'Superbug' now occurring in 42 states
Editors note: We need to consider the role of wastewater treatment plants in the transport of antibiotic resistant bacteria to farms and into lakes, rivers, and streams. But we also need to look at the wastewater treatment process in breeding and creating antibiotic resistant bacteria through the digestion process. Antibiotic resistant bacteria better survive the conditions in a wastewater treatment plant and therefore a higher percentage of surviving bacteria have multiple resistance. Some very pertinent reading:
Reinthaler, F.F., et al. ESBL-producing E. coli in Austrian sewage sludge. Water Res.
By Peter Eisler USA Today Sun Dec 2, 2012 1:01 AM
CHARLOTTESVILLE, Va. - The doctors tried one antibiotic after another, racing to stop the infection as it tore through the man's body, but nothing worked.
In a matter of days after the middle-aged patient arrived at the University of Virginia Medical Center, the stubborn bacteria in his blood had fought off even what doctors consider "drugs of last resort."
"It was very alarming; it was the first time we'd seen that kind of resistance," said Amy Mathers, one of the hospital's infectious disease specialists.
The man died three months later, but the bacteria wasn't done. In the months that followed, it struck again and again in the same hospital, in various forms, as doctors raced to decipher the secret to its spread.
The superbug that hit the Virginia hospital four years ago belongs to a family of drug-resistant bacteria that has stalked hospitals and nursing homes for a decade. Now, it's attacking in hundreds of those institutions, a USA Today examination shows.
The bacteria strains, known as carbapenem-resistant enterobacteriaceae, are named for their ability to fight off carbapenem antibiotics — the last line of defense. And so far, they've emerged mainly in health care facilities, killing the weakest of patients.
The bacteria made headlines this summer after a CRE strain battered the National Institutes of Health Clinical Center outside Washington, D.C. Seven died, including a 16-year-old boy. But that case was neither the first nor the worst of the attacks.
Research shows there have been thousands of CRE cases throughout the country in recent years.
Death rates among patients with CRE infections can be about 40 percent, far worse than infections such as MRSA or C-Diff, which have plagued hospitals and nursing homes for decades. And there are growing concerns that CRE could make its way beyond health facilities and into the general community.
"From the perspective of drug-resistant organisms, (CRE) is the most serious threat, the most serious challenge we face to patient safety," said Arjun Srinivasan of the Centers for Disease Control and Prevention.
Since the first case was reported at a North Carolina hospital in 2001, CREs have spread to at least 41 other states, according to the CDC.
USA Today interviewed dozens of health care authorities and reviewed hundreds of pages of journal articles, clinical reports, and state and federal health care data. The examination shows:
CRE infections already are endemic in several major U.S. population centers, including New York, Los Angeles and Chicago. Smaller pockets of cases have been reported across much of the country, including Oregon, Wisconsin, Minnesota, Pennsylvania, Maryland, Virginia and South Carolina.
There is no reliable national data. The CDC has urged states to track cases, but only a handful do so.
There is little chance that an effective drug to kill CRE bacteria will be produced in the coming years. Manufacturers have no new antibiotics in development that show promise.
Many hospitals — and an even greater percentage of nursing homes — lack the capacity to identify CRE, or the resources to effectively screen and isolate patients carrying the bacteria. Even when screening is possible, there's a lack of consensus on whom to target.
"We're working with state health departments to try to figure out how big a problem this is," said the CDC's Srinivasan, noting that his agency can pool whatever data states collect. "We're still at a point where we can stop this thing. You can never eradicate CRE, but we can prevent the spread.
Other experts are less optimistic.
"My concern is that there aren't a lot of methods in our tool kit that are significantly effective in curbing the spread of these infections," said Dr. Eli Perencevich of the University of Iowa's Carver College of Medicine.
The Virginia epidemiologists knew their CRE outbreak would be tough to contain, but it quickly became clear that this case would be even more difficult than most.
When the doctors began analyzing the bacteria in their first patient, who'd transferred from a hospital in Pennsylvania, they found not one, but two different strains of CRE bacteria. And as more patients turned up sick, lab tests showed that some carried yet another.
"We were really frustrated; we hadn't seen anything like this in the literature," said Costi Sifri, the hospital epidemiologist.
The doctors went back to the lab with even more urgency. It was January 2008, five months after the first case turned up, and they'd identified five patients harboring three distinct species of CRE.
Three of those patients already were dead.
One challenge is figuring out where CRE is showing up.
Based on academic studies and data from the few states and counties that require some reporting, it's clear that CRE is spreading fast.
In Los Angeles County alone, a year of surveillance through mid-2011 turned up 675 cases at hospitals, nursing homes and clinics. In Maryland, a 2011 survey by the state health department identified 269 patients carrying CRE and estimated that up to 80 percent of the state's hospitals had seen at least one case during the year.
It's important to know where CRE is emerging because it spreads with patients who bounce between or among clinics, surgical centers, rehabilitation facilities, nursing homes and, of course, hospitals.
In the Chicago area, where scores of CRE infections have been found since 2008, studies show that about 3percent of hospital patients in intensive care carry the bacteria, said Dr. Mary Hayden of Rush University Medical Center.
Those same studies have found CREs being carried by about 30 percent of patients in long-term care facilities.
Not all of those patients are symptomatic: The bacteria can lurk, unseen, until a carrier's immune system is compromised or until the bug finds a path into the body and infection sets in. And as those patients move from one facility to another, the bacteria move with them, often clinging to caregivers' hands — and moving to new victims.