The germs have closed a burn unit, torn through an organ-transplant ICU and transformed an extended-stay hospital into a regional threat.
Twelve outbreaks statewide since 2008 have affected at least 490 people, public records show, though it’s unknown how many have died. According to CDC estimates, the germs are dangerous, killing more than 40 percent of those with serious infections.
These multi-drug-resistant germs disproportionately strike frail, sick and immune compromised patients. Aggressive action must be taken now, doctors warn, or the germs will spread beyond hospitals and nursing homes to the wider community.
It may already be too late.
In 2008, the Florida Department of Health first learned that a deadly dangerous, drug-resistant supergerm had spread to 10 people in Broward County in a single month, seven of them at one long-term care hospital. The outbreak of what’s now referred to as CRE had an incredible mortality rate of 69 percent.
Top infection control experts from across the nation converged, and wrote in a scientific paper: “The speed at which the epidemic…is spreading in our healthcare system mandates urgent action.”
Despite that early warning, it has taken five years for state health officials to take the basic step of requiring laboratories to report cases of CRE. That finally went into effect June 4. Hospitals don’t routinely test for the germs because testing is expensive and not reimbursed by insurers. Meanwhile, they have resisted efforts to share information with each other.
The state did not respond to repeated requests for an interview with state Surgeon General Dr. John Armstrong. His office provided a video press release from March 2013. “While CRE is a serious germ, it not is an imminent threat to our population,” Armstrong said in the video, adding that the state was using CDC recommendations.
The normally reticent director of the CDC now calls CRE a “nightmare bacteria.”
“It can resist all antibiotics, kill a high proportion of people it infects, and spread from person-to-person and bacteria-to-bacteria readily,” said Dr. Thomas Frieden about CRE, short for carbapenem-resistant Enterobacteriaceae.
No new antibiotics
He called CRE “one of the most serious health threats we face today,” because the pharmaceutical industry has nothing in its pipeline to back up hospitals’ last-resort drugs, carbapenems.
“We risk entering a post-antibiotic era where even simple infections can be deadly. With a few bacteria, we’re already there,” Frieden said.
The health system may have a narrow window of opportunity to keep these germs from escaping health-care facilities, as MRSA has done, infectious disease experts say. But doing so will require coordinated and concerted action from hospitals and public health leaders, as well as the public.
The state health department is aware of the 12 outbreaks. It provided documentation to The Post on request, over a period of nine months. But in some cases, the names of the health facilities where the outbreaks took place were blacked out by the state’s lawyers, who cited an exemption in the open-records law for epidemiological investigations.
Critical to act now
“Hospitals are not particularly motivated to broadcast that they have highly resistant strains,” said Dr. Glenn Morris, director of the University of Florida’s Emerging Pathogens Institute.
Morris said it’s critical that public health officials and researchers learn the scale of the drug-resistance problem now, when medicine may be at a turning point.
That’s exceedingly difficult because of the lack of reporting and research money, he said.
State law requires that outbreaks of any germ be reported, but the law is lightly enforced. Florida’s Agency for Health Care Administration, which licenses and inspects hospitals, has cited only one hospital for failing to report an outbreak in the past five years, said agency spokeswoman Shelisha Coleman. The agency actually blacked out the name of the infectious agent behind the citation when The Post asked to see documents.
State health officials acknowledge they don’t know with certainty how widespread these nightmare germs are, nor how many people are being hurt by them. But they have an inkling: In 2011, Duval County’s health department surveyed all of its hospitals about CRE. It received reports of 113 cases across eight of 10 hospitals.
The “nightmare germ” was spreading.
Isolated cases here
Palm Beach County’s public health director believes there have been sporadic cases here, but no outbreaks. But she said there hasn’t been a local hospital survey on the scale of Duval’s.
“The communication both from the hospitals to us and us to the hospitals is very open,” said Dr. Alina Alonso.
Starting this month, the drug-resistant organisms become lab-reportable conditions to the state.
Health care administrators aren’t enthusiastic about the extra paperwork, Alonso acknowledged. But it’s the best way to understand the scope of the problem, she added.
“But if you can save a life, isn’t it better to report?” Alonso said. “The better information you have, the better you can protect.”
There have already been significant nightmare-germ outbreaks in Broward County and Miami-Dade County to the south, and in Daytona Beach and Shands Hospital in Gainesville to the north.
Besides CRE, other germs are gaining resistance to carbapenems. One of them is A. baumannii, which is common in soil and water.
Halifax Health Medical Center in Daytona Beach has battled a 4-year-long outbreak that has affected 125 people. The germ was an unusual version of A. baumannii that proved resistant to nearly every drug in the hospital, except one damaging to kidneys.
A 2012 state inspector’s report, midway through the outbreak, said nearly a third of infected patients had died during their hospitalization. Most had stayed on the fifth floor of the hospital, in Halifax’s medical intensive care unit. The evidence suggested that the same germ was being passed to multiple patients.
