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Ignaz Semmelweiss and hand hygiene resistance
In 1846, obstetricians were outraged when Ignaz Semmelweis reduced the mortality rate of Viennese women from puerperal fever from 16% to 3% by making doctors and medical students disinfect their hands between performing post-mortems and delivering babies: they felt he was criticising their professional practice. Semmelweiss lost his job and died in a lunatic asylum, while his dirty, deluded and dangerous colleagues abandoned his policies and returned the puerperal mortality rates to their previous appalling levels.
Of course they did not know then, as we do now, that puerperal fever is caused by Group A streptococcus, or that normal human skin is colonized with high concentrations of bacteria that transfer between patients on staff hands during routine patient care. 1,2 They would have been shocked to discover that there is now incontrovertible evidence that hand decontamination significantly reduces pathogen transfer and hospital- and healthcare-associated infections2 and that Semmelweiss has been vindicated. The epidemiology of common bacterial infections was elucidated between the 1890s and the 1950s and led to the universal introduction of standard hygienic measures such as handwashing, no-touch technique, gowning, instrument sterilisation, environmental cleaning, air filtration, the separation of beds and isolation of infected patients. Doctors and nurses in the 1950s were still afraid of infections: they washed their hands, made sure their hospitals were clean and kept strictly to good hygienic practice. They were rewarded by low rates of hospital infection and a certainty that cleanliness was indeed next to godliness.
|Professor French, delivering the Gary French Lecture at the Federation of Infection Societies meeting, 15 November 2018.|
The discovery of antibiotics – no more need to be clean?
The introduction of penicillin in the 1940s and the explosion of antibiotic discovery in the 1960s had a further dramatic impact on the control of infections, allowing astonishing developments in intensive care medicine, transplantation and surgery that earlier generations could never have imagined.
All drugs have side effects, and antibiotics came with a terrible one: it made doctors lose their fear of infection. Infections could be cured with a squirt of antibiotic, or two squirts - or two antibiotics. And if those didn’t work, there was a whole shelf of new agents that would. Infections had been vanquished, fever hospitals closed and isolation rooms re-allocated, Doctors and nurses stopped washing their hands and did not protest or even notice when managers stopped cleaning wards. In addition, the more relaxed social attitudes of the 1960s were at odds with the need for strictness in hygienic practice. In a startling return to the 1840s, doctors began to resent being told to be clean, and even in 1999 doctors were sending letters to the BMJ debunking the effectiveness of handwashing between routine patient contact.3,4
Doctors decontaminate their hands appropriately on average only 30% of the time,1 although they think they are much better than this. In one study, doctors thought they washed their hands between patients 73% of the time but their actual compliance was only 9%.5 Pritchard and Raper were astonished that “doctors can be so extraordinarily self-delusional about their behaviour”.6 Doctors seem equally blind to environmental cleanliness and the need to isolate infected patients. The Healthcare Commission report on the tragic outbreaks of Clostridium difficile infection (CDI) at Maidstone 2005/6 includes truly shocking photographs of filthy wards and dirty beds so close as to be almost touching.7 In case anyone might think this was a one off, similar failings of infection control and hygienic practice led to a similar dreadful outbreak at Stoke Mandeville in 2005/6.8
Behave badly, suffer the consequences
With the perfect storm of overuse of antibiotics and poor hygienic practice antibiotic-resistant bacteria flourish and hospital infections soar. By 2003, hospitals in England reported more than 6,000 MRSA bacteraemias per year . Although not all resulted from poor hygiene , many of them did. With 6000 bacteramias, there must have been around 60,000 serious MRSA infections, 600,000 colonisations and perhaps 6 million failures of infection control annually. And this was not just limited to MRSA: in 2007, hospitals reported more than 55,000 cases of CDI.10 most of them probably resulting from poor infection control and imprudent antibiotic prescribing.
In the end, it was the lay public, not the doctors, who put pressure on politicians to call a halt to this. Continuing front page headlines about superbugs and dirty hospitals, patient actions groups and parliamentary debates forced the Minister of Health to act. Hospitals were required to publish their rates of infection, audit practice and cleanliness and continually reduce their infection rates or face the threat of sackings and fines. In 2006, for the first time, the Health Act required healthcare institutions to have appropriate infection prevention and control in place, compliant with a Code of Practice.
Where decades of education and exhortation had failed, legal strictures had a dramatic impact, even on sceptical doctors, just as they had done on sceptical smokers and un-seat belted drivers. A target was initially set to reduce MRSA bacteraemias by 50%, a figure that most doctors thought was unachievable. But by 2011, MRSA bacteraemias in English hospitals had fallen by around 83% and cases of CDI by 66%,9,10 with associated reductions in mortality.11,12 This has been one of the most dramatic demonstrations of the effectiveness of good infection control practice in the medical literature and seems to have produced a genuine change in culture. Just as drivers now always use their seat belts and smokers never light up in pubs, many doctors now decontaminate their hands between patients without thinking and chastise their colleagues who forget.
However, there are still dirty wards, unisolated patients, imprudent antibiotic prescribing, unwashed hands and many avoidable infections. Some doctors remain sceptical. Christmas is coming with its judgement of the naughty and nice: time now to believe and be good.
Professor Gary L French MD FRCPath
French GL. Dirty, deluded, and dangerous. BMJ 2012;345:e8330
The inaugural Gary French Lecture, entitled 'The rise and fall of MRSA in England' was given by Professor Gary French during FIS 2018 on Thursday 15 November 2018. Slides from the lecture are available to HIS members.