A graduate of the University of Toronto, Dr. Susy Hota, MD, MSc, FRCPC is an infectious disease specialist. Since 2007, she’s worked in the University Health Network's Infection Prevention and Control unit. She’s spoken about many topics, everything from Ebola to the the H1N1 strain of influenza to treating recurrent C. diff infections with fecal transplantation. RL asked her to share her advice on how healthcare organizations can best meet the challenges facing infection control and antimicrobial stewardship today.
Antimicrobial resistance is a known major public health issue. How do you think hospitals should approach antimicrobial stewardship to reduce the prevalence of super bugs like MRSA and C. diff?
Antimicrobial resistance is one of the greatest health threats this generation is going to face. Hospitals need to invest in an infrastructure that will support antimicrobial stewardship, much like they did decades ago with infection control. Appropriate antimicrobial use needs to be taught as a core competency in medical schools and all residency programs.
This is especially important since most of the focus is still on antimicrobial stewardship in hospitals, but a lot of unnecessary and inappropriate antimicrobial use happens in the community as well. We are all part of one big microbial ecosystem and antimicrobial resistance honors no boundaries, so our approach must be far-reaching.
Good hand hygiene, especially frequent handwashing, is one of the ways healthcare workers can stop the spread of infections. Any other tips?
I can’t emphasize enough the importance of healthcare workers not coming to work when sick with respiratory viruses, diarrhea and other communicable diseases. The culture in healthcare is still such that nurses and physicians feel pressured to work unless they’re being admitted to hospital themselves! This has to stop.
We also have to get better at asking patients questions that trigger the possibility that they carry an infectious disease. All hospitals have screening programs but we don't always carry them out as well as we would like to. Like hand hygiene, excellent screening programs are our first line of defense in infection control.
You have consulted on several hospital-wide outbreaks of nosocomial infections in Ontario. What is the biggest challenge facing infection control in Ontario hospitals today?
Right now, there are two competing problems. One is the current fiscal environment of healthcare in Ontario. Hospitals are trying to find ways to do more with less and in many places, this translates into cutting staff while placing greater expectations on existing personnel. When it comes to cutting positions in a hospital, it may seem that the lesser evil is to reduce the number of support staff, such as environmental services. However, this comes at a great expense to patient safety, as good hospital infection control is very reliant on high-quality environmental management. Also, while existing staff are asked to improve their efficiency, lapses in infection control practices are more likely to occur.
At the same time, we are facing an unprecedented rise in antimicrobial resistant organisms. Many of these microorganisms are incredibly transmissible and they can cause devastating outbreaks in intensive care unit settings, where patients are already most vulnerable.
You ran Canada's first clinical trial evaluating fecal transplants for the treatment of recurrent C. diff infections. Can you tell us more about that?
This study was one of the most challenging things I have done, truly a labor of love! Back in 2008, many of us in infectious diseases realized that there was a pressing need for alternative treatments for recurrent Clostridium difficile infections. More and more patients were afflicted with this problem and the usual treatments with antibiotics were really just a band aid solution.
The fecal transplant study was a tough one to design, as recurrent C. difficile infection is not a simple disease (hence the name!). At the time, most hospitals would not even entertain the notion of doing fecal transplants, so it took some work to get institutional approvals. Health Canada had never before encountered a trial involving fecal transplantation, so they were unclear on how to approach it from a regulatory point of view.
Finally, when the study was up and running, we made an interesting observation about patient acceptance of fecal transplants. Many of our colleagues still balked at the prospect of fecal transplants, thinking that their patients would be turned off by the ‘ick factor’. Luckily, the patients themselves had the opposite view, often wanting to receive a fecal transplant straight away! While this was great for patient recruitment, it was also a challenge for us, since the study had a specific design and fecal transplants were not offered immediately to all patients.
Our study is over now and results have been submitted for publication. The field of fecal transplantation is rapidly progressing forward, although there is still much we need to learn about how to do it best. It is a very exciting area in medicine.
Health Quality Ontario has identified reducing C. diff infections as one its seven priority quality indicators. However, last year only 36% of Ontario hospitals decreased their rates of C. diff infections. Why do think it's so difficult for hospitals to reduce this HAI?
This is a great question! HospitalC. diff rates are actually an imperfect patient safety measure as there are too many external factors that influence the numbers. The main problem withC. diff infection is that many people carry the C. diff bacterium in their intestinal tracts and don't even realize it. Where they pick up the bug is often not known. Sometimes it’s from a hospital but we increasingly recognize that there are other reservoirs that must be spreading the infection.
People only become sick with C. diff infection when something disrupts the balance of microorganisms in their intestinal tracts. Usually, this is antibiotics, but it can also be medications that affect the immune system, surgery or other things that are associated with hospitalization. When patients develop diarrhea in hospital and are found to have C. diff infection, the hospital counts this as part of their C. diff infection rates. So the proportion of hospital-associatedC. diff infection is truly ‘owned’ by the hospital because of poor infection control or inappropriate antibiotic use is unclear.
What do you love most about your job?
Being able to influence the quality of healthcare on a broad level. When you are trained in medicine, a lot of the focus is on providing the best possible treatment for the individual patient. While this is critically important, I also like being able to do something that protects all of the patients in my hospital. In doing this, I get to work with diverse teams, inside and outside of the hospital. It helps me to understand the impact that one seemingly small decision can have on the entire system and that has changed the way I approach everything in medicine.
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