Finding of resistance may spur Japan’s control efforts
By Ann Hardee, RN
President, Rann Med International
San Antonio
As one who has a great interest in Japan having traveled there many times over the last nine years and spent time in its hospitals I was touched with great concern, but not surprise, at the emergence there of intermediate resistance to vancomycin in Staphylococcus aureus. I travel to Japan to lecture on infection control, universal precautions, home care, safe handling of chemotherapy drugs, and quality improvement. The intent of this column is to share with readers based on personal observations and interviews in Japan some of the reasons behind my lack of surprise at the appearance of vancomycin resistance in S. aureus.
Japan is a lovely country filled with kind, hard-working people. It is half the size of Texas, with half the population of the United States squeezed on 10% of the land. This is due to a mountain range running down the middle of the island.
Why did I die in the hospital?’
When I first visited Japan nine years ago, there was hardly any interest in infection control and very little in the way of a reporting system. Following the earlier work by infection control pioneer Hiroyoshi Kobayashi, MD, the most significant development came when Emiko Tomiie published a book about "In-nai Kansen" (hospital infection), known as "Why did I die in the hospital?"1,2 The author is a widow of a government official who contracted methicillin-resistant S. aureus while hospitalized and died a short time later. She was the first consumer advocate in Japan who helped start an "infection control movement."
Infection control is a hot topic of discussion in Japan today. As the payer of health care there, the Japanese government recently began paying hospitals 50 yen ($.60) per bed per day to do infection control. This requires the hospital to have a multidisciplinary infection control team and develop surveillance programs. There is no Japanese equivalent to the Centers for Disease Control and Prevention to write guidelines, but there is a core of young enthusiastic professionals that will make it a future reality.
There could be several reasons for the emergence of vancomycin-resistant S. aureus in Japan, including patterns of prescribing antibiotics. In Japan, antibiotic use is high and many different antibiotics are used routinely. Antibiotic usage has been reported to be as much or more than that in the United States, though Japan has a population half our size. For example, Japanese physicians are known to give intravenous antibiotics prophylactically for normal vaginal deliveries. The more expensive, exotic antibiotics are preferred to treat patients in many instances. This practice is reimbursement-driven, as the hospital’s main revenue is from prescribed pharmaceuticals and newer antibiotics have higher reimbursement rates.
Regarding infection control in general, there is very little availability of convenient disposable supplies. Items intended to be disposable are frequently reused, even between patients, including stopcocks and cardiac or arterial catheters. Treatment supplies can be very labor-intensive to use. One hospital home health department had the nurses return to the hospital after their patient home visits and spend three hours cleaning, repackaging, and sterilizing items for their patient care. Can you ever imagine that in the United States? It must be so costly.
In addition, research is questioning the traditional method of skin antisepsis used in Japanese hospitals. An example is in the traditional method of antisepsis consisting of a container where gauze or cotton balls are placed. Alcohol or other antiseptics are poured over them. The container is placed in the nurses station or on the medication cart. The nurses and doctors often obtain one with their hands and squeeze out the excess liquid back into the container. The saturated cotton ball can be laid down on many surfaces before it reaches the patient. The container is topped off daily and changed weekly at most. Japanese investigators recently reported that their hospital had "outbreaks of infection" from this method.3
Additionally, there persists "appearances" of cleanliness, such as removing your shoes before you enter the hospital. However, on the patient care wards the sinks and lavatories can be very few and inaccessible, and soap or paper towels are often not available to wash and dry your hands.
Infection control may hurt patients’ feelings
With few exceptions, universal precautions are not practiced in Japan, even while handling blood. Though their HIV rate is reportedly low, the hepatitis rate is high. Nurses tell me, "If I put on gloves it will hurt the patient’s feelings."
I have spent much time wondering, if the Japanese medical professionals have the information, why is there little change? It seems that culturally, it is taboo to speak against one’s own system. My fondest wish is to find a way beyond this cultural barrier. I hope this finding of vancomycin resistance in Japan will not be regarded as "information not to discuss." Instead, it could be an opportunity to improve and possibly begin a whole new era in infection control for the land of the rising sun.
References
1. Kobayashi H. Focus on Japan: Overview of health care system. Asepsis 1994; 16:4 2-6.
2. Tomiie E. In-nai Kansen (Hospital Infection). Tokyo: Kwaide Shobo; 1990.
3. Oie S, Kamiya A. Microbial contamination of antiseptics and disinfectants. Am J Infect Control 1997; 24(5):389-395.
(Editor’s note: A frequent traveler and lecturer in Japan, Ann Hardee is a member of the Association for Professionals in Infection Control and Epidemiology. She has been a registered nurse for 20 years with a clinical background as a transplant nurse at Hermann Hospital in Houston, and has worked in oncology, intravenous therapy, and chemotherapy at M.D. Anderson Cancer Center, also in Houston. She is president and founder of Rann Med International, a home infusion therapy business. Hardee originally became interested in Japan through her study of total quality management theories.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content