Superbugs are nature's revenge on humans for their ingenuity. For decades antibiotics, which work by honing in on particular bacteria, have been the chief line of defence against infection. But superbugs have developed clever means of resisting the medicines. Like hazardous shape-shifting objects of science fiction lore, they continually alter their structure, leaving antibiotics powerless at finding their targets.
Further underlining their adversarial relationship with modern medicine, they are particularly associated with hospitals. If left free to roam around unhindered, their potential for devastation is considerable.
Two of the most well known and deadly superbugs are Clostridium difficile (C. difficile) and Methicillin-resistant Staphylococcus aureus (MRSA). The first is the most common cause of hospital-acquired diarrhoea. In 2006, in the UK city of Leicester alone, it caused 49 deaths in eight months.
Meanwhile, MRSA symptoms begin with small reddish spots and in certain circumstances can transmogrify into a nightmarish pneumonia. Such an outcome is at the extreme end of the scale but, more typically, contracting the infection can slow down patient recovery and prolong hospital stays.
Methods of attack
The UK's Department of Health says that infection control is one of the five top priorities in the National Health Service (NHS)'s Operating Framework for 2008/09 and that all measures are being taken to tackle the problem. "We have a strategy we know will reduce infection and have equipped the NHS with the guidance and support to deliver it – all backed by substantial investment and a legal requirement to maintain proper infection control," says a spokesperson for the service.
It is planning additional investment of up to £270m per year by 2010–11 which would allow local organisations to invest up to £45m on specialist staff. Although these are not earth-shattering sums, the government department and individual NHS trusts insist that the impact will be felt as the funding is not being diverted from other areas of hospital life.
The method of attack at the heart of the NHS's assault on superbugs is largely based on prevention with mandatory hand-washing and other cleanliness measures now a priority in every UK hospital.
According to the Health Protection Agency (HPA) the transfer of micro-organisms between patients by the washing of hands between hospital staff contact with patients is especially important.
Particular risk procedures include those which may result in infection to the patient such as inserting an intravenous catheter or dressing a wound.
Systems are also in place to ensure that the greatest possible care is taken to avoid introducing or transmitting infection during invasive procedures, for example, ensuring the use of sterile supplies and making sure the risk of contamination to the equipment is minimal.
Protective clothing should be used to protect healthcare workers from exposure to micro-organisms from the patient and minimise the risk that they will be transferred on to clothing.
The HPA also stresses that there must be regular cleaning to ensure that micro-organisms are not allowed to build up in the environment. It emphasises the correct use of antibiotics to minimise the risk of antibiotic-resistant micro-organisms emerging and to reduce the risk of patients developing C. difficile.
On the front line
The North West London Hospitals (NWLH) Trust has a comprehensive infection control strategy, similar to that now aimed for across the UK. Staff training is mandatory and regular, there are also audits of hand washing compliance in all wards and departments carried out each week.
In addition, patient representatives conduct anonymous spot checks of hand washing and cleanliness. There are alcohol hand gel stations in the main public areas of its hospitals and also dispensers on wards, above clinical hand washing sinks and at the end of each patient's beds – as has become standard across the UK hospital network.
Higher-risk patients are now screened for MRSA before they are admitted or before they have their operation. The heads of the nursing staff are responsible for ensuring strict infection control and cleanliness measures are adhered to. When patients do contract infections they are isolated as early as possible to event the spread to other patients and their rooms are cleaned more frequently throughout the day. To ensure that this can happen, the NWLH Trust is investing in more side rooms to isolate patients.
The Trust has also relaunched its dress code to remind staff about what they should and should not be wearing to help reduce infections. Practitioners are linked with infection control champions across the trust to encourage best practice.
Alongside this, the Trust has a multi-agency Infection Control Committee chaired by the Trust's chief executive and it has appointed a director of infection prevention and control to ensure that infection control is a top priority for the board.
Anti-infection measures thus far seem to have been effective. There is a similar anti-infection strategy in place at Chelsea and Westminster NHS Foundation Trust in London. Its hygiene standards have been rated "excellent" by the National Patient Safety Agency and it has reduced its MRSA rate by 66% over the past three years.
According to the HPA, the national picture is of a similar reduction in infection rates, with a 21% decrease in the number of C. difficile infections on the 2007/08 average. Figures published in November showed a drop in C. difficile in the key over-65 age group by 18% on the previous quarter and 38% since the same quarter in 2007. In addition, the risk of becoming infected with MRSA is at its lowest rate for five years and MRSA infections are down 57% since 2004.
Despite the impressive reduction in cases, it may not be completely possible to eradicate superbugs from contemporary hospital life. "Advances in healthcare have meant that many more people now survive serious disease, but infection may be one of the many risks associated with their treatment," says an HPA spokesperson. "Therefore, the risk of infection has to be balanced against the need for, and benefits of, the treatment."
Adding weight to the rhetoric that the battle will never be completely won was a leaked memo in January 2007 by the Department of Health, in which officials said substantial cuts in MRSA rates were not achievable. In the document, which ended up in the hands of the press, officials admitted that C. difficile was, "endemic throughout the health service".
Then in November 2008 the new vice president of the Patients Association, Sir Richard Branson, revealed that he had paid for his father to have a hip replacement operation privately as he could not find an NHS hospital free from MRSA or C. difficile.
This came on the back of comments earlier in the year from the charity's president, Claire Rayner, who said she was too frightened to use NHS hospitals, having contracted MRSA in them twice. Branson suggested the NHS should introduce tougher measures to combat superbugs including putting all infected patients in isolation and screening all staff for MRSA.
A spokesperson for NWLH insists that there have been, "great strides to improve how we handle and tackle healthcare-acquired infections," but added a cautionary note: "there will always be challenges as the nature of infections change as they adapt or find ways of getting around new treatments."
It seems that the battle against superbugs may be being vigorously waged but clearly it is still far from won.