The Mystery That Makes Hospitals Sick

by the patients themselves. Welcome to Prognosis, a podcast about health and science, medical technology, and the changes that are underway across the world. I'm your host, Michelle fay Cortes. This season, we're talking about the rising threat of superbugs, bacteria that are resistant to the strongest infection fighting medications available.

In this episode, Bloomberg's Jason Gale explores how one hospital became wrapped up in a global mystery and how solving it created a new way to stop superbugs from sneaking into the hospital and harming patients. The solution is incredibly simple, and it's also incredibly important. These sorts of measures are what we need for the war against superbugs to succeed. And fair warning for the squeamish among our listeners. What you're about to hear has a lot to do with

them well human poop. Lindsay Gryson is standing over an empty hospital bed giving a demonstration. He's just rubbed his hands with some alcohol based sanitizer and talking as if he's admitting a patient. I'm glad you final him added into hospital. I'm sorry you're being unwell. Professor Grayson is head of the Department of Infectious Disease and Microbiology at Austin Health, a three campus hospital system in suburban Melbourne. He's rolled up the sleeves of his blue shirt and

tells the imaginary patient what to expect next. Over the next few days, we're going to have to sort out why you're so sick. Obviously, we're concerned about some infections. Professor Grayson grabs a plastic pack off the stand next to the bed. It contains a five inch long cotton tipped stick in His team routinely use these sticks to screen patients across the eight bed hospital system. They're looking for antibiotic resistant bacteria or superbugs. Superbugs can result in

life threatening infections for patients. Screening alerts Professor Grayson and his team to these gems and prevents them from spreading around the facility. The stick looks like a giant Q tip, but Professor Grayson has another name for it. Here's erect or swab. It's pretty straightforward, that's right. Professor Grayson collects and screens hundreds of fecal samples annually. You can either take it yourself or otherwise one of the nursing staff

can take it. The crucial things we need some fecal material on it. The testing schedule works like this for patients at high risk of getting an infection, such as those receiving an organ transplant, undergoing cancer treatment, or having spinal surgery. They're screened on admission and then weekly. Additionally, the Austin carries out a spot check every six months, subjecting every patient admitted over a one week period to the awkward exam. Professor Grayson and his team don't just

test patients every month. Waiting room chairs, telephones in nurses stations, and other hospital surfaces are also swab for drug resistant bacteria. The reason all of this testing happens is because it gives the hospital staff a snapshot of what superbugs are lurking waiting to spark an outbreak. That knowledge is giving Professor Grayson and his team more time to identify and

respond to problems before they turn into crises. Professor Grayson says he became a doctor because of his interest in people. What fascinates him about infectious diseases is the way microbes are constantly evolving to circumvent our treatments. Understanding how the microbes are changing requires him to be something of a Sherlock Holmes of superbugs, always looking for clues about which bugs are trying to sneak into his hospital like a detective.

You know, someone comes in with a problem. It's fairly undifferentiated. You're investigating him. You find the barb, your workout which antibiotics hopefully you can use. It's very satisfying. I like hol like humans and talking to humans. This screening process is revolutionary in how hospitals treat bacterial infections and use antibiotics. But it wasn't always this way. The story of how Professor Grayson came up with the rector swab came out

of the mystery. This mystery caused Professor Grayson to completely change how we thought about how hospitals care for their patients and even how hospitals are structured. Before this mystery came to the Austin, Professor Grayson would just see hard to treat infections and patients with weakened immune systems, and often we thrashed them with antibodics to say of their life, and you know, there's no surprise that they developed a superbug or they picked up a supermark. But something changed

a little over ten years ago. Increasingly he started seeing healthy people getting these superbugs. Middle aged businessmen were among the first cases. Even though they were fine otherwise, they were getting critically ill from a bacterial infection that required potent antibiotics. Professor Grayson had never seen cases like these before, but he noticed a common history. These patients had recently undergone a biopsy of their prostate land. Back then, the

procedure was pretty routine for checking for prostate cancer. It involved inserting a probe in the rectum and the probe would be fitted with a needle that would collect a dozen specimens for analysis. So the neurologists went put a scope in the rectum and then punched a hole through the erectal wall into the prostate. Very standard procedure, piercing the rector wall can enable bacteria from the bowel to get into the prostate, bladder and bloodstream. An antibiotic like

cipro was typically given to prevent an infection. Obviously, the patients worried about cancer, but in the past they would have got as of antibodys just before that procedure, so there wasn't transmission of bugs from their bowl into their prostate. But now we're seeing patients who the next day were suddenly had their super bug in their blood. These men were getting critically ill. They were sick because the cipro didn't work. The drug didn't work because bacteria in their

