Healthcare Hygiene magazine October 2019 | Page 36

patient safety & quality
By Kathy Warye
Learning from the Past to Protect
the Future
It
has been approximately 20 years since the publication
of To Err is Human, the landmark study that gave birth
to the patient safety movement. And while there has been
much progress made in the management of healthcare
associated infections, we are facing a growing crisis that
will demand that we do even better.
While the threat of antimicrobial resistance is well
known, in the practice of infection prevention, and the
delivery of healthcare in general, there is often a wide gap
between knowledge and action. There are many reasons
for this, from insufficient resources to resistance to change
to imperfect evidence.
Whatever the factors, when confronted with the rise
in healthcare-associated MRSA in the late 1990s, the U.S.
was late to act in comparison to other countries. And when
the action did occur, it was not as comprehensive as other
developed nations and lacked regional coordination. When
confronted with a rapid rise in MRSA early in the decade,
the UK took decisive action at a national level. The UK plan
was comprised of a combination of integrated components
which addressed the entire system of infection prevention
from elevation of IP leaders to positions of greater influence,
to mandatory reporting of MRSA to universal screening of
patients via newly available rapid diagnostic technology.
In 2001, the rates of MRSA isolated from infections in
the U.S. and the UK were almost identical, but over the next
15 years, the two different strategies produced dramatically
different results. From 2001 to 2015, the UK achieved a
decline in MRSA isolates from 45 percent in 2001 to just
over 10 percent in 2015. Over the same period of time, in
the U.S., rates of MRSA isolates increased to approximately
55 percent before returning to just under 45 percent. 1 While
it must be noted that the U.S. has achieved significant re-
duction in MRSA-related bloodstream infections and deaths
since 2005, MRSA is endemic in our healthcare institutions.
The emergence of Carbapenem-resistant or Carbapene-
mase-producing entererococci (CRE), a family of organisms
that is highly resistant to antibiotics, poses a new and po-
tentially far more dangerous threat. Carbapenemases, which
include the KPC enzyme which has been most prevalent in
the U.S., are plasmid-mediated. This attribute makes horizon-
tal transfer easier and the spread of resistance and infection
faster than with either MRSA or C. difficile. Estimates of
mortality with CRE-related bloodstream infection are as
high as 50 percent. In 2015, the combination of resistance
to antibiotics and the potential for community-associated
strains of CRE to emerge led then-director of the CDC,
Tom Frieden, to refer to CRE as the “nightmare bacteria.”
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Today, the CDC estimates that there are approximately
100 patients colonized with CRE for every infected patient.
This means that standard infection control practice, which
relies on clinical cultures from patients suspected of har-
boring MDROs to trigger intervention, will miss the vast
majority of CRE colonization. Since addressing the tip of
the iceberg alone will not contain the spread of CRE, CDC is
recommending that hospitals establish screening programs
for high-risk patients to identify what would otherwise be
a hidden reservoir of CRE colonization. 2 This is a notable
departure from CDC’s approach to MRSA, wherein little, if
any, guidance was provided on optimization of detection
methods to prevent transmission. New technologies are also
entering the market which will make detection of MDROs,
such as CRE, on the front line of healthcare and in the first
episode of care possible for the first time. Placed in units
where risk is highest, these technologies promise will make
active surveillance faster, easier and more affordable.
In parts of Europe, South America and Asia where CRE is
tracked, rapid increases have been observed. While rates in
the U.S. are still low, we know they are on the rise. If past
is prologue, the consequences for public health could be
dire. While the CDC has raised the alarm and encouraged
a coordinated regional approach to prevention, screening
protocols for CRE are inconsistent across U.S. hospitals
allowing a potentially large percentage of CRE to go
undetected and unmanaged. In many hospitals, infection
prevention still struggles for resources and leadership sup-
port. And in hospitals across the country, new, potentially
life-saving technologies face increasingly high bars for
adoption. While much has been learned from MRSA, there
is still much to do to close the gap between knowledge
of CRE’s emergence and the actions that must be taken
to limit the consequences of this nightmare bacteria to
public health.
Kathy Warye is the founder and CEO of Infection Pre-
vention Partners where she provides strategic guidance on
the commercialization of solutions that detect, prevent or
manage infection. Her work spans the product development
life cycle from front-end R&D to development of the market
toward adoption of the resulting products.
References:
1. Resistance Map, Center for Disease Resistance and Policy, Washing-
ton, DC. UK: European Antimicrobial Resistance Network (EARSNet) U.S.:
The Surveillance Network (TSN) 1999-2012; National Healthcare Safety
Network (NHSN) 2013-14.
2. CDC CRE Toolkit, 2015.
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