MAURICE NELIGAN HEART BEATTHE INCREASING problem of hospital-acquired infection was highlighted recently on a BBC Panorama programme. It dealt mainly with the problems posed by the organism Clostridium difficile, known to the dogs in the street as C.difficile.
It was a highly professional treatment of the subject and was addressed by a variety of experts in the relevant fields.
It is, as you know, an issue that has caused problems for us here in the recent past with outbreaks in both Ennis General Hospital and in Loughlinstown Hospital. The organism primarily infects elderly and vulnerable patients, particularly those post-surgery or with compromised immune systems.
This particular pathogen has been known for a long time and can flourish in situations where the normal organisms that inhabit the colon are disturbed or altered by almost any administered antibiotic. The organism is easily transmitted from person to person, can lie dormant on hospital fittings and furniture and is a classical hospital and institutional problem.
The symptoms are abdominal pain and diarrhoea of varying severity. In severe cases, perforation of the bowel occurs, leading in some instances to death. The treatment consists of stopping the antibiotic immediately if that is possible, depending on the clinical exigencies of each case. In most cases the symptoms then subside. If this is not so, the antibiotic Metranidazole is given and usually proves effective. Vancomycin had been the previous drug of choice.
Until recently it was not even a notifiable infection here and frequently escaped certification as even an adjunctive cause of mortality on death certificates.
In that respect it bore many resemblances to its better-known remote cousin MRSA. The whole gamut of inadequate institutional standards favoured their spread - overcrowding, poor cleaning, inadequate nursing numbers and lack of infection-control staff, particularly a dearth of the essential team leaders, the microbiologists. Poor bathroom facilities and a lack of isolation facilities compounded the problems as, in some cases, did haphazard hand hygiene.
All of these problems had been identified and reported. The response was - expressing it most charitably - totally inadequate. Possibly it appeared less threatening than MRSA because many of the stricken patients were elderly. In any case the problems of MRSA propagation were identical and they have not been addressed adequately either.
Significantly, neither Ennis nor Loughlinstown had a consultant microbiologist and both are among the most stressed hospitals in the State, running close to 100 per cent occupancy all the time. The problems are not confined to these hospitals and with mandatory notification we will see many more problems.
So long as our infrastructural defects persist, so also will C.difficile, and MRSA, while drug-resistant tuberculosis and Vancomycin-resistant pathogens wait in the wings.
There is, however, more to this problem than belated recognition. The infectivity of the organism has moved up a gear and recently identified variations are far more infectious and difficult to treat. This fact now poses very serious problems, particularly for the elderly in hospitals.
These strains are becoming largely resistant to Metranidazole, one of the two buttresses holding the dam in place. The development of resistance to the second (Vancomycin) would leave us with no fallback and potential problems of a cataclysmic nature. To add to the difficulty, the organism is impervious to the alcohol-based handwashing solutions employed in hospitals.
In crisis, now we feel the shortage of microbiologists and trained infection-control staff and time is not on our side. We need them and their back-up laboratory facilities as a matter of extreme urgency.
This is no time to prate about budgets and the necessity of hospitals staying within theirs; this is a time to focus on what this service is supposed to be about - the welfare of patients.
It is manifestly clear now that nearly all hospitals cannot live within their allocations even with gross curtailment of service and this leads to the inevitable conclusion that they need more money.
The English hospital at the centre of the Panorama programme had bed occupancy of 90-95 per cent. Nearly every hospital in the Republic approximates or exceeds 100 per cent. The report stated its wards were crowded and it lacked single rooms. Where have we heard that before? The inevitable inquiry found that local management had concentrated overly on dictates from above about waiting times in AE, average length of stay and cost overruns. They had lost sight of the needs of the patient. Over here we lost that vocational vision long ago.
• Maurice Neligan is a cardiac surgeon