British Hospitals Struggle to Limit 'Superbug' Infections

LONDON - When James Wollacott badly wrenched his knee while jumping on a trampoline in the back garden of his house, the healthy, athletic 20-year-old imagined a quick operation and a swift recuperation.

Instead, he spent three months in the hospital last year, bedridden and gravely ill, battling high fevers and a merciless staph infection. The infection was M.R.S.A., short for methicillin-resistant staphylococcus aureus, known as the "superbug,'' and Mr. Wollacott picked it up when doctors inserted in his kneecap four titanium pins.

More than a year after his accident, Mr. Wollacott, who lives in Essex, still has trouble walking, mostly because his knee failed to set and heal properly from the infection, and he faces long-term arthritis. "You just don't expect it," he said. "You don't expect going into a hospital and coming out worse."

Britain has one of the worst rates of hospital-acquired M.R.S.A. bloodstream infections in Europe, second only to Greece, and the problem is getting worse. The National Audit Office, a government watchdog organization, announced this month that there had been an 8 percent increase in the number of all staphylococcus aureus, or staph, infections in the bloodstream, to 19,311 in 2004 from 17,933 in 2001. Of those, 40 percent were resistant to the antibiotic methicillin.

But that reveals only a slice of the problem because the Department of Health, which began to keep figures on the infections in 2001, does not track the existence of staph infections outside the bloodstream, in wounds or in the urinary tract.

One in 10 patients contracts a staph infection while staying in England's hospitals, which rank among the oldest and most crowded in Western Europe. Because superbugs multiply easily in unhygienic surroundings, dirty hospital wards and unclean hands contribute to their spread from patient to patient.

While estimates remain sketchy, mostly because the cause of death is seldom narrowed to hospital-acquired infections, the National Audit Office stood by its assertion, first made in 2000, that the infections result in at least 5,000 deaths a year.

Staph infection rates in the United States are also increasing, said Dan Jernigan, a medical epidemiologist at the Centers for Disease Control and Prevention. An estimated 300,000 patients a year are in the hospital with staph infections, and a third of those patients have M.R.S.A., a rate that has steadily increased in the past 30 years.

Edward Leigh, a conservative member of Parliament and the chairman of the Committee on Public Accounts, said there had been an "appalling lack of progress" in tackling the infections. "The picture is bleak," he said. "It is a matter of shame that our M.R.S.A. infection rate is among the worst in Europe."

Prime Minister Tony Blair, while not as dire in his choice of words, conceded that it was a "serious problem."

Responding to the increase in infections, John Reid, the health secretary, announced plans this month to try to curb the infection rates, including flying in experts, installing hot lines by patients' bedsides so they can alert the cleaning staff if something is dirty, improving supervision of the cleaning staff and ensuring that hospitals publish and display their infection rates.

He also advised patients to ask nurses and doctors to wash their hands before touching them, a suggestion that was ridiculed by patients' rights groups that say people in hospitals are often too sick and vulnerable to make such demands.

M.R.S.A., a type of bacteria, is abundant in everyday life. Most people carry it on their skin, and typically it causes no harm. It is only when it enters the body, either through wounds or punctures from intravenous drips, for example, that problems can occur. It can cause skin infections, sepsis and toxic shock.

Often, exposure to a superbug results in only minor problems. But at times, particularly in the elderly and people with compromised immune systems, it can be fatal.

Most staphylococcus infections can be treated with antibiotics, but bacteria are constantly evolving and becoming immune to these drugs, many of which have been overused by the general population. For years, the infections were treated with methicillin. Now, a few stubborn infections must be treated with vancomycin, the last drug in the arsenal to combat staph infections.

With Britons keen on learning more about the dangers of infection, newspapers around the country have been clamoring to find victims and to publish their sordid stories.

Leslie Ash, a well-known television star here who appears on the BBC show "Men Behaving Badly," has been fodder for newspapers since she landed in the hospital in April with a broken rib and a punctured lung.

Ms. Ash was treated and sent home but then forced to return to the hospital almost immediately when M.S.S.A., or methicillin-sensitive staphylococcus aureus, attacked her body. The television star, who is still in the hospital, can barely walk and is seriously ill. For a time she was almost entirely paralyzed.

In Britain, staph infections have taken root for several reasons. A number of hospitals were built decades ago and are not designed to isolate infected patients; few have single and double rooms. Instead, wards of six or eight people are common, and there are frequently not enough wash basins. The government is also under pressure to prune long waiting lists for elective procedures, a factor that has aggravated crowding and increased workloads.

"I think from the patient's point of view, it increases anxiety," said Pat Troop, the chief executive for the Health Protection Agency, a government organization that focuses on public health protection. "People go into a hospital and they are anxious anyway. You can't stop these infections totally. There will always be a level of infection, but the aim is to keep it at a minimum."

Claire Rayner, the 73-year-old head of the Patients' Association and a prominent member of the community, said she had spent a lifetime vouching for Britain's National Health Service, the government agency in charge of medical care. But no more, she said.

Mrs. Rayner, a former nurse, is so worried about the spread of infections that she opted not to send her husband to the hospital after he fell and got a gash in his brow.

"The average wait can be up to six or seven hours," Mrs. Rayner said. "I'm not letting a man with an open wound sit in a ward with a room full of people, full of I-don't-know-what bugs."

Mrs. Rayner caught a minor case of M.R.S.A. three years ago, when she was in the hospital for an operation on her knee. She has been in several hospitals for a variety of reasons since then, and says she is appalled by the filth and the hygiene practices. In one case, she watched dirt and dust pile up in the corner of a ward. Nurses and assistants did not always wash their hands. She had to call for a basin when she needed to vomit, and then the nurse ran off and left her alone.

