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Speaker 1: Hospitals are where we go to get better, not sick.

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Speaker 1: But the scary fact is hospitals are some of the

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Speaker 1: most hazardous places in the world. On any given day,

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Speaker 1: about one and thirty patients in the United States gets

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Speaker 1: a healthcare associated infection. Increasingly, the germs that are the

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Speaker 1: hardest to treat, the ones that are killing patients the fastest,

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Speaker 1: are coming from outside the hospital. They're being carried in

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Speaker 1: by the patients themselves. Welcome to Prognosis, a podcast about

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Speaker 1: health and science, medical technology, and the changes that are

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Speaker 1: underway across the world. I'm your host, Michelle fay Cortes.

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Speaker 1: This season, we're talking about the rising threat of superbugs,

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Speaker 1: bacteria that are resistant to the strongest infection fighting medications available.

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Speaker 1: In this episode, Bloomberg's Jason Gale explores how one hospital

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Speaker 1: became wrapped up in a global mystery and how solving

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Speaker 1: it created a new way to stop superbugs from sneaking

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Speaker 1: into the hospital and harming patients. The solution is incredibly simple,

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Speaker 1: and it's also incredibly important. These sorts of measures are

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Speaker 1: what we need for the war against superbugs to succeed.

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Speaker 1: And fair warning for the squeamish among our listeners. What

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Speaker 1: you're about to hear has a lot to do with

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Speaker 1: them well human poop. Lindsay Gryson is standing over an

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Speaker 1: empty hospital bed giving a demonstration. He's just rubbed his

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Speaker 1: hands with some alcohol based sanitizer and talking as if

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Speaker 1: he's admitting a patient. I'm glad you final him added

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Speaker 1: into hospital. I'm sorry you're being unwell. Professor Grayson is

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Speaker 1: head of the Department of Infectious Disease and Microbiology at

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Speaker 1: Austin Health, a three campus hospital system in suburban Melbourne.

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Speaker 1: He's rolled up the sleeves of his blue shirt and

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Speaker 1: tells the imaginary patient what to expect next. Over the

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Speaker 1: next few days, we're going to have to sort out

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Speaker 1: why you're so sick. Obviously, we're concerned about some infections.

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Speaker 1: Professor Grayson grabs a plastic pack off the stand next

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Speaker 1: to the bed. It contains a five inch long cotton

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Speaker 1: tipped stick in His team routinely use these sticks to

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Speaker 1: screen patients across the eight bed hospital system. They're looking

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Speaker 1: for antibiotic resistant bacteria or superbugs. Superbugs can result in

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Speaker 1: life threatening infections for patients. Screening alerts Professor Grayson and

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Speaker 1: his team to these gems and prevents them from spreading

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Speaker 1: around the facility. The stick looks like a giant Q tip,

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Speaker 1: but Professor Grayson has another name for it. Here's erect

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Speaker 1: or swab. It's pretty straightforward, that's right. Professor Grayson collects

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Speaker 1: and screens hundreds of fecal samples annually. You can either

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Speaker 1: take it yourself or otherwise one of the nursing staff

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Speaker 1: can take it. The crucial things we need some fecal

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Speaker 1: material on it. The testing schedule works like this for

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Speaker 1: patients at high risk of getting an infection, such as

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Speaker 1: those receiving an organ transplant, undergoing cancer treatment, or having

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Speaker 1: spinal surgery. They're screened on admission and then weekly. Additionally,

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Speaker 1: the Austin carries out a spot check every six months,

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Speaker 1: subjecting every patient admitted over a one week period to

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Speaker 1: the awkward exam. Professor Grayson and his team don't just

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Speaker 1: test patients every month. Waiting room chairs, telephones in nurses stations,

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Speaker 1: and other hospital surfaces are also swab for drug resistant bacteria.

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Speaker 1: The reason all of this testing happens is because it

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Speaker 1: gives the hospital staff a snapshot of what superbugs are

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Speaker 1: lurking waiting to spark an outbreak. That knowledge is giving

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Speaker 1: Professor Grayson and his team more time to identify and

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Speaker 1: respond to problems before they turn into crises. Professor Grayson

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Speaker 1: says he became a doctor because of his interest in people.

