SPACE COAST DAILY HEALTH SPOTLIGHT: Growing Crisis of Multi-Drug Resistant Microorganisms

Barry Inman is epidemiologist for the Florida Department of Health in Brevard County

EDITOR’S NOTE: We are delighted to welcome Barry Inman, epidemiologist for the Florida Department of Health here in Brevard County, to provide an update on and insight into the growing healthcare crisis of Multi-Drug Resistant Microorganisms.

In 2013, the Center for Disease Control and PreventionCDC published a report outlining the top 18 drug-resistant threats to the United States. These threats were categorized based on the level of concern: urgent, serious, and concerning.

In general, threats assigned to the urgent and serious categories require more monitoring and prevention activities, whereas the threats in the concerning category require less.  Regardless of category, threat-specific CDC activities are tailored to meet the epidemiology of the infectious agent and to address any gaps in the ability to detect resistance and to protect against infections.

The Centers for Disease Control and Prevention (CDC), Department of Health-Florida and the Brevard County Health Department are extremely concerned about Multi-Drug Resistant Microorganisms (MDROs).

MDROs are defined by the CDC as microorganisms, predominantly bacteria, that are resistant to one or more classes of antibiotic agents.

The alarming increase in drug-resistant microorganisms has created a clinical crisis in which the loss of effective antibiotics undermines our ability to fight infectious diseases and manage the infectious complications common in vulnerable patients.

The CDC estimates that about 2 million illnesses and about 23,000 deaths occur as a result of MDROs in the United States annually. Methicillin Resistant Staph Aureus (MRSA), which has been the most high profile MDRO and one which has been the focus of monitoring and prevention activities for over a decade, has, with very aggressive prevention programs, shown a decline in occurrence.

The three microorganisms that the CDC now reports to be the most urgent threat to public health are: Clostridium difficile (C. diff), Drug-resistant Gonorrhea (DRG), and Carbapenem-resistant Enterobacteriaceae (CRE).

Clostridium difficile

Affecting nearly 500,000 patients annually, C. diff results in nearly 30,000 deaths and adds $1 billion in excess medical costs per year in the United States.

Patients at risk are usually over 65 years old, immune-compromised, have been previously exposed to antibiotics, and use of proton pump inhibitors. Although resistance to the antibiotics used to treat C. diff infections is not yet a problem, the bacteria spreads rapidly because it is naturally resistant to many drugs used to treat other infections.

C. diff infection causes diarrhea, often severe, with the development of pseudo-membranous colitis leading, in the most severe cases, to toxic megacolon, sepsis and death.

The primary underlying pathophysiologic cause in the development of C. diff associated diarrhea is a disruption of the normal intestinal bacterial flora (microbiota) by previous exposure to antibiotics, especially those with a broad spectrum of microbial coverage. Therefore, the prudent utilization of antibiotics is crucial in the prevention of C. diff.

Healthcare facilities are utilizing “best practices” to control this microorganism, such as improved hand hygiene, disinfection for high touch areas (doorknobs, toilets, bed rails, etc.) and detection of cases and isolation of patients with suspect or confirmed cases of C. diff.

 One in four patients with an initial episode of C. diff will develop a second episode of C. diff. Healthcare facilities are aware of their rates of infection for C. diff and other microorganisms and therefore monitor closely to ensure rates are within the national baselines established by the National Healthcare Safety Network (NHSN).

This organism can be acquired in the community, therefore persons in the community can reduce the risk by adhering to the following practices:

• Taking antibiotics only as prescribed by the physician and complete the prescribed course of treatment
• Tell your physician if you have been on antibiotics and get diarrhea within a few months
• Wash hands before eating and after using the bathroom
• Try to utilize a separate bathroom if you have diarrhea, or be sure the bathroom is cleaned well if someone in the family has used the toilet. One to ten dilution of bleach and water is used as a disinfectant for diff.

Drug-Resistant Gonorrhea

People who are sexually active and do not take proper precautions against sexually transmitted diseases, such as reducing sexual contact and use of condoms are obviously at risk for gonorrhea. The CDC estimates over 800,000 infections occur annually and approximately 250,000 are resistant to some antibiotics that are needed to treat this infection successfully.

Gonorrhea has progressively developed resistance to the usual antibiotic drugs prescribed to treat it. Following the spread of gonococcal fluoroquinolone resistance, the cephalosporin antibiotics have been the foundation of recommended treatment for gonorrhea.

However, the emergence of cephalosporin-resistant gonorrhea has significantly complicated the ability to treat gonorrhea successfully because cephalosporin-resistant gonorrhea is often resistant to multiple classes of other antibiotics. Currently, DRG is showing resistance to the following antibiotics: cefixime, ceftriaxone, azithromycin and tetracycline.

