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Lord Soulsby of Swaffham Prior: My Lords, this House must be very grateful to my noble friend Lady Gardner of Parkes for this debate on hospital-acquired infections at a time when hospital wards will be increasingly busy with the onset of winter, with more elderly people in those wards, more intensive and invasive procedures being performed for diagnostic tests, and, above all, a population of bacteria that are
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increasingly resistant to antibiotics, many of which are proving to be quite useless in the treatment of infection.
The organism of primary concern has been mentioned—namely, methicillin resistant staphylococcus aureus, or MRSA. This still hits the headlines in the news media. As other noble Lords have said, it is a sobering fact that European Antimicrobial Resistance Surveillance System in 2002 identified the United Kingdom as having the highest level of resistant MRSA bloodstream infections, as a proportion of all staphylococcus aureus bloodstream infections, in Europe—that is, 43.9 per cent. Nearly 50 per cent of all bloodstream aureus infections were resistant. That is compared with the system in Sweden, where the figure is 0.7 per cent, and in Denmark where it is 0.9 per cent.
I mention Sweden and Denmark particularly as those two countries have taken very strong measures to control antibiotic resistance in general, including the abolition of the use of antibiotics as growth promoters in livestock. It may to noble Lords seem a very far cry from resistance in hospital wards to staphylococcus aureus, or MRSA, to the use of antibiotics as growth promoters in animal feed. But there most likely is a connection, and the Swedes and Danes will recognise that because there is an increasing and massive environmental contamination of the genes of resistant organisms generally spread throughout the environment, derived from massive use of antibiotics in medical, veterinary and horticultural circumstances.
I tend to call it genetic zoonosis, whereby the genes of the resistant organisms are very widespread. We should remember that when we use antibiotics for the treatment of pathogens in whatever animal, whether human or otherwise, there is a far greater population of bacteria—the commensals—that are also exposed. They become resistant and transmit resistance to other commensals and other pathogens. That is an increasing problem, which I am glad to say Defra is now taking up to study in greater detail.
The statistics of hospital-acquired infections are of course horrendous. They have been mentioned by other noble Lords. At least 100,000 hospital-acquired infections occur per year, and 5,000 deaths are directly attributed to them. Another 15,000 deaths are contributed to substantially by such infections. Those statistics, as stated by the Chief Medical Officer, cannot convey the human toll that goes along with MRSA. There is an abundance of reports of previously healthy people who have become seriously ill or died as a result of hospital-acquired infection. We have just heard the noble Baroness, Lady Pitkeathley, give a graphic account of how near she was to death.
At times, people enter hospital for minor procedures and/or minor surgery, and then suffer from infection. A friend of mine recently told me that she went to a major hospital in an area not too far from here, having broken a bone in her wrist. Following surgery, her whole wrist became infected with MRSA. It was eventually controlled with vancomycin treatment, but she was warned that she might have to have her hand amputated if the treatment was not successful.
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So what do we have to do about this? There is no doubt that the magic bullets of antibiotics have lost their magic, and many people feel that the bugs are winning. The human toll is growing and the economic burden to the health service must be great. I wonder whether the Minister has any information on that matter. The report from the National Audit Office in 2000 estimated an amount of £1 billion a year. I wonder what that figure is now. Will the Minister give us some idea?
What progress has there been in the reduction of hospital-acquired infections? Mention has been made of the CMO's report of 2003, Winning Ways, which showed that the degree of improvement has been small. In the debate on 8 December 2003, when I had the privilege of introducing the Science and Technology Committee report on fighting infections, it was noted that the new Health Protection Agency would appoint an inspector of microbiology and in addition £12 million would be provided to tackle hospital-acquired infection. What progress has been made by the inspector? Has the funding been adequate, and is it still available for this important area?
While major attention is, rightly, directed towards MRSA, there are other organisms. One of these is the problem of antifungal agents. They have received a low profile in debate, but the yeast candida albicans is an opportunistic fungal pathogen causing severe and potentially fatal disease in immuno-suppressed patients, especially those with AIDS. Fungi differ from bacteria in that the potential for the rapid emergence of resistance is much less with candida than with bacteria. Nevertheless, the fungal infections in AIDS patients are a serious problem, leading to the appalling mouth infections that one occasionally sees.
