Survey finds health care workers fear infection with drug-resistant bugs

ICPs report worker infections, family concerns

Despite traditional reassurances and ongoing education, many health care workers are concerned about being colonized or infected with antibiotic-resistant pathogens in the nation’s hospitals, according to an exclusive survey by Hospital Infection Control.

Overall, 77% of the 96 infection control professionals responding to a recent "fax-back" opinion survey reported that health care workers at their facilities are becoming increasingly concerned about drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Indeed, the survey revealed that 29% of respondents reported that a staff member had been infected with MRSA within the last two years. (See results, p. 59.)

In addition, the survey found that nearly one-third of respondents reported workers had become colonized with MRSA. Overall, 22% of the ICPs polled have adopted an MRSA decolonization protocol to permit infected or colonized staff to continue working or return to work.

While it is well-known that the unwashed hands of health care workers can become transiently colonized long enough to carry pathogens from patient to patient, traditional wisdom has held that immune-competent health care workers treating patients with resistant bacteria are generally safe from acquiring the organisms. However, with reports of increasing drug resistance in virtually all pathogens, new community-acquired strains of MRSA, and emerging vancomycin resistance in S. aureus, many health care workers are rethinking their risks of infection, colonization, and bringing germs home to their families, survey respondents tell HIC.

"They are not taking it so lightly," says Lisa Lang, RN, director of infection control at Jones Memorial Hospital in Wellsville, NY. "They are seeing it in the community, so that brings the focus back to their kids and their sick grandmas, and whomever else may be at home."

Awareness also has increased because antibiotic resistance is emphasized more in staff education, and many frontline workers have witnessed the affects of such infections on patients, she adds. "They are seeing it more, and seeing that patients take longer to get better," she says. "They’ve seen a couple of [patient] deaths. Once someone has contracted a multidrug-resistant organism, the efforts of the doctors to try and combat it are sometimes fruitless, especially in older people that have comorbidity problems."

An unkind cut

In responding to the survey, Lang reported a case of a health care worker who underwent surgery and then apparently colonized his own wound due to MRSA nasal carriage. Several reports in the survey included finding that health care workers became colonized or infected with MRSA after undergoing medical treatment, making it unclear whether the source was their own flora from working in health care or receiving antibiotics; a nosocomial transmission at the treatment facility; or a strain from the community.

However, some occupational cases were more clear-cut — literally. "We had a health care worker who had a cut on her thumb and developed colonization [with] MRSA. Two of the patients she took care of ended up with MRSA," says Greg Carter, RN, CIC, an ICP at Kettering Memorial Hospital in Dayton, OH. "We didn’t probe it to see if it was exactly the same [strain]. But after she was treated, we didn’t have any other problems."

The staff member — who was thought to have acquired MRSA from a patient despite wearing a bandage over the cut — was put on antibiotics and furloughed until the wound healed, he said. "It was hard for her to get rid of and hard for us to treat," he says. "But once we found out what we were dealing with, she cleared up completely in about 10 days."

The Centers for Disease Control and Prevention recommends against screening workers for antibiotic-resistant organisms unless they are epidemiologically linked to transmission to patients. Likewise, attempts to routinely screen and try to eradicate MRSA nasal carriage, for example, are not recommended.1 Thus, ICPs typically emphasize infection control compliance with gloves and hand washing rather than wasting resources on routine screening and decolonization attempts. In general, workers who have wounds or skin breaks may be more vulnerable to acquiring MRSA in the hospital.

For example, workers with diabetic leg ulcers have become infected or colonized with MRSA at Monongahela Valley (PA) Hospital, reports Kathy Liberatore, BN, BS, CIC, an ICP at the facility. "I think they were probably colonized and then [MRSA] got in the wound," she says, adding that whether the source was the hospital or the community is not clear. "One individual — a clerical person — had no patient contact," she says. "The other works in laundry and does have contact with linens from patients."

Night of the iguana

In one of the more bizarre cases reported, an ICP at a facility in St. Louis described the case of a health care worker who developed an MRSA infection after being bitten on the leg by her pet iguana. "When it became infected and we cultured it, we noticed it was MRSA," says Herb Betian, BS, CIC, supervisor of microbiology and infection control at Southpoint Hospital. "Now, the MRSA probably didn’t come from the iguana — it probably came from her, assuming that she was carrying it. She had a heck of a time clearing that one out."

It was not necessary to restrict the worker because the wound was contained and covered by clothing, he says. Though reporting the unusual case, Betian was among the 23% of survey respondents who gave the opinion that health care workers are not becoming more concerned about antibiotic-resistant pathogens. "I have always had a core group of people who are very concerned about bringing bacteria and germs home to their families. We had one phlebotomist who not only changed her clothes but also her shoes and scrubbed up really good [before going home]," he tells HIC. "But just in conversations, I have not picked up an increased concern about bringing MRSA home to their families. One of the things that I have usually talked about is that most of the multidrug-resistant organisms are dangerous only if you are susceptible, and the majority of people outside hospitals are healthy, and therefore they are not susceptible."

