Wellcome Trust, Medical Research Council, DOH & Health Protection Agency 
Healthcare Associated Infections and the Patient Pathway
High impact practical solutions
Wellcome Trust
Friday 21st May 2010

The aim of the conference was to engage a wide range of stakeholders and researchers from different disciplines in identifying basic gaps at all levels of the patient pathway, and to accelerate patient outcomes by providing high-impact practical solutions that will be achievable within a five year time frame. MRSA Action UK were able to bring the patient perspective to the discussions and workshops hosted by the Wellcome Trust, Medical Research Council, Department of Health and Health Protection Agency. Derek Butler, Chair, brought some scenarios from private industry including his own Nuclear industry, where tracking systems and diagnostics play an important role in regulating hazardous substances, some of which can be applied to the pathogens and the problems that antimicrobial resistance are causing in the healthcare profession.

Dr Pat Goodwin gave an overview of the day, case studies and workshops, and introduced the first speaker in the plenary session who was Professor Gordon Dougan from the Wellcome Trust Sanger Institute.

Professor Dougan's presentation aimed to give an overview of healthcare associated infections and the position at the present time. There were many different types of bacteria which would cause us serious problems in the future. There was a need to be aware that as people live longer this in itself would cause problems in relation to healthcare associated infections. Professor Dougan also touched on the movement of bacteria around the world and emphasised that we needed to be able to track their spread, very much like the food industry does at present. There does seem however to be a lack of understanding of the issues in health management at all levels and this needs to be addressed.

One of his main concerns is that the bacteria are not only becoming more resistant, they are becoming fitter with this resistance as well. What is understood by this is that scientists have found in the bacteria genome, that the two elements that help bacteria to transpose the resistant gene, those being Transporans and Plasmids had in the past a flaw, in that they weakened the bacteria itself so that any outbreak was always certain to burn itself out. This is now not happening as the bacteria are no longer being weakened but have become stronger and this is giving cause for concern. Professor Dougan said that over the past twenty years we have created bacteria that are more mobile and that 20% of its genome is now transferable.

There was a need to develop new antibiotics as a priority, because of the lack of development over the last thirty years and the large pharmaceutical companies' reluctance to develop newer antimicrobials, there was a need to find new ways to support this and to develop newer targeted antimicrobials as the days of the broad spectrum antimicrobials were numbered. So who will work in partnership with these companies? Certainly research companies may, but due to the cost of developing antimicrobials only governments had the necessary financial resources to do so, however will they? We have to make better use of the ones we already have and research should be conducted to see if we can preserve them. Professor Dougan touched briefly on vaccines and asked could they work, there were some in the development stage and these should be available in a few years. He said there was a need to track bacteria in individual establishments and globally if we are to understand how they spread and how to treat them. Storage of data will require a super computer of the likes at the Wellcome Trust Sanger Institute. Finally Professor Dougan made the point that all the available evidence showed only one agent killed the bugs effectively, and that was Hydrogen Peroxide.

Professor Peter Hawkey from the University of Birmingham spoke about diagnostic screening. He outlined the conflict between current methods that have been used for decades, and the new type of rapid testing that is improving year on year. He said the old method was a tried and tested system that is labour intensive but does not give DNA typing. The new form of diagnostic testing gives those that use it a lot more information; however the downside is the cost. The cost should fall as this type of system becomes more widespread but its big advantage is that it gives real time results which are cost effective because the correct treatment can begin much sooner. Reliability of rapid testing methods is improving and will continue to do so.

Professor Gary French from Guys and St Thomas's Hospital London gave a presentation on treatment. Professor French said that antibiotics were the only medication that affected the environment. Whilst we have reduced the number of MRSA bacteraemias, there is evidence that while the sensitive Staph aureus are reducing, the proportion of resistant Staph is growing. Professor French agreed with Professor Dougan that the bacteria were becoming fitter when only twenty five years ago they were weakening. He asked, what were the options for the future - especially with the supply of antibiotics reducing rapidly, and with very few in the development stage. He said we should treat antibiotics as a precious resource that may run out if we are not careful. The solutions:

- focus on antibiotic stewardship, infection prevention and control, behaviours (this should include the general public)

- develop new antibiotics as a priority with Government help

- look at developing new vaccines

- consider Phage treatments

- consider Nucleic acid

- decolonise and detoxify

Professor Alison Holmes, Imperial College Healthcare NHS Trust considered how patient movement impacts on healthcare associated infections. The scope of patient movement in local Acute hospitals, and the movement of patients nationally and globally should not be considered in isolation this should also include healthcare staff.