As a postscript to the currently sad tale of hospital-acquired infections and MRSA, the pipeline for the development of new antibiotics is drying up. Major pharmaceutical companies are increasingly less interested in investing in the development of antibiotics. It is a prolonged and costly business to do so, and the product that is so developed may end up with a very short clinical life due to antibiotic resistance. Can the Minister give us any idea of what encouragement the Government are giving to pharmaceutical companies, large and small, to undertake antimicrobial discovery for the future?
The Infectious Diseases Society of America, which details problems in the United States which are very similar to those we are talking about today, has put out the following cryptic message:
I believe that we in the United Kingdom are very much in the same position: hospital-acquired infection is a public health crisis and antibiotic discovery is stagnating. Perhaps I may ask the Minister what action he and his department think needs to be taken to alter this situation.
Lord Turnberg: My Lords, I too am very pleased to commend the noble Baroness, Lady Gardner of Parkes, on introducing this very important topic. I am
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also aware that much of what I shall say has been said very eloquently by others. It was hard not to be moved by the speeches of the noble Lord, Lord Eden, and the noble Baroness, Lady Pitkeathley, who so eloquently described what happened to them. I have to express my interest as an ex-physician and as ex-chairman of the Public Health Laboratory Service, now the Health Protection Agency.
It is an opportune time to be debating this topic again because, as we have heard, the Government are trying very hard to get at the causes of hospital- acquired infections. I say "debating this topic again" because, of course, it is not the first time we have discussed it. Indeed, when I was thinking about what I might say, I realised that the reason it was so familiar was that I gave my own maiden speech in a debate on the subject four and a half years ago. Some might say that I am in a rut. But the issue was not new even then, and if the problem was easily soluble we would have done it by now. Certainly quite a lot of effort has gone into it. But just as the causes and contributing factors to these infections are multiple, so their prevention and treatment will have to be multifactorial too.
My overall request to my noble friend the Minister, as he attacks the problem with his customary vigour, is that the Government do not focus too hard on only one or two potential remedies, but look more broadly at a range of simultaneous actions that will be necessary, including the need for more research and information, which is surprisingly lacking in a number of areas.
There are some factors that contribute to the high incidence of hospital-acquired infection which we can do little about. For example, the patients who are most at risk of getting a bacteraemia—that is, the bacteria entering the bloodstream and potentially leading to septicaemia—are likely to be those who are the most sick and the most elderly. Of course it is not only those, but they are the vast majority. It is just those patients who are vulnerable and whose immunity is at its lowest ebb who die of hospital-acquired infections. But it is just those sorts of patients who require the care that only hospitals can provide, as the noble Baroness, Lady Pitkeathley, described. Most younger, fitter patients are treated at home. So we cannot do too much about that.
As other noble Lords have mentioned, there is also not much we can do, in the short term at least, about the horrendously high bed-occupancy rates: over 90 per cent in most hospitals and over 100 per cent in some. I could explain how it is possible to occupy beds over 100 per cent, if anyone so wished. However, these rates are the highest in Europe, where the average is nearer 70 per cent, and that is despite the enormous investment that the Government are making in new hospitals. The investment is making a difference, but we still have some way to go before we can afford what they seem to be able to do in Holland; for example, where they can close wards and even whole hospitals without apparent pain. We can ill afford to do that when waiting list initiatives would be frustrated and managers' jobs are on the line.
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Although I am delighted to commend the Government on increasing numbers of doctors and nurses in the health service—a very welcome step in the right direction—it is still the case in many hospitals that staff are run off their feet, and washing one's hands while running about is not an easy act. If, for example, you have a doctor doing a ward round of 30 patients, which is an average ward round, and she stops to wash her hands after every patient, which takes on average an estimated two minutes, that would add an extra hour to the ward round, to say nothing of the sore hands.
I know that more staff are in the pipeline, but, meanwhile, high patient throughput and rushed staff under pressure are not conducive to best practice. These background factors form the context in which we have to try to introduce change, and they will in themselves limit what can be achieved by the methods and the measures we can and should introduce.
