A healthy, 6-pound baby girl, sent home with her mother only two days earlier, was rushed back to a Florida hospital in 1979. Flushed with fever and convulsions, she was the third apparent victim of meningitis in the same hospital nursery over several months. The staff was becoming frightened.
A few days later she died. A fourth case and a fifth case of the rare infection followed. When doctors began tests they found that more than 150 healthy infants had been infected while passing through the nursery. Two died; three others have permanent paralysis or brain damage.
Citrobacter, the rare microbe that caused the epidemic in the Florida hospital, had not been known to strike infants. The Centers for Disease Control investigated and decided that the infection was transferred unwittingly from baby to baby on the hands of the pediatric nurses.
These Florida babies were victims of hospital-caused infections, illnesses that strike hundreds of thousands of Americans each year and kill a minimum of 20,000.
In the war between man and disease, the hospitals are the trenches.
Hospitals house the sick and defenseless, and patients lie by the thousands, vulnerable to attack. The sicker a patient is and the longer he is in the hospital, the more likely he is to get a hospital-caused infection. The problem is as old as hospitals, but there is something new:
We have built great healing institutions and in them have created ways for the profoundly sick--from tiny newborns to nonagenerians--to be treated with miraculous new technology. To these sick people we attach needles, tubes and machines, and each one makes a new pathway into the body for infectious organisms. For each new instrument, new method and new set of antibiotics, new microbes appear. They develop new poisons, new resistance, new means of transporting themselves.
So now the hospitals constantly face new deaths.
"Counting these things is difficult," James Hughes of the Centers for Disease Control said. "On the one hand you have a hospital-caused pneumonia in an 80-year-old man with cancer of the lung . . . who came into the hospital terminal in the first place. He develops a hospital-caused pneumonia and dies; he might have died of the cancer the next week anyway . . . .
"That's on the one end. There is the other end, too. Someone comes in for a minor surgical procedure and gets a bloodstream infection related to the intravenous tube put in him . . . . He came in for nothing more than a hernia, and now he is dead," Hughes said.
"The period once euphemistically called the Age of the Miracle Drugs is dead," wrote Marc Lappe of the University of California at Berkeley. "Only the most optimistic observers can believe that we stand much of a chance of recapturing the spirit . . . of that wonderful era when we believed we were on the verge of chemically conquering all infectious diseases. We tried, and the evolutionary prowess of the microbial world won out."
David E. Rogers, now head of the Robert Wood Johnson Foundation, wrote two decades ago about how the old infections were giving way to new ones, and he discussed a newly appeared microbe, Pseudomonas aeruginosa.
This bug now is responsible for tens of thousands of hospital-caused infections and hundreds of deaths a year.
Today's medical students learn that it is not only fatal to humans, but also that it is very resistant to drugs.
"So it has gone the full gamut," said Dr. William Schaffner, epidemiologist at Vanderbilt University hospitals and chairman of the department of preventive medicine. "It was a brand new organism two decades ago. Then it became recognized as a cause of human disease. And now it has become resistant to treatment. The whole cycle in less than 25 years." There is no doubt that a hospital is the best place to be when serious illness strikes. "Ninety-five percent of the people do not get these infections; you can't get those kind of odds at the track," said Timothy R. Townsend of Johns Hopkins University Hospital. Those who do get them also tend to be the very sickest people. One survey showed that the rate of hospital-caused infections may be as high as 10 percent among those with terminal illnesses because their illness makes them vulnerable. But the rates for non-terminal patients are far lower, near 1 or 2 percent.
"For the man who is in a highway accident and bleeding, if he says that he doesn't want to go to the hospital because he has a few percent chance of getting an infection there, you've got to tell him his chances of dying are closer to 100 percent if he doesn't go," Townsend said.
Hospital-caused infections, called nosocomial infections in medical literature after an obsolete name for a hospital, cost billions of dollars in extra hospital and doctor charges alone. But perhaps only 25 percent are preventable even with the most extraordinary measures, according to the CDC.
The single biggest factor in causing and preventing infections, however, according to Dr. Robert Haley, head of the hospitals infection branch of the Centers for Disease Control, is one of the oldest on the books: doctors' and nurses' need to wash their hands between examinations of patients.
A few years ago when Johns Hopkins Hospital beefed up its infection control staff, Townsend said, "We were able to cut, for example, urinary tract infections in half, simply because we were able to . . . go over to the ward and get doctors and nurses and aides to do what they already knew they should do--such as washing their hands after emptying a patient's catheter urine-filled bag.
"What they were doing was . . . forgetting to wash their hands, and going over to the next patient. In the process they would be passing on the first guy's bugs. These bugs then would grow up in the bag and ascend back up the catheter tubing into the patients . . . . We reminded people about many of these little things." They were critical, he said, "like the horseshoe nail that lost the war." Handwashing is critical, but cleanliness in general is not as important in preventing the spread of disease in hospitals as was once thought. Cultures from walls and floors, collected at the cost of tens of millions of dollars, are largely useless and a waste of money. One CDC study estimated that more than 2 million cultures were taken in U.S. hospitals during one year and that between 75 and 90 percent of them were probably useless.
"This is a funny story that is not so funny," Vanderbilt's Schaffner said. Recently a hospital with two intensive care units discovered that one had an outbreak of Serratia infections while the other had none. The hospital epidemiologist and infection control nurse began working to isolate and eradicate the Serratia from the unit. In the interim, an important meeting on infection control took place, and the epidemiologist left to attend it.
