Tue September 18, 2012
Hospitals Fight To Stop Superbugs' Spread
Originally published on Tue September 18, 2012 1:11 pm
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. The NIH superbug claimed its seventh victim last week, more than six months after specialists at one of the country's most prestigious hospitals thought they had the outbreak contained. The bug is called Klebsiella - I'll get it right - Klebsiella pneumoniae, or KPC for short, and most antibiotics can't kill it. It's one of several drug-resistant bacteria that many hospitals struggle to control. The best known is probably MRSA.
And experts warn these organisms continue to adapt and that we're running out of weapons against them and that we don't pay enough attention to ways to prevent infections that make people sick, sometimes very sick, in the hospitals and clinics where they go to get well.
If you work at a hospital, what's your experience with these superbugs? How's your hospital dealing with these infections? 800-989-8255. Email us, email@example.com. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, Washington editor Ron Elving joins us to parse Mitt Romney's 47 percent; the full video of that fundraising event has now been made public. But we begin with Maryn McKenna, the author of "Superbug: The Fatal Menace Of MRSA." She's also a blogger for Wired and a columnist and contributing editor to Scientific American and joins us now by smartphone from Ithaca, New York. And nice to have you on TALK OF THE NATION today.
MARYN MCKENNA: Hi, thanks for having me.
CONAN: And the NIH superbug, KPC, what happened there?
MCKENNA: This is - it's a really difficult and, I think, for the people at NIH must be a painful story. And it's important to emphasize we know about this because they went public. They actually, last month, wrote a paper in a medical journal describing everything that happened and everything they did. So it's not that this was something covert.
What happened was that a patient came into NIH's clinical center, which is a hospital that's part of NIH that is a very special kind of hospital. You pretty much can't go there unless you're invited. People are there because they're very sick, but also because they're participating in some kind of clinical trial of a treatment.
So a woman was transferred into this hospital from New York City, and without knowing it, she brought this infection, KPC, or CRKP it's sometimes called, with her. They - they put her under isolation. Actually, now that I think about that, they must have known she had it because they put her under isolation.
MCKENNA: But - and they did all the things that you're supposed to do, but the bug kept spreading. And for about six months, it spread through this hospital and ending - this outbreak started last summer, ended in December, and they thought they were done. And then this newest case popped up.
CONAN: And the measures they took to try to control it, and then once it couldn't be controlled, the measures that they took to eliminate it, these were way, way beyond what you would have thought that was necessary.
MCKENNA: Right, and that gives you a sense, I think, of what kind of formidable opponents these organisms are once they get this resistant. I mean, when this woman checked in, according to that original paper, they did the things that you're supposed to do. They put her under contact isolation. They emphasized hand washing. People had to wear gowns and gloves and things like that. And then this bug started spreading.
And when you read through the list of the things that they tried first to contain it to her. They did things like they limited who could go into her room. They kept equipment like a blood pressure cuff and a stethoscope and things like that, just for her. They really emphasized extra cleaning of her room.
And then they started doing things like putting people in special rooms, only allowing certain staff to work on them. They ripped out the plumbing. They built new walls. They bombed the rooms with hydrogen peroxide. They hired extra personnel to actually watch their own personnel, to make sure that no one was doing anything that accidentally spread this bug. And it just kept going.
CONAN: Because it, unlike some of the other superbugs, apparently, could be transmitted airborne.
MCKENNA: Well, so the thing about these bugs that makes them so extraordinary is, you know, we - you mentioned MRSA. And we think of - MRSA is a bug that primarily likes to live on our skin. And so we've gotten very used to, in medicine, to thinking about people having to wash their hands really rigorously to get it off skin.
But these - KPC and other bugs like it, which are generally known as the highly resistant gram-negatives, they don't just live on skin. They live on surfaces that other bugs have difficulty surviving on, things that aren't organic and that have very low nutrients and very low oxygen, like metal, like plastic, like the rails of a bed or the counter that a computer rests on.