Some hospitals do a better job than others. The problem is rare among England's handful of private hospitals, although those facilities seldom see the most vulnerable patients.

And while most Britons rely on government-financed National Health Service hospitals, a growing number, like Mrs. Rayner, are choosing to spend their own money on private care.

"It sounds awful complaining like this because in lots of way they were good," Mrs. Rayner said. "But I've stopped using the N.H.S. Our hospitals are going downhill."

Alison Langley, a spokeswoman for the Department of Health, said the agency was determined to do more to combat the infections. In the meantime, there is no need to panic, she said.

"I'm not sure how to reassure people," Ms. Langley said. "But M.R.S.A. is not a death sentence."

The basic outline of the story about my son James Wollacott, reported initially in the US by Lizette Alvarez (NYT 14 August 2004), is substantially correct in that he was admitted to hospital after an injury to his leg and, whilst in hospital, contracted MRSA and was very ill for several weeks. However, during subsequent re-publication, some vital inaccuracies have been introduced which need to be clarified. Some versions of the story give the impression that it was the insertion of the pins that facilitated the contraction of MRSA and some even report “…titanium pins, coated with the ‘superbug’”. Therefore, the question by ‘mean lunch lady’ is not unreasonable given the reportage (‘don’t they use sterile pins?’).

James is the eldest of our three sons and last May 2003 he sustained an accident whilst jumping on the trampoline in the garden. On admission to hospital the diagnosis was dislocation of the knee and a severed artery behind the knee. He underwent an immediate emergency arterial bypass operation followed a week or so later by a complete knee reconstruction, fixed in place by titanium screws. Each of these operations was successful and he had a good prognosis; he played roller hockey at competition level, cricket at local club level and was generally athletic and sporty, and although the doctors were unable to say at what level he would return to sport, there seemed little reason to suppose that after a few months of intensive physio, he would not be leading a fairly normal life. However, the contraction of MRSA and the extent of the illness it caused, the need for more surgery as a result, and the necessarily prolonged stay in hospital have scuppered this plan to the extent where, 15 months after the original accident, he is delighted to be able to walk 50 yards unaided, although even such a limited amount of exertion causes considerable pain and a need to rest afterwards.

More emphasis than is appropriate has been placed on the relevance of the titanium pins whereas the main focus of the discussion should actually be ‘Why is MRSA present in hospitals (or certainly, to the extent that appears prevalent by the burgeoning number of cases reported)?’ MRSA is contracted through an open wound, of which James had many as a result of the emergency surgery on admission, but there is no indication of at what time or at which location the MRSA was introduced, and certainly never a suggestion that it was introduced by means of the titanium fixings; we were assured by James’ surgeon that titanium fixings are by far the strongest remedy for the injury he had sustained. James began to feel unwell a few days after the reconstruction work, which we initially ascribed to post-operative trauma but which eventually was diagnosed as MRSA. MRSA can adhere to metal pins and form an impenetrable coat and it is for this reason that the pins became so crucial; despite the medical staff’s best attempts to eradicate the infection, the ultimate remedy was to remove the pins in order to clear the infection from his body. Obviously, removal of the pins holding his leg together necessarily meant that the repair work had all to be repeated, not only once but twice; the second attempt was made using ‘harvested’ materials from his other leg but was not particularly successful, and the third attempt at the beginning of June 2004 once again used metal fixings.

I think David Hunter’s point about subcontracting of cleaning in Britain’s NHS hospitals is the key. His comments are not overlooked by the majority of the British public, many of whom are making exactly the same points – bring back matron (or some other suitably qualified supervisor), bring hospital cleaning back within the auspices of the hospital itself, etc. The most outrageous element of the current advice is beyond belief – patients are not only to be responsible for the actions and hygiene of medical staff treating them, but should request cleaning staff to attend to noticeably dirty areas. Surely by the time dirt becomes obvious, the damage has already been done. Whilst I appreciate Mr. Hunter’s sentiment to ‘go private’, obviously in an emergency situation – like my son’s – it just is not possible. While it now appears that I should have been scrutinising the care and cleanliness of the hospital during James’ stay, I was more concerned with asking important questions, like “Will he die?” and “Will he be crippled for life?”

I have nothing but the highest praise for the clinical expertise and dedication of the medical staff and it is disgraceful that their best efforts are negated by a failure at what should be the lowest and cheapest element of any hospital procedure, that of basic hospital cleaning. The cleaning staff themselves cannot be held entirely at fault; it is impossible that every hospital cleaner is lax and the scale of the problem suggests a more centralised factor. Many people agree with Mr. Hunter that the implementation of subcontracting at the best tender is at the root of the problem, and patients informing staff of ‘dirty areas’ which need cleaning not only obscures the real problem but avoids the remedy by pushing the responsibility onto the end-user of the NHS – the patient. The ultimate outcome of this suggestion must surely be that any hospital patient contracting any HAI will be held in part responsible for his own misfortune by virtue of the fact he did not avail himself of the facilities provided to ensure a clean environment, however incapacitated he may have been at the time due to his clinical condition.

It should not be forgotten that the NHS is paid for with public money and every person admitted to hospital should be assured they are entering as clean and sterile an environment as possible; we have already paid for this. Every person working within the NHS is ultimately a government employee and it is an outrage that the British government should attempt to deflect its responsibility in such a manner.

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