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Speaker 1: What fascinates him about infectious diseases is the way microbes

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Speaker 1: are constantly evolving to circumvent our treatments. Understanding how the

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Speaker 1: microbes are changing requires him to be something of a

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Speaker 1: Sherlock Holmes of superbugs, always looking for clues about which

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Speaker 1: bugs are trying to sneak into his hospital like a detective.

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Speaker 1: You know, someone comes in with a problem. It's fairly undifferentiated.

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Speaker 1: You're investigating him. You find the barb, your workout which

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Speaker 1: antibiotics hopefully you can use. It's very satisfying. I like

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Speaker 1: hol like humans and talking to humans. This screening process

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Speaker 1: is revolutionary in how hospitals treat bacterial infections and use antibiotics.

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Speaker 1: But it wasn't always this way. The story of how

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Speaker 1: Professor Grayson came up with the rector swab came out

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Speaker 1: of the mystery. This mystery caused Professor Grayson to completely

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Speaker 1: change how we thought about how hospitals care for their

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Speaker 1: patients and even how hospitals are structured. Before this mystery

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Speaker 1: came to the Austin, Professor Grayson would just see hard

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Speaker 1: to treat infections and patients with weakened immune systems, and

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Speaker 1: often we thrashed them with antibodics to say of their life,

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Speaker 1: and you know, there's no surprise that they developed a

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Speaker 1: superbug or they picked up a supermark. But something changed

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Speaker 1: a little over ten years ago. Increasingly he started seeing

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Speaker 1: healthy people getting these superbugs. Middle aged businessmen were among

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Speaker 1: the first cases. Even though they were fine otherwise, they

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Speaker 1: were getting critically ill from a bacterial infection that required

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Speaker 1: potent antibiotics. Professor Grayson had never seen cases like these before,

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Speaker 1: but he noticed a common history. These patients had recently

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Speaker 1: undergone a biopsy of their prostate land. Back then, the

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Speaker 1: procedure was pretty routine for checking for prostate cancer. It

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Speaker 1: involved inserting a probe in the rectum and the probe

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Speaker 1: would be fitted with a needle that would collect a

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Speaker 1: dozen specimens for analysis. So the neurologists went put a

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Speaker 1: scope in the rectum and then punched a hole through

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Speaker 1: the erectal wall into the prostate. Very standard procedure, piercing

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Speaker 1: the rector wall can enable bacteria from the bowel to

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Speaker 1: get into the prostate, bladder and bloodstream. An antibiotic like

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Speaker 1: cipro was typically given to prevent an infection. Obviously, the

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Speaker 1: patients worried about cancer, but in the past they would

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Speaker 1: have got as of antibodys just before that procedure, so

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Speaker 1: there wasn't transmission of bugs from their bowl into their prostate.

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Speaker 1: But now we're seeing patients who the next day were

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Speaker 1: suddenly had their super bug in their blood. These men

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Speaker 1: were getting critically ill. They were sick because the cipro

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Speaker 1: didn't work. The drug didn't work because bacteria in their

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Speaker 1: intestines were chewing it up and spedding it out. You know,

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Speaker 1: we have liver transplant, regnal transplant, phone marriage and we've

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Speaker 1: got a lot of high risk patients here. So we've

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Speaker 1: got a pretty high risk population and we have to

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Speaker 1: be very careful with those patients. But we were seeing

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Speaker 1: otherwise healthy people coming. Professor Grayson told me about these

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Speaker 1: cases a decade ago at an Infectious Diseases meeting. It

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Speaker 1: seemed an interesting anecdote, but a month later a doctor

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Speaker 1: in Canberra said he was seeing the same thing that

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Speaker 1: sounded like a trend, and some googling confirmed it. Doctors

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Speaker 1: around the world were reporting prostate biopsy patients were developing

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Speaker 1: bloodstream infections and ending up seriously ill in the hospital

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Speaker 1: days after the procedure. One doctor in Toronto calculated a

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Speaker 1: mortality rate associated with a fifteen minute procedure. It was small,

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Speaker 1: but it was growing. I wrote about it. The story

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Speaker 1: got polished in many newspapers, researchers cited it in scientific

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Speaker 1: journal articles, and the American Neurological Association released a statement

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Speaker 1: acknowledging the risk. Urologists around the globe didn't know what

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Speaker 1: to make of these cases. For this was kind of

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Speaker 1: a big shift. So why were superbugs suddenly appearing and

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Speaker 1: healthy people? How were they getting there in the first place.

