COVID-19 Has Amplified the Superbug Crisis. Hospitals Must Respond.

When the world gains control over COVID-19, infection control experts won’t get a reprieve. To the contrary, hospitals will need to confront the “pandemic lying in wait”: antibiotic resistance.

For decades, pathogens have been outwitting the antibiotics that revolutionized medicine in the 1940s. Well before COVID-19 emerged, drug-resistant “superbugs” were a global menace, costing 700,000 lives a year and straining hospital resources. Resistance had arisen to over 70% of bacteria — and to every antibiotic ever developed for use in the ICU setting. Infections once easily treated were requiring more toxic and complex regimens. None of this stopped when SARS-CoV-2 exploded.

“In the shadows of the COVID-19 pandemic,” Croatian scientists have warned, “there has been an ongoing antimicrobial resistance pandemic.”

Actually, the superbug crisis isn’t just “ongoing”; it’s primed to accelerate. Even more patients have taken antibiotics they don’t need. At the same time, those in dire need — patients with drug-resistant tuberculosis, for example — have seen their treatments interrupted. Research on new antibiotics, already lagging, has been halted.

In combination, these developments may well spawn new lethal variants and vexing nosocomial outbreaks. Without immediate action, common procedures — caesarean sections, knee replacements, cancer chemotherapy — will become riskier.

“We might be soon headed towards a post-antibiotic era, where a simple wound or a dental infection can be fatal,” warns Hatim Sati, M.D., a member of a World Health Organization (WHO) task force on antimicrobial resistance. “That is what’s at stake here.”

In response, hospitals must act on two fronts, dispensing antibiotics more judiciously while deploying more robust precautions against infection spread. Critical among these precautions is air disinfection.

Hand hygiene and surface cleaning remain important, but as the COVID-19 catastrophe has laid bare, all the antibacterial rub in the world won’t halt the transmission of an airborne pathogen.

Among the most worrisome superbugs, deemed “urgent” or “serious” threats by the U.S. Centers for Disease Control and Prevention (CDC), are Mycobacterium tuberculosis, Methicillin-resistant Staphylococcus aureus (MRSA), Carbapenem-resistant Acinetobacter and Clostridium difficile — all readily spread via air currents.

“The uncontrolled movement of air in and out of the hospital environment makes the bacterial persistence worse,” a research team noted in the Annals of Clinical Microbiology and Antimicrobials, “since these infectious microorganisms may spread easily through sneezing, coughing, talking and contact with hospital materials.”

Routine activities — mopping a floor, making a bed, cutting a bandage, removing a glove — can propel drug-resistant bacteria into the air. These aerosols can hover for hours and travel far.

Hospitals must be equipped to destroy airborne superbugs on a continual basis before these bacteria infiltrate open wounds, are inhaled by vulnerable patients, or mutate into strains that are impossible to treat.

How COVID-19 Has Amplified The Superbug Crisis

Antibiotics, of course, are worthless against viral infections, whether COVID-19, influenza or the common cold. Yet these drugs are routinely prescribed for patients infected by a virus, a practice that fuels antibiotic resistance.

Prior to the pandemic, over 30% of oral antibiotic prescriptions were unwarranted. Then COVID struck, and the percentage shot up.

Initially, doctors had trouble distinguishing COVID-19 from bacterial pneumonia, often prescribing antibiotics as a default. Or, antibiotics were prescribed for fear COVID patients might have bacterial co-infections. In most cases, the drugs were administered before tests confirmed, or ruled out bacterial infection.

This scenario was repeated on a global scale. Among COVID patients at 38 U.S. hospitals, 56% of patients received antibiotics early on, though just 3.5% actually turned out to harbour bacterial infections. In Europe, 75% of severe COVID patients received antimicrobials, though only 15% had documented infections. Similar numbers were reported in Asia.

Rampant overprescribing of antibiotics to COVID patients has largely stopped, but the damage may already have been done.

