The CDC has a “toolkit” for health workers — an instruction manual on how to prevent one patient’s nightmare infection from becoming others’.
It reads like a how-to from the pre-antibiotics era, though it was published in 2012.
Its core recommendations: Make nurses wash hands every time they should. Keep the sick in their own wards, isolated from the uninfected. Make sure the infected are treated by separate staff with separate equipment. Avoid invasive devices. Retrain all hospital personnel on the new normal.
Faced with the growing threat of antibiotic resistance, health care is rediscovering 19th century germ-fighting strategies, while exploring the promise of 21st century tech. At stake is the ability to continue providing many life-saving surgical advances to older and sicker patients – joint replacements, organ transplants, heart surgery.
A bouquet of germs has become resistant to many antimicrobial drugs at a time when the drug industry has little else to offer. Beyond MRSA, there are gut germs like CRE and C. difficile, soil bacteria called CRAB, and sexually transmitted diseases including gonorrhea that won’t respond to most of the drugs long used to fight them. A few are gaining resistance to everything and killing high percentages of sick patients.
Florida health facilities have reported 12 outbreaks of germs resistant to the big-gun drugs called carbapenems since 2008, according to a Palm Beach Post investigation.
The infections are typically hitting the most frail and vulnerable – those in long-term acute care hospitals, on ventilators and in intensive care units, with open wounds and long-term antibiotic use.
If precautions aren’t taken now, doctors warn, these germs will become widespread in the community, as MRSA already has.
Old habits, new tools
Fighting their spread requires rededication to time-tested methods such as disinfection and isolation, experts say. But it also requires more: Computer-driven solutions like data analytics, hospital-wide microbe tracking, regional information-sharing, molecular studies, new testing technologies and whole-room disinfection.
New technologies are hitting hospitals seemingly every month. There are devices that emit ultra violet light to sanitize patient rooms; machines that vaporize hydrogen peroxide to sterilize surgical suites; laser tools that recognize and analyze germ samples, and sensors that know whether a nurse washed hands before touching a patient.
Meanwhile, a few small biotech firms are striking out in different directions from antibiotics. They are attempting to develop drugs that can disable the enzymes that cause resistance. They are exploring the bacteria-killing powers of a subset of germs called phages, which live to infect other germs.
Those drug solutions – if they work — are years or decades away. The change that matters most now is a change in attitudes, doctors said. That goes for consumers, doctors and health care administrators.
Sea change on antibiotic use
“We have a generation of people who grew up with the idea that if one shot is good, two shots are better,” said Dr. Timothy Flynn, chief medical officer at UF Health-Shands Hospital in Gainesville.
With antibiotics, that’s rarely true, he said.
“We have to stop the use of antibiotics that aren’t necessarily needed,” said Dr. Larry Bush, chairman of infection control at JFK Medical Center. “You’ve got to remember, most people get better, and did get better, without medicine. What did you give for urinary tract infection in 1918? Nothing.”
In 1843, before it was widely accepted that germs caused infections, physician and author Oliver Wendell Holmes Sr. asserted that doctors in Boston were almost certainly the ones passing a deadly childbirth infection called puerperal fever to laboring mothers.
Holmes’ argument was angrily attacked by obstetricians. But only after attitudes changed – after disinfection of hands and instruments became commonplace — did infants stop losing their mothers to the infections.
Dr. Tara Palmore and Dr. David Henderson of the National Institutes of Health recalled this lesson in an article in the April 15 Annals of Internal Medicine, calling for a culture change.
Over a year and a half, they said, 18 patients at the NIH clinic tested positive for CRE, carbapenem resistant Enterobacteriaceae, and seven immune-compromised people died.
They described how challenging it was to stop the 2011 CRE outbreak. As in Holmes’ day, strict hand washing proved key, they said. But with no margin for error, they went so far as to hire full-time minders to shadow nurses and stop them if they were about to do something that might spread germs.
But it took more: The NIH scientists devised a way to use lasers and a technique called mass spectrometry to profile the types of germs infecting a patient, a tactic that was expensive, but enabled same-day identification of the nightmare germs. That enabled precautions to be taken before other patients became infected.
Tools like that aren’t widely available outside the National Institutes of Health.
Testing takes days
Instead, the process of identifying a nightmare germ takes days. Hospitals that are actively looking must first collect samples with swabs. They send the swabs to their labs and literally wait for days for the germs grow on dishes. If they are treated with an antibiotic and keep growing, it means they’re resistant.
By the time they send results back to doctors and nurses, staff may have spread the germs all over the hospital.
Rapid, inexpensive tools are needed to spot the CRE germs in minutes, instead of days, scientists said.
The drug industry says the FDA is partly to blame for this state of affairs. Dr. David Shlaes, the former head of infectious disease research at Wyeth pharmaceutical, since part of Pfizer, writes that after the agency made a rule change which increased the size of clinical trials needed to win approval for new antibiotics, research plummeted. For a small degree of added certainty, the FDA had raised the cost of bringing a new antibiotic to market by more than 100 percent. He called on the FDA to reverse its stance.
For now, the CDC urges, everyone must practice stewardship of the antibiotics we still have.
There aren’t expected to be new antibiotics able to kill CRE for many years to come. Stewardship programs place tight protocols on when the most valuable drugs can be prescribed, to ensure they aren’t used unless absolutely necessary. And they impose standards on what to do when one type of antibiotic isn’t doing the job after 48 hours.