intestines were chewing it up and spedding it out. You know, we have liver transplant, regnal transplant, phone marriage and we've got a lot of high risk patients here. So we've got a pretty high risk population and we have to be very careful with those patients. But we were seeing otherwise healthy people coming. Professor Grayson told me about these

cases a decade ago at an Infectious Diseases meeting. It seemed an interesting anecdote, but a month later a doctor in Canberra said he was seeing the same thing that sounded like a trend, and some googling confirmed it. Doctors around the world were reporting prostate biopsy patients were developing bloodstream infections and ending up seriously ill in the hospital days after the procedure. One doctor in Toronto calculated a

mortality rate associated with a fifteen minute procedure. It was small, but it was growing. I wrote about it. The story got polished in many newspapers, researchers cited it in scientific journal articles, and the American Neurological Association released a statement acknowledging the risk. Urologists around the globe didn't know what to make of these cases. For this was kind of a big shift. So why were superbugs suddenly appearing and

healthy people? How were they getting there in the first place. Professor Grayson was on the case. We started to talk to those in the cases, men needing biopsies. Quite often, they've burn overseas recently. That was no coincidence. Around the same time, researchers in Australia and Sweden had published studies looking at the risks of acquiring superbugs while traveling overseas.

The scientists swabbed the butts of dozens of travelers before departure and again on their return to see whether they're normal intestinal bacteria or microflora contain multi drug resistant germs. The results were consistent. Most travelers to Asia, especially India, came back with bacteria capable of destroying some of the

strongest antibiotics. The researchers speculated they had ingested food or water that had been contaminated with drug resistant fecal germs, and those germs took up residency in their intestines, becoming part of the normal gut flora, like silent stowaways. Later, when these patients got their biopsy and the needle punctured the wall of their rectums, it opened the door for

superbugs to escape into the prostrate, bladder and bloodstream. We had been looking at these high risk patients and screening them for their own safety and to make sure they didn't spread bugs around the hospital. But something we realized that the picture was getting bigger than this, you know.

But now we're seeing otherwise healthy people. And there was this link with travel or occasionally misuse of antibiotics out in the community, but more more off a the NATO's travel globalization and the international movement of people and food helped explain a large part of the mystery. Another element has to do with the type of bacteria in our intestinal tract. These germs have a certain type of cell wall that appears differently under the microscope in response to

a dye. The dye is known as a gram stain, and so that's quite important because the structure of the cell wall gives us a cluse to which antibiotics are going to work better on the bacteria. Now, feces poo is very interesting compound because it's made up of both Gram positive and Gram negative bacteria. But the ones which make you sick quickest and cancute you very quickly are these gram negative bacteria which constitute a large portion of

our pooh. It's the Gram negative bacteria that are becoming more and more resistant to antibiotics. If that's not enough, Once these bacteria into your bloodstream, but they can release a toxin which is like a prepackaged hand grenade that drops your blood pressure, alters your whole body dynamics, and you go into septic shock without the need for the germ to actually multiply match. The mystery of why these

men were getting set was solved. Men had become susceptible to serious infections because they traveled overseas and picked up a superbug. Then, after they'd had their prostrates biopsied, those bugs were able to get into places they weren't supposed to, like the blood stream, and cause these infections. But the story wasn't over. Solving this mystery made Professor Grayson realized something that would change his entire perception of how hospitals work.

He realized that if travelers are carrying around these antibiotic resistant bacteria, you likely meant most people like you and me are walking around all day with these tiny heart to diffuse grenades in their bowls, even though we seem fine otherwise. The term for this is colonization. Bolonization is where the buggers in your system, but it's not causing

any trouble. And obviously infection is now causing trouble. If more and more of us are carrying these hand grenades and air intestines, then danger could lurk anywhere, and Professor Grayson could no longer think about the Austin as a place where superbugs were spread by only a handful of high risk patients. You know, we're one of the first hospitals in Australia to say we're going to assume the whole hospitals assess pit. Why don't we just assume the

hospital is filthy. It's with that idea in mind that Professor Grayson instituted a back to basic strategy when fighting superbugs at the Austin. For example, of something's dirty, bleach is a good way to clean it. So Professor Grayson backed in overhaul of the hospital's cleaning regime that includes bleach, lots of bleach. Professor of Medicine here said, lindsay, the hospital smells like it did when I was an intern. I said, yes, Jeff, because we're using bleach like we

used to back in the seventies and eighties. Bleach is neat, because it's good because it kills all of known super bugs.