What’s more, the pandemic-driven increase in telemedicine has increased antibiotic use among non-COVID patients. In the absence of physical exams or lab tests, doctors reflexively prescribe these drugs for a wide range of symptoms.

“Antimicrobial stewardship may be another casualty of the COVID-19 pandemic,” the Croatian team observed.

An additional casualty: the treatment of patients who actually require antibiotics. Microchips, sofas, and stoves aren’t the only commodities in short supply these days. Antibiotics and diagnostic tests have been scarce, too, what with manufacturing interrupted, stockpiles depleted, travel restricted, and medical clinics shuttered.

Read part 2 of this blog post here. 

“Air quality deserves close attention”: Preventing Airborne Infection in the Operating Theatre 

read part 1 of this blog post here.

Air Contamination in the Operating Theatre

For decades, a surgical patient’s risk of becoming infected was considered largely a factor of the patient’s own health, the surgical team’s skill, and the sterility of the surgical instruments.

Certainly, these factors matter. Patients who smoke, are obese, or have poorly controlled diabetes are at greater risk for infection. Procedures performed meticulously and with sterile instruments lead to fewer infections. However, as Danish scientists have noted, when it comes to infection risk factors, air quality is often disregarded.

It shouldn’t be.

In orthopedic and cardiothoracic operations, in particular, “the risk of surgical site infection is strongly correlated with the amount of airborne bacteria being present in the operating room and the surgical field,” asserts Mikael Persson, Ph.D., a Swedish mechanical engineer.

For example, research confirms airborne transmission of Mycobacterium chimaera from contaminated heater-cooler units commonly used in open-heart surgery. Patients have become infected even when the operating theatres were equipped with ultraclean air ventilation (laminar airflow).

With abdominal and breast surgeries, too, OT air contamination has been directly correlated with surgical site infection.

A team from Denmark and Ghana collected air samples during 124 surgical procedures, 11 of which (9%) resulted in confirmed infection. Substantially more air contamination was detected during the procedures that resulted in infection than during the procedures that did not.

Cementing the link, the scientists used genetic methods to match the bacteria captured in the air with the bacteria collected from the wounds.

In 8 of the 11 infection cases, a species match was found between bacteria isolated from the infection and the corresponding air isolates. In 6 cases, matching ribotypes were found.

The authors note that the hospital, a major teaching facility in Ghana, took great care to prevent infection. The scrub team wore sterile gowns and gloves. Incision sites were disinfected three times. Antibiotics were administered prior to first incision. Between procedures, surfaces and floors were cleaned with a 10% chlorine solution. The room was equipped with HEPA filtration.

Nonetheless, air sampling detected “high levels of airborne bacteria,” far higher, on average, than maximum levels recommended by the Healthcare Infection Society. Pathogens included S. aureus, Klebsiella spp. and Acinetobacter spp.

How do these bacteria infiltrate the operating theatre air and find their way into open wounds?

Airborne pathogens have many sources, including skin scales, dust, textile fibers, and aerosols produced by coughing and talking.

Particles can circulate via the convection currents created by the temperature differences between the body and the environment, explains French surgeon Dominique Chauveaux. In addition, particles settled on an unsterile floor can be dispersed by air eddies generated from opening doors and foot traffic.

In about 30% of SSI cases caused by airborne contamination, infection can be attributed to “direct settling of the particles on the wound,” according to Chauveaux. In the other 70% of cases, bacteria settle on the instruments and surgeon’s hands, “followed by transfer to the wound.”

Helping to Prevent Airborne Infection in the Operating Theatre 

For years, surgeons have relied largely upon prophylactic antibiotics to prevent surgical site infection. However, given the rise of antimicrobial resistance, overuse of antibiotics has become a serious problem.

“Everyone just wants to [use] more antibiotics, [but surgeons] have to be good antibiotic stewards so that we are not the ones who are complicit in creating antimicrobial resistance,” cautions Bryan Springer, M.D., an American orthopedic surgeon.

Recently, attention has turned to keeping the OT air clean, so pathogens don’t have the opportunity to infiltrate wounds or settle on surgical instruments.

