By Gary Evans, Senior Writer
Perhaps the tone was set in the early days of the Ebola outbreak; when projected death tolls and disastrous outcomes were linked to urgent requests for money and resources. Nevertheless, it is a bit shocking to see the CDC — an agency that often plays a more patient political game of consensus-building — send the realpolitik equivalent of a ransom note to Congress: “Give us the money or people are going to get hurt.”
Actually, an estimated 37,000 people are going to die in the next five years of antibiotic-resistant and Clostridium difficile infections unless Congress hands over $264 million dollars to the suddenly unsubtle CDC.
“If we just stay with business as usual, there will be hundreds of thousands of infections and tens of thousands of deaths that could be prevented,” Tom Frieden, MD, MPH, CDC director, said at a recent press conference. “We know what needs to be done and it’s up to Congress to [provide] the resources needed to protect Americans.”
The CDC project appears important enough to warrant that level of funding, as the agency is focusing on two of the most dangerous pathogens currently causing HAIs: C. difficile and Carbapenem-resistant Enterobacteriaceae (CRE). C. difficile causes close to half a million infections annually, and has an estimated death toll of 15,000 patients. While this “deadly diarrhea,” as the CDC calls it, is currently causing misery and death far and wide, CRE is just beginning to establish itself in the healthcare continuum. Extremely drug-resistant, if CRE gets established in the healthcare system we may start seeing infections that are difficult, if not impossible, to treat.
CRE is leading the vanguard of antibiotic-resistant bacteria, which have rendered useless whole shelves of the nation’s formulary and cause more than 2 million infections and some 23,000 patient deaths annually. The CDC is clearly concerned that CRE is going to continue to increase, raising the specter of a practically pan-resistant pathogen moving across the healthcare continuum. The kicker — and perhaps the reason the CDC dubbed CRE the “nightmare” bacteria — is that CRE’s drug resistance mechanisms can genetically transfer in nature via plasmids to other types of bacteria, creating the possibility of more and different bugs for which few treatment options are available.
Given the full picture of what the agency is up against, it’s little wonder that the CDC raised the stakes by calling out Congress in public.
The agency is requesting the money to set up “protection programs” in all 50 states and ten large cities.1 The idea is to link healthcare facilities — that see the same group of patients going in and out of their clinics, hospitals, long-term care — with health departments to share information on C. difficile, CRE and other problem pathogens.
“These funds will also make it possible to [detect] outbreaks sooner, improve laboratory testing, and track antibiotic resistance much better than we can today,” Frieden said at the Aug. 4 press conference. “We really hope that when all is said and done, we can get the resources we need to help protect Americans so that people aren’t unnecessarily at risk of getting serious and potentially fatal infections in healthcare facilities.”
Based on past experience with CRE and other pathogens, in the absence of such connections and communication the bug will move across the healthcare continuum undetected via transferring patients. As a result, a web of hospitals, clinics, long-term care, and nursing facilities that all treat the same patients at various stages may soon begin experiencing CRE outbreaks, which are difficult to contain because the pathogen is resistant to almost all available antibiotics. Thus, the CDC is proposing the establishment of formal state networks, with the state health department taking the lead and getting the various healthcare settings to communicate and coordinate patient transfers and visits to other settings for care.
“One of the things that facilities can do is to implement warning systems so that when they transfer a patient who’s got C. difficile or a drug-resistant bacteria, the hospital or nursing home receiving that patient knows that in advance,” Frieden said. “That way, the facility can prepare to isolate the patient in advance before they can spread it to others.”
Specifically, CDC projects that — with full funding — the state protection programs could prevent 619,000 antibiotic-resistant infections and CDIs and the aforementioned 37,000 deaths over five years. The projections are based on an elaborate mathematical model that predicts the consequences of various levels of interventions — from staying at the status quo to establishing fully connected healthcare networks.