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Speaker 1: Professor Grayson was on the case. We started to talk

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Speaker 1: to those in the cases, men needing biopsies. Quite often,

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Speaker 1: they've burn overseas recently. That was no coincidence. Around the

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Speaker 1: same time, researchers in Australia and Sweden had published studies

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Speaker 1: looking at the risks of acquiring superbugs while traveling overseas.

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Speaker 1: The scientists swabbed the butts of dozens of travelers before

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Speaker 1: departure and again on their return to see whether they're

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Speaker 1: normal intestinal bacteria or microflora contain multi drug resistant germs.

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Speaker 1: The results were consistent. Most travelers to Asia, especially India,

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Speaker 1: came back with bacteria capable of destroying some of the

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Speaker 1: strongest antibiotics. The researchers speculated they had ingested food or

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Speaker 1: water that had been contaminated with drug resistant fecal germs,

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Speaker 1: and those germs took up residency in their intestines, becoming

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Speaker 1: part of the normal gut flora, like silent stowaways. Later,

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Speaker 1: when these patients got their biopsy and the needle punctured

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Speaker 1: the wall of their rectums, it opened the door for

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Speaker 1: superbugs to escape into the prostrate, bladder and bloodstream. We

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Speaker 1: had been looking at these high risk patients and screening

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Speaker 1: them for their own safety and to make sure they

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Speaker 1: didn't spread bugs around the hospital. But something we realized

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Speaker 1: that the picture was getting bigger than this, you know.

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Speaker 1: But now we're seeing otherwise healthy people. And there was

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Speaker 1: this link with travel or occasionally misuse of antibiotics out

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Speaker 1: in the community, but more more off a the NATO's

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Speaker 1: travel globalization and the international movement of people and food

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Speaker 1: helped explain a large part of the mystery. Another element

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Speaker 1: has to do with the type of bacteria in our

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Speaker 1: intestinal tract. These germs have a certain type of cell

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Speaker 1: wall that appears differently under the microscope in response to

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Speaker 1: a dye. The dye is known as a gram stain,

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Speaker 1: and so that's quite important because the structure of the

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Speaker 1: cell wall gives us a cluse to which antibiotics are

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Speaker 1: going to work better on the bacteria. Now, feces poo

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Speaker 1: is very interesting compound because it's made up of both

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Speaker 1: Gram positive and Gram negative bacteria. But the ones which

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Speaker 1: make you sick quickest and cancute you very quickly are

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Speaker 1: these gram negative bacteria which constitute a large portion of

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Speaker 1: our pooh. It's the Gram negative bacteria that are becoming

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Speaker 1: more and more resistant to antibiotics. If that's not enough,

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Speaker 1: Once these bacteria into your bloodstream, but they can release

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Speaker 1: a toxin which is like a prepackaged hand grenade that

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Speaker 1: drops your blood pressure, alters your whole body dynamics, and

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Speaker 1: you go into septic shock without the need for the

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Speaker 1: germ to actually multiply match. The mystery of why these

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Speaker 1: men were getting set was solved. Men had become susceptible

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Speaker 1: to serious infections because they traveled overseas and picked up

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Speaker 1: a superbug. Then, after they'd had their prostrates biopsied, those

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Speaker 1: bugs were able to get into places they weren't supposed to,

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Speaker 1: like the blood stream, and cause these infections. But the

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Speaker 1: story wasn't over. Solving this mystery made Professor Grayson realized

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Speaker 1: something that would change his entire perception of how hospitals work.

