At least 12 health care-based outbreaks of carbapenem-resistant germs have been documented by Florida public health officials since 2008, according to state records and scholarly journal articles assembled by The Palm Beach Post. There are almost certainly more as the state tightens its hospital reporting requirements, which started this month. Here are the germs found:
CRE - Carbapenem resistant Enterobacteriaceae
Strains of digestive tract germs that are becoming resistant to nearly every antibiotic available.
CRAB - Carbapenem-Resistant Acinetobacter baumanii
Ubiquitous in soil and fresh water, normally don’t make people sick. Strains resistant to nearly all antibiotics making very ill people, especially those recovering from burns and needing invasive devices, develop life-threatening or even fatal infections.
Volusia County - CRAB
4-year-long outbreak in Daytona Beach
On Jan. 8, in Daytona Beach, state infection control specialists met with Halifax Health Medical Center staff. On the agenda: A 4-year-old outbreak of CRAB.
By then, 125 people had been colonized or infected.
Nearly a third of the infected Halifax patients died during their hospitalization, a 2012 report said. Most had stayed on fifth floor of the Daytona Beach hospital in its intensive medical care unit. The same germ was apparently being passed to multiple patients: Of 48 samples sent to the state laboratory, 75 percent had matching DNA patterns.
“The hospital lacked appropriate staffing levels for an in-house infection control and prevention program; thus, daily expert guidance was not available for months,” a state reviewer found.
In July 2010 the state first stepped in, citing 18 known cases. A state inspector recommended a detailed list of precautions, germ-tracking and staff education. But nearly two years later, the state found most recommendations had been ignored.
“Lack of compliance with standard infection control procedures at the hospital and poor leadership were significant contributing factors that led to failure to control the outbreak,” a Department of Health review found.
The hospital said it had tried and failed to recruit an infection control specialist, so it was having to train its own staff person to do the job. That was taking time.
In January, things had improved. The hospital asked the state to sign off on a reduced reporting plan. Because only 15 of its 31 positive cases in 2013 had been hospital-acquired, Halifax offered a plan to educate its partnering doctors, nursing homes and home health agencies. The state agreed.
Halifax staff told state epidemiologists that its new cases were mostly sporadic and brought in from other facilities, especially five nursing homes around the Daytona Beach area.
Alachua County - CRAB
Shands rolls out robots for sanitizing
The chief medical officer of the University of Florida’s-based Shands hospital called a press conference July 29 to announce that the hospital’s burn unit was temporarily closed for a redesign. They had discovered a germ resistant to every antibiotic except Colistin, which damages kidneys. It had infected seven patients there since March, he said. The hospital didn’t disclose how many patients had died.
Normally, the germ they found wouldn’t cause illness. But, UF Health-Shands’ Dr. Timothy Flynn said, patients in the burn unit are vulnerable to any sort of infection. The strain they encountered was something they hadn’t seen before.
“We began to see this Acinetobacter pop up and it had a very aggressive antibiotic pattern,” he said.
Genetic fingerprinting showed the seven patients had acquired the same strain. Somehow, it was passing from patient to patient. They studied their processes top to bottom and made changes, he said.
“One of the things we did learn is that there are surfaces that don’t routinely get cleaned, like the ceiling or the wall, and they can harbor the organism,” Flynn said.
The hospital purchased rolling ultra violet disinfection robots, redesigned the rooms to make them easy to sanitize, and now uses the robots between patients, after normal room cleaning.
“This is just one little tool in what is just a constant struggle between us and the bugs,” Flynn said. “There is no one silver bullet.”
Charlotte County - CRE
Incompletely sterilized devices
In an unusual step, the Department of Health in December 2012 sent letters to hospitals throughout Charlotte County, asking them to check for several species of bacteria that might be showing resistance to carbapenem antibiotics. They had discovered an outbreak possibly linked to incompletely sterilized endoscopes, reusable devices used to inspect the upper digestive system.
The agency wanted all of the region’s hospitals to test for the germs.
“Due to the interconnected nature of health-care facilities in the county, tracking the burden of CRE at all local hospitals is a priority for the prevention and control of this important organism,” wrote Dr. Henry M. Kurban, director of the Charlotte County Health Department. “Please report all CRE positive cultures immediately.”
Up to that point, the outbreak had affected 22 people, seven of whom died, a state report showed. Eighteen of them had undergone endoscopic procedures. An outbreak in Chicago was recently traced to incomplete sterilization of such instruments.
State health officials did not name the health care facility whose outbreak prompted the letter.
Duval County - CRAB
15 cases at 1 hospital; no details released
In August of 2012, state health officials had documented 15 cases of CRAB at a single hospital. The state did not name the hospital or provide details on the outbreak.
Broward County - CRE
32 people affected at Kindred
In July 2011, state records show, Kindred Hospital Fort Lauderdale reported four cases of CRE.
