started.
17:26I had a lot of problems from clinicians. There was a lot of antagonism, a lot of yelling.
17:32And there were a lot of them and one of me, and I was copping the brunt of it.
17:37What concerned the doctors most was that a patient making a steady recovery might be
17:41removed from their ward. And some of them doubted whether the reasons for doing so were
17:46valid.
17:47Does it feel better since the operation?
17:48There's a difference between the presence of an organism or a germ, perhaps on someone's
17:52skin or in the air, and anybody getting harm from it. It's not necessary to go around
17:58on a tiger hunt searching for little germs in every armpit and on everybody's skin
18:05or up their nostrils. I think that's what worried clinicians most, that there was an
18:09overboard reaction, that here were germs, something drastic had to be done, such as
18:14isolating a patient away from the general run of their care, and that this might be
18:19harmful to them.
18:22Isolation is designed to protect the rest of the hospital from germs. But to doctors,
18:26the elaborate precautions detract from patient care. Val Humphrey remembers a particular
18:31incident when she isolated a patient with staphylococcal pneumonia.
18:35It is generally accepted around the world that anybody with staphylococcal pneumonia
18:41is isolated. It's not something I cooked up. And when the consultant went up to the
18:46ward and found this, he was really angry and he ripped the isolation precautions sign
18:53off the patient's door. He refused to wear a gown to see the patient. And he implied
18:59that the patient would be receiving second-rate care because they were being isolated.
19:04Well the isolation unit has two sorts of people in it. The ones who are quite healthy and
19:08don't need to be there, and it's not really a problem for them, it's an expense and a
19:12nuisance for everyone. The frail patients who go there, who are actually suffering from
19:17an infection, they do get less attention of necessity. People can visit them less easily
19:25and look after them less effectively. And they are the ones who suffer, and there have
19:30been patients who have died as a result of being there, who may not have died if they
19:34were in an ordinary ward situation.
19:38The nurses bitterly contest that the quality of care is any different in the isolation
19:42unit. On the contrary, they maintain that it is superior, since the staff-to-patient
19:47ratio is higher than on a normal ward.
19:55Such issues created so much tension in the hospital, Dr. Harvey felt he should defuse
20:00it in some way.
20:01What I now propose to do is to explore the psyche of the actors in this drama, for it
20:06is there that I believe our problems lie.
20:11First, I would like to introduce to you the infection control team, and first of all,
20:20professors of microbiology. These are often august gentlemen, heavy with wisdom, capable
20:27of ex grafida pronouncements on any topic. But unfortunately, the modern variety seems
20:32more concerned about recombinant DNA than it is about exploring the mundane and messy
20:39problems of battling hospital-acquired infection.
20:43Next, we have hospital microbiologists, often keen and enthusiastic chaps, but somewhat
20:50innocent of the power politics of large institutions, symbolised by the fig leaf worn on their head.
20:58Then we have infection control sisters, chosen not so much for their good looks, but for
21:03their ability to stick their noses into other people's business, nevertheless representing
21:08the sole frontline troops of the infection control team, and often the only members of
21:13a team capable of any coherent action at all.
21:17In the other corner, so to speak, are our clinical colleagues. First, the surgeons.
21:24Now, this particular species never has a problem with hospital-acquired infection, and just
21:29to make sure, he issues instructions to his staff banning swabs being taken on any of
21:34his patients who produce pus.
21:38Next comes our astute and knowledgeable physicians. This chap has just been asked if he'd like
21:43to give up some of his beds to form an isolation unit. And finally, we have medical administrators.
21:49Now, with a cast like this, is it any wonder that the control of antibiotic-resistant organisms
21:56has been slow and painful?
22:00Then a far more critical problem emerged. At that time, the Royal Melbourne had no heart
22:05surgery unit of its own, so all operations were done at the neighbouring St. Vincent's.
22:12A 1980 unpublished survey showed a scandalously high infection rate.
22:21Immediately after the operation, the patients did well, but after they transferred back
22:25to the Royal Melbourne, problems emerged days, weeks, or even months later.
22:34A third of heart surgery patients were picking up a highly resistant staphylococcus, and
22:38the infection rate was at least ten times above the acceptable level.
22:51Mr. Carr was one of their patients who fought a three-year battle against this resistant
22:55germ after a series of heart operations.
23:03His wife has watched the debilitating effect it had on him.
