New superbugs threatening UK hospitals

Microbiologists call for improvements in cleaning and hand hygiene and the adoption of technology to prevent the spread of new resistant infections such as CPE, VRE and Ebola

Improvements in hand hygiene compliance, adoption of innovative new technologies, and more single rooms are needed to save hospitals from the threat of new antibiotic-resistant superbugs, experts are warning.

Delegates at Healthcare Estates 2014, held in Manchester last week, heard that new killer bugs such as Carbapenemase-producing Enterobacteriaceae (CPE) and Vancomycin-resistant enterococci (VRE) could cripple hospitals in the coming years unless action is taken to improve infection prevention.

While more well-known bugs such as C.difficile and MRSA are already high on the agenda, and hospitals have to submit regular data on outbreaks on the wards, some of the newer bugs are ‘coming up in the rear view mirror’ and could catch trusts unaware, say microbiologists.

Professor Kevin Kerr, director of infection prevention and control at Harrogate and District NHS Foundation Trust, said: “It remains a sad fact that one in 12 people without an infection will acquire one during their stay in hospital. Behind the scenes there are individual patient stories and some infections can be life-changing.

It remains a sad fact that one in 12 people without an infection will acquire one during their stay in hospital. Behind the scenes there are individual patient stories and some infections can be life-changing

“While healthcare associated infections (HCAIs) have attracted immense scrutiny over the last few years, sometimes by focusing on just a few infections we do not see what it coming up in the rear view mirror.”

Increasingly, new strains of bacteria are being found and, unlike MRSA, there is no antibiotic cure.

Professor Kerr said: “One new threat every hospital needs to be aware of it CPE. This is a group of bacteria that is very interesting to microbiologists.”

CPE belongs to a family of bugs that includes e.coli. But, unlike C.difficile and MRSA, which patients are screened for before being brought onto the wards, CPE is difficult to detect in the laboratory and there is no gold standard for prevention and control.

“Every trust has to report cases of MRSA, but there is nothing similar for CPE,” said Professor Kerr.

“Because of this, we do not know how bad the problem is. These organisms can rip through a hospital in a very short space of time.”

A single case of CPE on one ward in a hospital in Italy spread to a number of patients across three wards within weeks, he said, despite enhanced cleaning regimes.

During laboratory studies, it appeared that CPE could survive longer in the environment than previously thought. This means hospitals need to reconsider their cleaning regimes.

Professor Kerr said: “If we look at other parts of the world that are successfully controlling the spread of CPE, they are doing it through the isolation of patients and dedicated staffing.

“In estates and facilities departments across the UK we need to be thinking about building more side rooms. We also need to improve hand hygiene.

“Estates professionals fitted more alcohol hand dispensers because staff told us they didn’t want to keep washing their hands at sinks because it was too time consuming and difficult or there were too few sinks. We can put more basins in, but we might be fooling ourselves if we think people will use them. We need to find other ways to ensure hand hygiene compliance.”

This means introducing auditing procedures or new technologies such as automatic hand hygiene compliance systems, which give an audible or visual warning to healthcare workers to wash their hands when in direct contact with patients, or through video monitoring technologies.

But Professor Kerr said: “New technology is expensive, both to install and to run, and I would ask why should we spend all that time and effort encouraging hand hygiene among healthcare workers when we ignore the patients? We need to encourage patients to be pro-active about hand hygiene as well.

“Moving forward technology is only part of the solution and if we are going to employ technology to help us, then it needs to be part of a multi-faceted, multi-disciplinary approach to HCAIs.”

This approach was supported by Dr Jonathan Otter from the Centre for Clinical Infection and Diagnostic Research at King’s College London. He said particular attention needed to be paid when a previously-infected patient was discharged or moved to another ward or side room. Evidence shows the risk of a patient acquiring an infection doubles if the previous occupant of the room was carrying a bug, even if the room has been cleaned.

“This is something we can fix by doing a better job of cleaning and disinfecting,” he added. “And, while cleaning is vital, it is not the most important thing we can do. Hand hygiene is the single most effective thing.”

Moving forward technology is only part of the solution and if we are going to employ technology to help us, then it needs to be part of a multi-faceted, multi-disciplinary approach to HCAIs

He warned healthcare workers that, while many usually wash their hands after direct contact with patients, just touching a bedrail or other surface could cause the infection to spread in the same way.

“Some infections have been found to survive on surfaces for far longer than we thought they could,” he told the conference. “One study showed that VRE was still found on surfaces four weeks after an outbreak and was still viable. If we do not actively stop them, they will survive.”

This could be catastrophic if new infections such as Ebola and Norovirus continue to spread around the world.

Dr Otter said: “I have sleepless nights about this and it is on every microbiologist’s agenda. We need to watch the situation very closely. We need to find out more about why certain infections survive in the environment for longer and we need to clean up and declutter and make sure surfaces are accessible so they can be properly cleaned.”

He also appealed to manufacturers to make products that are easy to clean and contain antimicrobial materials.

“We also need tools to check how well we are cleaning, such as using bioluminescence,” he said: “At the time of patient discharge we need to thoroughly clean rooms, and we need to ensure hand hygiene protocols are adhered to, particularly as we are using more and more mobile devices such as laptops and smartphones.

Improved hand hygiene is the 'single most important' thing trusts can do to help stop the spread of infection

“There are things we can do to improve disinfection and cleaning. We don’t necessarily need to do everything, but it’s not going to be solved by doing just one thing.”

To offer some fresh guidance, Health Protection England has recently published a series a guidance documents, including one on the clinical management of Ebola1; and another of the early detection of CPE2.

The CPE document states: “The toolkit was developed to respond to the urgent need to get ahead of the curve in relation to stemming the spread of CPE in England. The toolkit sets out a pragmatic approach to preventing and reducing transmission and is based on the best available evidence, expert opinion, guidance, experience and case reports from the UK and abroad a applied to England.

“The toolkit encourages strong intra and inter-regional communication as a method of keeping abreast of current hotspots in England. This requires a transparent and pro-active approach by all trusts including good internal communications, awareness raising, and training of admitting staff.”

Among the recommendations are calls to screen patients on admission and 48 hours later to give the best chance of detection within a manageable timeframe. And it calls on NHS boards to develop contingency plans for the isolation of every high-risk patient.”

References

1. Ebola: infection control and prevention for acute trust staff (Health Protection England). Click here

2. Carbapenemase-producing Enterobacteriaceae: early detection, management and control toolkit for acute trusts (Health Protection England). Click here

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