Fighting infection

Combat superbugs, other threats with multifaceted, regional approach

February 24, 2009|By Ramanan Laxminarayan and Eli Perencevich

Most people come to a hospital expecting to get better. But many don't realize that on average, one in 20 patients admitted to a hospital in the United States will contract an infection during his or her stay. These infections cause a staggering 99,000 deaths per year. And a growing proportion of these infections no longer respond to a wide range of antibiotics. Doctors must turn to more costly antibiotics or ones with more side effects - if they can cure the infection at all.

A 2005 report showed that hospitals could charge the cost of health care-associated infections to third-party payers such as Medicare and Medicaid. Medicare has changed its rules in response to these concerns and will no longer reimburse hospitals for the excess costs associated with the care of patients who contract a hospital-associated infection. But now hospitals have no incentive to accurately report their infection levels. If Medicare were to provide hospitals with more resources for infection control, rather than just penalize them for caring for very sick patients who contract a hospital-associated infection, hospitals might perform better.

Baltimore hospitals are on the front lines in the fight against these infections, many of which are caused by "superbugs" - infections resistant to most common antibiotics. The Baltimore Health Department reported last month that the rate of infections caused by the superbug methicillin-resistant Staphylococcus aureus (known as MRSA) runs twice as high in Baltimore hospitals as in neighboring regions. Often, the disease can be detected with only expensive screening programs.

Last month, the U.S. Department of Health and Human Services released a plan urging hospitals and other health care facilities to adopt increased use of sterile techniques and follow strict protocols to prevent such infections. These include guidelines on the proper insertion of catheters and disinfection of ventilators, as well as practices that minimize risk of infection before, during and after surgery.

The University of Maryland Medical Center screens all patients at high risk for MRSA when they are admitted. Screening includes patients in intensive care units and those who have been in another health care facility during the past year. The tests are repeated during the hospital stay. Isolation precautions are instituted for those who test positive for MRSA. During the past year, the hospital has performed more than 33,000 MRSA screening tests. This aggressive action has slashed the hospital's rate of MRSA infection by more than 30 percent and has saved lives.

Unfortunately, many hospitals are struggling financially, and most have little incentive to take these steps. For one thing, unlike most medical problems, there is no direct reimbursement to hospitals for providing these expensive and lifesaving preventive measures.

A further challenge is that patients with health care-associated infections move among hospitals, other health care facilities and nursing homes, and can spread the infections regionally. That means that a specific hospital does not necessarily receive all of the benefits from its infection control activities.

What's the solution? Infection control efforts should be regionally targeted, and HHS and the Centers for Medicare and Medicaid Services should provide hospitals with tools and incentives to work together so that they can coordinate infection-control measures. If regional coordination existed, infections wouldn't just be transferred from one place to the next.

Health care-associated drug-resistant infections are a complex problem. The overselling and overuse of antibiotics, as well as the lack of new antibiotics in the research pipeline, are driving the high rates of resistant infections. Timely prescribing of antibiotics can help reduce infections in hospitals, but we have to work to reduce overprescribing as well. Our government leaders need to deploy a strategy that addresses all factors driving this epidemic.

Ramanan Laxminarayan is a senior researcher at Resources for the Future, a think tank whose Extending the Cure initiative aims to extend antibiotic effectiveness. His e-mail is ramanan@rff.org. Eli Perencevich is medical director for infection control at the University of Maryland Medical Center, and associate professor at the UM Medical School. His e-mail is eperence@

epi.umaryland.edu.

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