23:07I'd never heard of it until three years ago, until after the heart operation, and when
23:13he was transferred from St. Vincent's back here to the Royal Melbourne, that they discovered
23:18it. And evidently, it's been in his system all this time because it's flared up again
23:25after this third open heart surgery. I think it's just wrong luck, but I think if Frank
23:35could tell you right now, he can't speak to you because he's got the trachea in the throat,
23:40as you know, but I would say he's totally fed up with the whole thing. Totally fed up,
23:47but he's going to get better.
23:53Unfortunately, Mr. Carr died two weeks later.
24:00The infection control team at St. Vincent's was deeply concerned. They quickly went to
24:04work to try to find where the MRSA was coming from. They tested the air, put plates all
24:10around the operating room, and swabbed all the equipment.
24:18The lab results were inconclusive. They could not trace the source of the infection to any
24:23particular place. Next, they turned their attention to the people working in the operating
24:28room. Could the deep-seated germ in the sweat glands of their hands be passing through their
24:34gloves? They checked each pair of gloves for holes. Some indeed were punctured, and now
24:42surgeons are encouraged to wear two pairs as an extra precaution.
24:50But it was hardly likely to be the major reason for the high infection rate. Many other measures
24:55were introduced. After more vigorous cleaning, the room was left empty between operations
25:01for long enough to allow clean air to dilute out any remaining bacteria.
25:06But the most important change in practice is that patients no longer spend several days
25:10in the hospital before the operation. Now they are admitted the night before, so that
25:15they can get into surgery as quickly as possible, before they have a chance to pick up any resistant
25:20organisms that might be lingering on the wards.
25:25The cumulative effect of all these measures seems to have been successful. Although the
25:29alarming attack rate of the early 80s could never be satisfactorily explained, St. Vincent's
25:34now boasts a virtually infection-free record.
25:41Yet a far more fundamental and long-term problem remains. Hospitals around the world have to
25:48cope with the increasing problem of resistant infections.
25:51Hospitals are fascinating environments. We herd together lots of susceptible patients,
25:57or patients susceptible to infection. We pour into that closed environment kilograms of
26:03a variety of antibiotics. Something like 30 to 40% of all patients in this institution
26:11receive antibiotics at any one time. They excrete them in their urine and their faeces.
26:17They excrete them in their sweat. The entire environment is permeated with antibiotics.
26:22If we pick up dust from the floor, we can measure finite concentrations of antibiotics.
26:27Staff and patients coming into this environment breathe it in, and it acts as a selective
26:33pressure on their own organisms.
26:36The more an antibiotic is used, the more likely it is that resistance will emerge.
26:42The antibiotic allows the resistant organism to survive.
26:47But where does resistance come from in the first place?
26:52Resistance, of course, was not something that we invented. It existed in nature for millennia.
27:01Antibiotics are drugs that are made normally by bacteria that generally are living in the soil.
27:08And they need to protect themselves against their own products, so they have mechanisms
27:13of resistance. And through evolution, bacteria living in the same environment as they have
27:19developed resistance. We believe that this is the initial origin of these resistance genes,
27:26these resistance determinants that now are being picked up in bacteria that actually cause
27:31infections in man or live in association with man.
27:35Bacteria have several mechanisms of resistance. Most commonly, resistance genes are carried
27:41on plasmids, small ring-like chains of DNA shorter in length than chromosomes.
27:48A bacterial cell can have many of these plasmids. Initially, it may be a single cell that carries
27:54these genes. But when an antibiotic to which these genes are resistant is introduced into
28:00this environment, all the other cells are killed except the cell with the resistant genes.
28:07This cell will then multiply and flourish without competition in the presence of the
28:11antibiotic. Perversely, the continuing use of that antibiotic actually encourages the
28:17growth of the cells with resistant genes.
28:19It's like inadvertently killing off all the healthy grass on a lawn, and you have one
28:24resistant piece of crabgrass. You've left the lawn wide open for all those other crabgrass
28:29seeds to come in and take over the lawn. This is what can happen. It's kind of Darwinian
28:35selection but not natural, because we are actually introducing the strong selective
28:40force, the antibiotic. We've made them in enormous quantities, and now we can use them
28:44in large quantities. These antibiotics kill off any bacteria which is susceptible. That
28:52makes sense. But what survives? The surviving bacteria are those that, by chance, picked
28:58up a resistance gene. And now they find an environment completely clean of normal competitors.