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Speaker 1: He realized that if travelers are carrying around these antibiotic

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Speaker 1: resistant bacteria, you likely meant most people like you and

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Speaker 1: me are walking around all day with these tiny heart

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Speaker 1: to diffuse grenades in their bowls, even though we seem

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Speaker 1: fine otherwise. The term for this is colonization. Bolonization is

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Speaker 1: where the buggers in your system, but it's not causing

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Speaker 1: any trouble. And obviously infection is now causing trouble. If

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Speaker 1: more and more of us are carrying these hand grenades

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Speaker 1: and air intestines, then danger could lurk anywhere, and Professor

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Speaker 1: Grayson could no longer think about the Austin as a

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Speaker 1: place where superbugs were spread by only a handful of

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Speaker 1: high risk patients. You know, we're one of the first

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Speaker 1: hospitals in Australia to say we're going to assume the

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Speaker 1: whole hospitals assess pit. Why don't we just assume the

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Speaker 1: hospital is filthy. It's with that idea in mind that

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Speaker 1: Professor Grayson instituted a back to basic strategy when fighting

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Speaker 1: superbugs at the Austin. For example, of something's dirty, bleach

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Speaker 1: is a good way to clean it. So Professor Grayson

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Speaker 1: backed in overhaul of the hospital's cleaning regime that includes bleach,

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Speaker 1: lots of bleach. Professor of Medicine here said, lindsay, the

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Speaker 1: hospital smells like it did when I was an intern.

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Speaker 1: I said, yes, Jeff, because we're using bleach like we

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Speaker 1: used to back in the seventies and eighties. Bleach is neat,

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Speaker 1: because it's good because it kills all of known super bugs.

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Speaker 1: The Austin's programs are cutting edge by today's standards for

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Speaker 1: how hospitals treat patients, but Professor Grayson says a lot

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Speaker 1: of these practices ironically are rooted in the meticulous attention

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Speaker 1: paid to cleaning and scrubbing that Florence Nightingale, the founder

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Speaker 1: of modern nursing, pioneered in the eighteen hundreds there were

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Speaker 1: some basic principles which over the years had been forgotten

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Speaker 1: because of we had antibiotics. You know, my mom was

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Speaker 1: born in and when they had a scarlet fever outbreak

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Speaker 1: at their primary school, everyone was sent home in the

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Speaker 1: school was shut down for a week or two to

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Speaker 1: stop to spread a strap to cock eye spatial separation.

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Speaker 1: We don't do that anymore. This old school approach is

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Speaker 1: also why Professor Grayson started using the rectal swabs. Initially,

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Speaker 1: the program costs the Austin Australian dollars or about one

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Speaker 1: U S dollars a year, but has since come down

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Speaker 1: by about half. Robotic equipment and technology has automated the

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Speaker 1: testing process. It's enabled doctors to know much faster whether

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Speaker 1: a patient is harboring drug resistant germs they could increase

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Speaker 1: the risk of a difficult to treat infection, and if so,

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Speaker 1: how best to manage that patient, Especially if an infection occurs.

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Speaker 1: This kind of screening program has enabled the hospital to

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Speaker 1: spot new dangers, making patients vastly safer. For example, the

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Speaker 1: Austin was the first hospital in Australia to identify a

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Speaker 1: fast spreading superbug that's especially problematic for liver transplant patients.

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Speaker 1: It's called vanke myce and resistant ENTRECOC, or just vr E.

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Speaker 1: About half of the liver transplant patients who get a

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Speaker 1: vr E bloodstream infection will die from it. We were

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Speaker 1: the first hospital in Australia to identify the r and

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Speaker 1: it wasn't because we're dirty, it's because we looked. We

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Speaker 1: were the first hospital to identify a number of the

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Speaker 1: multi resistant gram negatives was because we had a screening

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Speaker 1: program where we looked. If you don't look, you don't find.

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Speaker 1: And I think there's still a bit of a culture

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Speaker 1: in other places you don't look because you don't want

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Speaker 1: to know, whereas there's always been a culture. We want

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Speaker 1: to know, and it's only when you know that you

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Speaker 1: can design a solution. Looking for these superbugs has also

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Speaker 1: helped the hospital begin to predict how they spread. For example,

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Speaker 1: for every patient with an infection caused by vr E,

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Speaker 1: another twenty patients will be colonized with the gut bacteria

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Speaker 1: but not have the disease. There was a recognition that

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Speaker 1: most people who have an infection are colonized first, and

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Speaker 1: the type of German you've got defines how many people

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Speaker 1: are more likely to be colonized for every infection. So

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Speaker 1: if you've got one patient with her, you're only attract

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Speaker 1: infection with r You've probably got nineteen patients out there

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Speaker 1: in the ward who you don't know got R E colonization.

