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It is resistant to almost all antibiotics, and some of its strains are resistant to all of them. Klebsiella pneumoniae New Delhi is in the vast majority of hospitals in Warsaw and is now spreading throughout Poland. Almost a year ago, in an interview with Medonet, Dr. Tomasz Ozorowski, microbiologist and president of the Association of Hospital Epidemiology, warned that this would be the case and said what to do to prevent an epidemic. Unfortunately, we just have it.
Agnieszka Sztyler-Turovsky, Medonet: “Poland is threatened by an epidemic. The bacteria resistant to almost all antibiotics were found in several hundred patients ”- you said a year ago. How many are infected today and is it true that we have an epidemic?
Dr. Tomasz Ozorowski, microbiologist, president of the Association of Hospital Epidemiology:
Yes. The situation in hospitals in Mazovia certainly meets the criteria of an epidemic. They are defined in the act on infectious diseases. According to the data of KORLD (National Reference Center for Antimicrobial Susceptibility), by November 2016, the presence of bacteria was confirmed in 2300 patients. As far as I know, their number is still growing rapidly. Mostly among people hospitalized in Warsaw hospitals.
Hospitalized in public or private hospitals too? And what about those near Warsaw – at the Children’s Health Center, the European Health Center in Otwock or in the cardiac surgery hospital in Anin, we also already have Klebsiella pneumoniae New Delhi?
There is no official list of hospitals in which New Delhi was found, but it is known that the problem affects the vast majority of Warsaw and many hospitals in Mazovia.
Should we be afraid of visiting clinics too?
No, don’t be scared as long as the staff adheres to basic hygiene rules and disinfects their hands. Unfortunately, the New Delhi bacterium was also detected in people who had not been hospitalized before. It is difficult for me to assess the way these people became infected with this bacterium. Perhaps it happened through home contact with a person who had previously been treated in hospital.
Who is the main culprit? Who are we to “thank” for the epidemic?
This situation is the result of many negligence, incl. non-compliance in hospitals with the most important methods of interrupting the transmission of microorganisms, such as basic methods such as hand hygiene. Also underestimating the problem of the growth of bacterial resistance by the entire health service for years. And the effect of legal acts that, in terms of infection prevention, induce hospitals to act ineffective or even fictitious. It is also the lack of specialists in the field of hospital epidemiology, or their too weak position in the hospital structures. In addition, there is also the unpreparedness of the hospital infrastructure – it is simply about the lack of isolation rooms. The recommendations of the National Antibiotic Protection Program (available at www.antybiotki.edu.pl) were not followed
How is it infected? Is a handshake dangerous?
Infection spreads in two stages: the first is the transmission of the microorganism between patients, most often through the hands of hospital staff, which are not cleaned or disinfected. Usually, this only results in the so-called carrier, i.e. the bacterium remains in the digestive tract without causing infection.
The second stage is the formation of an invasive infection, when the patient has a gate through which the infection can penetrate into sterile areas of our body. It may be tissue damage after surgery, or a catheter inserted into the bladder or a central vascular line (e.g. the so-called port through which, for example, oncological patients are administered “chemistry” – ed.)
Hospitals will defend themselves by saying that they were unaware that the threat was so serious. Will they be right?
Last year, the problem of New Delhi appeared not only in the media, it was the subject of numerous communications and recommendations, and training and inspections were carried out in hospitals. And information on the scale of the threat was presented at the June meeting of the parliamentary team for public health. Relevant information and suggestions regarding the procedure to be addressed to the Ministry of Health.
And the Ministry of Health did something about these suggestions?
Unfortunately, these actions had no effect.
The problem in Poland began with Poznań, but they dealt with it there. Warsaw did not manage. Why?
All remedial actions were successfully implemented in Poznań, and hospital staff complied with the available guidelines. In Warsaw, despite warnings about infection and the high probability of rapid spread of bacteria, similar measures have not been effectively implemented.
What are these activities?
Screening tests to identify carriers, isolation of patients, strict adherence to basic procedures to prevent transmission of the microorganism, incl. hand hygiene, decontamination of handheld items …
How does it look in practice? For example, what is “hand hygiene” or is it simply washing your hands with soap and water? Are there also guidelines – what kind of soap, how many times do you need to soap your hands and what should the water temperature be?
The point is that medical personnel must rub an alcoholic disinfectant into their hands before and after contact with the patient and the patient’s immediate environment. This is an absolute priority! And screening is taking a swab from the anus, thanks to which we can detect an asymptomatic carrier and isolate it.
And this “decontamination of handheld items” …? Is it just about disinfecting a stethoscope or smartphone, etc.?
Yes. Many studies confirm that the sleeves of gowns and other medical workers are the habitat of dangerous microbes. Handheld equipment such as cell phones, pens, and stethoscopes are also contaminated.
In many countries, regulations are introduced regarding the safe for patients, the clothing policy of hospital staff, the so-called the principle of “nothing below the elbows” (short sleeves, no jewelery, short nails without tips) and limiting the carrying of items in pockets and subjecting them to regular disinfection.
What can hospitals that already have the bacteria do?
They should implement corrective procedures as soon as possible that will allow for the effective implementation of nosocomial infection control programs. The first concrete information on how to do this was developed last year by several associations professionally involved in hospital epidemiology.
It is known that the superbug “set out” in Poland. What about the facilities it has not yet reached? Anyway, can any hospital be sure that she does not exist?
Teams similar to those in Poznań should be established in each voivodship to assess the state of preparation of their hospitals for the rapid diagnosis of New Delhi and disrupting its transmission routes.