29:06And since nutrients for growth are limited in the environment, they now have an open
29:11area with plenty of nutrients to grow, and they're obviously surviving the antibiotic.
29:16And while the antibiotic is there, they have a selective advantage.
29:21But this is just the beginning. Genes carrying this resistance trait can move around freely
29:26within cells. Other mobile genetic elements called transposons or jumping genes can travel
29:32from a temporary place on the plasmid to a more permanent position on the chromosomes
29:37or vice versa. These jumping genes can also transpose themselves from one cell to another.
29:43They can even move between cells of different species of bacteria. In this way, many organisms
29:50can acquire new multi-resistant patterns without the evolutionary process of chromosomal
29:55inheritance. A single plasmid can accumulate a whole battery of genes, each resistant to
30:00a different antibiotic. Up to eight have been found on one plasmid.
30:06This has sinister implications. This organism has now acquired multiple resistance. So if
30:12one of these eight antibiotics is introduced, it kills off the non-resistant cells as before,
30:17but now all the surviving cells are resistant to eight antibiotics, even though they have
30:22only been exposed to one. This is the way more and more antibiotics are rendered impotent.
30:33Today, antibiotics are abundant worldwide. The U.S. alone produces 35 million pounds
30:39each year. With so much in the environment, what does the future hold?
30:45Lots of people question whether or not we're going to return to the pre-antibiotic era.
30:51Are we actually going to be through with these kinds of drugs? And I don't think so.
30:57I think that we're approaching a time where the cost of treating infections is increasing
31:04and the ability for us to treat in an effective way. Large numbers of people are being curtailed
31:11extremely by the resistant bacteria. In the developed world, if cost isn't the issue,
31:17new antibiotics are coming available.
31:21But antibiotic resistance is not confined to the developed world. In fact, the most
31:26worrisome reports of antibiotic resistance come from the developing nations. In many
31:31of these countries, anyone can buy antibiotics over the counter. The chance for overuse is
31:36far greater and resistant organisms flourish. International travel can spread them even further.
31:44This has been demonstrated in the problem of gonorrhea, which started in Southeast Asia,
31:48then became a problem in Europe and the United States. Typhoid fever, resistant in Mexico,
31:53became a problem in the United States. Diarrhea syndromes, which were part of a problem in
31:59one country in Central America, soon spread to all of Central America and even into the
32:04United States. So an organism really knows no national boundaries. It doesn't need a
32:11passport to go from one country to the other. And in fact, it travels very easily. This
32:16kind of intercontinental, transcontinental spread is now becoming more obvious as we're
32:22learning more about resistance genes and being able to track them.
32:26Dr. Levy is president of a pressure group called the Alliance for the Prudent Use of
32:31Antibiotics.
32:33I think we want to keep it concise. Bonnie, how much room do you think we'll have for
32:38the Bangladesh article if we leave it like that? There's very little room left at the
32:42bottom of that. Fine.
32:43Through a regularly published newsletter, this organization promotes the appropriate
32:47use of antibiotics and tries to influence the prescribing habits of doctors worldwide.
32:52Yeah.
32:54Dr. Ken Harvey is also a member of the Alliance. Back in Melbourne, he is running his own vigorous
32:59campaign.
33:02The simple solution to antibiotic-resistant organisms is to withdraw the selection pressures.
33:07The problem with withdrawing all antibiotics is that patients are going to die from infection,
33:11so we can't do that. All we can hope to do is maintain a balance, is to use the least
33:17amount of antibiotics consistent with curing patients and preventing infections in the
33:21most discriminating way we can. Certainly not to use them prolifically like we are at
33:27the moment and indiscriminately and inappropriately.
33:31Dr. Harvey did a survey which revealed that half of the antibiotics prescribed in his
33:35hospital were not being prescribed properly. He also discovered that doctors were resorting
33:40far too regularly to the so-called broad-spectrum class of drugs, drugs which attack a range
33:45of different bacteria.
33:47Clinicians like broad-spectrum drugs, the refuge of the diagnostically destitute, we
33:52call it, because in theory it doesn't matter what you treat. If you've got a broad agent,
33:59it will kill all germs. In practice, life's never as simple as that. And in practice one
34:06can be much more discriminating in your selection of antibiotics as a rule. The danger of using
34:12broad-spectrum antibiotics to treat any infection is that you're selecting out resistance on
34:19a broad front. If they're active against 20 microorganisms, then all those 20 are being
34:24put under selection pressures to become resistant.
