In February, two people died from infections linked to contaminated endoscopes at a hospital in Lincoln County, N.C. That same month, two others died in a similar outbreak in Los Angeles, according to the national Centers for Disease Control and Prevention.
These patients and others have fallen prey to carbapenem-resistant Enterobacteriaceae, a family of bacteria that’s highly resistant to even the strongest antibiotics. Between 2012 and 2014, for example, 11 people in the Seattle area died in CRE cases involving endoscopies.
“CREs are particularly resistant to antibiotics, and … I will acknowledge, [it’s] a scary family of bacteria,” says Chris DeRienzo, Mission Health’s chief patient safety officer. For infected patients, the death rate can be 40 percent or higher, the CDC reports.
Endoscopes are inserted into the gastrointestinal tract or other natural openings to help detect cancer, clean out clogged veins, find gallstones and much more; if contaminated, they can deliver bacteria to the bloodstream or internal organs and transfer those bacteria to other patients. In the Lincoln County case, more than a dozen people were infected with CRE.
To date, no comparable outbreaks or deaths have occurred in Western North Carolina.
“We’ve been ahead of the concern around endoscope processing for some time,” says DeRienzo. Mission, he explains, uses a different model of scope, and its prevention and sterilization procedures exceed state and federal standards.
Nonetheless, such cases highlight the broader issue of health care-associated infections — a daunting problem that has local hospitals and health professionals scrambling to stay ahead. In 2011, about 1 in 25 patients in the United States had at least one health care-associated infection. Of the roughly 722,000 HAI patients in acute-care hospitals that year, about 75,000 died, according to the CDC’s Healthcare-Associated Infection Prevalence Survey.
Park Ridge, a small hospital in Hendersonville that’s affiliated with the Florida-based Adventist Health System, takes similar steps to ensure patient safety, says epidemiologist Donna Goering, the hospital’s infection preventionist. “We have to be aware of outbreaks and trends [and] constantly tweak and adjust processes,” she notes. That means keeping an eye on everything from flu outbreaks to Clostridium difficile. Much more common than CREs, C. diff can cause severe diarrhea and is “very hard to get rid of in the environment, because it turns into a spore,” Goering explains.
Like Mission, Park Ridge uses a different brand of endoscope and applies a “higher level of sterilization” to defend against CREs, she says. And in the wake of the Lincoln County outbreak and recently updated Food and Drug Administration and CDC recommendations, Park Ridge has added “extra measures of prevention and an extra test” for endoscopes, notes Goering.
Yet the FDA acknowledges that cleaning these devices properly may be difficult even when following recommended procedures, and both federal agencies are reviewing the problem further. Meanwhile, at least one manufacturer has released revised cleaning procedures, and North Carolina’s Department of Health and Human Services has initiated a data-collection project for CRE cases, says Jacie Volkman, Mission Health’s director of infection prevention.
Enterobacteriaceae is a particularly resistant family of bugs that makes infections hard to treat, says epidemiologist Zack Moore of the N.C. Division of Public Health. CREs aren’t common in North Carolina, he says, but “more than half our hospitals have seen it, and some nursing homes.” Gathering data and observing this “emerging risk,” he says, is a key first step in prevention.
State health officials already track several common infection types via the N.C. Healthcare Associated Infection Prevention program. Since 2012, North Carolina lawmakers have required hospitals and other facilities to report five major groups or types of HAIs: those involving C. diff; hysterectomies and colon operations; catheter-associated urinary tract cases; infections connected to central lines placed in a large vein in the neck, chest or groin to deliver medication or fluids, or to collect blood for tests; and the potentially deadly methicillin-resistant Staphlyococcus aureus (aka MRSA).
Moore and DeRienzo, both of whom serve on the advisory board for the state program, note that it doesn’t require health care facilities to report CREs. “There are a lot of these resistant [bacteria], and what we found is that there wasn’t agreement [among] labs across the state,” Moore explains. “You can’t measure or track something if you can’t specifically define what you’re trying to measure.”
Education, collaboration and collecting data on threats ranging from CREs to ventilator-associated pneumonia help hospitals “target areas where we see increases in infections,” notes Volkman. “Our focus in this area has led to an observable decrease in health care-associated infections.”
The infection prevention program’s quarterly and annual reports confirm that Mission is doing better than the national base lines in several categories. Last year, for example, there were 11 observed infections related to central lines, and none for neurosurgery and surgical cardiothoracic procedures. These stats contributed to a “better than predicted” rating in that category. Meanwhile, the 127 C. diff cases were far fewer than anticipated. Central lines, an alternative to short-term IVs, can carry bacteria directly to the patient’s heart, other organs or bloodstream, DeRienzo explains.
Statewide, most hospitals reduced their infection rates last year, Moore reports. Catheter- and central-line-associated infections are both down by nearly half, he says; surgical-site infections have also declined but still slightly exceed national averages.
Moore credits collaborative initiatives like those organized by the North Carolina Quality Center, created by the N.C. Hospital Association, and national programs like Get Smart, which focuses on educating patients and medical professionals about appropriate antibiotic use. North Carolina is one of only four states that partners with the Safe Injection Practices Coalition’s One and Only Campaign to raise awareness.
Regional prevention leaders, notes Goering, started meeting and comparing notes about best practices more than a decade ago. “Every [infection and other illness] in the community can walk in our hospital doors,” she says. So if a colleague has found an approach that helps prevent problems, “We can compare practices as a group.”
Getting to zero
Thirty years ago, the medical community accepted high infection rates as a given, says DeRienzo, but as treatments have evolved, so have prevention practices. In the early 2000s, he notes, researchers at hospitals like Johns Hopkins “identified and implemented a bundle of processes [that showed] these infections could be eliminated.”
For example, the combination of keeping skin clean at the insertion site, covering it properly and safely removing the central line as soon as it’s not needed significantly reduces infections, DeRienzo emphasizes. “But bacteria are smart. Over time, they figure out how to be resistant to antibiotics,” making even simple procedures less effective and treatment more difficult, he says.
Inappropriate use of antibiotics exacerbates the problem, helping create drug-resistant superbugs, says Moore. “Fifty percent or more of prescribed [antibiotics] are not appropriate or necessary,” he says. “Antibiotics don’t cure the flu or the common cold,” though they’re often prescribed in such cases.
“Robust stewardship” by doctors and pharmacists, adds DeRienzo, can also help. That includes choosing an antibiotic that targets the specific organism rather than a broad-spectrum drug that kills every bug it encounters, he explains.
Earlier this summer, Moore met with representatives of medical and pharmacy schools to talk about teaching the appropriate use of antibiotics. Training medical professionals, he says, is “a big part of our prevention efforts. Antibiotics are an important resource, but they shouldn’t be taken for granted.”
Educating the public is also important, continues Moore. “Patients need to be aware; doctors need to be aware. Instead of asking for an antibiotic, ask if an antibiotic would [really] be helpful.” Simple practices like washing your hands and covering your mouth or nose when you sneeze or cough, adds Goering, can ward off most infections.
DeRienzo, meanwhile, urges families and patients “to be educated … and join us in that conversation about their care.”