Delray Medical works hard
Delray Medical Center is aggressive about antibiotic stewardship. It has to be. It’s one of two Palm Beach County specialty trauma centers where accident, shooting and other emergency cases are sent, making it a likely hot spot for drug-resistance. And, it serves large retirement villages like King’s Point, which are populated by thousands of frail 80- and 90-year-olds, with their complex health needs.
Given Delray’s patient demographics, it should have some of the highest rates of infection anywhere in the region. But it doesn’t.
According to data reported to the CDC and released by the Centers for Medicare and Medicaid Services, it has some of the best scores for key indicators like bloodstream infections and urinary catheter associated infections, where drug-resistant germs can cause life-threatening infections.
It’s no accident, said Dr. Anthony Dardano, Delray’s chief medical officer.
“Anytime a patient is admitted to the ICU, they are screened for MRSA, VRE, active TB, if suspected, and C. difficile, just to see if they are colonized,” Dardano said. “A person colonized would automatically be isolated.”
Delray Medical has adopted most of the “toolkit” recommendations, and beyond, he said.
“We have an automatic order to remove that catheter on day one or two after surgery. The longer that catheter remains in a person’s body, the greater the likelihood of infection,” said Pharmacy Director Bert Munoz.
“We go on rounds with the doctors and make sure to use the right antibiotic at the right time for the shortest duration possible.”
They also use their electronic medical record on a weekly basis to look for doctors with outlier prescribing or infection patterns.
And, importantly, they are thinking regionally. They look for problems among the nursing and long-term care hospitals that their patients go to for longer recoveries, and they alert those facilities when it’s clear there’s a problem.
“When they leave here, they are clean, and then they come back with an infected wound? That’s just terrible,” Dardano said. “We have periodically pulled in nursing home directors to tell them which ones are sending us the most patients with complications.”
It’s clear from the 12 known Florida outbreaks that one hospital’s nightmare-germ problem is an entire region’s problem. A culture of secrecy has been keeping the true scale of the problem under a veil.
In 2011, Duval County public health officials lifted that veil. Hospitals haven’t had to report cases of drug-resistance to the state, so Duval County’s health department had no idea whether CRE was a problem in their community.
Once they asked, they learned that eight of 10 of Duval County’s hospitals had seen CRE cases the year before — and not just one or two cases. The state officials tallied up a total of 113 CRE-infected or colonized patients treated in 12 months.
Palm Beach County is where Duval was, pre-survey. Nobody has looked, so nobody really knows how widespread the nightmare infection problem may be here.
The Florida Department of Health last year proposed forming a collaborative between Broward and Palm Beach county hospitals, and applying for a federal grant. The plan was to develop a survey, similar to the one Duval conducted.
It didn’t happen. One state official confided that hospitals here didn’t care to participate. They were coping with new data reporting demands about health care associated infections from the U.S. Centers for Medicare and Medicaid, so it was bad timing.
“The data burden seemed overwhelming to the hospitals at that particular time,” said A.C. Burke, who heads the health care-associated infection prevention program at the Florida Department of Health.
Instead, she found 12 hospitals in other parts of the state willing to participate.
The CDC says it’s important that hospitals and nursing homes to create regional collaborative groups, because information sharing is critical to prevention. They’ve created forms they want hospitals and nursing homes to use when moving patients from place to place, so that proper precautions are readied if needed. Few places are using them.
Jackson Health System epidemiologist Dr. L. Silvia Munoz-Price says there’s very little information sharing from nursing homes and rehab hospitals now, because of the economic consequences of potentially losing patient referrals.
The workaround, one that’s not especially nice for patients, is for hospitals to assume that all transferred patients are infected with nightmare germs until testing proves otherwise. That means putting them immediately under what’s called “contact precuations,” an isolation protocol that requires washing hands, and putting on gloves and gowns for each entry into the patient’s room, even from visitors. It involves using disposable food trays and medical equipment wherever possible.
It’s hard on patients and it’s hard on nurses, Bush said.
“It does not make them happy,” he said. “It ostracizes you. People are less likely to go into the room when you need something. It’s cumbersome.”
But it’s the new normal.
“Things are very different from when I started out 30 years ago,” said Dr. Glenn Morris of the University of Florida’s Emerging Pathogens Institute. “We had antibiotic resistance then, but we didn’t see the major problems we have now, with organisms that are bordering on untreatable.”
He’s eager to see what the data shows now that Florida has begun requiring labs to report all antibiotic resistance. It could be an eye-opener.
“We need to better understand the transmission patterns in the community, so we don’t think about it only when there’s a patient dying of a God-awful infection,” Morris said.
“We are in a window of opportunity,” he said. “We are really going to need to think of creative, out-of-the-box solutions.”
Core measures to stop the nightmare germs:
The CDC says these core measures sould be used to minimize the spread of drug-resistant germs:
- Rigorous, monitored hand-washing
- Isolation of patients who test postivie as well as those who are transferred in from high-risk places like long-term acute care hospitals
- Designated staff and supplies for for patients who test positive
- Education of nurses and assistants
- Minimal use of invasive devices like catheters and medication ports
- Screening of roommates of positive patients and those who shared the same health care workers
- Notification of positive status when transferring patients
The CDC recommends these additional steps:
- Screening of high-risk patients on admission and during their stay
- Screening of patients from any health care facilities known to have CRE
- Bathing of positive patients daily with an antiseptic called clorhexidine
- Stewardship of antibitoics to use them only when necessary and only if they are effective
- Intense disinfection of high-touch areas around hospital rooms occupied by positive patients