So they're really, really challenging, and also you may not know they're there. And they're particularly challenging because they can walk into the hospital without - with people without - anyone knowing they're there because they survive in people's guts really well.
CONAN: And so this is going to be a more dangerous problem? Is it going to be more prevalent?
MCKENNA: Well, it's pretty prevalent now. KPC or CRKP or these highly resistant gram-negatives, are really kind of an untold story in medicine. They have been spreading across the United States and subsequently across the world - they're actually a homegrown problem, they originate here in the United States - for about 10 years now.
And now they've been found in 39 states at the last count, and a couple of territories, as well. And they've spread into Europe, and they've spread into South America. We don't have any formal really careful surveillance for how these are counted. So they might actually have gone more widely than that. But they're pretty widely distributed.
CONAN: Most hospitals have infection control specialists on staff. They investigate and document outbreaks in their hospitals and help limit their spread. Dr. Eli Perencevich does exactly that. He's a professor of medicine and epidemiology at the University of Iowa's Carver College of Medicine. He also directs the CADRE Center at Iowa City VA Health Care System. And he joins us now from Iowa Public Radio. And Dr. Perencevich, nice to have you with us today.
DR. ELI PERENCEVICH: Thanks for having me.
CONAN: And people hear about something like this at NIH, they wonder why couldn't it have been stopped sooner, and if it can happen at NIH, clearly this can happen anywhere.
PERENCEVICH: Yeah, that's a very good point. This isn't an NIH superbug. This is a world superbug. According to reports from the CDC, six percent of hospitals in the United States, at any one time, are fighting outbreaks with this KPC infection. And it's prevalent in at least 41 states in the United States. So it's not just an NIH problem.
And NIH, after the nice description from Maryn McKenna, they literally did everything. They hired nine, you know, infection preventionists to monitor hand hygiene around the clock and make sure everyone was doing everything they were supposed to do and did numerous things, ripped out plumbing, and yet they still weren't able to halt it.
And it points out that there are two main issues with antibiotic - antibacterial resistant infections, KPCs in the gram-negatives. Other ones are Acinetobacter and Pseudomonas and E. coli. There are two major drivers of this, and one is we don't exactly know how to halt their spread. We have very good advice and very good guidelines from CDC, and yet we still don't know how to prevent them from spreading, as evidenced by this NIH outbreak.
And the other is we don't have antibiotics that treat these. And that's, you know, a very important, kind of, tipping point we've reached. We - four of these infections in the NIH outbreak, antibiotics were completely ineffective. So the bacteria were completely resistant to all known antibiotics. And so the doctors really couldn't prevent their infection and their mortality.
CONAN: So what were the mortality rates? If you got the infection, were you - was that a death sentence?
PERENCEVICH: In this case, I believe seven of the patients died, a little less than half. Overall, if you look at the literature, the mortality rate is about 50 percent if you get these infections in your blood.
CONAN: Have you dealt with this kind of situation yourself?
PERENCEVICH: Yes, we - when I was a hospital epidemiologist back in the state of Maryland, we had an outbreak with a similar bacteria called Acinetobacter. And that was in 2002. It's very prevalent on the East Coast. And it got into our hospital, and we had to close several of our intensive care units and had to do many of the measures that the NIH had to do.
And we were successful in halting the outbreak, but it was a long process. It's very difficult, and again we don't necessarily have all of the best interventions. We need to do more research in figuring out how to prevent these from spreading, because there are no antibiotics in the immediate horizon. We have no new classes of antibiotics that are going to be able to treat these infections.
CONAN: And when you're battling one of these outbreaks, there's all kinds of ethical questions that emerge. I mean, how can you be treating somebody for one disease and risking exposing them to something that has a 50 percent mortality rate?
PERENCEVICH: Yeah, I guess in - it depends on the situation. I mean, you have to obviously treat their underlying disease, whether that's - you know, they've had a motor vehicle accident and have to have immediate surgery, or they have aggressive cancer, and they need chemotherapy. You have to do those, but you have to also do everything possible to prevent the bacteria spreading.
