In the war against infections, some clever bacteria, such as carbapenem-resistant Klebsiella pneumoniae, are mutating into super bugs and gaining the upper hand by becoming resistant to antibiotics, especially in New York and New Jersey, reports the U.S. Centers for Disease Control and Prevention.
Carbapenems are broad-spectrum antibiotics and include imipenem, meropenem and ertapenem, prescribed for bacterial meningitis, sepsis and hospital-associated sinusitis or pneumonia. The resistant bacteria produce enzymes that make them resistant to the effects of carbapenem, penicillin, cephalexin and other drugs. Bacteria capable of producing the enzyme can teach other bacteria how to do the same, says Mary Beth Kelly, RN, BSN, director of infection prevention and patient safety at AtlantiCare Regional Medical Center in Atlantic City, N.J.
The bacteria are more clever than we are, Kelly says. They continue to evolve and develop resistance.
Carbapenem-resistant infections may occur in the lungs, urinary tract or wounds. Klebsiella pneumoniae in the lungs produces a serious infection. It tears the lungs up, and [the body]walls the pneumonia off and forms an abscess, Kelly says.
Carbapenem-resistant organisms first were reported in North Carolina in the late 1990s, but by 2009 they had been identified in 24 states, according to the CDC. The infections have become common in sections of New York and New Jersey.
This can be a life-ender, this bug, Kelly says. Gone are the days we could be cavalier about infections because there was an antibiotic that would take care of it. This is one of the bugs that is about to create a bacteria [infection]that cannot be treated.
St. Lukes-Roosevelt Hospital Center in Manhattan saw a spike in respiratory carbapenem-resistant cases in its ICUs from 2006-07, with a decrease after putting aggressive measures in place to control transmission, says Barbara A. Smith, RN, CIC, nurse epidemiologist at St. Lukes-Roosevelt. The hospital monitors staff compliance with gloving, gowning and hand-washing. Smith has found staff members take these cases seriously and practice good precautions. The other issue thats important is environmental cleanliness, Smith says. It can survive on a surface, maybe a respirator or equipment going from room to room.
To reduce infection rates, St. Lukes-Roosevelt leaves as much equipment in the room as possible and encourages staff to wipe down surfaces.
On the other hand, St. Josephs Regional Medical Center has not identified one case of carbapenem-resistant infection, says Marie Rella, RN, MS, CIC, manager of infection prevention and control at the Paterson, N.J., hospital. Even so, she and staff remain vigilant, monitoring all microbiology reports for multidrug resistance and setting policies for antibiotic administration.
Theres a resistance pattern that were seeing thats sustained, Rella says. The patients are complex with multiple things happening at one time. Its a fine balance doctors have to achieve in using antibiotics prudently.
Patients without symptoms may be colonized and serve as reservoirs for transmission, the CDC reports. Dimple Patel, clinical pharmacy specialist in infectious diseases at JFK Medical Center in Edison, N.J., says carbapenem-resistant organisms are easily passed from patient to patient.
People with chronic, debilitating conditions, such as those on prolonged courses of broad-spectrum antibiotics and individuals with frequent hospitalizations or nursing home stays, are more at risk for carbapenem-resistant infections. A study reported in the February 2011 issue of the Southern Medical Journal found that ICU admission within two weeks and prior exposure to carbapenems or glycopeptides were independent risk factors for nosocomial carbapenem-resistant Klebsiella pneumoniae infections.
The long-term person on a ventilator is more at risk for it, but it can attack other people, too, Smith says.
Plan of Care
The first step requires the laboratory to detect the resistance and notify infection control officers and the nurses caring for the patient. The CDC reports that some automated systems may fail to detect low-level resistance, and additional testing may be necessary.
Physicians may try treating patients with colistin or tigecycline, but the antibiotics have serious side effects and are expensive. If you get an antibiotic that kills the bacteria, it starts to have bad effects on the host, says Kelly, adding that debilitated patients typically dont have a margin to compensate.
St. Lukes-Roosevelt and Saint Barnabas Medical Center in West Orange, N.J., place an alert on the electronic health record, so if a discharged patient with a history of a carbapenem-resistant infection returns for care, infection control is notified.
The CDC recommends hospitals place carbapenem-resistant infected or colonized patients in isolation with contact precautions to prevent the spread of the bacteria. St. Josephs says if a patient is diagnosed with the bacteria, it would keep the patient in isolation until discharge.
Its difficult to get rid of it, says Eileen Yaney, MS, MT, CIC, director of infection control and prevention at Saint Barnabas Medical Center. They become colonized, and it becomes a revolving door. They come back and still have it.
Nurses also must stay vigilant in educating about proper antibiotic use. We have to be keyed in to not accepting an antibiotic unless we have an infection and the susceptibility is known, but there are some exceptions, Kelly says. We all have to be good antibiotic stewards.