Widespread panic

by Melanie Wolkoff Wachsman

It is highly resistant to antibiotics and can pass antibiotic resistance to other types of similar bacteria. It can also exist in a carrier state, where patients may not exhibit symptoms but can spread the bacteria. And it can kill as many as half who get bloodstream infections from it. It’s called CRE— and it’s nearly unstoppable.

According to the Centers for Disease Control and Prevention (CDC), CRE—short for carbapenum-resistant Enterobacteriaceae—is a family of more than 70 bacteria that are a normal part of the digestive system, but it can cause infections when it gets into areas such as the bloodstream or bladder.

Most CRE infections occur in already-sick patients undergoing medical care in hospitals or long-term care facilities. Patients whose care requires devices such as ventilators, catheters, intravenous catheters or who are on long courses of antibiotics are at most risk. However, CRE can also spread to otherwise healthy people making them sick.

CRE infections are virtually untreatable.

“Collistin is the only antibiotic which has some effectiveness against CRE, but this antibiotic is seldom used because of the high rate of kidney toxicity,” said Kevin T. Kavanagh, MD, board chairman, Health Watch USA, Somerset, Ky.

The rise in CRE can be attributed to overuse in antibiotics, gaps in infection control in hospitals and long-term care facilities and from patients with CRE who are transferred between healthcare institutions.

Mandatory Reporting
The Courier-Journal reported that approximately 20 CRE cases have been treated in Louisville hospitals over the past two years. Yet, the Kentucky Department for Public Health has received only one report of an outbreak. (The hospital or county it was in was not released.) The Courier-Journal also recently reported that the Kentucky Department for Public Health and Kindred Healthcare are investigating the presence of CRE in about 40 patients since July at Kindred Hospital Louisville.

Currently, neither Kentucky nor the federal government tracks individual cases. Instead, hospitals are left on their own accord to interpret “outbreaks” and must only report greater-than-expected numbers of cases.

Kavanagh is trying to change this. He has the support of State Rep. Tom Burch, D-Louisville, who recently sent a letter to Gov. Steve Beshear seeking support for mandatory reporting of CRE bacteria. Burch plans to introduce a bill on mandatory public reporting in next year’s General Assembly.

“This is a problem which affects the entire healthcare system, many different types of facilities and the community as a whole,” Kavanagh said.

Some hospitals are already onboard. All KentuckyOne Health facilities, which includes the University of Louisville, Jewish Hospital & St. Mary’s HealthCare and Saint Joseph Health System, already report every case of CRE.

“Transparency is the right thing to do in matters of public health,” said Linda Hummel, director of clinical quality and patient safety, University of Louisville Hospital (ULH). Hummel said ULH had two cases of CRE over the past year.

Baptist Health Louisville also tracks cases of multidrug-resistant organisms, including CRE. “We identified a total of eight cases in 2012,” said Connie Barker, MSN, vice president, quality and clinical effectiveness for Baptist Health Louisville.

Why the Resistance?
However, some healthcare facilities are resistant to the idea of mandatory reporting.

“There is always a fear that reporting may cause patients not to enter a hospital,” said Kavanagh. “However, in facilities that know the source of the CRE and are taking active steps, reporting should reassure the public that the hospital is vigilant in their control efforts.
Every hospital is faced with multiresistant drug organisms. With proper control the incidence of these organisms can be decreased.”

Another argument is the cost and time mandatory reporting requires on the part of state health officials. But isn’t it more cost-effective for the patient, and Kavanagh thinks so.

“The State Health Department should consider requesting an increase in  their budget to offset some of these expenses by providing rapid testing facilities around the state,” he said. “In addition, they could also consider having specialized equipment such as fogging units for use in hospitals with outbreaks where the source is not known.”

Where to Begin?
The Kentucky Department for Public Health educates healthcare providers about superbug prevention. However, Kavanagh
feels that’s not enough.

“Hospitals have a responsibility to suspend admissions, at least on a unit level, and notify the public if they have an outbreak of CRE and have not identified the source. The public deserves no less,” he said.

“To be extra-vigilant we continue to implement immediate alerts when the lab identifies a CRE, alert receiving and transfer facilities when a patient has a CRE, and identify these patients at subsequent visits,” said Hummel. “In addition, we follow infection control recommendations such as the use of hand hygiene, dedicated rooms, dedicated staff if possible, dedicated equipment and require the use of gloves and gowns with these patients. Other ways we adhere to the prevention of the spread of CREs are by prescribing antibiotics wisely and the removal of temporary medical devices as soon as possible.”

Because preventing CRE from being transmitted from patient to patient is the same concept in every hospital, new infection-control measures are only needed if the means of implementing them is not working, said Hummel. For example, Hummel continued, “if staff are not wearing gowns and gloves to enter the room of a CRE patient, then it is not the practice of donning the protective equipment that needs changed; it is the enforcement of it.”

Likewise, Baptist Health Louisville is continuing their ongoing efforts related to infection prevention including education, hand hygiene and isolation precautions. In addition they are following recommendations from the CDC and are working closely with the state public health department as cases are identified.

“We are continually evaluating our environmental cleaning and looking at new disinfection technologies,” Barker added.

Dana M. Stephens, director of infection prevention and control at Saint Joseph Hospital, Lexington, part of KentuckyOne Health, said that Saint Joseph East/Saint Joseph Hospital (SJE/SJH) believes in transparency. “Transparency is the right thing to do in matters of public health,” she said. “We support the reporting of cases and continue to partner with the state’s public health department.”

CRE organisms have been a part of routine multi-drug resistant organism (MDRO) surveillance. At SJE/SJH MDRO’s are entered by microbiology and infection prevention and control departments in electronic systems so that patients can be identified and subsequently isolated for every visit.

Bottom-line: healthcare workers must stay vigilant, since superbugs threaten us all.

“This is a problem which affects the entire healthcare system, many different types of facilities and the community as a whole,” Kavanagh said.