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Team:Elan Vital South Korea/h promotion
From 2014hs.igem.org
Promotion of Information Sharing in Hospitals
According to a report released by medical news today, around 94,360 invasive MRSA infections are diagnosed annually in the US, with 18,650 associated deaths. Approximately 86% of all invasive MRSA infections are health care associated. In Korea, situation is more serious. Due to the sensitivity of the nature, general hospitals are reluctant to release accurate statistics regarding infection cases and many of the individual clinics do not have proper prevention system. We feel urgency given the current situation to encourage proper management of the infection prevention. By the initiative of Soo Jung Lee, we have visited more than 20 hospitals and clinics and explained the importance of accumulating statistical information and the implementation of proper prevention policy. We have distributed information brochure and requested them to display it so that patients can see it for their interest. Also, Soo Jung conducted an interview with a doctor. It was very useful for all of us to understand the current management status and it was very happy for our team to get support from medical professional in our efforts.
Following is the contents of the interview
Interview date : May 17, 2014
Interviewer : Lee, Soojung
Interviewee : Kim, Keonhwa
The Interviewee, Kim Keonhwa, went throught the following education programs:
Inje University College of Medicine(2009-Present)
Harvard Medical School-Brigham and Women’s Hospital, 221 Longwood Avenue Brigham Dermatology Associates, and Boston Children’s Hospital Division of Rheumatology/Immunology/ Allergy Student Intern (May, 2014)
Scheduled MD Degree (Jan, 2015)
Question: I have heard there were frequent incidents of infection inside hospitals. Is this true?
Yes, infections that occur inside the hospital environment or any type of health care providing service centers are common and also a major problem both inside and outside of the US. The incidents that happen inside these environments are what we call hospital-acquired infections(HAI). There are many types of HAI that are classified by the route of transmission. The most common types, just to name a few, are blood stream infections(BSI), pneumonia, urinary tract infections(UTI) and surgical site infections(SSI). Blood stream infections are mostly due to the excessive drawing of blood for laboratory studies of patients. Contaminated needle tips or insufficient sterilization of the blood-drawn area are the most common causes. Pneumonia is usually caused by patients that are under bed-ridden states with ventilator association. The decreased breathing functions causes aspiration of foreign bodies into the respiratory tract. Urinary tract infections are mostly caused by catheter insertions to patients who have impaired bladder functions. Last but not least, surgical site infections are mostly due to insufficient sterilization and contaminated dressing procedures. The US Center for Disease Control(CDC) estimates around 1.7 million HAI and a total of almost 100,000 deaths due to HAI per year. This is a major problem that is preventable by physicians and health care professionals and should never be overlooked.
Question: In case such things happen, what kind of action takes place in the hospital?
Sterilization and antibiotic injection is what is mostly done to patients. Most patients recover from these infections if they are not in an immunosuppressed state or have severely impaired immunologic functions. However, the major problem is not only the recovery of infected patients but also the advent of microorganisms that are more highly resistant than the previous types. A couple of examples would be VRSA(Vancomycin Resistant Staphylococcus Aureus) and CRE(Carbapenem Resistant Enterobacteriaceae) which I, myself, have also seen in my university hospital Medical Intensive Care Unit(MICU). If such infections happen, the whole hospital floor or unit is shut down and access is restricted to everyone but health professionals. It is always safest to prevent any HAI by frequent hand washing and preventing redundant contact to patients with any contaminated object.
Question: What should the public and government do to prevent reoccurrence?
The public should always be aware that infections can be possible in any type of place or situation. The first step is to always keep your hands clean by washing them frequently and thoroughly with antibacterial sanitizers and minimizing infectious contact to others and yourself. The government should always sufficiently subsidize the Center for Disease Control and keep a statistically detailed track of the incidents and death rates due to HAI. Physicians and health care professionals should always be self-conscious about their own hygiene before encountering anyone in the hospital. Abiding by these basic sanitation rules will significantly decrease the rate of any type of infection inside and outside of the hospital.
Question: What kind of advice would you give to Lee, Soojung for her future as a medical scientist?
First, I would like to say it was a pleasure having this interview with you and I appreciate you taking medical advice from me. There are many different paths in pursuing a career in medical science, it can be a physician who works in hospitals and takes care of patients, a scientist who does research in laboratories for medical technology, a physician assistant, a nurse, an emergency medical technician and etc. But regardless of the field of study you may major or job you may have, anything that is related to medicine or medical science should be for the care and good of the people in need of help, patients. There is a short and famous saying for health care professionals : “Do no harm.” Which means, before you can treat or make a patient feel better, you should at least not do anything that aggravates the patient’s situation. That directly refers to the issue we have just talked about, hospital-acquired infections. Live by this rule, and you’ll see yourself positively contributing to yourself and the people around you in the world of medicine. There’s always much more to say, but I think it’s best to keep an advice simple for it to be followed. Thank you, and good luck with your future.