34:28In cooperation with other hospitals all over Australia, Ken Harvey drew up a list of restricted
34:33antibiotics. To prescribe these, doctors must get permission from microbiologists.
34:38Yes, although the patient does have the approved infection, we still have to have a microbiologist
34:43opinion, and we will need to have the name of the microbiologist that you consulted.
34:48Yes, that's right.
34:50But it would be totally impractical to have microbiologists check every prescription for
34:54every antibiotic. And Dr. Harvey had sympathy for the doctors who could not be expected
34:59to master a very complex field, which is often complicated by drug company propaganda. Yet
35:05Ken Harvey felt he must try to educate the doctors in some way.
35:11The first thing we did was to produce a simple booklet giving guidance on appropriate antibiotic
35:18use, thinking that that would solve the problem. But it didn't. Patterns of misprescribing
35:24continued, although there were some improvements. So faced with the fact that giving scientific
35:31information didn't really seem to change things, we felt we should try another track, another
35:36tack. And based on the experiences of the pharmaceutical industry and success they had
35:42with their promotional material, we thought we should consult a professional manipulator.
35:47With a $10,000 grant in his pocket, Dr. Harvey went to one of the largest advertising agencies
35:52in the city, who normally wouldn't touch a commission worth less than half a million.
35:57But Jeff Gudkin, the company's general manager, took up Harvey's crusade.
36:03But we will push you as far as we can, simply because we need a simple, single message that's
36:12powerful. And often it's those sorts of messages that offend.
36:17The advertising agency proved a fascinating experience. According to them, it was just
36:22a simple marketing problem. People weren't doing the right things. That's fine, you've
36:27got experimental animals, you provide an appropriate series of stimuli to those animals, and they
36:32will change their behaviour. They saw no problem at all.
36:35We knew we were dealing with a very sensitive category of people in the medical profession.
36:41And as we worked further into the campaign, it proved to be correct. Nevertheless, we
36:48took the decision to be powerful and intrusive and single-minded, and to use pretty much
36:56the same techniques as drug companies do. Almost slick commercialism. That's what we're
37:01good at. And so we chose one drug that we had a good story behind it, but it focused
37:11the attention of what we were trying to do.
37:14They homed in on this expensive, broad-spectrum drug, too often used against pneumonia. In
37:19its place, they wanted doctors to use the cheaper, more specific penicillin.
37:24Every doctor in the hospital was sent a courtesy pad and free pen plastered with catchy messages,
37:30urging them to prescribe more wisely. Dispensers containing free copies of Ken Harvey's guidelines
37:36were placed around the hospital, and posters were put up everywhere, from nursing stations
37:41to the men's lavatory.
37:44The question was whether these slick advertising techniques would change the doctors' habits.
37:50The results were quite remarkable. Before the campaign, the particular form of treatment
37:56we were trying to influence was only occurring in about 44% of occasions. After the campaign,
38:02that went up to 92% of all treatments were in accordance with the guidelines.
38:07And it was sustained, indeed. We repeated our particular audits three months after the
38:13campaign had finished, and there was very little slippage. We've repeated them 12 months
38:17later, and again, the results seem to be sustained.
38:21In the long term, Ken Harvey's attack on antibiotic prescribing habits will not only save money,
38:26but also increase the risk of pneumonia.
38:30In the long term, Ken Harvey's attack on antibiotic prescribing habits will not only save money,
38:35but should also help slow down the emergence of new antibiotic-resistant organisms.
38:43In the meantime, the Royal Melbourne's strict infection control dramatically cut the number
38:48of infections by 1984.
38:52But 1985 was on its way to a bad start.
39:00Christmas and New Year brought with them the usual toll of car accidents and multiple traumas.
39:07Casualty was busier than ever.
39:13Intensive care was short-staffed and overstretched. A familiar problem was about to emerge.
39:19Bad news from this unit. We are getting too many positives. We've got the Burns fellow,
39:24the Burns fellow, who has now got heavy colonization.
39:31A quick check on the number of new MRSA cases in intensive care produces an alarming statistic.
39:37And while we're in the same unit, this is a new potential positive, which we found today.
39:43It's not fully tested yet.
39:45I think they've got a real problem. That's 14 this month, isn't it?
39:48Yes, I've marked them.
39:50The hard work and strict procedures of previous years have taught Val Humphrey
39:54that fast action is the key to preventing an outbreak from becoming an epidemic.
