The Enemy Within
Forget his sterile latinate title. Dr. David A. Pegues is nothing more than a snitch. He noses around the UCLA Medical Center sniffing out doctors, nurses, janitors, visitors or anyone else he believes is not taking enough precautions to avoid the spread of infectious disease. It makes him very popular . . . with patients.
At the moment, however, his job has him taking the stairs two at a time up to his own third-floor office. An emergency has turned his day upside down. TV helicopters are buzzing outside. A worker in a building nearby has opened an envelope to find a letter declaring: “You have just been exposed to anthrax.” Dozens of people may have been exposed, and they are coming to the medical center.
Pegues’ office is a cool white space, barely wide enough to hold a desk, files and two straight-backed chairs for visitors. He slips on a telephone headset and starts calling, learning details of the anthrax threat. Emergency workers are preparing to bring in 39 people. Over the phone, Pegues advises colleagues in the emergency room to use respirators when they deal with these patients and to seal off access to the area where they will be examined. “There’s a vaccine available in Michigan,” he says. “If we need it, I can get it pretty fast.”
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In an age where medicine is accomplishing miraculous breakthroughs, potent new germs have become an increasingly daunting enemy. Diseases held in check for decades by antibiotics have turned chameleon and are spreading at alarming rates. “For simple, unicellular organisms, bacteria are amazingly crafty,” Pegues says. “They’ve been around for a lot longer than we have and they know how to adapt. It’s a fluid, inexorable process of evolution. Every time we figure out a way to kill them, new resistances eventually emerge.” As a result, hospitals around the country are responding by hiring germ warriors like Pegues [pronounced peh-GEESE], whose sole purpose is to fight back.
Most recently, Pegues has been deep in thought about a one-cell organism called Burkholderia cepacia. During the last 100 days, seven patients at the medical center had been found to have respiratory infections caused by this drug-resistant little beast. Though otherwise healthy patients will beat it, “B. cepacia,” as it’s called, can kill. In the lungs it can destroy tissue and drown a patient with fluid. In the bloodstream it can cause a raging infection that shuts down organs, one by one, until the brain is darkened by coma and the heart is stilled.
Pegues is one of a handful of infection control experts in the country who can claim residencies in epidemiology, infectious disease and public health. He is dogged, and even at age 39, his 6-foot, 150-pound frame gives him the look of a gangly adolescent--one who always seems to be in a hurry. “Even among scientists, David is more thorough, more obsessive-compulsive--right down to being super neat--than anybody else,” says Sam Miller, a doctor at the University of Washington, who trained Pegues at Massachusetts General Hospital.
In the three years since he was recruited after working as an epidemic intelligence service investigator for the federal Centers for Disease Control and Prevention, Pegues has turned a once-quiet little office at the medical center into anti-microbe SWAT team headquarters. His hands are in everything the hospital does. He has the power to quarantine patients and to shut down any hospital unit. His mandate is so broad that his approval will be required on the plans for the $450-million, earthquake-proof medical center that UCLA will build soon. He may just kill a fountain planned for the lobby because its mist could spread germs.
The rising power of Pegues and other germ warriors is remarkable when you consider that not long ago, they occupied a backwater of medicine. For decades this job had been the unglamorous domain of monitors known best for nagging doctors and nurses to wash their hands. The appearance of HIV/AIDS in the 1980s began to change both the image and the practice of infection control. Suddenly every life inside every hospital became dependent on containing germs.
The battle focuses on hospitals because they are the most likely breeding grounds for new bacteria and because they are supposed to shelter the sick and injured. Public fear of acquiring a new illness while in the hospital seeking care is justified. It happens at least a million times a year, and contributes to more than 90,000 deaths.
As a result, a new generation of aggressive microbe hunters has become a major influence on life in large hospitals nationwide. “I’m not saying we are going to beat every bacteria,” says Dr. Julie Gerberding, director of the hospital infections program at CDC. “Actually, in the end the bacteria always win. But we can hold them back, limit them.”
In 1990, Pegues was a freshly commissioned officer of the CDC locked in one of his first investigations of B. cepacia. A number of young adults attending Cystic Fibrosis Foundation summer camps had been infected, and the CDC wanted to know if this bacteria could be spread person to person in an open environment.