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Speaker 1: If you know how many people are likely to have

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Speaker 1: a superbug, it changes how you think about the layouts

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Speaker 1: of hospitals, as well as how much to invest in

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Speaker 1: infection control and surveillance. So here you can see these

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Speaker 1: pink colonies are quite different to these dark blue ones.

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Speaker 1: So whereas Professor Grayson gave me a tour of the

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Speaker 1: Austin's microbiology lab, it's teeming with technicians in white coats,

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Speaker 1: bacterial specimens, and robotic equipment used to culture and test

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Speaker 1: the microbes. Professor Grayson told me that superbug mystery made

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Speaker 1: him realize the importance of identifying patients colonize certain high

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Speaker 1: risk germs. For one thing, they should be given individual

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Speaker 1: rooms and not share bathrooms. But if you've got someone

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Speaker 1: who's carrying a super bug, I'm sorry, but they get

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Speaker 1: priority because that's the safety of the hospital at stakes.

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Speaker 1: So safety of patient care now dominates everything else, and

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Speaker 1: that's probably an important change. The Austin hospital was built

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Speaker 1: with private rooms making up a third of its capacity.

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Speaker 1: Professor Grayson says future hospitals will have to rethink that

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Speaker 1: design and it won't be cheap at least in the

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Speaker 1: short term. You know, I would often say the rule

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Speaker 1: is pretty simple, one bumper toilet. Well men. In the past,

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Speaker 1: many people say, well, isn't it too expensive to have

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Speaker 1: single rooms and a toilet for every patient? But actually

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Speaker 1: from an infection control point of view, and now in

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Speaker 1: the era of superbugs, this will be standard practice in

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Speaker 1: the future. This needs to be built into government thinking

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Speaker 1: and funding that what seems expensive at the start will

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Speaker 1: pay off very quickly in terms of disease transmission. Professor

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Speaker 1: Grayson spends a lot of time thinking about superbugs and

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Speaker 1: how to fight them, something he's known for internationally. Harvard graduate,

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Speaker 1: he has a national hand hygiene initiative, advises the World

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Speaker 1: Health Organization on infection control, and as editor in chief

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Speaker 1: of a key academic text on antibiotics. It's now in

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Speaker 1: three volumes and sits among the reference books lining his office.

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Speaker 1: The next frontier, he says, will address the antibiotic resistance

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Speaker 1: genes that superbugs harbor. A microbiologist once told me that

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Speaker 1: these bacteria accumulate genetic mechanisms for fending off antibiotics like

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Speaker 1: trains attached carriages. A big difference is that bacteria of

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Speaker 1: different species can share these methods for evading drugs with

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Speaker 1: one another, giving modern medicine little time to catch up.

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Speaker 1: But for now, the practical efforts of the austin have

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Speaker 1: at least provided some balance in the fight against superbugs.

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Speaker 1: Even things as simple as a sign you know as

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Speaker 1: you will have seen when you came to the hospital,

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Speaker 1: is a big stand there saying oh, I'll rub your hands,

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Speaker 1: don't bring your bugs into the hospital, But secretly, as

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Speaker 1: you're walking out of the lifts, it actually says, don't

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Speaker 1: take our bugs home. As we face a post antibiotic

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Speaker 1: era in which something as simple as a scratch knee

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Speaker 1: could once again kill, these basic principles seem inexorably important.

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Speaker 1: Stopping bacteria at their source will be our key defense. Thankfully,

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Speaker 1: the century has given us better tools to do that.

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Speaker 1: And that's it for this week's prognosis. Thanks for listening.

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Speaker 1: Do you have a story about healthcare in the US

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Speaker 1: or around the world We want to hear from you.

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Speaker 1: Find me on Twitter at AA Cortes or send me

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Speaker 1: an email m Cortes at bloomberg dot net. If you

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Speaker 1: are a fan of this episode, please take a moment

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Speaker 1: to rate and review us. It really helps new listeners

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Speaker 1: find the show, and don't forget to subscribe. This episode

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Speaker 1: was produced by Toford Foreheads. Our story editor was Rick Shine.

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Speaker 1: Special thanks to Drew Armstrong, our healthcare team leader, francesco

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Speaker 1: Leivia's head of Bloomberg Podcasts. We'll be back next week

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Speaker 1: with a new episode. See you then,