39:59They all seem to be colonized, followed by a respiratory infection,
40:02so it may be something related to technique and the respiratory care.
40:06Yes, but we shouldn't be getting 14 in a month. I think we'd better go down and talk to them.
40:12And so the impromptu investigation begins immediately.
40:15What has gone wrong in intensive care?
40:17Are the staff members so busy that the extra precaution normally taken there is being ignored?
40:30Floor two.
40:35Going down.
40:37All their powers of diplomacy will be needed on this visit.
40:41Do you think it's worth looking at other things down here?
40:44I mean, do you think it's worth doing hand washing?
40:47Yes.
40:48This is a subtle way of asking if the strict infection control procedures are being neglected.
40:53I think that things have just probably been so busy.
40:56We'd like to come down here sometime in the next couple of days and do something.
41:01I mean, we'd like to come down here sometime in the next couple of days and do something.
41:06We'd like to come down here sometime in the next couple of days and do something.
41:09And do some cultures.
41:12Val Humphrey noticed temporary help attending to patients.
41:15Normally, each patient in intensive care has one nurse.
41:19Nurses assigned to a patient are not allowed to attend to other patients except in emergency.
41:24But this is the holiday season and nursing staff was in short supply.
41:30But not on a witch hunt.
41:32Just take a look at people's hands to show that, you know, they pick up transient organisms on their hands
41:38and you can be carting it around from patient to patient, particularly when they're busy.
41:42Just to raise people's awareness that they can transmit stuff from one patient to another.
41:47Yeah, well, I don't think people here would think it's a witch hunt.
41:49I think they'd be horrified.
41:53Sharon, can we just take a look at your staff and patients here?
41:55After checking the isolation room, Val Humphrey finds something disturbing in one of the patient's lab reports.
42:01Here's a problem. One Susan Nichols. Is she still here?
42:04No, she went to the ward yesterday.
42:05I'll just see if she went.
42:09It turns out that Mrs. Nichols was transferred to the renal unit before they knew she was MRSA positive.
42:15That could be a problem.
42:17The kidney transplant patients are particularly vulnerable to staphylococcal infection.
42:22Five years ago, seven people in the renal unit were infected and one died.
42:26Ever since, they've tried to keep this deadly germ out of here.
42:31We have this positive result on the patient down there, and I believe she's up here.
42:36Yes, she is indeed.
42:37She's got MRSA in her sputum.
42:40Oh, right.
42:41And she's possibly coming up tomorrow.
42:44We haven't got the results for sure yet, but she's probably also got other body sites colonised.
42:49Oh, they've taken more swabs downstairs, have they?
42:52Yeah, they took them.
42:54Is she in a room by herself?
42:56Yes, she is in a single room.
42:58What do you think we can do? I believe she's had hemodialysis as well.
43:01This morning, yes.
43:03It's usually a policy not to have patients with MRSA on your ward.
43:07Yes, it is.
43:08Do you think we'd better have a talk to the medical staff about it?
43:10Yes, certainly. Our doctor is actually here at the moment, if you'd like me to get him for you.
43:14Yeah, please.
43:15Mrs. Nichols' kidneys are failing.
43:17She needs dialysis and specialised nursing care.
43:22The dilemma is that her needs are in direct conflict with those of other patients.
43:27Should she be transferred to the isolation unit downstairs,
43:30or should she be allowed to remain here, where her worsening condition can be monitored?
43:38Hi.
43:39Yes.
43:40What's the bad news?
43:41Mrs. Nichols has got MRSA in her sputum.
43:44Right.
43:45And probably other body sites are colonised too.
43:49Well, that means problems for the renal unit, doesn't it?
43:51It does indeed.
43:52Yes. Well, we'll have to talk over with Gavin Becker.
43:54She can't stay in 7 South East with our transplant patients if she's got MRSA in her sputum.
43:59All right.
44:01Are you going to try and move her tonight or not?
44:04No, probably not. That's the answer.
44:06The problem is with the dialysis as well.
44:09They agree that she should be moved to isolation as soon as possible.
44:13I'll speak to Gavin Becker.
44:15The next morning, however, a new problem is emerging.
44:18Mrs. Nichols has an open line to her bloodstream for emergency dialysis.
44:25Patients with such lines are normally not taken to the isolation unit.
44:29The staphylococcus that abound there might get into their bloodstream via this route and cause septicemia.
44:36The only other option would be to transfer Mrs. Nichols to the infectious diseases hospital.