The Austin's programs are cutting edge by today's standards for how hospitals treat patients, but Professor Grayson says a lot of these practices ironically are rooted in the meticulous attention paid to cleaning and scrubbing that Florence Nightingale, the founder of modern nursing, pioneered in the eighteen hundreds there were some basic principles which over the years had been forgotten

because of we had antibiotics. You know, my mom was born in and when they had a scarlet fever outbreak at their primary school, everyone was sent home in the school was shut down for a week or two to stop to spread a strap to cock eye spatial separation. We don't do that anymore. This old school approach is also why Professor Grayson started using the rectal swabs. Initially, the program costs the Austin Australian dollars or about one U S dollars a year, but has since come down

by about half. Robotic equipment and technology has automated the testing process. It's enabled doctors to know much faster whether a patient is harboring drug resistant germs they could increase the risk of a difficult to treat infection, and if so, how best to manage that patient, Especially if an infection occurs. This kind of screening program has enabled the hospital to

spot new dangers, making patients vastly safer. For example, the Austin was the first hospital in Australia to identify a fast spreading superbug that's especially problematic for liver transplant patients. It's called vanke myce and resistant ENTRECOC, or just vr E. About half of the liver transplant patients who get a vr E bloodstream infection will die from it. We were the first hospital in Australia to identify the r and

it wasn't because we're dirty, it's because we looked. We were the first hospital to identify a number of the multi resistant gram negatives was because we had a screening program where we looked. If you don't look, you don't find. And I think there's still a bit of a culture in other places you don't look because you don't want to know, whereas there's always been a culture. We want to know, and it's only when you know that you can design a solution. Looking for these superbugs has also

helped the hospital begin to predict how they spread. For example, for every patient with an infection caused by vr E, another twenty patients will be colonized with the gut bacteria but not have the disease. There was a recognition that most people who have an infection are colonized first, and the type of German you've got defines how many people

are more likely to be colonized for every infection. So if you've got one patient with her, you're only attract infection with r You've probably got nineteen patients out there in the ward who you don't know got R E colonization. If you know how many people are likely to have a superbug, it changes how you think about the layouts of hospitals, as well as how much to invest in infection control and surveillance. So here you can see these pink colonies are quite different to these dark blue ones.

So whereas Professor Grayson gave me a tour of the Austin's microbiology lab, it's teeming with technicians in white coats, bacterial specimens, and robotic equipment used to culture and test the microbes. Professor Grayson told me that superbug mystery made him realize the importance of identifying patients colonize certain high risk germs. For one thing, they should be given individual

rooms and not share bathrooms. But if you've got someone who's carrying a super bug, I'm sorry, but they get priority because that's the safety of the hospital at stakes. So safety of patient care now dominates everything else, and that's probably an important change. The Austin hospital was built with private rooms making up a third of its capacity. Professor Grayson says future hospitals will have to rethink that design and it won't be cheap at least in the

short term. You know, I would often say the rule is pretty simple, one bumper toilet. Well men. In the past, many people say, well, isn't it too expensive to have single rooms and a toilet for every patient? But actually from an infection control point of view, and now in the era of superbugs, this will be standard practice in the future. This needs to be built into government thinking and funding that what seems expensive at the start will

pay off very quickly in terms of disease transmission. Professor Grayson spends a lot of time thinking about superbugs and how to fight them, something he's known for internationally. Harvard graduate, he has a national hand hygiene initiative, advises the World Health Organization on infection control, and as editor in chief of a key academic text on antibiotics. It's now in three volumes and sits among the reference books lining his office.

The next frontier, he says, will address the antibiotic resistance genes that superbugs harbor. A microbiologist once told me that these bacteria accumulate genetic mechanisms for fending off antibiotics like trains attached carriages. A big difference is that bacteria of different species can share these methods for evading drugs with one another, giving modern medicine little time to catch up.

But for now, the practical efforts of the austin have at least provided some balance in the fight against superbugs. Even things as simple as a sign you know as you will have seen when you came to the hospital, is a big stand there saying oh, I'll rub your hands, don't bring your bugs into the hospital, But secretly, as you're walking out of the lifts, it actually says, don't

take our bugs home. As we face a post antibiotic era in which something as simple as a scratch knee could once again kill, these basic principles seem inexorably important. Stopping bacteria at their source will be our key defense. Thankfully, the century has given us better tools to do that. And that's it for this week's prognosis. Thanks for listening. Do you have a story about healthcare in the US or around the world We want to hear from you. Find me on Twitter at AA Cortes or send me

an email m Cortes at bloomberg dot net. If you are a fan of this episode, please take a moment to rate and review us. It really helps new listeners find the show, and don't forget to subscribe. This episode was produced by Toford Foreheads. Our story editor was Rick Shine. Special thanks to Drew Armstrong, our healthcare team leader, francesco Leivia's head of Bloomberg Podcasts. We'll be back next week with a new episode. See you then,