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Hospital Infections: Past, Present and Future

Exploring the history of hospital infections from early pioneers in hospital cleanliness to the rise of the so-called 'Superbugs'.

by Thomas Dormandy

In the Crimean War patients admitted to Florence Nightingale's legendary field hospital in Scoutari were significantly less likely to survive than those taking part in the Charge of the Light Brigade. The comparison though is of course a statistical outrage. Most of those admitted to the hospital in Scoutari were already dying from infected wounds, blood loss and exposure or, most commonly, a combination of all three. Their chances of survival were probably better than if they had been left to rot on the battlefield (as tens of thousands were). Yet hospitals in the mid nineteenth century were undoubtedly dangerous places where patients expected to die and mostly did.

The change, when it came, was largely the achievement of a few remarkable individuals. (The politically correct notion that great medical advances are the products of team work is a modern figment.) Among the pioneers, was a young Hungarian doctor called Ignác Semmelweis who, in 1846, found himself working as a junior assistant in the Midwifery Department of one of Europe's most prestigious hospitals, the Allgemeines Krankenhaus of Vienna. Prestigious but also dreaded among the young women of the Imperial Capital. At times 1 in 5 healthy young mothers-to-be admitted to give birth never left the building alive; and their mode of death, childbed fever, usually striking within a few hours of labour, was one of the most painful at a time when physical suffering was commonplace. Nobody knew the cause: lunar radiations and other lunacies were widely canvassed. The problem drove young Semmelweis to distraction, the more so since the catastrophic mortality in his own department contrasted with the comparatively low death rate in the adjacent department staffed entirely by midwives.

His "moment of truth" came on his return from a holiday when he was told that his closest friend, Kolletschka, a forensic pathologist, had suffered a cut finger performing a post-mortem examination and had died a few days later from blood poisoning. The symptoms and the lesions at his own post-mortem seemed to be exactly the same as those Semmelweis had seen in hundreds of young women who had died in childbed fever. Semmelweis realised that the mothers' illness was caused by infection introduced into the open wound of the womb by doctors and medical students, often arriving in the labour ward directly from performing post-mortem examinations in the mortuary. Midwives did not perform post-mortem's: hence the lower mortality in the midwives' ward. To clinch the evidence, the introduction of thorough scrubbing of hands with carbolic acid before entering the labour ward, slashed the incidence of childbed fever.

The Allgemeines Krankenhaus University in Vienna

Semmelweis was a short-tempered and inpatient foreigner in the hierarchical setting of Imperial Vienna. When the hidebound obstetric establishment failed to be convinced by what seemed to him the "blazing truth", he threw up his job and returned to his native Pest (today's Budapest). From there he dispatched a stream of open letters to the leading but benighted obstetricians of Europe, telling them that they themselves were responsible for millions of young mothers dying unnecessarily and comparing some of them unfavourably to Nero. This was ill received. Eventually he was declared insane and lured to a lunatic asylum in Vienna. During a scuffle as he was put into a straightjacket, he cut his finger. Ten days later he was dead himself from blood poisoning.

It is uncertain if Semmelweis's beloved doctrine of cleanliness would ever have prevailed without the brilliant work of the English surgeon, Joseph Lister. By the 1860s epidemics of "hospital sepsis" both in Britain and on the Continent were becoming catastrophic. Those outbreaks killed not only patients but also hospital staff and even visitors. It was seriously suggested in Parliament that all hospitals in Britain should be closed to be replaced by hutted encampments in open spaces like Hyde Park and the New Forest. Lister, the scion of an English Quaker family, was at that time professor of surgery in Glasgow. His "moment of truth" came when a colleague, a professor of chemistry, drew his attention to the work of the French chemist Louis Pasteur. Pasteur had discovered - and had indeed demonstrated beyond doubt - that the atmosphere was teeming with millions of invisible but living "germs". An inspired piece of lateral thinking convinced Lister that if these "germs" could spoil wine and sour milk, they could also be responsible for wound infection and hospital sepsis. He proved his idea by eliminating germs using a device known as the antiseptic spray. This was like a giant insect spray but containing an antiseptic fluid. It enveloped the operating theatre in a highly irritating cloud of vapour; but, for the first time, open fractures, which used to be inevitably fatal unless the limb was immediately amputated, healed without infection and without causing general blood poisoning.