And oftentimes these bacteria are in the environment. So they can bring them in. So there's literally nothing you can do to prevent them from spreading in the hospital.
CONAN: Well, is there something that - some things that every hospital or every clinic should be doing in order to minimize the risk?
PERENCEVICH: I think one of the most important things they can do is make sure their microbiology lab is able to detect these strains. So unlike the MRSA, the Methicillin-resistant Staph aureus, these strains are a little bit harder to detect. So the standard microbiology available in the microbiology lab, to - you can detect that it's a Klebsiella bacteria, like it's an E. coli bacteria, but you - it's harder to detect whether it's a KPC or a resistant strain.
And so oftentimes labs have to send these out to other facilities, and it can take time. And so, that's probably one of the first things they can do. And then attention to detail and infection prevention, really focusing on the basics of infection control such as improving hand hygiene compliance in their hospital. And, you know when these are detected, isolating the patient and being very compliant with wearing gowns and gloves, making sure they have their own room, making sure the staff is educated with how to handle these, that they don't share equipment like blood pressure cuffs and things between patients.
So there is a lot that they can do, but again the ultimate issues are we don't have antibiotics, and so that usually is one of the ways to treat these and prevent these from spreading.
CONAN: We're talking about superbugs, infections in hospitals that are resistant to most, if not all, antibiotics. If you work in a hospital, what's your experience with these superbug outbreaks? How's your hospital dealing with this infection problem? 800-989-8255 is out phone number. Email us, firstname.lastname@example.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. We're talking about the antibiotic superbugs that sometimes spread through hospitals around the country. We've started with a recent case at the National Institutes of Health Research Hospital. As we heard, doctors thought they had that outbreak contained last year. Then another patient died last week from the infection.
The NIH declined our invitation to come on today's program but sent us this statement: We are deeply saddened by the deaths at the NIH Clinical Center related to KPC. The clinical center is taking strong action to keep KPC from spreading further, redoubling its efforts to ensure that all the infection control and isolation strategies recommended by the Centers for Disease Control and Prevention are followed stringently, that testing for KPC in our patient population in hospitals' inanimate environment is ongoing and that hygiene and decontamination protocols are followed by staff at all times.
We're keeping the CDC and county and state officials informed of KPC infections, that statement from the NIH. If you work at a hospital, what's your experience with these superbugs? How's your hospital dealing with these infections? 800-989-8255. Email email@example.com.
Our guests are Maryn McKenna, author of "Superbug: The Fatal Menace Of MRSA." And Dr. Eli Perencevich, who's the professor of medicine and epidemiology at the University of Iowa Carver College of Medicine and director of the CADRE Center at the Iowa City VA Health Care System.
Let's get a caller on the line. This is Jordan(ph), and Jordan's with us from Casper, Wyoming.
JORDAN: Hi, Neal.
JORDAN: Hey, I work at the regional state medical center here in Casper, Wyoming. It's a Wyoming medical center. It's the largest hospital in the state, though that's not saying much for a state of only 500,000. And I work in a non-clinical area. I'm a patient access specialist. And even I have to take extreme precautions with MRSA.
I mean, I love my job, and, you know, I go to work with a sense of, you know, duty and responsibility, but even then, going to work is almost a crapshoot for us hospital employees. We have to deal with MRSA and now hearing about this strain. Thankfully, we haven't had to deal with this one yet. It's scary for not only the patients but hospital employees who happen to work there.
I know that we have stringent guidelines that block us from contact with MRSA, such as the basic personal protection equipment: gowns, gloves, masks, all that. But even then we also have to take extreme precautions with equipment, making sure that we have special wash-down procedures for our environmental specialists.
Everyone in the hospital is essentially affected by this.
CONAN: It's interesting; I hadn't thought about that. Thanks very much for the call.
JORDAN: Thank you.
CONAN: Maryn McKenna, it was interesting, he's talking about administrative staff. In your latest piece for Scientific American, you stress the importance of another underappreciated group of workers at the hospital: the janitors.