So what can we do? First, we have to recognise that the organisms that cause the life-threatening infections may be very widespread on carriers who themselves are not affected by them. Such is the case for staphylococci, which many of us carry in our noses and which of course may be carried by staff and visitors as well as patients. I speak here not of MRSA—not of methicillin resistant staphylococcus—but of sensitive staphs, which means that they are potentially treatable with methicillin. But we should not make the mistake of believing that that is a minor infection. It will kill vulnerable patients just as readily as MRSA if it gets into their bloodstreams and they do not get their methicillin quickly enough. So it is potentially dangerous, but we cannot easily prevent it getting into hospital.
What about MRSA? This seems to be much less widely distributed in the population, but even here we do not know much about its distribution. We can do with more research on that. It is found mainly in hospital patients, most of those affected being carriers, for example, on their wound infections and the like, and in nursing homes. It is most often spread by patients coming from other hospitals and by staff. Incidentally, the high use of agency staff who move around quite a bit from hospital to hospital is a potential risk. I would certainly urge my noble friend to look at whether agency staff present a real risk or simply a theoretical one.
It follows from all of that that the major teaching hospitals and specialised hospitals—which receive most patients from other hospitals, who are often the most sick—are most at risk.
One way of tackling the problem of inter-hospital transmission would be to use a simple, rapid diagnostic test on nasal swabs of all patients on transfer to a new hospital, a test that would have to be available and tell one within a few minutes whether a patient was clear of MRSA. That would be enormously beneficial, but unfortunately such a test is not yet available. There is research into this. Perhaps I may urge my noble friend to invest in the continuing research needed to bring such a test into practice.
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Perhaps I may also say a few words about MRSA, in contrast to the comments of the noble Lord, Lord Soulsby. I have had conversations with colleagues at the Health Protection Agency about the problem of development of antibiotics. I understand that although MRSA is certainly resistant to methicillin, they believe that it is not untreatable. The picture is somewhat less bleak, in that there are now at least four new antibiotics in use to which MRSA is sensitive and five others are undergoing trials. I am trying not to downplay the dangers of MRSA, but simply to point out that all staphylococci are dangerous if they enter the bloodstream. They are very nasty and need urgent treatment. It is not just MRSA that needs treatment.
I have deliberately steered clear so far of the business of cleanliness—not because it is unimportant, as the noble Lord, Lord Eden, so graphically described; it is clearly very important—but because I wished to put it into the perspective of everything else that needed attention. Clean wards are an entirely desirable basic need; they are the baseline upon which we should be working. Even more important is the thorough cleaning of beds, mattresses, lockers and all the various telephones and attachments which patients use when one patient goes out and another comes in. However, all that comes at a cost—in this case to the patient, who may have to wait another hour on a trolley in the accident and emergency department while all of that is going on, due to high bed-occupancy rates.
Of course, cleaning hands between patients is vital. But washing at a sink is impractical, as other noble Lords have said. But now we have available alcohol gels which are probably much more effective than soap and water. It is an important advance, because hands can be cleaned much more quickly and it is good for the skin, too. I understand that ladies love the gel because it contains glycerol and makes hands feel nice and soft. This is a practice that clearly needs to be spread far and wide and is something that could be monitored, for example, by hospital pharmacists who could keep a note of the ward usage of gels. It is a matter of monitoring.
There are yet more areas that need exploration. Greater attention to aseptic techniques in the insertion and aftercare of intravenous lines, which are a potent cause of bacteraemia, has already been mentioned. There should be a survey of the practices of those hospitals which seem to manage to avoid hospital-acquired infections, at least regarding MRSA. MRSA rates vary enormously, from around 1 per cent to some 50 to 60 per cent of all bacteraemia. It is unclear why there is such a variation. Why has the Homerton Hospital only a 1 per cent rate? That would certainly merit some research. Research into why some carriers of infection seem to be so-called super-shedders, who spread their germs much more widely than others, would be of interest.
There is much that can and should be done. But if we are to surmount the problem we will need to attack it in a number of ways—multi-focused attacks. I hope that I can encourage my noble friend to take a holistic approach.
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4.23 p.m.
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