In relation to patient movement it should be easily identifiable which patients contracted a healthcare associated infection, and information available on any risk. A similar method in use today is in the Netherlands, but in an ideal world this should be adopted globally. Professor Holmes pointed to the Dutch method using single rooms, adequate staffing and comprehensive discharge communication. Care pathways were an effective means of giving the correct information and communication, especially when transferring patients between healthcare facilities. Being able to track and look back at a patient's medical history, using a mapping route showing the patient's journey is an important factor in communicating risk and tracking antimicrobial prescribing and resistance.

The Lancet have just this week published findings to justify implementing a risk assessment framework for assessing risks of further worldwide spread of Clostridium difficile PCR ribotype 027. The framework first requires identification of potential vehicles of introduction, including international transfers of hospital patients, international tourism and migration, and trade in livestock, associated commodities, and foodstuffs. It then calls for assessment of the risks of pathogen release, of exposure of individuals if release happens, and of resulting outbreaks. Health departments in countries unaffected by outbreaks should assess the risk of introduction or reintroduction of C difficile PCR ribotype 027 using a structured risk-assessment approach. (Source: The Lancet Infectious Diseases, Volume 10, Issue 6, Pages 395 - 404, June 2010)

Professor Holmes reiterated that rapid testing for healthcare associated infections would bring an added cost, but this would be far outweighed by the benefits for the patient giving the correct treatment at the earliest opportunity and bring about the most efficient use of hospital resources.

Dr Kieran Hand, Southampton University Hospitals Trust, gave a short presentation on antibiotic prescribing. He said that the biggest factor in antibiotic prescribing over the past few decades has been doctors erring on the side of caution in the fear that if they did not give a patient an antibiotic when they suspect they have an infection that the patient may die. Rapid testing has the advantage of being able to detect if the patient has an infection and if an antibiotic needs to be prescribed removing, to a large extent, the doctor having to second guess. Dr Hand's presentation touched on antimicrobials and animals. As much as 50% of all antibiotics are used for treating domestic pets and in farm husbandry. It is important that we look at family history, previous treatments, occupations and a patient's social life, such as holidaying abroad; only by doing this will we be able to find out how, where and why bacteria transfer from continent to continent.

Dr Hand finished by outlining that there had to be rigid stewardship of antibiotic prescribing.

Professor Liam Smeeth, London School of Hygiene and Tropical Medicine gave an interesting presentation on electronic health. He was very clear that computers are the future way of all health records. However history has shown us that in the 1960/70s people said the same thing, even now we are starting at a very low level of only 3.5% of the nation's health records being on computer. He said one of the main problems with electronic health records is that virtually all hospitals have systems that are slightly different from the others and he agreed with Professor Dougan's earlier presentation that the NHS will have to have a super computer and a central system for electronic storage of data on antimicrobial resistance.

Having records on computer, he firmly believes, will allow staff to be more efficient and to give appropriate and timely treatment for healthcare associated infections, it will also have the added benefit of not only being able to track the patient but the bugs as well.

Professor Jenny Roberts, London School of Hygiene and Tropical Medicine touched on the effects that healthcare associated infections have on the viable economy of hospitals, she made reference to the Public Accounts Committee reports and the National Audit Office reports over the last decade. There was a cost to the whole health economy and the much quoted 1 billion pound cost, this was an under-estimated cost as only 70% of cases are taken in consideration and this estimate is in great need of updating as it does not take into account those infections that are not reported. Professor Roberts demonstrated that a patient who contracts healthcare associated infections such as MRSA or Clostridium difficile add to the cost of care that is sometimes up to three times more than if the patient hadn't contracted that infection. The patient also spends two and a half times longer than they normally would, adding to the massive burden. Professor Roberts spoke of the ultimate statistic, 2.5% of all those who contract a serious healthcare associated infection die leaving families devastated.

If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at info@mrsaactionuk.net