Bill Warner, a concrete mixer driver in North Carolina, had always been a “strong” and “innovative” man, according to his wife, Carla. But after undergoing a routine endoscopic procedure at a local hospital in early 2013, the once robust 55-year-old developed a raging infection—a superbug—that rendered him “unable to do even the simplest tasks for himself,” his widow recounted last year in testimony before the U.S. Food and Drug Administration.
Warner, it turns out, had contracted Carbapenem-resistant Enterobacteriaceae, or CRE, a highly resistant bacteria that kills up to half of patients infected with it. The superbug ravaged Warner’s body. He lost more than 60 pounds, required tube feedings and was racked with excruciating pain. In November of 2013, after eight months of battling the infection, he died.
Drug-resistant organisms like the one that killed Warner are on the rise—and health officials warn that lethal infections will become more widespread unless the health care community takes aggressive action. Fueled in part by the overuse and misuse of antibiotics, drug-resistant germs cause more than 2 million illnesses and kill at least 23,000 Americans every year, according to the Centers for Disease Control and Prevention (CDC). Cases of Klebsiella pneumoniae carbapenemase (KPC), the most common type of CRE, have increased sevenfold over the past decade.
With a shrinking arsenal of antibiotics to combat these virulent infections, and a scarcity of new drugs in the development pipeline, health care officials warn that superbugs could lead to a global crisis. At the rate things are going, superbugs could kill 10 million people a year worldwide by 2050, according to one recent report on antimicrobial resistance backed by the British government.
The good news is that infection control experts say there is still time to act. Edward Septimus, MD, the medical director of infection prevention and epidemiology at HCA and a professor at Texas A&M Medical School, told attendees of last year’s international Infection Prevention Society (IPS) conference that the world is at a “tipping point.” With proper infection prevention strategies and better antimicrobial stewardship, he says, it’s still possible to slow the spread of supergerms, but “if we don’t take these warning signs seriously, we are going to be headed into a full-blown crisis.”
With that in mind, here’s a look at the three antibiotic-resistant pathogens that the CDC has classified as the most “urgent threats” and information on what nurses can do to help combat the problem.
Carbapenem-resistant Enterobacteriaceae (CRE)
The Threat: This so-called “nightmare” bug is not just one germ, but actually several different strains of bacteria within the Enterobacteriaceae family, which live in the gut. What all CREs have in common—and what makes them different from “normal” species of Enterobacteriaceae—is that they are resistant to carbapenems, powerful antibiotics generally reserved as “last-line” agents for the gravely ill. This leaves clinicians with few options in treating such infections. Symptoms vary, but CRE can cause sepsis, pneumonia, meningitis, and urinary tract and wound infections. Immunocompromised patients, and those being treated with invasive devices, such as central lines, urinary catheters, and mechanical ventilation, are more susceptible to illness.
Danger Zones: While CRE has been reported in most states, the pathogen—at least for now—is mostly confined to acute care hospital settings. Long-term acute care facilities are especially good at incubating the microbe. During the first half of 2012, 4% of short stay-hospitals reported a CRE infection, compared to 18% of long-term facilities, according to a 2013 CDC Morbidity and Mortality Weekly Report. Several CRE outbreaks around the country have been traced to a contaminated duodenoscope used in an endoscopic retrograde cholangiopancreatography (ERCP) procedure, which is used to diagnose and treat problems in the pancreas and bile ducts. Rooms of infected patients are also a breeding ground for CRE. The most contaminated areas include bedside tables, infusion pumps, and sheet surfaces that surround a patient’s pillow, legs and “crotch,” according to a 2013 study in the Journal of Clinical Microbiology.
What You Can Do: Hand hygiene is the number one way to prevent CRE infections and personal protective equipment should be used when caring for patients. Identifying infected patients early is also key. Hospitals should take pre-emptive precautions for patients transferred from high-risk facilities—and once a patient is found to have CRE, contact precautions should be initiated. Ideally, patients should be isolated in a single room. If that’s not possible, patients and staff should be “cohorted” to reduce the risk of transmission. There’s also growing evidence that bathing CRE-positive patients with antiseptic washes like Chlorhexidine can reduce contamination.
Clostridium difficile (C. difficile)
The Threat: This aggressive intestinal bug causes half a million infections in the United States each year and is responsible for one-third of all health care infections, according to the CDC. Toxins produced by C. difficile damage the lining of the intestine and lead to explosive and watery diarrhea. Older age, recent antibiotic use, and immune system dysfunction are all risk factors for developing C. difficile. The infection can be stubbornly difficult to eradicate and relapses are common.
Danger Zones: While some infections are occurring in the community, the vast majority of cases are contracted in health care facilities. Studies have shown that the hearty C. difficile spores can persist for up to five months on hard surfaces in hospital rooms. Hot spots for contamination include floors and bedrails—but windowsills, toilets, call buttons, telephones, and other objects also harbor the germ. C. difficile spores are often spread to other patients on the hands of nurses and other health care providers.
What You Can Do: Frequent handwashing with soap and water is the number one way to reduce the spread of C. difficile, as alcohol-based hand sanitizers DO NOT kill the bug. Patients should also be placed on contact precautions in single rooms. All visitors and caretakers should wear disposable gloves and gowns when entering a patient’s room, according to the CDC, and rooms should be cleaned daily with bleach or another EPA-approved spore-killing disinfectant.
Neisseria gonorrhoeae (N. gonorrhoeae)
The Threat: In 2006, there were five different treatment options for this common sexually transmitted disease. Today, the CDC warns, there is only one effective class of antibiotics left to treat gonorrhea—the cephalosporins—and new strains emerging in Japan, England, and other countries have proved to be impervious even to those treatments. Currently, the CDC recommends dual therapy for patients—an oral dose of azithromycin and single shot of ceftriaxone—and it is still “highly effective” here in the United States. Gonorrhea can be insidious, though, and women, in particular, may be asymptomatic. When symptoms do occur, they may experience vaginal discharge, abdominal pain, and painful urination. Men frequently present with burning pain upon urination and a purulent urethral discharge. Infection can also occur in throat and rectum.
Danger Zones: Unlike the other two pathogens mentioned in this article, drug-resistant gonorrhea is flourishing in the community—not the hospital. While anyone sexually active is at risk, gonorrhea is common among younger people, between 15 and 24 years of age, and disproportionately affects racial and ethnic minorities as well as men who have sex with men (MSM).
What You Can Do: Candy Hadsall, RN, MA, an STD nurse specialist with the Minnesota Department of Health, says the most important thing nurses can do is stay up to date on the latest CDC treatment guidelines and share the information with their colleagues. Infections should be treated right away with the two medications listed above—and treatment of sexual partners is also a top priority. More than three dozen states, including Minnesota, also provide “expedited partner therapy,” which allows providers to send patients home with a prescription to treat their sexual partners, though it’s still best for individuals to see a clinician so they can receive the IM injection that is most effective in curing the infection. Be sure to instruct patients to complete the entire prescription and to return for retesting by culture and antibiotic susceptibility testing if symptoms persist. Treatment failures should be reported to the health department. Sexually active MSM and women with new and/or multiple partners, or a partner with an STD, should be tested at least once a year for gonorrhea.