44:41But she is too weak to be moved so far away.
44:44So an exception is made.
44:46Dialysis will be arranged for her in isolation.
44:50OK. Righto. Yes, I'm quite happy with that.
44:53OK. Thanks a lot. Right. Bye.
44:55Do you understand about the infection?
44:57Val Humphrey must reassure Mr. Nichols.
45:00It's a highly infectious type of disease.
45:06It's a type of disease that's transmitted to everybody.
45:20She's been very sick and she's picked it up.
45:23It's a staph infection, which you've probably heard about.
45:26Now, it's not something that you're likely to pick up at all.
45:30So there's no concern with you or your family.
45:34It's really only with people who are extremely unwell, as your wife has been picked up.
45:39She is treatable and we're giving her the antibiotics for it at the moment.
45:44But because this is a renal ward and you've got the transplant patients here and the dialysis,
45:51we're very reluctant to have patients with you in this ward.
45:56We prefer to have them in other parts of the hospital if we can.
46:01You can visit her as much as you like and she'll get good nursing care.
46:05And it won't mean that she'll get any less care than she will here.
46:11Right.
46:27Special renal nurses have been sent downstairs to the isolation unit to set up the dialysis machine.
46:33She'll be carefully monitored by the renal team.
46:41Hmm.
46:46Her condition is critical.
46:52Can you tell me where you are?
46:56Do you know what this place is?
47:00What is it?
47:04Outside, the Nicholls family anxiously awaits news.
47:11Come on.
47:14To protect other patients, everything that's been in contact with Mrs. Nicholls is scrubbed with disinfectant.
47:20Even the unused resuscitator is wrapped and sent away for sterilization.
47:27What is that?
47:35In the meantime, the microbiology team arrives in intensive care.
47:41A nurse who spots them coming quickly washes her hands.
47:49Dig your nails.
47:52Okay.
47:54The swabbing and sample collecting goes on uneventfully
47:58until Val Humphrey spots an orderly handling respiratory equipment.
48:02Many of the infected cases were respiratory, and she notices he has dermatitis.
48:07He could be shedding ten times as much skin as a normal person, and perhaps ten times as much bacteria.
48:14How's that?
48:15Oh, that just broke out again. We're in about three weeks.
48:18I usually keep it covered, but when you said that you were taking swabs, I didn't bother about covering it.
48:23Let's see it in a couple of days. Have you got any further problems?
48:26You got anywhere else on it?
48:28The test showed he was positive, so he was sent home until his sore healed.
48:36Five days later in the isolation unit, Mrs. Nicholls is much better
48:40thanks to the regular dialysis she has been receiving.
48:44A couple of weeks later, she went home after a complete recovery.
48:48Progress had not been hindered by her stay in isolation.
48:54Downstairs, the staff of the intensive care unit gathered to hear the results of the survey.
48:59We found five people in the area had positive MRSA cultures for their fingers and their fingernails,
49:06and they were from the impression plates we did.
49:08Apart from that, we found also that two people had MRSA on the fronts of their pennies.
49:16It probably wasn't terribly significant, but I think it does show that MRSA does get onto your clothing,
49:23and MRSA in any staff will pass through the cotton on your gowns or your uniforms,
49:29and you've got to change them fairly regularly.
49:32The report on this outbreak confirms that some of the staff members were carrying MRSA on their hands.
49:38And most of you did go and wash your hands when you knew you were going to be cultured.
49:42That didn't bother us from the point of view of the survey,
49:45because, I mean, if you wash your hands and then we culture you and find you negative, that's good.
49:49That's terrific.
49:50But if you've washed your hands and we find that you're positive,
49:54and just, you know, the points that you've missed in your fingers,
49:58then perhaps that's saying something else, isn't it?
50:01Val Humphrey wants them to realize that the object of the exercise is not to victimize anybody,
50:06but to keep everyone on their toes.
50:09The past few years have not been easy for Val Humphrey.
50:12She sometimes felt as unpopular as the germ she's trying to eradicate.
50:18I don't think I will ever reconcile to the fact that I am part policeman in the eyes of many of the staff.
50:26I still get the impression when I walk into a ward that people see me coming and I'm trouble,
50:31and I'm going to tell them they've got an infection.
50:34Nevertheless, all the education and vigilance of the past have paid off.
50:42Today, most surgeons and doctors have been persuaded to go along with the Royal Melbourne's isolation policy.
