April 5, 2018

These 'nightmare' bacteria are widespread—but hospitals can help, CDC says

Daily Briefing

    "Nightmare bacteria" that are both spreadable and resistant to last-resort antibiotics are more common in the United States than previously thought, with more than 200 cases found last year, according to a CDC report released Tuesday—but public health officials say aggressive action by hospitals and nursing homes can limit the spread of these drug-resistant germs.

    The current state of hospital antibiotic stewardship

    Antibiotic-resistant bacteria have been a growing threat in the United States, often affecting individuals in hospitals and nursing homes. The bacteria are known as carbapenem-resistant Pseudomonas aeruginosa, or CRPA, and as carbapenem-resistant Enterobacteriaceae, or CRE, which includes antibiotic-resistant strains of E. coli, Klebsiella pneumoniae, and Enterobacter, according to CDC. Carbapenem is a last-resort antibiotic.

    Bacteria that are carbapenem-resistant are particularly fatal among the elderly and people with chronic conditions, with about half of such patients dying from the untreatable infections, Anne Schuchat, CDC's principal deputy director, said. In total, about two million U.S. residents develop infections from antibiotic-resistant bacteria annually and 23,000 die from those infections.

    CDC for years has been working with hospitals and nursing homes—two places the so-called "nightmare bacteria" are most common—to stem the bacteria's spread, but until now, CDC had not examined the full scope of the problem.

    Report details

    In this first-of-its-kind report, CDC sought to provide a clear picture of how prevalent "nightmare bacteria" are in the United States. To do so, the agency tested thousands of samples collected from health care facilities in 27 states between January 2017 and September 2017 for CRE and CRPA via the agency's Antibiotic Resistance Laboratory. CDC established the laboratory in 2016 to bolster national capacity to quickly detect and respond to antibiotic resistance.

    CDC in the report also released data from the National Healthcare Safety Network on the prevalence of certain antibiotic-resistant bacteria in health care settings between 2006 and 2015.

    Key findings

    Out of the 5,776 samples tested in 2017, CDC found 221 had unusual genes for resistance to almost every drug. Officials said the number was higher than they had expected, and likely was an underestimate because the report involved only certain states.

    Schuchat explained, "These verge on untreatable infections." Schuchat said, in many cases, the only treatment option might be supportive care, such as fluids and machines to maintain life to allow the patient a shot at recovery.

    Schuchat said CDC's lab network found "rare resistance patterns were widespread" and not unique to a certain "age, race, or gender."

    Further, the lab network found that one-quarter of the 5,776 samples had genes that allow them to transmit resistance to other bacteria and create new drug-resistant bacteria. According to Kaiser Health News, in nearly 10% of cases, people infected with antibiotic-resistant bacteria spread the germs to others—such as patients, doctors, or nurses—who then became asymptomatic carriers of resistant bacteria.

    Discussion

    Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, said the "unusual" genes discussed in the report are the "worst of the worst." He said, "There are certain bacterial genes that are more worrisome than others, that are much harder to treat," adding, "These genes are lurking in American patients and they are spreading in hospitals and health care facilities."

    Separately, Jay Butler, CMO for Alaska's Department of Health and Social Services and past president of the Association of State and Territorial Health Officials, said, "Even in remote areas" this threat is real, as patients move between different locations for care.

    Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy, compared the rise of antibiotic-resistant bacteria to a "slow-moving tsunami." He said, "This isn't an acute crisis where a wave just hits you," adding, "But we see these rare cases of resistance in remote areas of the world, and within a year or two, it's everywhere."

    Limiting the spread

    But experts said the new report offers a glimmer of hope: Research has shown that hospitals and nursing homes can stem the spread of antibiotic-resistant bacteria by 76% through aggressive screening and preventive measures.

    For instance, Schuchat said hospitals have had success preventing new infections by requiring providers caring for infected patients to wear gowns and gloves.

    In one example, CDC said its lab network helped identify an unusual bacteria carrying resistant genes in an Iowa nursing home patient that had spread to an additional five patients. To prevent further spread, the facility adopted an infection control protocol that included the use of gloves and gowns. In another case, CDC's lab network helped Tennessee health officials identify drug-resistant bacteria in a patient who had recently traveled abroad. Infection control assessments and colonization screenings were conducted at the hospital within 48 hours of identifying the case and no spread was detected.

    To help hospitals and nursing homes better identify and safely treat antibiotic-resistant bacteria, CDC recommended that facilities:

    • Adopt precautions for treating patients with unusual resistance, such as using gloves and gowns;
    • Ask patients about recent travel or health care that might reveal risk for unusual resistance;
    • Clearly communicate a patient's antibiotic-resistant status if they are transferred;
    • Establish protocols that "immediately notify" health officials, providers, and infection control staff of unusual resistance;
    • Know which isolates to send for testing; and
    • Work with health departments to prevent spread.

    "As fast as we have run to slow (antibiotic) resistance, some germs have outpaced us," Schuchat said, adding, "We need to do more and we need to do it faster and earlier" (AP/New York Times, 4/3; Szabo, Kaiser Health News, 4/3; Harris, "Shots," NPR, 4/3; McKay, Wall Street Journal, 4/3; Weixel, The Hill, 4/3; Ross Johnson, Modern Healthcare, 4/3; Woodworth et al., "Vital Signs," Morbidity & Mortality Weekly, 4/3; Siddons, CQ News [subscription required], 4/3).

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