MCKENNA: Right. So it turns out that the challenge of these highly resistant gram-negatives is that they kind of - they sort of call on us to rework or maybe even invert some of the kind of power differential in hospitals. I mean, Dr. Perencevich talked about all the things that infection preventionists do, which is incredibly important, I do not discount that at all.
But for a long time, I think when we think about how to prevent infections in patients and how to keep infections from moving from patients, we've focused on the people who actually come close to the patient and touch them: the doctors, the nurses, the paraprofessionals and so forth.
And we haven't thought so much about the environment around the patient. It turns out that that's what janitors know really well, or, to be more polite, building services people or environmental services people. When they go in the room, they're not actually focusing on the patient, they're focusing on all the stuff around the patient: the bedrails, the counters, the call buttons.
And they know which compounds to clean them with and where the dirty nooks and crannies are. At the same time, they're really low-status, low-paid people who haven't traditionally been someone that hospitals invested in a lot, and now it turns out they're really important to controlling things like this, and they have to be sort of lifted up and brought into the calculations.
CONAN: Superbugs like the KPC that's plagued the NIH Clinical Center are often thought of problems for big cities or big-city hospitals. The reality is they're everywhere. According to the CDC, KPC or closely related organisms have now been found in hospitals in 39 states. Dr. Deverick Anderson is co-director of the Duke Infection Control Outreach Network. He and his team advise hospitals with limited resources about infection control, and he joins us now from the studios of Duke University in Durham, North Carolina. Nice to have you on TALK OF THE NATION today, Dr. Deverick.
DEVERICK ANDERSON: Thank you, it's my pleasure.
CONAN: What do we know about smaller hospitals and outbreaks of these superbug infections?
ANDERSON: Well, one of the key messages we try and provide for these community hospitals is that they're really not on an island. They are just like the other hospitals that have been described so far in this conversation. But they usually just don't believe that, that is that when you read information about these superbugs, MRSA, other ones like these KPCs, they seem to think of it as well these are just going to happen in the ivory towers of, you know, the NIH and Duke and Harvard and so on.
But that's just really not true. We actually have plenty of information from our network of 42 community hospitals that in fact some of these drug-resistant organisms are as common in these community hospitals as they are in the ivory towers that I just mentioned.
CONAN: And a lot of us might like to go to the Harvard hospital if we're sick, but we're more likely to end up in a community hospital.
ANDERSON: That is absolutely right because approximately 60 to 70 percent of the hospitals in the United States actually have 200 beds or fewer. And of course along with that, comes quite a bit less investment in some of the basics of infection control. And so that's where we try and spend some of our time focusing, is to try and get in front of the leadership, make sure they know about these problems and make sure that they do try - that they do provide adequate investment for the infection preventionists, the environmental services groups, as was mentioned earlier, and others that can help us try and stem the tide.
CONAN: Well, with limited resources, what can they do? Obviously hand washing is not expensive, but some of these other things are.
ANDERSON: Absolutely, and you're right - well, as Dr. Perencevich mentioned earlier, what we will often preach is simply to go back to the basics. And so certainly hand hygiene is on there. Contact precautions, using the gowns and gloves, do add some cost, though they are not amongst the most expensive interventions that we have.
There are certainly a lot of - there's a lot of testing going on for different ways to better clean the environment, as well: different chemicals, different products that are being explored. We're not yet to the point, however, where we think we can recommend anything more than simply the basics that we currently recommend.
CONAN: And would these hospitals, community hospitals, typically have the lab facilities that Dr. Perencevich was talking about, with the ability to tell the difference between a drug-resistant bacteria and a common garden one?
ANDERSON: Well, to some extent yes, but I certainly think it's worth underscoring Dr. Perencevich's point, that is some of the basic ones that are more and more common, that is MRSA, I think you're not going to have a problem with the basic laboratories at these community hospitals finding that particular organism.