If cephalosporin-resistant gonorrhea becomes widespread, the public health impact during a 10-year period will result in a much higher risk of complications from gonorrhea, including pelvic inflammatory disease, endometritis, epididymitis, septicemia, endocarditis, and conjunctivitis, particularly in newborns. Also, HIV is more readily transmitted when someone is co-infected with gonorrhea.

To reduce the risk of DRG, the CDC has now recommended that ceftriaxone 250 mg IM plus azithromycin 1g orally, both in a single dose, as treatment. Sex partners within the 60 days preceding the onset of symptoms should be referred for evaluation, testing, and presumptive dual treatment.

If the patient’s last potential sexual exposure was over 60 days before the onset of symptoms or diagnosis, the most recent sex partner should be treated. To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.

Because there are few antibiotic options left to treat gonorrhea that are simple, well-studied, well-tolerated and highly effective, it is critical to continuously monitor antibiotic resistance to gonorrhea and encourage research and development of new treatment regimens

Carbapenem-Resistant Enterobacteriaceae

CRE is a family of bacteria that are normally found in the gut and have become difficult to treat because they have high levels of resistance to antibiotics. The organisms involved are usually Klebsiella and E. coli species that have become resistant to carbapenems, a class of antibiotics, considered the drugs of last resort for such infections.

According to the CDC, CREs are a serious threat to public health. Infections with CRE are difficult, and in some cases impossible, to treat and have been associated with mortality rates up to 50%.

CRE usually occurs in patients who are in hospitals, acute long-term care, nursing homes, and other healthcare settings.

Patients at most risk for CRE infections are frequently immune-compromised and require care that includes devices through which the bacteria can enter the body like ventilators (breathing machines), urinary (bladder) catheters, or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics. CRE can also cause infections when they enter the body through wounds caused by injury or surgery.

At least 4 percent of short-stay hospitals had at least one patient with CRE infection and 18 percent of long term acute care hospitals had at least one. In the past years, CRE has been found in nearly every state in our country becoming endemic in the northeastern states, Florida and California.

Due to the movement of patients throughout the healthcare system, if CRE are a problem in one facility, then typically they are a problem in other facilities in the region as well. CRE germs are usually spread person to person through contact with infected or colonized people, particularly contact with wounds or stool.

Active surveillance for CRE of high-risk patients (see above) in healthcare settings is highly recommended. Practices such as meticulous hand hygiene, minimizing the use of invasive devices, proper use of antibiotics, and placing patients on strict contact precautions are imperative preventative and control practices.

The CDC also recommends cohorting patients and staff if outbreaks occur., as well as chlorhexidine baths for all patients in settings where CRE could be present.

For patients to reduce their risk of CRE, the CDC recommends the following:

• Tell your doctor if you have been hospitalized in another facility or country.
• Take antibiotics only as prescribed.
• Expect all doctors, nurses and other healthcare providers wash their hands with soap and water or an alcohol-based hand rub before and after touching your body or tubes going into your body.
• Clean your own hands often, especially:
  • Before preparing or eating food
  • Before touching your eyes, nose, or mouth
  • Before and after changing wound dressings or bandages or handling medical devices
  • After using the bathroom
  • After blowing your nose, coughing, or sneezing
• Ask questions. Understand what is being done to you, the risks and benefits.

Considerations To Reduce The Overall Risk Of MDROs

Here are some tips to reduce the overall risk of MDROs and ensure appropriate utilization of antibiotics:

• Do not take antibiotics for a common cold, or other viral upper respiratory infections
• Practice good hand hygiene
• Be well immunized. If you do not acquire infection no antibiotics are needed!
• Sore throat: treat only with a positive test for Streptococcus
• Acute bronchitis: no antibiotics are generally needed and no microbiogical testing is needed
• Acute sinusitis: “watchful waiting” for at least 7 days for patient with uncomplicated acute sinusitis
• Don’t treat asymptomatic bacteruria with antibiotics
• Do not test for Clostridium difficile without diarrhea

ABOUT THE AUTHOR

William “Barry” Inman, BA/BS, CIC has 40 years of experience as an epidemiologist, is Certified as an Infection Control Preventionist by the CBIC and received his BA and BS of the University of Florida in 1974. He is employed by the Brevard County Health Department in Merritt Island, Florida. He is responsible for control of communicable diseases by surveillance and investigation methods in the Brevard County area-Space Coast. He works directly with the Infection Control personnel in hospitals, long term care, acute long term care, NASA, etc. with assistance in identifying diseases which are communicable.

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