50:53Staphylococcus is endemic in many large hospitals throughout the world.
50:57The Australian experience is only unique because it got so out of control
51:01that thousands of patients were put at risk, and many may have died as a result.
51:06With the virtue of hindsight, more aggressive action early on might have curtailed a lot of our problems.
51:12And that, I think, is the message for other institutions,
51:15to look at the problems that we've got into and to see whether they couldn't circumvent them
51:20and curtail them by more energetic measures taken early on.
51:24What happened in Australia, I think, is an extreme example of what can happen in parts of the world
51:30where one is not expecting that kind of problem and are caught, more or less, with their pants down.
51:36That is, an infection, resistant infection arrives,
51:40and one is really not expecting it to go any further and is not prepared to begin tracking it.
51:47I'm happy to say that that has not occurred elsewhere in the world,
51:51but we're more aware of it because of Australia's experience and how they've managed to handle it.
51:56But even today, in other parts of the world, in the United States,
52:00the incidence of MRSA is rising in hospitals, in this case, teaching hospitals,
52:07going from about 6.5% four years ago to about 12% now.
52:12In the United States, there has been no single infection outbreak as serious as the Australian epidemic.
52:18But since the late 60s, antibiotic resistance has been on the rise.
52:23The first methicillin-resistant infection outbreak was at Boston City Hospital in 1967.
52:29In the 70s, published studies cite similar incidents
52:32at the University of Virginia Hospital in Charlottesville,
52:35Harborview Medical Center in Seattle, and at the Henry Ford Hospital in Detroit.
52:40These are only a few examples.
52:42The National Centers for Disease Control in Atlanta
52:45monitors infection outbreaks through a voluntary hospital surveillance program.
52:50A recent report estimates that approximately 2 million patients are infected each year.
52:55It is difficult to be more precise about either the extent of the problem
52:59or the institutions responsible because hospitals are not required to report outbreaks.
53:04It may seem paradoxical that the worst resistance problems
53:07occur in some of the best teaching and community hospitals.
53:10But these hospitals care for the gravely ill patients who are the most vulnerable to infection.
53:15Fortunately, since the 70s, most of these hospitals have set up permanent infection control programs.
53:21Antibiotic resistance is not a problem unique to Staphylococcus.
53:25Many other organisms such as Streptococcus, gonorrhea, and typhoid
53:29are displaying disturbing patterns of multi-resistance.
53:33Neither is antibiotic resistance confined to hospitals.
53:36Overzealous prescribing of antibiotics for minor ailments
53:39has made its own contribution to the pool of resistant bacteria.
53:43If this pattern of antibiotics abuse continues,
53:46what is hanging in the balance is not only the control of infectious disease,
53:50but the incredible advance of medical science itself.
53:54Today, most organ transplants, surgery, and cancer therapy are dependent on antibiotics.
54:00If these drugs are rendered useless,
54:02the risk of patients acquiring resistant infection will increase
54:06and make these modern medical procedures dangerous.
54:09I think most of us believe in human ingenuity
54:12and thinking that we will, by one means or the other,
54:15succeed in maintaining our control over bacteria.
54:19But it's going to cost us something, either in using the drugs better
54:23or in finding new means of using our old drugs or new drugs.
54:28Recently, drug companies have been working on new chemicals
54:31that block the enzymes which cause resistance.
54:34The race between bacteria and biochemists
54:37continues.
54:41Have you ever taken penicillin before?
54:43Yes.
54:44Okay, you've never had any reactions to it.
54:46I think if one looks back on the history of the interaction
54:49between organisms and antibiotics over the last 40 years,
54:52it's a dynamic interaction.
54:54At times, the organisms do well.
54:56At times, the chemists make breakthroughs and get very far ahead.
55:00But I think this is a concept to have,
55:02that it is a dynamic balance
55:05of man's ingenuity versus microbial evolution.
55:09I've got confidence in the chemists,
55:11but I think it's terribly important
55:13that doctors and patients understand
55:16that microbial evolution is very powerful
55:19and that if we're to give our chemists time to catch up
55:22and to get ahead and to keep in front,
55:24that we should be as discriminating
55:26in the use of what's a very valuable natural resource as we can be.
55:35For more information, visit www.nasa.gov
55:39NASA Jet Propulsion Laboratory, California Institute of Technology
56:04NASA Jet Propulsion Laboratory, California Institute of Technology
56:34NASA Jet Propulsion Laboratory, California Institute of Technology
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