“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.
Three months ago, Halifax Health hired a new infection control professional, microbiologist Brent Price. He said the outbreak is controlled now. But evidence suggests that it’s escaped the hospital and spread to nursing homes in the area.
The same organism caused an outbreak in the burn unit in Gainesville’s UF Health-Shands Hospital last fall. The outbreak prompted the hospital to close and redesign its burn unit for optimal infection control, said Dr. Tim Flynn, Shands’ chief medical officer.
The largest hospital-based CRE outbreak in Florida hit on the west coast. It spanned 2009 to 2011, and affected 99 people in one institution, Kindred Hospital Bay Area St. Petersburg, plus another 16 people transferred there from other institutions in the Tampa Bay region.
At one point, epidemiologists with the CDC found 60 percent of Kindred St. Petersburg’s patients were testing positive for the outbreak germ, as overworked hospital staff were taking shortcuts on handwashing and equipment sanitizing.
Alarmed, the state alerted hospital officials in the region: “Recent laboratory findings have indicated a high number of positive carbapenem-resistant (CRE) cases at healthcare facilities in Pinellas County,” they wrote in December 2010. “It is important that hospital staff monitor for this infection and ensure proper prevention and control measures are in place.”
They ominously added: “Due to the limited antibiotic options for treatment, prevention constitutes the main intervention to combat these organisms.”
The warning was handled so discreetly that the public, and few health care workers, knew of the CRE outbreak. Meanwhile, Kindred continued admitting and sending patients back and forth to other institutions.
By the time the CDC left, four other hospitals had cases.
Kindred executives said they had worked closely with the CDC to overcome the outbreak, and eventually brought new infections down to zero.
Germs move with devices
The outbreak showed just how readily harried health care workers can spread the germs from patient to patient. If they overlook scrupulous hand-washing and disinfection of shared medical devices, such as stethoscopes, finger-tip pulse oximeters and blood-pressure cuffs, the germs move with them.
Inadequate room cleaning can also be a problem, as demonstrated by an outbreak among organ transplant patients in an intensive care unit within Jackson Medical Center in Miami in 2009. Nine patients were infected, and six died.
A thorough investigation led by hospital epidemiologist Dr. L. Silvia Munoz-Price revealed that hospital bed rails and IV poles weren’t being cleaned, because housekeeping staff thought the nurses cleaned them, and nurses thought housekeeping staff did it. That problem was solved, and the germ hasn’t returned, she said.
Prevention is the only real option with these germs, Munoz-Price said.
“Once the antibiotic is not active anymore, you have very, very limited options,” she said. “At this time, what hospitals are doing in order to fight this type of resistant bacteria is basically to prevent the spread of these infections.”
The CDC’s Frieden warns that many routine invasive procedures will become too dangerous if these germs aren’t controlled. Dr. Larry Bush, chairman of infection control at JFK Medical Center in Atlantis, agreed.
What’s at stake? Organ transplants, joint-replacement surgery, open heart surgery, back surgery – they all require prolonged recoveries and antibiotics to minimize infection risk, he said.
“Before the advent of real antibiotics, you couldn’t do organ transplants. All these invasive things? Joint replacements, open heart surgery? They have all tagged along with the advent of antibiotics,” Bush said.
Health care workers aren’t solely responsible for spreading nightmare germs, doctors said, and they alone aren’t the key to preserving the usefulness of antibacterial drugs. Consumers who demand antibiotics for minor problems share some of the blame, they agreed.
“When we treat that common cold with a Z-Pack, all the bacteria in your body and in your kid’s body and your husband’s body will become somewhat resistant,” Bush said. At the moment, he said, CRE remains confined mostly to health-care settings. But that may change.
Fifteen years ago, another drug-resistant germ, MRSA appeared in jails and then in hospitals. Today, the CDC estimates MRSA infections kill 11,000 people in the United States a year and sicken 80,000. MRSA is everywhere now, Bush said, but CRE is more deadly, on a per-case basis.
“CRE will be where MRSA is, but it will be more severe,” Bush predicted.
Nightmare germ carriers
People can easily become colonized with the nightmare germs without being sick from them. A stay in a rehabilitation hospital can leave someone colonized for a year or more, without their knowledge, leaving them to spread the germs to their family and friends.
Controlling the nightmare germs now and developing better antibiotics against them are critical, he said.
“Doctors have to stop pleasing patients by giving them an antibiotic because of the fear that if I don’t give it to you, you might go to somebody else and you won’t be my patient anymore,” Bush said. “The next thing is, we have to ask patients that when your physician or your nurse walks in your hospital room, do not be embarrassed to ask them, ‘Have you washed or used the alcohol wipe on your hands?’ Because that’s the key thing. Handwashing is the major step in stopping the spread of these germs.”
©2014 The Palm Beach Post (West Palm Beach, Fla.)