Indeed, health care workers have long been taught that they are at little risk of harm from such organisms as long as they follow proper infection control protocols and have competent immune systems.

"Ah, but there’s the rub," says Barbara Moody, RN, CIC manager of infection control at Parkland Hospital in Dallas. "Look at our world today. People in all walks of life are immunocompromised, doing all kinds of jobs. These people already have several strikes against them, and many of them are health care workers. Many, many health care workers have all kinds of underlying diseases and are working fine. As long as they are using good procedures, there is no reason they shouldn’t work. But I think there is probably some increased risk to them, and certainly an increased risk if they break technique."

For MRSA-colonized workers who are linked to transmission to patients, Moody has developed a decolonization protocol that is used in guiding decisions for safe return to work. (See protocol, p. 60.) "We do take them off [duty] for 24 hours if they have MRSA," she says. "But only if there are some reasons to think that there is a risk. For instance, with an infection on the hand, they can’t work anyway. It has nothing to do with MRSA. Our policy also says it may be necessary to [stay out longer] than 24 hours, as determined by occupational health and infection control, based on risk of transmission and the population of patients that they are working with."

VRE colonization a staff fear

In addition to its MRSA policy, Moody’s department has developed a "myths and facts" sheet about VRE to allay some of the staff concerns about that pathogen. (See Parkland’s VRE myths and facts sheet, p. 61.) "We had people who thought they had to shed their clothes outside the house," she says. "So it was really helpful." Only 2% of HIC survey respondents said they had staff members become colonized with VRE in the last two years, and no one reported any VRE infection in a worker. However, some health care workers may fear VRE more than MRSA because there is no consensus decolonization protocol for the pathogen.

While some ICPs responding to the survey noted that the level of worker education may be a major fear factor, Moody says even staff physicians have expressed concerns about becoming colonized with VRE. "The fears that drive the average health care worker may appear in the house staff. There is no magical line there that says they are above and beyond all fear." she says. "We don’t have any method for decolonizing them, and [their] concern is that this could hamper their livelihood if they were known to have VRE."

Indeed, researchers report that eradication of resistant enterococci from human carriers is difficult, because both patients and health care workers can harbor resistant enterococci in their gastrointestinal tract.2 During one outbreak of gentamicin-resistant enterococci, a 14-day course of oral vancomycin and rifampin with total body chlorhexidine scrubs was used to eradicate carriage in a nurse.3 Attempts to eradicate VRE from the intestinal tract using various oral antimicrobial regimens have yielded only limited success, another study found.4

The possibility of spreading VRE colonization to family members of health care workers was suggested in a study by Riad Khatib, MD, chief of infectious diseases at St. John Hospital and Medical Center in Detroit, and colleagues.5 They collected 228 stool swabs from healthy volunteers among 92 households of hospital employees. Those included 52 households (137 individuals) with patient-contact employees and 40 households (91 individuals) with no patient contact. VRE colonization was exclusive to household members with patient-contact employees (5/137 vs. 0/91). Overall, VRE stool colonization was identified in 3 (6%) of 52 households with patient-contact employees. Identical molecular patterns suggested intra-household spread of the organisms. Although the method of acquisition was uncertain and may have occurred from nonoccupational sources, the lack of colonization in non-patient-contact households suggests occupational acquisition, they concluded.

"The implication of our findings is that health care workers should be aware of their risk and try to practice universal [standard] precautions so they don’t get exposed to or colonized with these kind of bacteria," Khatib tells HIC. Indeed, the upside of increased staff awareness of antibiotic-resistant pathogens may be improved compliance with infection control measures like standard precautions that include hand washing and appropriate glove use, Lang adds. "I’m seeing better compliance," she says.

References

1. Centers for Disease Control and Prevention. Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in health care personnel, 1998. AJIC 1998; 26:289-354.

2. Chenoweth CE, Schaberg DR. "Enterococcus Species." In: Mayhall, ed. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1999, pp. 1,015-1,020.

3. Rhinehart E, Smith N, Wennersten C, et al. Rapid dissemination of B-lactamase-producing aminoglycoside-resistant Enterococcus faecalis among patients and staff on an infant-toddler surgical ward. N Engl J Med 1990; 323:1,814-1,818.

4. Boyce J. Vancomycin-resistant enterococcus: Detection, epidemiology, and control measures. Infect Dis Clinic North Am 1997; 11:367-384.

5. Khatib R, Ramanathan J, Baran J, et al. Vancomycin-resistant Enterococcus faecium colonization in healthcare workers. Presented at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco; Sept. 26-29, 1999.