August 16, 2010

Region acts to guard against drug-resistant bacteria

Local expert says NDM-1 outbreak poses little threat here

The Winnipeg Health Region is reminding staff to be vigilant after two Canadians were found to be infected by a potentially fatal antibiotic resistant strain of bacteria, believed to have originated in India or Pakistan.

Dr. John Embil, Director of Infection Prevention and Control for the Winnipeg Health Region, says a memo has been sent to hospital staff to raise awareness about the newly described antibiotic resistant bacteria, and to remind everyone to follow the principles and procedures outlined in the Region's infection prevention and control manual for the detection of persons who may harbor this and other antibiotic resistant bacteria.

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Tips for preventing the spread of germs

Embil says the measures needed to identify persons potentially at risk of having acquired this or other antibiotic-resistant bacteria are straight forward. The process entails asking people attending hospitals if they have received medical treatment outside Manitoba. This question serves as a trigger for more questions and, if necessary, placing the person in a private room pending testing for the presence of antibiotic resistant bacteria.

"While the reports of the new bacteria are interesting and certainly raise concerns there is really nothing different in the management of persons who may harbor this organism than there is with any other new germ," says Embil. "We do this every day."

"The beauty of the protocol that we (the Region) have in place, is its simplicity. We ask people if they have been in a health care facility out of the province when they present to (hospital). This allows us to capture anything new and out of the ordinary. This broad screening approach allows us to always be on the lookout and ready, and not to have to panic every time there is a report of a new infectious agent."

Health officials confirmed last week that one patient in Alberta and another in the Vancouver area had tested positive for bacteria containing the enzyme New Delhi metallo-beta-lactamase 1, or NDM-1. In both cases, the patients recovered. No cases have been reported in Manitoba.

Dozens of people in Britain, India and Pakistan have tested positive for the bacteria.
News reports suggest that of 29 British residents who tested positive for the infection, almost half had been admitted to a hospital in India or Pakistan recently, often for elective or cosmetic surgery.

Some health officials have suggested that drug-resistant infections like NDM-1will become more prevalent, in part because of the growth in medical tourism - where patients travel the globe obtain medical services for less than they might pay at home.

But Embil says it is important to keep things in perspective.

"It's an interesting observation," says Embil. "But we've had two cases in Canada with a population of 32 million."

He also notes that the cases described so far involve a high number who have people who have gone to India and Pakistan for medical procedures. "So, a word to the wise, don't go to abroad to undergo elective medical procedures."

Embil says screening patients is not unusual. For example, if someone broke an ankle skiing in the Swiss Alps and was being transferred back to a Winnipeg hospital, Embil says Region staff would ask Swiss authorities to test the patient for the presence of communicable agents such as methicillin resistant Staphylococcus aureus (MRSA), and vancomycin resistant enterococcus (VRE). Staff would also inquire about possible infections at the hospital in question.

If the Region was satisfied that the patient was clear of potentially communicable infections, he or she would be placed in a regular room. But if the results were not ready before the patient arrived in Winnipeg, or there was any concern that he or she was infected or colonized (where a person carried the bacteria, but shows no symptoms) with a microorganism, the person would be placed in a private room and managed under infection prevention and control precautions until the results of the tests became available either from the other country or by having been repeated in Winnipeg.

Embil says the NDM-1 bacteria should not be confused with VRE, Clostridium difficile, or MRSA which occasionally cause outbreaks in Winnipeg's hospitals.

VRE is a strain of the enterococcus bacteria that has become resistant to vancomycin, which is an antibiotic used to treat bacterial infections. Enterococcus is one among many bacteria that can be found in the bowels of healthy people, and it generally poses no threat to the population. But it can become a problem if it evolves into an infection and becomes resistant to drugs such as vancomycin.

That usually happens only in people who are already very sick, which is why it is one of the most common infections found in hospital patients. The Centres for Disease Control and Prevention in the United States, for example, has reported that enterococci can cause as many as one in eight infections in American hospitals, with VRE accounting for about 30 per cent of the total. In the Winnipeg Health Region, the rate of VRE infection was about 0.7 per 1,000 patients in 2008/09, a number in line with hospitals throughout North America.

Generally speaking, VRE is spread from person to person on unclean hands or indirectly by contact with contaminated equipment or furnishings. A person with VRE may or may not show symptoms. In any case, most VRE infections can be treated with antibiotics other than vancomycin.

Outbreaks of multidrug-resistant organisms (MDROs) like VRE have become a growing problem in hospitals around the world over the last decade or so. They are hard to detect, difficult to treat and can undermine a patient's health, prolonging their stay in hospital.

As a result, the Region has bolstered efforts to contain outbreaks. The Infection, Prevention and Control Program has stepped up monitoring, surveillance and reporting of MDROs. In addition, the Health Sciences Centre is a collaborating centre for the Canadian Nosocomial Infection Surveillance Project (CNISP), which includes 49 participating hospitals from nine provinces across Canada. Participating members share information and work to develop guidelines on how best to deal with these issues.

"At any given time in a city the size of Winnipeg, you will have one type of outbreak or another. It could be VRE, it could be MRSA, or it could be something else. Generally speaking, these are treatable and don't pose a threat. But, of course, there are always cases where someone can already be very sick and the added problem of infection undermines that person's health that much more," says Embil.


Vancomycin-resistant enterococcus

Enterococcus is a normal bacterium in the bowels. It becomes vancomycin-resistant enterococcus (VRE) when it becomes resistant to antibiotics that could normally treat it. It can then spread from person to person on unclean hands or indirectly by contact with contaminated equipment or furnishings. There may be no symptoms or symptoms may include (depending on where the infection is): fever, purulence (pus), inflammation and pneumonia. You may find signage at the door on the infection prevention and control precautions you should take. Please confirm with the nursing staff as to how you can limit transfer of the infection. The best prevention of these bacteria is to practice proper hand hygiene.

Clostridium difficile

C. difficile is a bacterium that causes diarrhea and more serious intestinal conditions like colitis, the inflammation of the bowel. C. difficile can be difficult to treat, can spread to other patients and is a common cause of diarrhea in hospitals and long-term care facilities. It can spread from person to person by unclean hands or indirectly by contact with contaminated equipment or furnishings. Symptoms of C. difficile include: watery diarrhea, fever, loss of appetite, nausea and abdominal pain/tenderness. You may find signage at the door on the infection prevention and control precautions you should take. Please confirm with the nursing staff as to how you can limit transfer of the infection. The best prevention of these bacteria is to practice proper hand hygiene.


In the community, most MRSA infections are skin infections that may appear as pustules or boils which often are red, swollen, painful, or have pus or other drainage. These skin infections commonly occur at sites of visible skin trauma, such as cuts and abrasions, and areas of the body covered by hair (e.g., back of neck, groin, buttock, armpit, beard area of men). Almost all MRSA skin infections can be effectively treated by drainage of pus with or without antibiotics. More serious infections, such as pneumonia, bloodstream infections, or bone infections, are very rare in healthy people who get MRSA skin infections. MRSA is usually transmitted by direct skin-to-skin contact or contact with shared items or surfaces that have come into contact with someone else's infection (e.g., towels, used bandages).*

* Source: Centres for Disease Control and Prevention

Tips for preventing the spread of germs

Germs can be spread directly by physical contact, such as shaking hands, or indirectly, when someone touches an item someone else may have touched such as equipment, telephone or other objects. This is called contact transmission. Contact precautions help stop the spread of germs carried by contact transmission.

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