“Measures that decrease airborne particle counts are central to diminishing the risk of contamination by airborne microorganisms,” asserts Chauveaux.

Some of these measures rely on the behavior of surgical staff. For example, the surgical team should limit door openings, talk only when necessary, and enter the theatre one by one, rather than as a group. Healthcare workers should remove their gloves away from the surgical instruments and avoid cutting or stretching bandages near the surgical site.

But these strategies can only accomplish so much. As American surgeons have noted, behavioral measures have had just “a marginal impact” in reducing OT contamination or the risk of infections related to joint replacements.

What would have a larger impact? Air disinfection, particularly NanoStrike technology from WellAir.

WellAir’s Novaerus devices utilize NanoStrike Technology to inactivate airborne viruses, bacteria and mould spores. The technology harnesses a range of physical concurrent pathogen inactivation processes to safely disinfect the air. NanoStrike coils provide a powerful strike that works to burst airborne pathogen cells, rapidly inactivating them, ensuring they are no longer a threat of infection. Installed in operating theatres and ICUs worldwide, Novaerus devices safely operate next to the most vulnerable patients.

Though HEPA filtration is considered the gold standard in air purification, filters only trap pathogens. NanoStrike technology inactivates them, one reason Novaerus units are a critical addition to environmental control in the operating theatre.

Cleared by the FDA as a Class II Medical Device, the Novaerus Defend 1050 also protects OT personnel from exposure to “surgical smoke,” the toxic mix of volatile organic compounds (VOCs), other gases, and ultrafine particles emitted by lasers and cautery devices. As the U.S. Centers for Disease Control and Prevention confirms, these particles can cause headache, asthma-like symptoms, and eye, nose and throat irritation.

Surgical site infections are a global problem, affecting countries of all income levels. The cost of these infections, to patients and hospitals alike, is enormous, and hospitals must deploy every possible precaution, including air disinfection.

Writing in The Lancet Infectious Diseases, an American surgeon, Robert Sawyer, describes the magnitude of the SSI crisis, imploring hospitals worldwide to implement more robust measures. “An ounce of prevention,” he asserts, “is worth a pound, yuan, birr, or peso of cure.”

“Air quality deserves close attention”: Preventing Airborne Infection in the Operating Theatre 

A few years back, in an operating theatre at a Japanese hospital, two physicians and two nurses donned gowns and gloves and prepared for a total knee replacement surgery. As the surgical team readied the instrument table and wrapped the patient’s leg, a highly sensitive camera filmed the action — not the team’s performance but rather the whirl of airborne particles stirred up by their movements and illuminated by a green laser. 

Nobody’s knee was actually replaced in that room. The procedure was a simulation, designed to determine which movements spawn the most airborne particles which cause airborne infection in the operating theatre (OT) and where in the room these particles congregate.

Preventing Airborne Infection in the Operating Theatre 

These are vital concerns. Airborne particles — dust, bandage fibers, skin scales, respiratory aerosols — can transport dangerous bacteria onto a surgeon’s gloves or scalpel or directly into an open wound, triggering serious infection.

Surgical site infections (SSI), the costliest and most feared of all healthcare acquired infections, plague hospitals worldwide. In low-income countries, over 10% of surgical patients become infected; in some regions a C-section or GI surgery might carry an infection risk of 19% or 23%. Even in wealthy countries, 2% to 4% of surgical patients develop infection; in emergency trauma surgery, that risk may rise to 15%.

Treatment for SSI can require a lengthy hospital stay and complex revision surgery. In the United States, surgical site infections are associated with nearly 1 million additional inpatient days, and 3% of surgical site infections turn lethal. In Africa, the death rate is nearly 10%.

Mortality rates are highest among patients infected with drug-resistant bacteria, such as Methicillin-resistant Staphylococcus aureus (MRSA), a common scenario and grave concern in the superbug era.

Even when hospitals take extreme care to disinfect wounds, sterilize devices, and clean the operating theatre, infections can take root. That’s because in most SSI cases — perhaps 80% to 90% — infections are triggered by pathogens that descended from the air.