"While he was away, with all good intentions, the hospital administrator ordered the intensive care unit 'cleaned up.' He moved all the patients, including the infected ones, out of the one unit and into the other while the first was scrubbed, painted, and disinfected. Then he moved the patients back. Now, to his surprise, he had two intensive care units with outbreaks of Serratia where before he had only one," Schaffner said.
Antibiotics, once believed to be the magic-bullet cure for scores of diseases, now turn out to be a cause of disease as well. Because microbes can change from generation to generation, using antibiotics can make new generations of microbes stronger and more resistant to treatment than the ones before them. Antibiotics also can cause trouble when they enter the human system, because they wipe out all the harmless microbes populating the territory. When the harmless inhabitants are gone, there is free food and space for the more deadly ones.
Virtually all disease organisms are becoming more and more resistant to drugs. If we continue to use antibiotics freely, said Walter Gilbert, a Nobel laureate in biochemistry, "There may be a time down the road when 80 to 90 percent of infections will be resistant to all known antibiotics."
The common dose of penicillin required to treat an infection is now 50 times the size of the dose used to treat the same infection 30 years ago.
A tale from the trenches.
Schaffner recalled: "When I went to medical school there was a group of organisms called Serratia that produced a red pigment. They were taught to us only as a curiosity because they produced this pigment. In fact, we had demonstrations with it, of how bacteria can climb up catheters into the bladder. We painted them on the end of the catheter . . . ."
"On purpose. And later recovered them from the urine of the human volunteer. It was safe, because we all knew these organisms were not pathogens."
Now, Schaffner's and several other hospitals have had large outbreaks of infection caused by this bacterium. In one Tennessee hospital recently the organism got spread widely throughout the wards and caused a wide variety of diseases, including arthritis, abscesses in the abdomen, surgical wound infections, blood infections. When Serratia "first came into our hospitals it came in fully resistant to every commercially available antibiotic," Schaffner said. Doctors began desperately mixing antibiotics to come up with something in combination that would be better than a single medication, taking with that the risk of multiple toxic effects. Eventually they were also able to get hold of an antibiotic not yet on the market that worked against Serratia.
In response to the hospital outbreaks of the 1950s, one of the quiet revolutions in modern medicine has taken place. Around 1970, uncovering and fighting hospital-caused infections became a specialty in itself. Now every accredited hospital in the United States is required to have at least one infection-control officer. The profession does not exist in most other countries.
Tales from the troops are sometimes astonishing. Microbes seem able to live anywhere, to adapt to anything. Outside hospitals, bugs can survive, frozen, in the Antarctic, or boiled in sulfur in the hot springs of the West. In hospitals, they have been found to survive and multiply in pure distilled water with apparently nothing to eat.
Doctors at the CDC were stunned when they discovered two epidemics of hospital-caused infection that originated in the one place they thought could not harbor germs.
They found that iodine-based antiseptics used to cleanse skin and instruments were now, for the first time known to medicine, growing germs and infecting patients.
"This was a great surprise to us," Martin Favero of the Centers for Disease Control said, "even though some of us are supposed to be experts on these things . . . . It was almost unbelievable. I could not really believe bacteria could live in iodine . . . . It is supposed to kill them."
A few facts from earlier eras mark the immensity of the problem: in colonial America, hospitals were built of rough wood and intentionally burned to the ground every two years to stop the spread of plagues not to--but from--the hospitals.
In the next century, an amputation in a hospital would take the patient's life 60 percent of the time. Having the same surgery at home cut the death rate in half.
"Nothing really changed from then until after World War II," Haley said. "Then we got the antibiotics, and people thought that would be the cure-all. They were used wholesale, both to prevent infections and to cure them. But by the late 1950s we suddenly found ourselves in the middle of a great epidemic of staph infections in hospitals."
In the worst cases, a third to a half of all new mothers and their babies in hospitals became infected. Patients in other areas of the hospital also came down with infection.
"That pandemic really woke up the doctors of the country to what was going on," Haley said.
The organism involved--Staphylococcus aureus and other varieties--in about 1954 suddenly underwent two dramatic changes: it gained resistance to penicillin, and it gained virulence.
No efforts of doctors during the late '50s and early '60s seemed to alleviate the problem. But eventually, as unexpectedly as they came, the infections declined.
Other organisms have now risen to deadly prominence to take their place among the worst of hospital infections. A whole bundle of organisms called as a group "Gram negative bacteria," such as the Serratia, or the Pseudomonas that infected antiseptics, suddenly began to appear in more and more outbreaks, in unexpectedly virulent forms.
The latest bug to gain resistance to treatment is one of the oldest and still one of the deadliest scourges of man: the pneumococcal pneumonia. Doctors have watched it for 40 years, and have never seen it resist treatment with penicillin. Until now. First there was a case in South Africa. Then one in Denver. Now we have spotted many of them across the country," said Vanderbilt's Schaffner. "This has come as a great shock. Lots of other organisms have become resistant, but our friend the pneumococcus, one of the classic causes of human disease, had remained sensitive. You could rely on that one. One of my senior colleagues, when he first heard about the resistant pneumococcus, looked out the window and said "Chicken Little . . . . The sky is falling!"
Even though drug companies have introduced antibiotics in the past year that are powerfully effective against Gram negative bacteria, the microbes are still ahead, Richard Wenzel of the University of Virginia said. We are beginning to see the circumstantial signs of a resurgence of some of these other bacteria, and another threat, yeast infections that no antibiotic can treat, he said.
And so another round begins. In the hospitals, doctors are beginning to realize the truth in what eminent microbiologist Stanley Falkow says:
"Bet on the microorganisms. We can't beat them. It's all we can do to try to catch up."
NEXT: Toxic shock syndrome