NURSING REVIEW talked to nurse researchers and an infection control nurse specialist who share stories of fighting infection before antibiotics, the 'H-bug' epidemic of the 50s and today.
Antibiotic histories: Fighting pus in pre-antibiotic days
Fighting sepsis was a major preoccupation of nursing in the pre-antibiotic days, says nursing historian Dr Pamela Woods.
Unfortunately, she says, antimicrobial resistance might see that return and her collection of antique nursing texts on pre-antibiotic surgical nursing and aseptic wound dressing might need to be dusted off and put into use once again.
The EIT associate professor spoke recently at a major research symposium in London looking at the past and future of hospital infection control, presenting a paper called Pus and pedagogy: sepsis, surgical nurses and suppurating blame 1900–1935.
Wood says hospital gangrene and other horrific post-surgery infections were the norm in the early days of surgery and surgical success depended on the prevention of sepsis.
The first significant technological inroad into fighting sepsis began with Joseph Lister in the 1860s championing ‘antisepsis’ by using carbolic acid as an antiseptic to kill off the newly discovered, airborne, disease-causing microbes.
The discovery that most microbial infections were transferred by contact not by air saw the advent in the 1880s and 1890s of ‘asepsis’ and the sterilising of anything and everything possible, including instruments and dressings. But as you couldn’t “boil a nurse or surgeon” antisepsis or antiseptics had their place.
The combination in the early 20th century of asepsis and antisepsis – including stringent hand washing and surgical gloves – made a “huge difference” to hospital practice, says Wood, and for the first time surgeons could expect that surgical patients would heal and recover.
The professional responsibility for following the strict aseptic, sterile procedures for pre and post-operative wound care was given to the surgical nurse.
Wood, after studying nursing journals, textbooks, exams and memoirs of the time, says it becomes clear that nurses in pre-antibiotic times were either valued by surgeons as guarding patients from “microbial attack” or blamed if wounds became infected. “Septic wounds meant septic relationships.”
Wood says there was also a strict nursing hierarchy in who could do what, with the junior trainee nurses taught medical asepsis or medical cleanliness that focused on keeping the environment and patient’s body clean. It was only the senior nurses who were taught surgical asepsis, including responsibility for sterilising theatre instruments, cleaning the surgical site preoperatively and doing the aseptic dressings after surgery.
“They understood the need for really careful aseptic technique, including lengthy hand washing before doing a dressing, and if there was an infected wound on the ward they would save that to last to reduce the risk of cross-infection.
“And if there were more septic wounds then senior nurses would share the job. One would do the all the clean, uninfected wounds – she was called the ‘clean nurse’ – and the other who did the infected wounds was the ‘dirty nurse’.
“Now we are at this time where we can’t rely on antibiotics – we simply can’t – we need to think back to those pre-antibiotic days and see what were they doing that was so successful – including scrupulous aseptic practice.”
Antibiotic histories: H-bug takes human toll in the ‘50s
Penicillin first became available, initially in limited supplies, in New Zealand public hospitals in 1944.
Just a few years later Dr Doris Gordon, the Director of Maternal Welfare from 1946 to 1948, observed worrying signs that increasing reliance on antibiotics was already leading to a slipping in maternity care standards developed to reduce the risk of infection.
Dr Deborah Jowitt, who did her master’s thesis on the H-bug epidemic in New Zealand, says that Gordon visited one North Shore maternity home during her post-war baby boom directorship to find 18 mothers jammed into a premises licensed for 12 and their 18 babies squeezed into a nursery so tiny that cot touched cot. The matron explained her simple method of housing extra babies – “just put two babies head to toe in one cot”.
“Today’s doctors blandly tell me,” Doris Gordon later wrote, “that penicillin will take care of cross infections! My prophecy is that penicillin may not always take care. It’s not a panacea for carelessness and someday these Staphylococci will stage a comeback…”
In the mid-1950s to early 1960s her prophecy was proven right with an epidemic of penicillin-resistant staphylococcal infections occurring in New Zealand hospitals and communities. Called the ‘H’, or Hospital, bug, these infections occurred frequently among mothers and babies in maternity units.
In her master’s thesis Jowitt – who is currently an infection prevention and control specialist at the Health Quality & Safety Commission and a member of New Zealand’s AMR Action Planning Group – described the impact of these infections on her own family at that time.
“As children in Kaitaia we all suffered from recurrent boils and our baby brother became very ill after being admitted to hospital with our mother as a boarder baby,” wrote Jowitt.
“She took him to Auckland several times before he was diagnosed with a penicillin-resistant infection. The medical superintendent at Kaitaia Hospital was able to dispense erythromycin, a new antibiotic developed in the early 1950s and he recovered.
“Our baby cousin was not so lucky – she died of staphylococcal pneumonia the following year.”
Antibiotic histories: Hips, knees, and MDROs
In modern hospitals reducing antimicrobial resistance (AMR) is a major focus for infection prevention and control (IPC) nurses.
This is reflected by three nurses with IPC backgrounds being part of New Zealand’s AMR Action Plan group. One of those is Lakes District Health Board’s infection control nurse specialist Waverley Newson – the representative of the Infection Prevention and Control Nurses College, NZNO, on the group.
Newson says the IPC sector has long been aware of AMR and in particular trying very hard to prevent the transmission of MDRO (multi-drug-resistant organisms) in hospital and other settings. This is a dual role of trying to prevent the transmission of MDRO from patients known to be colonised and also trying to prevent the risk of MDROs developing through reducing unnecessary or inappropriate antibiotic use.
She says IPC nurses’ ability to directly influence inappropriate prescribing has been more limited but one recent success has been influencing the prescribing of prophylactic antibiotics during hip and knee surgery.
The surgical site infection (SSI) improvement project, led by the Health Quality and Safety Commission, included very clear advice on reducing AMR by focusing on the timing, dose and length of prophylactic antibiotic therapy following hip and knee surgery.
Newson says in the past quite frequently prophylactic antibiotics were given for much longer than the best practice advice of 24 hours post-operatively. The research indicated extending antibiotics use beyond 24 hours provided no benefits and instead increased the risks of side effects and the potential for antibiotic resistance.
“I believe infection control nurses have been very influential in providing education and feeding back audit results to the orthopaedic teams, and we’re now seeing a very good compliance with that measure,” says Newson. She says a further spin-off appears to be better prophylactic use of antibiotics in other surgical specialties.
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