“Contamination by airborne microorganisms plays a central role in the pathogenesis of surgical site infections,” asserts Dominique Chauveaux, a French orthopedic surgeon, who urges hospitals to make SSI prevention a “major priority.”

U.S. surgeons, writing in the American Journal of Infection Control, consider bacterial contamination of OT air “an underappreciated factor” in the origin of prosthetic joint infections.

Air quality deserves close attention

How do airborne pathogens infiltrate the operating theatre despite high disinfection standards and use of HEPA filters? Most important, how can the particle count be reduced?

The Japanese knee-replacement simulation offered some insight. Even the smallest movements — removing a glove, cutting a bandage, lifting a patient’s leg — can unleash an abundance of particles. When a surgical team files into the operating theatre, another study found, the particles stirred up by their shoes and gown hems drift to the level of the operating table.

Certainly, moving less, talking less, and limiting OT personnel can minimize air contamination. Still, measures like these aren’t enough. Neither are ventilation and air-filtration systems.

As U.S. surgeons point out, traditional precautions “have thus far resulted in failure to reduce the risk of microbial aerosols or contamination of implantable devices during arthroplasty surgery.”

Given the prevalence and virulence of surgical site infections, the surgeons argue, hospitals must augment traditional precautions with “innovative air purification technologies.”  

A clean, quiet operating theatre and skilled surgical staff can do much to protect a patient from infection. Air disinfection technology that inactivates pathogens at the DNA level can amplify that protection considerably.

Prosthetic Joint Infections: “Particularly devastating”

Appendectomy, abdominal hysterectomy, craniotomy, coronary bypass — all surgical procedures carry a risk of infection. However, prosthetic joint infections are “particularly devastating,” as Japanese scientists observe. Reducing these infections is both urgent and challenging.

“Since fighting infections depends on blood flow (which artificial implants obviously don’t have), both for an effective immune system response and to deliver antibiotics to the area, joint replacements can become safe havens for bacteria,” explains Jonathan Cluett, M.D., an American orthopedic surgeon.

What’s more, as the global population ages and obesity rates rise, hip and knee replacements will become increasingly common. Experts project a 13% increase in joint replacements and a 14% increase in resulting infections by 2030. A single infection can cost over $400,000. The death rate in these cases is an estimated 2% to 7%.

“A periprosthetic joint infection can be as medically challenging to the patient as having cancer,” says Jeremy M. Gililland, M.D., a American orthopedic surgeon. Though the infection risk is 2% for a low-risk patient, “if that patient gets an infection, it is 100% detrimental to them.”

In many cases, the surgeon must remove the infected implant, cleanse the joint cavity, and implant a temporary joint spacer that is removed after 6 weeks of IV antibiotic treatment. About 10% of all arthroplasties are revisions. For these surgeries, the infection risk rises to 15% to 20%.

It’s not just joint replacements that often require re-operation after infection. In a British study, for example, 8% of neurosurgery patients became infected, and 9 out of the 20 infected patients required reoperation.

Read part 2 of this blog here.

Read part one of this blog post here.

“We Need to Face Reality Here”: Hospitals Must Prepare for the Next Pandemic

What Hospitals Must Do to Avert the Next Pandemic

Certainly, many critical pandemic precautions fall beyond the scope of hospitals. Governments, for example, must invest in more robust pathogenic surveillance — that is, sampling of animal populations to detect viruses that lurk — and in the development of vaccines that protect against multiple viruses at once. At the same time, much can be done at the hospital level.

Covid-19 Pandemic Effect On Hospitals 

When Covid-19 struck, overrun emergency departments not only lacked the staff to care for infected patients but also lacked sufficient personal protective gear. On top of that, public-health experts assumed SARS-CoV-2 did not spread via aerosol, the same deadly and erroneous assumption that had been made decades earlier with measles and tuberculosis.