Promotion in hospitals
In addition, Ji Hoon Kim visited hospitals in Atlanta, Georgia when he came there and met with local medical professionals to know about the infection control measures. His input was very valuable for us to understand that there exists a big gap in the country specific policies and make us think about the necessity of establishing global standard and management system.
Promotion in Crestwood Medical Center
Young Chan Kim wrote an essay about MRSA infection statistics in Korea to make a better understanding on the current status of MRSA control system.
Introduction
MRSA stands for Methicillin Resistant Staphylococcus Aureus. Methicillin is a type of drug used commonly to cure infections, and MRSA is a strain of Staphylococcus that is resistant to Methicillin. MRSA can be quite dangerous, so it is a focus of medical attention today. It can cause a number of infections on soft skin, and can cause death. MRSA also generally exhibits multi-drug resistance in addition to methicillin resistance. In some studies, it was suggested that MRSA acquired from hospitals were more dangerous than MRSA imported from the general public. When I heard this claim, I was interested because that would mean that hospitals are more dangerous for the disease. To test this, I will compare the drug resistance of acquired (in hospital) MRSA and imported (from the general public) MRSA. I expect that acquired MRSA will show more drug resistance than imported MRSA.
Materials and Methods
Getting data for this project was nearly as impossible, because most of the data were classified for national security reasons. In the end, I asked one of my neighbors who is a medical doctor for help, and acquired several reports of collaborative researches by hospitals on MRSA sponsored by the government: Korea Center for Disease Control and Prevention and Korean Society for Nosocomial Infection Control. It had some raw data I could use. The data was collected from a number of local and general hospitals. To distinguish between imported and acquired MRSA, they counted all MRSA found within 72 hours of hospitalization of the patient to be “imported,” and all MRSA found after 72 hours of hospitalization of the patient to be “acquired.” I ran the Chi-square tests and regression analysis on them. Note that these reports were counted as classified, so you might not be able to access these.
Data
I acquired a table with data for MRSA resistant to different kinds of drugs. All the data came from the sample collected by the hospitals involved in the study. The total sample was 733 for Acquired MRSA and 354 for Imported MRSA. In this analysis, the source of the MRSA is the independent variable, with nominal scale data, and the percentage of MRSA resistant to drugs is the dependent variable, with ratio scale data.
| Resistance to drugs | Acquired MRSA | Imported MRSA | Ciprofloxacin | 457 | 167 |
| Tetracycline | 329 | 118 |
| Clindamycin | 442 | 163 |
| Sulfamethoxazole | 38 | 16 |
| Total | 733 | 354 |
Statistical Analysis
For the project I used Chi-square analysis and Regression analysis. Since I think that Acquired MRSA is more dangerous than Imported MRSA, I hypothesized that Acquired MRSA will also show higher amounts of drug resistance than Imported MRSA. The data and the ratios that resulted from the data seems to suggest this is true, but to make sure this isn’t because of sampling error or bias from personal opinion, I need to run Chi-square tests for association. Regression analysis helps create possible models for linear relationships, and can predict what we would see if we collected some more data. Normally, I would not use regression analysis for such a small set of data, but the Acquired Resistance Rate Vs the Imported Resistance rate ratio stays almost exactly the same for almost all of the data, and since it would make sense that acquired MRSA resistance rate ad imported MRSA resistance rate would be directly related, I found a mathematical model connecting the two values using regression analysis, particularly model 2 regression analysis.
First, I noticed that the ratio of resistant MRSA seemed to be higher for Acquired MRSA then Imported MRSA. Therefore, I ran Chi-square test for associations for the 4 different drugs tested. For the different number of drug resistant MRSA, I calculated the number of MRSA sensitive to the drug by subtracting the number of MRSA resistant to the drug from the total. Then I ran Chi-square tests for association for all the different types of drugs.
| Ciprofloxacin | Acquired MRSA | Imported MRSA | Ciprofloxacin Resistant | 457 (0.6235) | 167 (0.4718) |
| Ciprofloxacin Sensitive | 276 (0.3765) | 187 (0.5282) |
H0: There is no statistical significance, so there is no difference in the Ciprofloxacin resistance level of imported and acquired MRSA.
HA: There is statistical significance, so there is a difference in the Ciprofloxacin resistance level of imported and acquired MRSA.
Since the table is 2x2, we have to use Yate’s correction.
The degree of freedom is 1.
The chi-square value is 22.47>3.84=critical value for 95% confidence.