Credit Moody Medical Library

Joseph Lister, 1827-1912

Unlike Semmelweis, Lister was part of the Victorian establishment, surgeon to the Queen (if only in Scotland), a man on friendly terms with some of the leading doctors of his day. Even so, it took him the best part of thirty years to convince his colleagues that germs were real, that they caused wound infections and that they could be eliminated. His doctrine which he called antisepsis was more readily embraced on the Continent, especially in Germany. It was adopted by the great surgeon Billroth in Vienna, though he continued to operate smoking a giant cigar.

Together with anaesthesia, introduced more or less at the same time. Antisepsis transformed surgery from skillful butchery, severely limited in scope to the limbs and superficial lesions, into a craft, art and science. No part of the body was now inaccessible. Children with acute appendicitis and adults with perforated ulcers no longer inevitably died. Lister lived long enough to become the first surgical peer, president of the Royal Society and, in 1901, founding member of the Order of Merit. Ironically, by then, antisepsis was giving way to a new and more radical approach to combatting hospital infection, a change which Lister himself deplored.

If surgery could be rendered comparatively safe by killing noxious germs, how much safer would it be if germs were never allowed near wounds in the first place? The answer was the doctrine of asepsis, as distinct from Listerian antisepsis. Gowns, masks, caps, rubber boots, the thorough and prolonged scrubbing of hands preliminary to the donning of rubber gloves and filtered air in the operating theatre made Lister's carbolic-acid spray obsolete. Asepsis was brilliantly successful and remained unchallenged until the 1950s.

Many medicines are produced with the help of fungi, most notably, the antibiotic, Penicillin.

In the 1950s, the advent of penicillin inaugurated the age of antibiotics, seemingly the final triumph over hospital sepsis. So effective were the new wonder-drugs in the few cases of infection which still occurred that in the 1960s some eminent and otherwise sane surgeons began to advocate that all patients admitted for surgery should be routinely started on antibiotics and kept on "antibiotic cover" while in hospital. This was madness, a return to Listerian antisepsis in a new and more dangerous guise. (Medical history would be an arid subject if human folly did not continually resurrect past situations.)

The doctrine never received official blessing; but the profligate use of antibiotics ruled and was inevitably accompanied by a relaxation of aseptic and even of basic hygienic precautions. The day of the new super-bug had arrived...

These superbugs are in fact neither new nor particularly super. Staphylococci were described by Pasteur 150 years ago: the hybrid term means berries in a bunch to distinguish them from streptococci which are berries in a chain. Thousands of different strains exist, most of them harmless inhabitants of the human nose, throat and skin. The dangerous strains were among the first successful targets of penicillin. When penicillin stopped being effective, other antibiotics came along. The trouble is that the survival of the fittest operates among invisible microbes even more effectively than it does in the visible world. Whether by adaptive selection or by genetic mutation, it is a fair guess that resistant strains will eventually be bred to every new antibiotic. Microbes have existed for millions of years before homo sapiens. They are likely to survive the species by many more million years. Of course, it is the micro time of decades and centuries which matters to us.

Predictably, the place where resistant organisms are selectively bred first and most effectively are hospitals. This was so long before micro-organisms were thought of; but it has become more critical with the advent of antibiotics. Age and illness makes the hospital in-patient population exceptionally susceptible to infection. Hospitals have been permeated with antibiotics for fifty years. Nurses and doctors continually move between patients, spreading resistant organisms unless a few elementary precautions are taken. These were second nature fifty years ago. They are no longer. (Watch next time you are in a hospital.)

Today more than 5000 patients die prematurely every year in England from multi-drug-resistant organisms. (The current technical acronym is MRSA's or, for the more severe form, VRSA's.) The figures are rising and rising at an increasing rate. Where will it all end? As in Semmelweis's and Lister's days, informed opinion is divided. Some doctors tacitly think that the menace is exaggerated. Others even more discreetly suspect that, even if not exaggerated., nothing can be done about it. Hospitals have been dangerous places for centuries. After a pleasant but short lull, they will become dangerous places again. Others believe, some passionately, that the danger can and should be eliminated. Patients will always die. They should not die of a disease they catch in hospital.


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First Science 2014