You said that for this to work, it is necessary to isolate infected patients from others. Only that Polish hospitals lack free beds, not to mention the rooms …
Yes, and therefore the situation is very dangerous. In addition, even if an infectious diseases hospital had enough isolation cells, the transfer of these patients is unrealistic. Usually they were infected e.g. in cardiology and nephrology departments and require specialist treatment. The Infectious Disease Hospital won’t get them. It is such a difficult situation that hospitals in Warsaw should create special units for patients with NDM.
Would infected patients lie in a common room?
Yes. This is called cohortation – placing several patients with the same infection in one room. Hospitals in which New Delhi cases have been detected must organize such isolation facilities on their premises. All you need is a room with its own bathroom, separated from the rest of the ward.
Co can those who go to hospital for elective surgery do to minimize the risk of infection?
First of all, they should demand that the staff adhere to the basic principles of our safety, which is the aforementioned hand hygiene.
What about those who came out of the hospital with the superbug?
Fortunately, most of these people will remain only carriers. However, when a symptomatic infection develops, such as cystitis or pneumonia, they can only count on their immune system to defeat the superbug on its own.
Can they somehow strengthen immunity to help in this fight?
No, there are no documented and effective methods of immune support to prevent infection of New Delhi.
So they will be ill for the rest of their lives ?! When do we find an antibiotic on New Dehli?
We do not know if an effective antibiotic will ever be invented. And if it does, it will take us at least several to several dozen years.
Should all those who were hospitalized in Warsaw hospitals in the last year have a New Delhi carrier test?
Not. However, screening tests should be performed on patients who are currently admitted to hospital and who report in the interview that they have been treated in hospitals in Warsaw in the last two years.
If someone is infected with a superbug in a hospital, but doesn’t know it, it infects the family after leaving the hospital?
No, the bacterium is dangerous for patients with the aforementioned gates of infection, for healthy household members, including children, it should not pose a threat.
And if a child cuts himself or his milk tooth falls out and his gums bleed, is there a risk of infection?
If the parents or guardians follow the basic rules of hygiene, i.e. wash their hands before applying the dressing, they will not infect the child. This also applies to all infected who have been discharged from the hospital. If they follow the rules of hygiene, they don’t have to worry. Infection is also not transmitted by droplets.
And if someone in the household is bedridden, a nurse visits him and, for example, gives injections?
If the nurse leaves the hospital and goes directly to the sick person, and does not wash their hands and disinfect the items beforehand, they may infect the sick person.
We all pass people in public restrooms who don’t wash their hands. They probably didn’t get it out of the house. The sight of a doctor or nurse in a similar situation is even more surprising. They don’t teach basic hygiene rules in medical schools?
In all medical schools, students are taught proper hand hygiene, but we do not cultivate this habit in hospitals. Bacteria are not visible and staff are often unaware of the risks themselves.
Is Poland somehow impaired when it comes to hygiene? Although this may already be a question for a sociologist?
Rather for a psychologist, but taking into account the fact that Poland is one of the last in the ranking of health services among European Union countries, the use of the word “handicapped” may be justified.
How did the superbug get to us?
The first Polish case of New Delhi infection was recorded at the end of 2012 in a patient who, after returning from Tanzania, was sent to one of the hospitals in Poznań. However, almost all other infections, and this concerns well over three thousand patients, are cases of transmission of the microorganism from patient to patient already in Polish hospitals.
How are other countries doing? Also as bad as Poland?
In the countries of the European Union and the USA, the appearance of this group of microorganisms is given an absolute priority in the implementation of methods to prevent transmission. In Great Britain, where such microorganisms are found much more often, the patient is immediately isolated at the stage of suspicion of the presence of New Delhi. Although the problem of New Delhi bacteria concerns several European countries, as well as the USA, none of them has found such an extremely fast transmission of one strain as in Poland!
Someone is even worse than us?
It is worse in India and Pakistan, perhaps in some African countries. There, the superbug has spread from hospitals to almost 30 percent of the population. This scenario may also apply to Poland in the future.
Dr. Tomasz Ozorowski is a microbiologist, expert of the National Antibiotic Protection Program, chairman of the Section for the Control of Hospital Infections at the Clinical Hospital of the Transfiguration of the Medical University in Poznań and president of the Association of Hospital Epidemiology.
*Klebsiella pneumoniae New Delhi
Pneumonia rod. The bacterium causes not only pneumonia, but also urinary tract, bone and joint infections. Inflammation of the meninges is also present in young children. In extreme cases, infection with the bacterium may lead to sepsis.
Klebsiella pneumoniae type NDM was first detected in a patient with urinary tract infection in 2008 in New Delhi (NDM stands for New Delhi metallo-β-lactamase). NDM is a gene that codes for a certain enzyme. It is this compound that gives bacteria resistance to antibiotics. Worse, the gene encoding the enzyme resides on a plasmid – a spherical molecule with genetic material that bacteria can exchange with each other.
Bacteria bearing this gene were then found in other regions of India, in Bangladesh and Pakistan. In 2010, infection with superbugs was diagnosed almost all over Europe, North America and Asia. In the same year, the first fatal case that could be unequivocally linked to NDM was recorded in Belgium.
In 2015, there were 16 outbreaks of superbugs in Poland.
The number of infected people is growing rapidly on a scale that has not yet been seen in Europe. It is estimated that currently around 1100 people are infected in our country, and the bacteria is extremely easily transmitted from person to person.
You can also read about Klebsielli pneumoniae New Delhi in Poland in the first issue of this year’s “Health Manager”, in an article by Tomasz Ozorowski and Szczepan Cofta.