The hospitals in India have a high burden of infections in their intensive care units (ICUs) and general wards, many of which are resistant to antibiotic treatment, according to a report by Global Antibiotic Resistance Partnership (GARP) – India Working Group and Centre for Disease Dynamics, Economics and Policy (CDDEP). The 2011 GARP report - Situation analysis: Antibiotic use and resistance in India, also states that a large proportion of these hospital-acquired infections (HAI) are preventable with proper increased infection control measures.
Antibiotic resistant infections are difficult and sometimes impossible to treat. They lead to longer hospital stays, increased treatment costs, and in some cases, death. The GARP research estimates that of the approximately 190,000 neonatal deaths in India each year due to sepsis – a bacterial infection that overwhelms the bloodstream – over 30 per cent are attributable to antibiotic resistance. Antibiotic resistant hospital infections can be especially deadly because antibiotics are used intensely in hospitals compared with the community, and frequent use drives the development of highly resistant bacteria. A large proportion of these hospital infections are easily preventable with increased hospital infection control, including stepping up hygiene practices.
Hospital-acquired infections
Organisms causing hospital infections in India are similar to those around the world, with S. aureus and P. aeruginosa among the most common disease-causing pathogens. A prospective study of 71 burn patients at Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh found that up to 59 patients (83%) had hospital-acquired infections: 35% of pathogens isolated from wounds and blood were S. aureus, 24% were P. aeruginosa, and 16% were ß-haemolytic streptococci. Research on hospital infections in India reveals several concerning trends. In Indian ICUs, the rate of vancomycin-resistant enterococcus (VRE), a dangerous hospital infection, is five times the rate in the rest of the world. Rates of methicillin-resistant Staphylococcus aureus in Indian ICUs are also high, with one study finding over 80% of S. aureus samples testing positive for resistance to methicillin and closely related antibiotics.
An another six-month study conducted in 2001 of ICUs at AIIMS in New Delhi, found that 140 of 1,253 patients (11%) had 152 hospital-acquired infections, where P. aeruginosa made up 21% of isolates, 23% were S. aureus, 16% Klebsiella spp., 15% Acinetobacter baumannii and 8% Escherichia coli. Further, a study of 493 patients in a tertiary teaching hospital in Goa also found that 103 people (21%) developed 169 infections.
Infection control practices
In India, however, hospitals often do not follow infection control practices, and this leads to the spread of disease. In response to the growing burden of HAIs in India, GARP is issuing several key recommendations that aim at reducing the prevalence of HAIs, including increased hand-washing, use of isolation rooms for infected patients, increased availability and uptake of diagnostic tests, reminders to limit catheter use, and use of gloves and gowns. The ministry of health and family welfare task force also recommends that all hospitals create an infection control plan, committee and team.
Surveillance of antibiotic resistance, combined with tracking physician prescribing patterns, can be the foundation of successful infection control programme in hospitals. But, surveillance is a challenge in many places, where microbiology labs and trained staff may be unavailable. Infection control committees have to meet with uncooperative hospital staff and administrators. The greatest challenge is to empower infection control committees and make hospital staff aware of their activities and recommendations.
In all these instances it has been found that existing infection control practices such as hand washing and judicious use of disinfectants to clean the equipment is of limited benefit. The most commonly implicated method of transmission of infection within such closed environments such as the ICU is the touch surface. These touch surfaces comprise of all the material in the ICU that is commonly handled by all the medical and paramedical staff as well as visitors and the patients themselves.
Disinfection of these touch surfaces made of conventional materials do not remain sterile for long and in fact act as reservoirs of infection causing bactria, fungi and viruses. Objects in closest proximity to patients have the highest levels of staphylococcus, MRSA, and VRE. This is why touch surfaces in hospital rooms can serve as abundant sources, or reservoirs, for the spread of bacteria from the hands of healthcare workers and visitors to patients. However, if the surfaces are made of the alloys of copper containing at least 60% of copper then they automatically eliminate all forms of organisms, becoming sterile within few hours.
Studies being conducted at the University of Southampton in UK are proving that copper and its alloys, brass and bronze, effectively eliminate bacteria and viruses that cause illness. The research has also shown that conventional touch surfaces do nothing to help eradicate germs. Once contaminated, a stainless steel doorknob, faucet or handrail can harbour bacteria and viruses until it is disinfected, usually with harsh chemicals, even then the organisms would survive in the micro Scratches on their surfaces.. However, uncoated copper, including brass and bronze alloys with high copper content, are intrinsically antimicrobial and begin eliminating pathogens such as streptococcus, staphylococcus and Influenza A on contact. Microorganisms are known to survive on inanimate ‘touch’ surfaces for extended periods of time. This can be especially troublesome in hospital environments where patients with immunodeficiencies are at enhanced risk for contracting nosocomial infections (hospital-borne infections), often with fatal consequences.
