Why Dutch hospitals are so good at beating MRSA and other superbugs
Originally published on Inews
The seventh floor of Vrije University Medical Centre (VUMC), a 700-bed hospital in Amsterdam, houses what staff call the “Ebola room”. To enter, you have to wait in a pressurised antechamber until a monitor on the wall turns green. The difference in air pressure keeps germs from escaping. Nurses and doctors who check on a patient in the room must wear surgical gowns and respiratory masks. As many as 60 sets a day are used in looking after someone quarantined here, says Femke Overkamp, a nurse.
The hospital has yet to see its first Ebola case. Isolation rooms like this one, sprinkled through its wards, have long been used for the kinds of patients who in other European countries are often in open-plan wards: those who harbour superbugs like MRSA (short for methicillin-resistant Staphylococcus aureus), a bacterium resistant to several widely used antibiotics. Here, as in other Dutch hospitals, some patients are even quarantined pre-emptively until tests for such bacteria come back negative.
Suspects include workers on animal farms and those who have recently stayed in a hospital abroad. When an unexpected MRSA case is found on a ward, everyone who has been near that patient, including health workers, is tested.
This “search and destroy” approach to superbugs is a Dutch speciality, though variations are also used in the Nordic countries. It helps explain why the Netherlands has the second-lowest mortality from infections resistant to antibiotics in the EU, after Estonia. As Rosa van Mansfeld, who oversees infection prevention at VUMC, points out, when MRSA outbreaks sweep through German hospitals, they stop at the Dutch border. That is no small feat. In 2016, about 30,000 patients crossed that border to get healthcare.
Superbugs are spreading fast
The rest of Europe is looking to the Netherlands because superbugs scarier than MRSA, once rare, are spreading fast. They include CRE (for carbapenem-resistant Enterobacteriaceae), gut bacteria resistant to the last-resort antibiotics that are deployed when all else has failed. CRE blood infections are deadly in about 50 per cent of cases, compared with 10 to 30 per cent for MRSA.
In Europe, the prevalence of superbugs is particularly high in Greece, Italy and Romania, but international travel has put other countries on notice. Even in the Netherlands, which has used antibiotics prudently for decades, the prevalence of some superbugs in the general population has almost doubled in the past five years.
For preventing deaths, hospitals are the front line. People can harbour superbugs on the skin, around the nostrils or in the gut, where they are usually harmless. But if they slip into a wound or the bloodstream they become dangerous. In Europe, 73 per cent of deaths caused by superbugs are from infections that occur in medical settings.
Many European hospitals cannot replicate the Dutch model wholesale because they have few single-bed rooms or none at all. Choosing which of its features to prioritise is tricky. The evidence for the effectiveness of any one tactic, such as pre-emptive isolation or testing all patients for superbugs, is thin. National and EU-wide guidelines instead tend to rely heavily on experts’ beliefs that a given measure matters.
Dr van Mansfeld likens the measures at her hospital to slices of Swiss cheese stacked together: each has holes through which something can slip, but the chances that it will get all the way through are slim. She admits that, unlike cash-strapped hospitals in countries like Greece, hers has the luxury of being able to afford to do everything thought to be effective.
No money is spared in the fight against germs. The corridors are lined with beds wrapped as tightly as sandwiches in clear plastic foil. All have been through the room-size cleaning machine that whirrs in the hospital’s sprawling basement (“Our dishwasher for beds,” says Dr van Mansfeld). A designated elevator brings down used beds; another is reserved for clean ones going up to the wards. Before shifts, staff pick up fresh uniforms from stations that look like vending machines.
‘In the end, it’s all about hand hygiene’
Such extras are a dream for most hospitals, even in richer countries like Britain. But any hospital manager awed by such infection control must reserve envy for something else that this hospital is zealous about: the basics. “In the end, it is all about hand hygiene,” says Dominique Monnet, of the European Centre for Disease Prevention and Control (ecdc), the eu’s public-health agency. Though superbugs can lurk on clothes, sinks, toilets and indeed almost any surface in a hospital, the most common way they get transmitted to patients is by the hands of health workers.
A survey in 2011-12 found that the amount of sanitising hand-rub used per patient per day in Bulgarian, Italian and Romanian hospitals was less than a fifth of that in Norway, Denmark or Sweden. After a tour of several Italian hospitals in 2017 an ECDC team concluded that “most personnel seemed unaware of basic hand-hygiene principles”. It also found that alcohol hand-rub was often placed where it was “unrealistic” to expect its routine use.