As a result, Covid-19 ripped through hospitals. A review of early cases in China found 44% of Covid-19 infections were hospital acquired. At a hospital in South Africa, a single case led to 119 infections and 15 deaths among staff and patients at five hospital wards, a nursing home, and dialysis unit. Eventually, precautions and protocols changed. Today, lessons learned from the early Covid period are driving hospital planning for the next pandemic.

Increasing surge capacity is a top priority, and plans run the gamut. Some hospitals are training rheumatologists and pediatricians to jump to intensive care in a pinch. Others are looking to architectural solutions, such as airport-like docking stations with interlocking modules that could quickly expand the emergency department — an improvement over the tent-in-the-parking-lot approach hospitals deployed at the height of the Covid crisis.

“Most EDs are poorly designed to protect staff, other patients, and visitors from highly contagious airborne transmission of an epidemic disease,” says Frank Zilm an architect specializing in healthcare design at the University of Kansas in the United States.

A hospital in Italy installed a “plug-in biocontainment pod” devised from a shipping container. In Los Angeles, architects are working on a way to erect, within days, a medical mini-city that could accommodate 1,000 patients and 6,000 staff.

Less grand and expensive ways of defending against pandemic disease include zero-contact intake systems, which allow for remote triage and patient registration. At one Boston hospital, for example, an iPad-equipped robot named Spot acts as intermediary between medical staff and potentially infectious patients. Still, all the innovations in architecture, robotics, and telemedicine won’t change reality: Hospitals are full of human beings, including infectious ones who need to be cared for, up close, by medical staff, and who share the same air as vulnerable patients on the premises.

That’s why hundreds of hospitals have turned to air dis-infection, particularly Novaerus NanoStrike technology by WellAir, as a means of preventing spread of Covid-19 and other airborne diseases, current and future.

Even before SARS-CoV-2 emerged, hospital-acquired infections — whether caused by viruses, bacteria, or fungi — were endemic. Each year in high income countries, 5% to 10% of hospitalized patients, including 30% of patients in intensive care units, were contracting an infection during their stay. Before Covid-19, in Europe and the United States, hospital pathogens were infecting nearly 6 million patients annually and were responsible for 140,000 deaths.

Covid-19 has only amplified the crisis and brought more attention to the airborne route of transmission.

NanoStrike Technology 

NanoStrike is the unique, patented technology at the core of all Novaerus portable air dis-infection devices. The nanotechnology harnesses a range of physical concurrent pathogen inactivation process to safely dis-infect the air. Hospitals in over 65 countries have deployed Novaerus devices, particularly in operating rooms, intensive care units, emergency departments, waiting rooms, and surgical theatres.

Independent laboratory testing shows that within 15 minutes, the Novaerus Defend 1050 achieves a 99.99% reduction of the MS2 bacteriophage RNA virus, an accepted surrogate for SARS-CoV-2.

NanoStrike technology has shown similar efficacy with other airborne pathogens that hover in hospitals, including influenza, Clostridium difficile, Aspergillus, and surrogates for Measles virus, Mycobacterium tuberculosis, and Methicillin-Resistant Staphylococcus Aureus (MRSA).

In a 2015 article titled “The Next Pandemic: Hospital Management,” three physicians wrote: “The threat of pandemic infectious disease lurks quietly beneath the surface of everyday hospital operations and society at large.”

Though “moments of panic inspire waves of planning,” the doctors continued, the waves inevitably crest, planning becomes submerged by daily demands, and ultimately, nothing changes.

Post-Covid, of course, complacency is impossible. Hospitals, nursing homes, society at large — we’ve all experienced a tidal wave, and the threat of the next one can’t be ignored.

Even when the Covid pandemic ends, SARS-CoV-2 will remain among us, and the next pandemic pathogen will almost certainly be airborne as well. No matter what other precautions hospitals invest in, they must also upgrade their air dis-infection technology, one of the least expensive and most effective defenses against the spread of deadly disease.  

If you are a medical or healthcare facility interested in learning more about the Novaerus products, additional information can be found here, or please contact Novaerus.