Pegues flew to camps in Ohio, Utah and Ontario, Canada, to investigate.
Water samples from the pools, lakes, fountains and faucets at the camps were clean, but B. cepacia was found in the lungs of 46 of 237 campers. By the time camp was over, 11 more kids were infected. Though it seemed persuasive, the evidence was merely circumstantial until Pegues’ team confirmed it with a DNA study: People with cystic fibrosis face special risk from a respiratory infection.
The study led to an article in the journal Pediatrics and helped Pegues begin making a name for himself. It also drew him deeper into a specialty that is a blend of science and sleuthing. The CDC sent him to the Navajo reservation hospital in Shiprock, Ariz., where he determined that what looked like an epidemic of blood disease was actually a false alarm set off by contaminated test vials. In Alabama, he again chased his nemesis B. cepacia, eventually tracing 14 cases to contaminated intravenous fluid in a cancer-treatment center. While he was in Alabama, Pegues also was asked to look into lead poisoning in a rural county. A local hospital had detected it during blood tests on nine adult patients. The only factor that stitched the cases together was alcohol: All of the patients had been admitted for alcohol-related diseases.
The big government sedan that Pegues drove into the Alabama countryside didn’t help his investigation. But eventually the proprietors of the little country taverns where he stopped were convinced that he was a doctor, not a revenuer. He managed to collect a few alcohol samples to take back to his lab, and his hunch was proven true. The lead was in local moonshine, which had been distilled in contraptions built from auto radiators with lead-soldered parts.
He loved working at the CDC. “But when this job came along, I realized that I could get in on something important. Hospital epidemiology is a hot field. UCLA is a premier medical center. They seemed to need me, and I liked the challenge, especially since I would be able to see some patients in addition to doing infection control.”
When he arrived in 1996, Pegues found a hospital with a subpar surveillance system that had never had an epidemiologist assigned full time to infection control--unusual for a medical center and research site with more than 500 patients. The Joint Commission on Hospital Accreditation, which certifies hospitals nationwide, had recommended improvements to UCLA’s system for tracking infections.
Pegues’ counterpart at USC Medical Center was in place about 20 years ago, when the new superbugs began to appear. At the time Dr. Peter Heseltine was a fledgling hospital epidemiologist. “The general feeling then was that if someone got an infection in the hospital, it was not really a big deal because he could be cured with an antibiotic and that was that. No one really expected these drugs would begin to fail to work. But they did.”
In fact, the very first drug-resistant bacteria were discovered in the 1940s soon after penicillin--the first antibiotic--became widely available. By the end of the decade researchers were warning that evolution could render so-called miracle drugs powerless. But at the time, new antibiotics were being developed so quickly that it seemed as if researchers would stay ahead of the bugs indefinitely.
Ironically, the harder scientists worked to make new drugs, the more they contributed to the resistance problem. This is because the drugs themselves are a critical part of the evolutionary process. “Imagine that the antibiotic is like some alien race that comes to Earth and kills everyone who’s 5-foot-10 or shorter,” says Heseltine. “What you have left over is a bunch of big, angry people who reproduce and create even more big, angry people.” To make matters worse, he adds, bacteria know how to share resistance, so that a tiny, innocuous bug that just happens to be resistant to a drug can pass on that trait to a much nastier creature, which suddenly refuses to succumb to a former miracle drug.
Hospitals are perfect settings for this evolutionary process because they house plenty of bacteria in an antibiotic-rich environment. In this hothouse, the most virulent strains emerge. Once they develop, hospital-bred superbugs may attack patients rendered all but defenseless by disease or by medical interventions. At UCLA, where hundreds of transplants are done every year, every patient who receives a new organ or a bone marrow transfer is at special risk.
Pegues learned about the dangers of infection in transplants years before he became an epidemiologist, when his father received a heart transplant in 1985. His father had been the first neurologist to practice in their hometown of Moorestown, N.J., and had inspired Pegues to become a doctor himself. As a transplant patient, he endured the drugs that suppressed his immune system, but the transplant failed anyway. He died at age 57.
At the time, Pegues was just beginning to study in his specialty. Then, and now, one of the most effective methods of slowing and even reversing the evolutionary process involved careful control of antibiotic use. When this is done, the so-called “wild strains” of bacteria--those that can be killed by antibiotics--reclaim their turf from the mutants.