Extensive testing found 32 people had been colonized, and 25 had become ill with CRE between March 2010 and November 2011. The state doesn’t know with certainty how many died. State investigators had looked at 18 of the cases by November 2011 and counted eight deaths. The state believes the outbreak has been controlled.
Aggressive germ-tracking and prevention efforts, plus staff education, brought the prevalence down from 17 percent of patients to 4.5 percent, according to state reports.
Pinellas County - CRE
Large outbreak at long-term hospital
One of the largest documented CRE outbreaks in Florida raged between March 1, 2009 and Feb. 28, 2011, and may have touched at least five hospitals, a CDC investigation found.
At its epicenter was one long-term acute care hospital, Kindred Hospital Bay Area – St. Petersburg.
There, state and federal inspectors found nurse-patient ratios so high that staff were overwhelmed with work, causing high turnover. They found hand washing happened only a third of the time necessary, invasive devices weren’t always properly sanitized and equipment wasn’t always disinfected after a patient used it.
Authorities documented 115 cases of CRE at that one hospital over two years. The majority had acquired their infections within the hospital, the CDC found. Only 17 had it when they were admitted.
The outbreak finally wound down when the hospitals and the health department implemented the CDC’s recommendations. They included isolating colonized patients and using dedicated equipment for them; collecting rectal swabs from patients on a bi-weekly basis to monitor for the germ; and training nurses and housekeeping staff at least annually on best infection control practices.
Collectively, those measures brought the CRE prevalence down from more than half of patients tested at Kindred St. Petersburg to 8 percent by the investigation’s end. New cases were finally brought down to zero.
Orange County - CRE
Nursing home ‘won’t comply’
Department of Health records indicate that a nursing home had sent two CRE-infected patients to a long-term acute care hospital. But when state officials attempted to get more information, the nursing home “would not comply” with state investigators, leaving the investigation incomplete. The state did not name the facilities.
Duval County - CRE
Survey: 113 cases, 8 of 10 hospitals
The county health department, surveying county hospitals, found 113 CRE cases distributed across eight of 10 hospitals. The state did not provide additional information.
Highlands County - CRAB
Nursing home didn’t notify hospital
The county health department investigated a multi-facility outbreak of CRAB among frail patients. The state found 16 cases, most associated with a nursing home, Royal Care Avon Park. The nursing home had failed to notify a partnering hospital of the patients’ infection, the state found. The state advised the nursing home to bring in an outside infection control consultant, and consider stopping admissions if they couldn’t get the outbreak under control. Its unclear if the advice was followed.
Miami-Dade County - CRE
Bed rails, IV poles covered in germ
Jackson Memorial Hospital and the University of Miami documented a CRE outbreak in Jackson’s 20-bed surgical intensive care unit, where organ transplant recipients were recovering. Over the course of a year, nine patients were infected or colonized with the same germ. Four died of blood infections. Two others died of other causes.
An intense investigation revealed that high-touch surfaces including bed rails, mattresses, ventilator tubing, IV poles, vital-sign monitors, a computer keyboard and the television were all covered with CRE. A technique called UV light surveillance showed that the surfaces of the mechanical ventilators and the bed rails were not being cleaned. Housekeeping thought the nurses were responsible, and the nurses thought housekeeping was responsible for cleaning those surfaces.
“We discovered that neither environmental services’ personnel nor nursing staff were cleaning bed rails on a daily basis in any of the rooms,” wrote Dr. L. Silvia Munoz-Price in a scholarly article about the outbreak.
Solving the housekeeping problem stopped the outbreak, along with aggressive infection control that included bathing patients regularly with clorhexidine wipes, separating them from other patients, and educating hospital staff. Jackson hasn’t had such an outbreak since implementing those best practices, said Munoz-Price.
Orange County - CRE
Facility name redacted from records
After alerting health providers to the Broward County CRE outbreak, Orange County’s health department learned that patients at a long-term care facility tested positive for CRE. An investigation found that 18 people had been colonized or infected. Some had clearly acquired the germ at other health care facilities. The state redacted the name of the facility from public records.
Broward County - CRE
First outbreak: ‘Urgent action’ needed
A man gravely ill with pneumonia was transferred to a Broward County hospital from a long term care facility. He died the next day, March 2, 2008. Urine samples sent to the CDC revealed he was infected with a type of CRE that didn’t respond to hospitals’ big-gun antibiotics, carbapenems. Records were searched from a lab that served 13 hospitals, eight rehabilitation hospitals and 14 long-term care facilities in South Florida.
They revealed that during a single month, March 21 to April 20, 2008, 10 people had been infected with the dangerous supergerm, seven of them at a single long-term care hospital. The mortality rate was a shocking 69 percent.
A scientific paper about the outbreak was published in the Journal of Antimicrobial Chemotherapy in 2009 with this warning :
“The speed at which the epidemic…is spreading in our healthcare system mandates urgent action.”
It was the first outbreak of a carbapenem resistant germ documented by the Florida Department of Health.