However, when you get to some of these more complicated ones, just like we're talking about now, with KPCs and some of these meaner and nastier gram-negative pathogens - in fact they do not have the resources to identify these a lot of the time, and that is a major problem.
CONAN: And that mindset, though, of oh this is somebody else's problem, how do you change that?
ANDERSON: Well, we think - for one thing, we have to get their own data back to them, and that's what we really strive to do in our network. We use their data to say listen, this is happening at your hospital. This is not what we're publishing at Duke. This is data from your hospital. This is a problem that you have. Here is your data. Look at how this compares to other community hospitals in your local area.
And so we really think that we can use a hospital's own information to try and drive their performance.
CONAN: Dr. Anderson, thanks very much for your time today, appreciate it.
ANDERSON: My pleasure, thank you.
CONAN: Dr. Deverick Anderson, co-director of the Duke Infection Control Outreach Network and assistant professor of medicine at Duke Hospital. He joined us from a studio there at the university. Let's get another caller in. This is Aaron(ph), Aaron with us from Jacksonville.
AARON: Hi, can you hear me?
CONAN: Yes, you're on the air, go ahead, please.
AARON: OK, thanks for taking my call.
AARON: I'm a nurse practitioner in Jacksonville. I actually am working for the past couple years in an infectious disease specialty. And I just find it unusual that this is a topic that's just now coming under the national spotlight. My mom told me last week, she was like: Did you hear about that infection at NIH that killed all those people?
And when in fact I've seen this infection for years, and not only - I mean, we have many hospitals in Jacksonville, big hospitals, and I've working at many of them, and nursing homes. And I've seen it not only in the hospitals, but also in the nursing homes. And I think that one of the problems with the nursing homes here in Florida, is that they don't have the funds and the resources to truly, you know, to do the epidemiology and to do the necessary contact precautions and cleaning and those sorts of things.
CONAN: That's scary.
AARON: Yes, it is scary, but it's - you know, I do think that this effort to do more of a national effort to look at these problems is important because I see a lot of individual institutions doing their own studies to track within their own institutions, but to get a better idea of what the problem is and what we need to do and whether we need, you know, some federal assistance targeting these problems or not would be, you know, a big question.
CONAN: Dr. Perencevich, is there a national system that tracks and targets and is working on research on how to defeat these?
PERENCEVICH: It's a complicated question. There are great teams at CDC tracking these. They have a system in 10 states that tracks antibiotic-resistant infections, but there is no national strategy for the specific infections. Definitely people looking in it, people feeding it to their health departments, but not a full national reporting system.
There was a large outbreak in Israel of KPC in 2006 and '07. The strain probably originated in the U.S., maybe New York City to Israel, and 1,300 people, at the peak, had this infection in high mortality. And they created a - kind of a mandatory reporting system in the whole country where they could communicate who had these infections among facilities so that a patient infected or colonized in one facility would be known and isolated if transferred.
And they also created a nationwide task force with statutory authority to intervene to prevent these outbreaks and to control the outbreaks. And I think that some level of that will be needed. It's hard to track. There's no national microbiology database yet, and so it's hard to track these things outside of the CDC's 10-state system.
CONAN: Obviously a lot easier to do on a small country like Israel, but it could be a useful model.
CONAN: All right. Erin, thanks very much for the phone call.
ERIN: Sure. Thanks for taking it.
CONAN: Sure. Let's see. We go next to - this is Julie(ph), Julie with us from Cincinnati.
JULIE: Oh, yes. I'm an ICU nurse in Cincinnati, and I would say the janitors are probably most important because they do clean the parts of the patient - touches - who's infected. And I also want to point out with all honesty, we have a casual approach going into the room, using personal protective devices. We don't always use it. We're cautious, but we don't always use it.
And also, as far as 50 percent of the patients with the infection dying when they're drug - with the drug-resistant bugs, is it the whole hospital population, or is it compromised patients like chemotherapy patients or sepsis patients?
CONAN: Dr. Perencevich?