Therefore reject H0, accept HA. There is a difference in the Ciprofloxacin resistance level of importance and acquired MRSA.
| Tetracycline | Acquired MRSA | Imported MRSA | Tetracycline Resistant | 329 (0.4488) | 118 (0.3333) |
| Tetracycline Sensitive | 404 (0.5512) | 236 (0.6667) |
H0: There is no statistical significance, so there is no difference in the Tetracycline resistance level of imported and acquired MRSA.
HA: There is statistical significance, so there is a difference in the Tetracycline resistance level of imported and acquired MRSA.
Since the table is 2x2, we have to use Yate’s correction.
The degree of freedom is 1.
The chi-square value is 13.15>3.84=critical value for 95% confidence.
Therefore reject H0, accept HA. There is a difference in the Tetracycline resistance level of importance and acquired MRSA.
| Clindamycin | Acquired MRSA | Imported MRSA | Clindamycin Resistant | 442 (0.6030) | 163 (0.4605) |
| Clindamycin Sensitive | 291 (0.3970) | 191 (0.5395) |
H0: There is no statistical significance, so there is no difference in the Clindamycin resistance level of imported and acquired MRSA.
HA: There is statistical significance, so there is a difference in the Clindamycin resistance level of imported and acquired MRSA.
Since the table is 2x2, we have to use Yate’s correction.
The degree of freedom is 1.
The chi-square value is 19.65>3.84=critical value for 95% confidence.
Therefore reject H0, accept HA. There is a difference in the Clindamycin resistance level of importance and acquired MRSA.
| Sulfamethoxazole | Acquired MRSA | Imported MRSA | Sulfamethoxazole Resistant | 38 (0.0518) | 16 (0.0452) |
| Sulfamethoxazole Sensitive | 695 (0.9482) | 338 (0.9548) |
H0: There is no statistical significance, so there is no difference in the Sulfamethoxazole resistance level of imported and acquired MRSA.
HA: There is statistical significance, so there is a difference in the Sulfamethoxazole resistance level of imported and acquired MRSA.
Since the table is 2x2, we have to use Yate’s correction.
The degree of freedom is 1.
The chi-square value is 0.22<3.84=critical value for 95% confidence.
Therefore accept H0. There is no difference in the Sulfamethoxazole resistance level of importance and acquired MRSA. (But I suspect this might be type II error resulting from a sample size not big enough.)
Therefore, I concluded that Acquired MRSA generally had more drug resistance then Imported MRSA. After I conducted the Chi-square tests, I noticed that the ratio of resistant Imported MRSA VS the ratio of resistant Acquired MRSA seemed to be constant. Therefore, I ran a regression analysis. Since there were only 4 sets of data, it might not have been such a good idea, but the ratios were almost exactly the same for every drug except for Sulfamethoxazole, which seemed to suggest strong correlation. Since the data was count data, I cannot run any correlation coefficient tests, so I went straight for the regression analysis.
Since neither of the variables was controlled and there was no clear dependence relationship, I used model 2 regression.
The Standard Deviation of Acquired MRSA: 0.2650
The Standard Deviation of Imported MRSA: 0.1985
b=0.1985/0.2650=0.7491
The mean of Acquired MRSA: 0.4318
The mean of Imported MRSA: 0.3277
Therefore, the regression line is y=0.7491x+0.0042
Discussion
I concluded that in terms of drug resistance, Acquired MRSA has a higher rate of drug resistance then Imported MRSA, and is more dangerous, which fit my original hypothesis. I also found the regression line to be y=0.7491x+0.0042, and the data fit very well with the regression equation. If I could do things differently, I would have preferred to get some more raw interval/ratio data about MRSA so that I could analyze the results more closely. Analyzing the data made me want to analyze the effect of MRSA on other drug resistance levels. Does Acquired MRSA always exhibit higher resistance? Or does it happen only with certain drugs?
Reference
Note: You might not be able to access some of these as they were classified to some extent. But I assure you I didn’t break any laws in accessing these reports.
JinHung Yoo. “Analysis of clinical characteristics and assessing the effectiveness of active surveillance/decolonization on the occurrence of nosocomial MRSA”. 2009
Seoul National University Hospital Bundang. “Analysis for changes of epidemiology in Staphylococcus aureus infections and predictive factors for methicillin resistance in Korea”. 2012
Jae-Il Yoo. “Laboratory surveillance system of vancomycin-resistant Staphylococcus aureus”. 2010
Jae-il Yoo, Kisoo Kang. “Characterization of vancomycin intermediate Staphylococcus aureus (VISA) isolated from hospitals”. 2012
Kyungtae Chung. “Monitoring of antimicrobial resistance in clinically important pathogens from non-tertiary hospitals in Korea”. 2011