Touch surfaces commonly found in hospital rooms, such as bed rails, call buttons, touch plates, chairs, door handles, light switches, grab rails, intravenous poles, dispensers (alcohol gel, paper towel, soap), dressing trolleys, and counter and table tops are known to be contaminated with high levels of potentially dangerous bacteria, including Staphylococcus, Methicillin-resistant Staphylococcus aureus (MRSA), one of the most virulent strains of antibiotic-resistant bacteria and Vancomycin-resistant Enterococcus (VRE).
Recently, to evaluate their effectiveness as secondary infection control measures, these products have been made from copper and its alloys and deployed in hospital geriatric wards, ICUs, and general medical wards around the world. Clinical trials are being conducted on microbial strains unique to individual healthcare facilities around the world to evaluate to what extent copper alloys can reduce the incidence of infection in hospital environments. The success of these clinical trials to date, which are summarized here, are prompting hospitals around the world to specify antimicrobial copper touch surfaces as an additional weapon in the fight against infection.
Clinical trials in UK
In the United Kingdom, around 300,000 patients contract nosocomial infections each year and at least 5,000 patients die of complications from infections contracted in hospitals. For these reasons, a cross-over clinical trial (a test method designed to eliminate variability bias from patients, staff, cleaning efficacy, outbreaks, etc.) evaluating antimicrobial copper alloys was carried out at Selly Oak Hospital over an 18-month period in 2007-08 by the University Hospital Birmingham NHS Trust and Aston University.
Frequently touched surfaces typically manufactured with standard materials (i.e., plastic, chrome, aluminum) were replaced with copper alloys. These included a copper alloy set of sink tap handles (60% Cu, 40% Zn) and a ward entrance door push plate (70% Cu, 30% Zn).Contamination reductions of 90-100% were observed for , Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Enterococcus spp., and Candida albicans on the copper alloy surfaces versus the non-copper standard surfaces. A microorganism reduction of 100% was observed on the hot tap copper alloy handle. The high degree of clinical performance suggested that copper alloy surfaces may increase the effectiveness of existing infection control practices and may lower the risk of infections acquired in healthcare facilities.
Based on the results of this and other lab and clinical studies, St. Francis Private Hospital, a 140-bed facility located in Mullingar, County Westmeath, Ireland, decided to become the first hospital in the world to fully specify hygienic copper door handles throughout its facility as part of its infection control program. A full upgrade of all door furniture (i.e., 250 doorsets, incorporating handles, push plates and privacy locks) to antimicrobial copper in the hospital and nursing home commenced in January 2010.
Clinical trials in Chile
In Chile, 70,000 nosocomial infections are reported each year, most commonly from common hospital-borne pathogens such as S. aureus, P. aeruginosa and A.baumanii.
In a 30-week clinical trial at the Hospital del Cobre, in Calama, extensive microbial analyses were implemented at the facility’s ICU. Nine hundred ninety copper surfaces from 90 rooms containing 6 different copper objects were studied against an equivalent number of rooms and surfaces containing non-copper objects. Over-the-bed tables were made from copper alloy. Bedrails were cladded with copper alloy foils. Visitor chairs were fitted with copper alloy armrests. Copper alloy intravenous poles were provided. Writing pens used to input data on a touch screen were made from brass (70% Cu, 30% Zn).
Results of this clinical trial demonstrated an approximately 90% reduction of microorganisms on the copper items compared to the controls after ten weeks. A reduction in the total microbial burden was seen for each class of microbe evaluated. Furthermore, continuous antimicrobial activity of copper persisted throughout the study. Copper was effective in reducing microbial loads on all 6 surfaces tested (i.e., bed rails by 91%, bed levers by 82%, tray tables by 83%, chair arms by 92%, monitor pen by 49%, and IV poles by 88%).
Average microbial burden counts in rooms with copper touch surfaces were significantly lower than in rooms without copper surfaces. Staphylococci were the most predominant microorganism isolated and copper was effective in reducing the Staphylococci microbial burden. Further studies regarding the clinical implications of copper’s intrinsic ability to reduce microbial burdens in hospitals are being planned.
Clinical trials in Japan
Researchers from the Kitasato University School of Medicine conducted antimicrobial studies of S. aureus, E. coli, and P. aeruginosa on various Japanese copper alloy coins and on copper alloy plates. The microbes were strains from hospital environments. Copper and its nickel-silver, cupronickel, and brass alloys were found to kill the bacteria within a short time. Due to the success of these results, a 2-year clinical trial was conducted to monitor contamination levels of nosocomial bacteria in the dermatology ward and neonatal intensive care unit (NICU) at Kitasato University Hospital. The antimicrobial efficacy of copper on floors, sinks, push plates, showerheads and doorknobs was evaluated by comparing bacterial loads on these surfaces and on their non-copper counterparts.
