Drug resistant pathogen kills patients in Sri Lanka's leading public hospital

Three patients are dead and others have been affected after a multi-drug resistant bacteria struck the Cardio Thoracic Unit (CTU) at the National Hospital, Sri Lanka's leading public hospital. By December 16, the hospital had turned away more than a hundred patients who were on the waiting list for heart surgery.

The CTU operating theatre and the Surgical Intensive Care Unit (SICU) have been closed for cleaning and disinfection. Hospital authorities say the units will reopen soon but have given no definite date. One of the High Dependency Units (HDU) had also been closed for few days, leaving the hospital short of facilities for other critically ill patients.

The three patients died after their surgical wounds became infected with methicillin resistant staphylococcus aureus (MRSA). Another two patients are in a critical condition with the same infection. According to some nurses from the Cardio Thoracic wards, the surgical wounds were already infected when the patients came under their care. The exact source of the MRSA outbreak is yet to be traced, however.

The crisis has exposed the inadequacies of the hospital's CTU, infection control unit and pathological laboratory. These are products of a far broader lack of trained staff, up-to-date equipment and other resources in the public hospital system as a whole.

Even after two post-operative heart patients died, no preventive measures were taken to control and contain the bacteria. No awareness program was conducted among the staff until another two patients were infected. Cardio Thoracic surgeons demanded a full screening of the CTU staff, CTU wards, HDUs, operating theatres and the SICU. It was to no avail, however, because the hospital's laboratory lacks the capacity and staff to carry out such screenings. Only a few random samples have been taken from the CTU for testing.

Because the National Hospital laboratory has no methicillin discs to culture and test the organisms, its staff could not identify the strain as MRSA, only that it was multi-drug resistant. The laboratory at the private Asiri Hospital revealed the bacteria's identity after testing pus from an infected patient.

The National Hospital's infection control unit also faces an acute shortage of trained nurses to report communicable diseases and promote preventive measures. Moreover, heavy workloads limit the participation of staff, including nurses, in awareness programs and lectures on MRSA.

Infection control nurses are only able to promote hand washing by staff members, but the World Health Organisation recommends measures such as isolating infected patients, screening other patients and staff, and treating of nasal carriage sites.

Hospital-acquired infections, including MRSA and other antibiotic-resistant organisms, spread because of overcrowding, staff shortages, prolonged hospital stays and inadequate facilities, such as for hand washing and disinfection.

The National Hospital's CTUs and HDUs are usually overcrowded with heart patients suffering post-operative complications or other thoracic ailments that require surgical intervention. These wards are also congested with the parents of children undergoing surgery.

Because of delays, heart patients can wait for months in these wards, with operation dates stretching out to 2009. Because of severe nurse shortages, relatives are allowed to organise “bystanders” (outsiders) to look after patients, even in HDUs. With meagre facilities, it is impossible to maintain basic hygiene precautions.

After surgery, especially open-heart surgery, patients transfer to the SICU for intensive care. It is a small hall with five beds in a single line, 4-6 feet apart. It is packed with medical equipment and a relatively big staff, consisting of surgeons, anesthetists, doctors, nurses, physiotherapists and so on. There are no isolation facilities or separate staff to take care of infected patients. MRSA patients had been isolated only by a single panel.

Despite the threat of infection, there is no system of timely screening of wards, HDUs, the SICU and the operating theatres. Even cleaning and disinfecting cannot be done often because these units are under constant pressure. Moved by the plight of patients, thoracic surgeons perform more and more surgeries even though the post-operative care is not satisfactory. This has led to post-operative complications, including MRSA infection.

These units lack basic facilities such as linen, antiseptic detergents, disinfectants and essential surgical instruments. There is no adequate waste disposal system. These conditions can lead to a MRSA contagion not only in the CTU but in other units and wards.

Heart patients affected by the National Hospital CTU shutdown cannot go elsewhere, unless they can pay for private surgery. There are CTUs at the Nawaloka Private Hospital in Colombo and the semi-government Sri Jayawardhanapura Hospital. The only other government-sponsored CTU—at the Galle General Hospital in the Southern Province—has more than 3,500 heart patients on a waiting list that stretches to 2010.

Drug-resistant organisms have become a major health care crisis worldwide. They are the result of overusing drugs in developed countries and, paradoxically, misusing and under-using them in developing countries. MRSA strains are usually resistant to several antibiotics and occasionally are sensitive only to vancomycin and teicoplanin.

While the current MRSA outbreak has not yet caused an island-wide crisis, the crumbling state of the country's health system poses the danger that the infection will be transmitted to other hospitals.