News, via the Washington Post‘s hard-working health reporter Brian Vastag: After 6 months with no cases, carbapenem-resistant Klebsiella has surfaced again at the Clinical Center of the National Institutes of Health, and has killed a boy from Minnesota who came to the specialty hospital after a bone-marrow transplant meant to address an immune deficiency. This sad event makes the boy the 19th patient to contract the extremely resistant hospital organism, and the 12th to die from it, since the outbreak began.
You can find here my last post analyzing this outbreak (which was originally reported by the Post following a write-up by NIH staff in the journal Science Translational Medicine). I’m looping back to the subject not just because of this new death, but also to add a few new publications to the discussion, one of them mine.
You might remember from the initial coverage (including great blog posts by physicians Judy Stone and Eli Perencevich) that CRKP or KPC is a challenge for several reasons. First, it is extremely drug-resistant, responding to only a few remaining antibiotics. Second, it is extremely persistent in the environment, able to live on inorganic, low-nutrient surfaces such as metals and plastics. And, third, it can be harbored asymptomatically in patients’ guts, meaning that patients can bring in into a hospital, or acquire it in one hospital and take it to another, without it being detected — or at least, not until an outbreak begins.
There were several papers about CRKP during the ICAAC meeting last week. Some were on early-stage antibiotic compounds that might work, if they continue to progress through trials. But several looked at how widely distributed the organism might be. Those made it clear that, as I said last month, CRKP is everywhere — an emergency in slow motion, happening all around us, all the time.
- A survey of patients on ventilators in hospitals and long-term care facilities in Maryland (where NIH is located) found the highly resistant organism in 6 percent of patients and 25 percent of facilities. (JK Johnson et al.)
- A similar survey in Indiana found that over 14 months, 14 Indiana medical centers housed 71 patients carrying carbapenem-resistant organisms, 79 percent of which were KPC. (K. Bush et al.)
- And a study conducted in Cleveland — where the VA hospital says it experienced a 2-year KPC outbreak from 2008-10 — found the gene that confers resistance in CRKP (blaKPC) moving into other organisms as well. (F. Perez et al.)
So how do hospitals combat this threat? By coincidence, I talk about this in my latest column for Scientific American, which is in the September issue and has just gone live on the web. It turns out that the key to controlling CRKP and similar organisms may require turning the hospital hierarchy upside-down — because the key personnel for eliminating these resistant bacteria turn out to be not the highly paid preventionists, but the building services personnel. Or, bluntly, the janitors. From SciAm:
Just a few years ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA, or methicillin-resistant Staphylococcus aureus. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds…
“This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, president of the Society for Healthcare Epidemiology of America. Traditionally, medical centers regard janitors as disposable workers—hard to train because their first language may not be English and not worth training because they may not stay long in their jobs.
The piece discusses a project, the “Clean Team,” that was launched by NYU Langone Medical Center after KPC began making inroads there in the early 2000s. Clean Team relies on something that most hospital staff don’t think about: When they go into a room, they are focused on a patient, but the janitors focus on everything around the patient, from the counter to the keyboards to the bed curtains and the doorknobs. The project capitalizes on that granular knowledge by pairing janitors with infection preventionists and charge nurses, making them equal partners (with people who would otherwise be far above them in the professional hierarchy) and scoring them all up — or down — on how well their joint team performs.
For another approach to the same problem — coming to grips with how crucial low-status, high-turnover workers are to a hospital’s success — take a look at this video, filmed by the Illinois Department of Public Health. Its title is a message that, in the era of CRKP, hospitals need to hear: “Not Just a Maid Service.”