“We Need to Face Reality Here”: Hospitals Must Prepare for the Next Pandemic 

Back in 2018, a year before SARS-CoV-2 began stalking the globe, American scholars issued a report on the likely traits of the next pandemic pathogen. 

The scholars, from the Johns Hopkins Center for Health Security, were on the hunt for microorganisms that could cause worldwide catastrophe — “a sudden, extraordinary, widespread disaster” that would trigger great suffering, death, and economic damage. 

What they concluded: The culprit would be airborne, and the resulting respiratory disease, with a low but significant fatality rate, would be contagious before symptoms surface. 

“We need to get serious about respiratory viruses,” Amesh Adalja, M.D., the report’s lead author, warned at the time. “There’s a lot of focus on diseases that aren’t going to be able to change civilization in a way that something that’s spread through the respiratory route would be.” 

Of course, Adalja’s report, which listed coronaviruses among the most likely suspects, was spot on. 

Now that the predicted catastrophe has materialized and much of the world was caught flat-footed, experts have issued a new warning they hope will be better heeded: We must prepare, in a more serious way, for the next pandemic.  

“The risk of pandemics is increasing rapidly, with more than five new diseases emerging in people every year, any one of which has the potential to spread and become pandemic,” warns a United Nations report, issued during the Covid crisis. 

Whether the pandemic is set off by a coronavirus, an influenza strain, or another pathogen altogether, Adajla says today, preparations should focus on “any kind of efficiently spreading respiratory virus” — in other words, disease with the capacity to spread through the air. 

“We need to face reality here,” says Edward Holmes, Ph.D., a virologist at the University of Sydney, who monitors bat viruses and suspects another coronavirus pandemic is imminent. “The next one could come at any time. It could come in 50 years or in 10 years. Or it could be next year.” 

When it does come, will hospitals be ready?  

As they continue to battle Covid-19, healthcare facilities are simultaneously planning ahead, exploring, if not already implementing, protocols and technologies that will better protect patients and staff from airborne microorganisms. 

Given the toll of the current pandemic, no hospital can delay preparing for the next one, says Richard Waldhorn, M.D., an expert on hospital emergency preparedness with the Johns Hopkins Center for Health Security.  

“It’s very important to prevent the hospital from becoming a disease amplifier.”  

“The Virusphere is Just Immense” 

Pathogens harboured by animals have jumped to humans for decades, but in the distant past, when individuals acquired deadly infections this way, they likely fell ill and died in the vicinity.  

“Now an infected person can be on a plane to Paris or New York before they know they have it,” says Dennis Carroll, PhD, an emerging infectious disease expert with the U.S. Agency for International Development. 

Global travel and trade, urbanisation, deforestation, agricultural expansion, climate change — all are bringing humans into closer contact with bats, livestock, and other animals that harbour dangerous viruses.  

“We are rolling the dice faster and faster and more and more often,” says Raina Plowright, Ph.D., a virus researcher at the Bozeman Disease Ecology Lab in Montana. 

According to the U.N. report, mammals and birds may host more than 800,000 undiscovered viruses that could be transferred to humans. 

Edward Holmes, the Australian virologist, found 24 new coronaviruses in several hundred bats in a small region of southern China; a number of the pathogens were related to SARS-CoV-2 and SARS-CoV, the virus that caused the 2003 SARS outbreak in China and four other countries. 

“We’re only just starting to scratch the surface,” says Holmes. “The virusphere of coronaviruses is just immense.” 

Then again, the next pandemic pathogen may not be a coronavirus. The deadly Nipah virus, another airborne virus carried by bats, ranks among the World Health Organization’s top 10 priority diseases. So does MERS, a respiratory coronavirus harboured by camels that emerged in 2012 in the Arabian peninsula and remains a threat. 

Then there’s influenza: 30 influenza pandemics have occurred in the past 400 years, including four in the last century.  

“Based on [influenza’s] genetic structure, it’s really only a matter of time before new strains emerge that have the capacity for efficient human-to-human transmission,” says Amesh Adalja. 

Read part 2 here.