No mathematical model is needed to demonstrate how patients spread infections across the network of healthcare facilities that deliver various aspects of their care. There are sufficient real world examples. A textbook case of this phenomenon occurred across a spectrum of facilities treating a common group of patients in adjacent counties in Illinois and Indiana. A single strain of the pneumoniae carbapenemase (KPC) variety of CRE infected some 40 patients in an outbreak involving a staggering 36 healthcare facilities. “We observed extensive transfer of KPC-positive patients [throughout] the exposure network of 14 acute care hospitals, long-term acute care hospitals and 10 nursing homes,” the researchers reported.2 Eleven of the patients (27.5%) died of the CRE infections, with the authors concluding by calling for the establishment of coordinated CRE networks overseen by public health departments — essentially the very plan CDC is now pitching to Congress for $264 million. Indeed, the 2011 study was conducted by one of the CDC’s Epicenter Programs, clinical settings that collaborate with the CDC to conduct innovative infection control research.
“There are a number of regions that are making moves in this direction, including a coordinated approach in the state of Illinois,” said John Jernigan, MD, director of the CDC Office of HAI Prevention Research and Evaluation in the Division of Healthcare Quality Promotion. “They have a system in place in which they are made aware of every patient identified as being infected with CRE, and these data are placed in a central repository. Other facilities, when they are admitting patients, can query this database and find out if patients coming into their facilities are carriers of these types of germs and for whom they need additional infection control precautions.”
In some cases, additional or more sensitive testing may need to be done on asymptomatic patients suspected as carriers.
“What the coordinated approach allows us to do is to recognize the emergence of a problem early, say in a single hospital in the region, and to alert the hospitals around them to take additional infection control precautions that they might not otherwise take,” Jernigan said. “[But] sometimes patients can be carriers of these organisms and no one knows because they don’t show up in the routine clinical test. One of the triggers that might be enacted [based on a predefined threshold] is to provide additional testing to patients to find out which patients are carriers and if that patient is moving from one facility to another.”
Still, it’s a fair question to ask why it has taken so long to move on this in other states, even voluntarily with current resources. It would certainly be to the healthcare facilities’ ultimate benefit to work together with their health departments and begin forming these networks in the absence of federal funding. One problem is that unless all facilities in a regional network buy-in and participate in a network, the collaboration is likely to fail, Frieden said.
“Even if an individual hospital makes significant improvements, it’s dependent on other hospitals in the area also making improvements,” he said. “So going it alone isn’t enough. In addition, although there have been some improvements, we know that the systems have to be in place. Just urging doctors to wash their hands or use antibiotics [judiciously] — without having a systematic approach across the hospital to track and ensure that’s happening — just doesn’t result in consistent, sustained improvements.”
The CDC funding would be used to hire health department staff and increase lab capacity so that CRE and C. difficile in one location can be identified quickly and the other facilities in the region alerted to the situation.
“To implement a coordinated approach, states need to be able to identify — number one — all the healthcare facilities in their area and know how they’re connected with regards to how they share patients,” said Jernigan. “They need additional staff to improve these connections and to help the coordination that needs to happen between the healthcare facilities in their area. They need to develop a communication plan so that information can be smoothly and seamlessly shared. Very importantly, they need to work with CDC to use the data available to them for action to better prevent infections and improve antibiotic use for healthcare.”
The funds would also be used to bolster state labs so that pathogens and drug-resistant patterns can be rapidly identified and communicated to a wide variety of facilities, added Michael Bell, MD, deputy director of CDC’s Division of Healthcare Quality Promotion.
“There’s the need not only for staffers at health departments but also for building capacity in one form or another at the ever-growing array of healthcare facilities that we’re dealing with,” he said. “Healthcare continues to migrate away from acute care hospitals into ambulatory centers, nursing homes, and a wide range of places that increasingly need assistance to deal with the spread of infections.”
- Centers for Disease Control and Prevention. Vital Signs: Estimated Effects of a Coordinated Approach for Action to Reduce Antibiotic-Resistant Infections in Health Care Facilities — United States. MMWR 2015;64(30);826-831
- Won SY1, Munoz-Price LS. Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2011;53(6):532-40