One of the most impressive experiments with this strategy occurred not in the controlled environment of a hospital but in a broader setting. In Finland, public health officials noticed outbreaks of erythromycin-resistant bacteria that cause common illnesses such as ear infection, and banned use of the drug. Doctors could cure infections with drugs less powerful than erythromycin--a broad-spectrum bug killer--though this involved some trial and error as well as tests to find out which bacteria might be infecting the patient. In little more than a year the resistant strain had practically disappeared, replaced by the wild type, which could still be killed by the antibiotic.
At UCLA Medical Center, Pegues presides over a program that limits physicians’ prescription power. The most powerful antibiotics cannot be given unless Pegues or another infectious-disease specialist approves. “In most cases when we do a culture and report back to the physician, the computer won’t even tell them that the virus is susceptible to the most powerful and expensive drug. The computer suppresses that information and reports only the simpler, cheaper drugs that are just as effective.”
Though one might expect physicians to resist these kinds of controls, Pegues says the conflicts are few. “Doctors know about this problem and they aren’t going to turn to these drugs unless the reason is sound. If they’ve got that kind of argument, I go along with it.”
Controlling drugs is just one defensive measure Pegues uses. Another powerful tool is surveillance. This doesn’t mean spying on doctors and nurses, though Pegues’ team does spot-checks to make sure they aren’t spreading diseases via their hands and instruments. Instead, this means gathering information on infections throughout the hospital, and then sifting through the data to find patterns.
“The surveillance system that was in place when I got here was like something you would find at a community hospital,” Pegues recalls. The most compelling result of the changes he has put in place is a reduction in problems with pneumonia patients who were breathing with the help of ventilators. Pegues’ team noticed a high number of infections and observed the way nurses and respiratory therapists had been using tubes to suction fluid from the patients’ lungs. The team found plenty of opportunities for bacteria to be transferred to the lungs. Through better equipment and more careful nursing, there has been a 49% decrease in infections since 1996. A similar approach, used to combat bloodstream infections, led to a 33% reduction.
Success doesn’t always come so easily. Pegues’ staff admits that there are doctors who resent his power. “It’s not like we have a lot of enemies, but people can be nasty,” says Patricia Hamm, a member of Pegues’ team. “One thing people aren’t supposed to do is wear protective clothing--like surgical masks and the little booties that cover shoes--in the hallways or cafeteria. They could be carrying germs all over the place. When we try to talk to people about this, they sometimes just walk away. I’ve had someone say, ‘What are you, the shoe police?’ They know that if it gets serious, David can take an issue up the chain of command and make something happen. I think they don’t like it.”
Upcoming on Pegues’ agenda is a more aggressive program for scrutinizing individual physicians. Soon he will be able to track the number of postoperative infections among each surgeon’s patients. He then will compare the types of patients each doctor treats and come up with comparative infection rates. Delivering these findings will require exquisite diplomacy.
“The idea is not just to catch someone,” Pegues says. “But we do know that some surgeons seem to do better [at preventing infection] than others. When you give them information about how they are doing, they will immediately try to get better.” Pegues insists that he’s not yet been forced into a showdown with any of UCLA’s doctors, but he expects one someday. “The good thing is, I’m pretty high up on the food chain here.”
Nurse/infection control officers Hamm, Valerie Kern and Judy Lundal meet with Pegues frequently to discuss the more serious problems they have uncovered in their daily spot-checks and reviews of hundreds of pathology reports. On a recent day, as they gathered round a conference table over lunch, there was good news: Staff injuries from “sharps” such as needles and scalpels are down 21% from the previous year. That’s important because needle sticks can transmit HIV. The numbers also show that nurses working in patient rooms are getting jabbed most often, usually as they transfer blood to a vial or dispose of a needle. So infection control officers remind them of the hazards of handling needles after they’ve finished working with a patient--a time when it is easy to relax.
But talking won’t help fix a problem that occurred at one of the medical center’s 24 operating rooms earlier in the day. Just as a surgeon was poised to make the first incision, a mysterious vapor entered the room from somewhere overhead. The patient was covered, and the O.R. then was scrubbed clean. But Pegues is unhappy to hear that this had happened before. “How could air be coming in on a patient like that?” he asks his staff afterward. “Find out if there are filters on the vent line leading to the O.R. And find out if maintenance has been notified, and how they are going to fix it.”