The number of viable Staphylococcus spp organisms on surfaces containing copper and its alloy were reduced by half to one-thirtieth of that on control surfaces, depending upon surface humidity and the frequency of contact. Similar definitive findings were also obtained for Pseudomonas aeruginosa. The bactericidal activity of copper was also tested against two strains of MRSA and S. aureus in vitro to determine whether copper alloys are effective in preventing the spread of contamination on the touch surface products used in the hospital ward. MRSA and S. aureus counts fell below detection limits within 180 minutes. The results indicated that copper has a strong bactericidal effect against S. aureus, including MRSA.
When a copper plate was situated on an MRSA-infected floor in the dermatology ward around a bed of a MRSA-infected patient, the bacterial count of S. aureus, including MRSA and the other Staphylococcus on the floor covered with a copper plate was significantly less than on a floor unprotected by copper alloys. These results suggested that the copper plate helped to prevent the spread of MRSA contamination in the hospital.
Clinical trials in South Africa
Multidrug-resistant and extremely drug resistant Mycobacterium tuberculosis (MTB) is responsible for the spread of tuberculosis in South African hospitals. Test strains of Candida albicans, Pseudomonas aeruginosa, Klebsiella pneumoniae meticillin-resistant Staphylococcus aureus (MRSA), and MTB were isolated from South African patients at a hospital’s intensive care unit in order to establish the minimum in-vitro copper concentrations to produce sterilization against these microbes and yeast. Acinetobacter baumannii was isolated from a patient in a burn unit and two clinical strains of MTB were collected and tested.
Copper and its alloys demonstrated antimicrobial activities against multiple-antibiotic-resistant nosocomial bacteria and C. albicans isolated from the hospital. Copper and its alloys showed a marked inhibitory effect (88-98%) on MTB despite the strain’s drug resistance. The researchers concluded that the minimum concentration of copper to be an effective antimicrobial agent is >55% for yeasts and bacteria. Higher concentrations of copper were found to be necessary to inhibit MTB.
Clinical trials in USA
In the USA, a high degree of statistical significance is needed to provide a convincing argument to U.S. federal government healthcare authorities, such as the Centers for Disease Control and Prevention (CDC), regarding the effectiveness of copper alloys in reducing microbial loads and cross infection in healthcare environments. For this reason, clinical trials at three major US hospitals examined environmental bacterial loads, infection rates, and impacts on cross-contamination in intensive care unit (ICU) rooms retrofitted with copper touch surfaces versus rooms without copper surfaces.
The trials were funded by the US Department of Defense (DoD) under the Telemedicine and Advanced Technologies Research Center (TATRC), a section of the United States Army Medical Research and Materiel Command (USAMRMC). DoD has extraordinary interests in the potential for antimicrobial copper surfaces to reduce hospital-acquired infections because it wants to prevent hospital-acquired infections among thousands of its enlisted armed forces servicemen and servicewomen who have been injured in recent conflicts. TATRC, which funds a Military Infectious Disease Programme. The studies are coordinated through the Advanced Technology Institute in Charleston, South Carolina.
The clinical studies involve intensive care units (ICUs) at Memorial Sloan-Kettering Cancer Center in New York City, one of the world’s most prestigious cancer facilities, the Medical University of South Carolina, and the Ralph H. Johnson VA Medical Center in Charleston, South Carolina.
An evaluation of the microbial burden of various objects in the ICU rooms has been documented and is available. Early results disclosed in 2011 indicate that the coppered rooms demonstrated a 97% reduction in surface pathogens versus the non-coppered rooms. This reduction is the same level achieved by “terminal” cleaning regimens conducted after patients vacate their rooms. Furthermore, of critical importance to health care professionals, the preliminary results indicated that patients in the coppered ICU rooms had a 40.4% lower risk of contracting a hospital acquired infection versus patients in non-coppered ICU rooms.. The final analysis indicated that the infection rate in the ICU areas where almost all the targeted bed units and equipment was made from Copper Alloys the Infection rate was lower by as much as 69%. The US Department of Defense investigation contract, which is ongoing, will also evaluate the effectiveness of copper alloy touch surfaces to prevent the transfer of microbes to patients and the transfer of microbes from patients to touch surfaces, as well as the potential efficacy of copper-alloy based components to improve indoor air quality.
Clinical trials in India
Considering that infections in the ICU environment leads to major costs escalation and poor outcomes in treatment in India, in Jan 2013, it was decided to run a pilot study in the ICU of one of the major cancer hospitals in Mumbai. Retrofitting of the bed units in ICU ward of 4 beds was done for the bed rails, the foot rails, the bedside table, the over bed table and the IV stand as well as the top surface of the dressing trolley in the ICU. A similar unit of 4 beds across the passage was used as the control where no retrofitting was done. Swab samples from the touched areas were collected and plated to check for colonies that grow. The data collected is now being studied for the total no of colony forming units (CFUs) from both the ICU areas and the results are awaited.
(The author is with J.J. Group of Hospitals)