PERENCEVICH: That's a very - two good comments and very good question. The mortality, typically, at that level, people that get these - get colonized with these bacteria and then develop infection tend to be the sick or immune-suppressed, postoperative patients. And so that's where most of the mortality occurs.
But our hospitals these days are taking care of sicker and sicker patients. We early-discharge patients who aren't sick. And so the hospitalized populations in the country are increasingly at risk for these infections.
CONAN: Thanks for the call, Julie.
JULIE: Oh, thank you.
CONAN: We're talking about superbugs. You just heard Dr. Eli Perencevich, professor of medicine and epidemiology at the University of Iowa Carver College of Medicine. Also with us is Maryn McKenna, author of "Superbug: The Fatal Menace of MRSA," a blogger for Wired Science and a columnist and contributing editor to Scientific American. You're listening to TALK OF THE NATION from NPR News.
And you repeatedly said, Dr. Perencevich, we need new antibiotics. Is research underway?
PERENCEVICH: There definitely is some research underway, although antibiotics are kind of a special case drug. So they're very expensive, like all drugs, to develop, and they take years to develop. But the development over the past decades - 20, 30 years - have largely been little minor modifications of existing antibiotics, and no new classes have really - that's a slight exaggeration, but predominantly just kind of minor changes of existing antibiotics.
And there's also little financial incentives for drug companies to develop these antibiotics. Patients only take them for one to two weeks. They're not chronically on them like a hypertension med or even an HIV antiviral. And additionally, when drug companies, if they do develop a new antibiotic, immediately they're asked not to market it, to - patients not to take it unless they absolutely need it. You're saving the new antibiotic for the severe cases like we have here.
So they're very difficult to develop. There have been some laws proposed and, I think, some approved to address these, but it's a major public health issue that needs to be addressed financially with incentives and other changes.
CONAN: Maryn McKenna, you've obviously been dealing with this, not just for your book two years ago, but ongoing. And is awareness of the severity of the situation most people know?
MCKENNA: You know, the caller who spoke just a moment ago, who sounded surprised that we were talking about this now, she's entirely right. This has been going on for a while. I mean, the KPC epidemic is actually - the very first case surfaced in North Carolina in 1996. And starting in about 2002, was epidemic in Manhattan.
So this has been going sort of below the radar and with people not really noticing it and not talking about it for a decade now. And you can see that in the lack of action, as Dr. Perencevich is talking about, in not fully funding surveillance networks, in not putting the incentives and money into new drug development. It's really sort of on a - the trajectory is not good, and there hasn't been the political will or attention to really turn it around.
CONAN: This from Steve in Phoenix: My stepfather was admitted to Mayo for cancer treatment, and later after he was sent home it was determined he had contracted MRSA. Upon readmission, the hospital required gowns, gloves and masks. But then doctors and nurses would answer their cellphones they had in their pockets with their gloves on, put it back in their pocket and probably go use it somewhere else. So it's easy to miss something, Steve concludes.
And I suspect he's right. And casual things like that like our nurse practitioner was talking about just a moment ago, that can be really important in all of this. And that's going to be something we're going to have to be more stringent about as we look forward to this crisis. An emergency in slow motion, I believe, Maryn McKenna has described this. But thank you very much for your time today. We appreciate it.
Maryn McKenna, author of "Superbug: The Fatal Menace of MRSA." She joined us from Ithaca, New York. And we also would like to thank Dr. Eli Perencevich, professor of medicine and epidemiology at the University of Iowa's Carver College of Medicine, Director of the CADRE center at Iowa City VA Health Care System. Thanks very much for your time today.
PERENCEVICH: Thank you very much.
CONAN: When we come back, we're going to be talking about Mitt Romney and the 47 percent. NPR's senior Washington editor Ron Elving will join us after Mother Jones released the full video of that evening back in the spring when Mitt Romney was addressing a private fundraiser in Florida. Stay tuned. I'm Neal Conan. It's the TALK OF THE NATION from NPR News. Transcript provided by NPR, Copyright National Public Radio.