Next comes the possible B. cepacia outbreak. Lab reports on specimens taken from patients in the hospital show genetic variations in their germs, suggesting that at least some of the B. cepacia had been brought to the hospital by the patients themselves. A computer study has found that all of the patients had had surgery or had tubes inserted in one part of their bodies or another--providing an entry point for the bacteria -- but there is no evidence that they were all being treated in the same place or by the same people. “They all had different procedures, so I doubt it’s an O.R.-related problem,” Pegues says. They are beginning to conclude that each of the patients brought B. cepacia along when he or she came to the hospital.
When the meeting ends, Hamm returns to her tiny office to review papers she will hand out at a workshop for hospital staff. “I know you have to be kind of diplomatic in this work,” says Hamm, an outspoken and Type A personality. “If you tick people off when you’re trying to get them to be more careful with how they work, you get zero cooperation. Most people remember being told to wash their hands when they were kids. They can resent being told as adults, if you don’t do it the right way.”
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The anthrax scare is building. Although Pegues is fairly certain how best to treat anyone exposed, he grabs “The Control of Communicable Disease Manual” just to make sure. He also dials the number of the U.S. Army’s Medical Research Institute of Infectious Disease at Fort Detrick, Md. An Army major there asks if any powder was visible on the letter or in the envelope and, more important, if it could have been puffed into the air by a sneeze or a shake. When Pegues tells him that the letter bore water stains, but no powder, and that nothing had been tossed into the air, the major advises him that the letter is probably the prop for a hoax, one of more than a dozen that have occurred in recent weeks but have been kept quiet by government officials.
Though he’s betting it’s a hoax, Pegues can’t help thinking about the gruesome death that anthrax brings--victims hemorrhage and drown in their own blood. With this in mind, he recommends that emergency room doctors start all of the incoming patients on antibiotics. If this case turns out to be a real attack, four weeks of medicine and three doses of anthrax vaccine will prevent the anthrax from causing disease.
As if that weren’t enough to stoke their anxiety, the 39 office workers arriving at the hospital must submit to the humiliation of being stripped and decontaminated by hazardous materials specialists who wear protective suits and rinse the patients off in inflatable kiddie pools set up on a loading dock. Each patient is given a set of green hospital scrubs and is led to a makeshift quarantine center in the wood-paneled lobby of the hospital’s neuro-psychiatric institute.
Pegues explains the health threat to the FBI agents and draws up a fact sheet listing the signs of anthrax illness, which begin with flu-like symptoms. He interviews the woman who opened the letter. When the health department calls to say that initial tests on the letter found no trace of the poison, he is asked to speak to the patients.
Though the most conclusive test will not be completed for 72 hours, the evidence of a hoax is strong enough to allow the office workers to go home. Pegues reassures those who may have been exposed that it is practically impossible for them to infect anyone else. At the FBI’s request, he asks them to help discourage copycat crimes. “There’s a slew of media out there waiting to interview you,” he warns. “The best thing you can do is just avoid them.”
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The next day, pegues awakens thinking about a patient he will see at 9 o’clock. Afflicted with a chronic immune deficiency disorder, Brigid Brown has spent most of the past year locked in a life-or-death war with a fungus too small to see without a microscope. She has lost part of a lung, and nearly has died several times. But with Pegues’ help she may at last be getting the upper hand.
In an exam room at the hospital Brown smiles as Pegues, whom she describes as “the man who keeps me alive,” uses a stethoscope to listen to her lungs. She’s a small woman with short strawberry-blond hair and an easy smile. “I’ve seen a lot of bugs, and had a lot of trouble getting rid of them, but nothing has been like this fungus,” says Pegues. He has put her on aggressive and expensive treatment: $500 worth of antifungal medicine five to seven times a week for five months. As with many radical therapies, the treatment is almost as bad as the disease. It threatens her kidneys and was keeping her homebound. But so far, side effects have been minimal.
“It’s easy to think that the job is to defeat all these infectious agents, but it’s really about taking care of people,” Pegues says. “I mean, we’re never going to conquer bacteria. But we have to stay one step ahead.”
