PACCARB Day 1 Presentation: Antibiotic Resistance in the Healthcare Environment

PACCARB Day 1 Presentation: Antibiotic Resistance in the Healthcare Environment


We are now going to call on — we started
new feature this meeting, we’re going to have some individuals who have been personally
affected by antibiotic resistance speak. And our first patient to discuss her situation
is Sherry Dornberger, a member of PACCARB, one of our voting members.
She will tell us about her life-changing battle with infection from her transition from being
a nurse to patient with antibiotic resistance organisms.>>Thank you very much.
I was I guess — you could say top of my game. I was in my younger 40s throughout I had the
bull by the horn. I was director of nurses at 286 bed long term
care facility and president of national director of nurses association when I got abdominal
pain. Like anyone else any good nurse we’re the
last ones to get to see a doctor. As I’m sitting on the committee with 24 of
them. But we’re the last ones to go.
I went. To see the doctor and of course you don’t
want surgery so they give you a few medications. Well, I went in with a full blown bowel obstruction.
They did the surgery, I have fine though I was marked for a colostomy I — they didn’t
think I needed one. Well low and behold five hours after the surgery,
the physician that did my surgery, he sewed my intestine back together for the colostomy
using a staple gun and not hand stitching it.
The staples lasted five hours and I became septic as they opened up.
I had a fever of 105 I was in ICU for four day when all of my intestines kidneys, everything
start shutting down. I was transferred from that hospital to a
higher acuity care hospital because I needed dialysis at the time because also my kidneys
shut down. So they put dialysis in my leg, I had 18 bags
so I’m told of fluid around me. Within a coma for 18 days. Waking up from
the coma, I thought I had been asleep over night like one night.
I didn’t know I was out for 18 days, I was wondering why people were applauding and all
this stuff. My family was in my room giving each other
high fives and I thought what are you guys doing?
Both of my feet were totally black. And I thought oh my goodness, where did I
wake up at? I have black feet what did they do to me overnight?
I didn’t know that because of the pressers I have given I lost circulation to both my
feet. So I lost pretty much half of both feet.
At the time they waited because I was black, I was necrotic at the ankles to ankles.
So they waited to — for my feet to demarcate a little bit instead of amputating at the
ankle because I thought I was going to be a nurse and chase people around at the time.
You never think you’re as sick as you are. And I said no, wait, you can’t take my feet
all. You have to wait a little bit, let’s see what
happens. Meantime I had about seven months in the ICU
to bait because I had a 14 — my abdomen because of the tissue necrosed, I had surgery five
days in a role, they ended up just putting — TEGADERM on my stomach and taking me back
to surgery because I was in coma anyway so I work up with a 14-inch hole in my abdomen,
black feet, necrosis on my tongue, scratchY throat from having a tube down my throat for
so long. I had no to my head because my nurse put a
cushion behind my head but forgot the tell people it was there so it had to be surgery
removeded from my head with cushions to stretch the skin over it.
Watching people in my room, we’re talking antibiotics.
Antibiotics phased me but what almost killed me is the nurse not washing her hands.
I washed a nurse come into my room, I had a — she had overlay nails on her fingers
and I’m thinking gosh, we allow didn’t allow it many years in my facility, here she is
with fake nails. the other thing I want to impress upon this
committee, even if they wash their hands, I believe that we push gloves way too much.
And people get a sense of security with the pair of gloves on because they think they
can go from thing to thing to thing. And not do any hands washing when they’re
really like typhoid Mary taking all the germ around with them from one room to the other.
From one patient to another. So she took care of me.
This nurse. I ended up getting MRSA and C DIF.
She gave me a yeast infection she had from not cleaning her nails really well.
She had a vaginal yeast infection. She gave it to me in my eyes and in lungs
because I was so debilitated I couldn’t fight it off.
So then I had to be treated with all of those antibiotics and yeast killers and everything
to get rid of that. So then that’s when I became resistant with
MRSA and CDIF at that time. I had three COLOSTOMIES.
The nurses will tell you the thing they never want is a COLOSTOMY.
I had three, a ileostomy, a rectal stump and colostomy.
I now have four feet of intestines they had to take out the rest.
Every three days I get IVs, all my minerals through the ports, because I don’t absorb
any of that. Out of $64 million med — I had a $64 million
medical bill. I missed a year of my daughter’s life.
This is when I get upset because I talk about that.
The thing that I want to impress upon you with sweet talk of antibiotics and we talk
about making other drugs but what we have to do is get people to take care of what they
have now. Nurses chose my life.
Nurses decided not to turn me. I searched pressure ulcers that nurse decided
not to wash her hands to take that short cut. She almost kept me from seeing my daughter
who is now a doctor. So while we’re spending all this money I think
we also have to talk about what we’re doing to make sure people wash their hands.
And make sure they just don’t stick on one pair of gloves in the morning and think it
will do them all day lounge because it doesn’t. The thing I miss most in the hospital was
the sound of birds, sound of music and being in eyelation for seven months, having somebody
touch you without having gloves on. You missed the human contact of things.
So when you think about everything we’re going to do here think about the white coats we
take from room to room, the stethoscopes that don’t get cleaned the hands that don’t get
washed and the gloves that gets used to have been.
Thank you for listening to my story. [Applause]>>Thank you so much for sharing your very
difficult story. Think speaking for all of us we appreciate
that you tell us about h because it really explains why we’re here today.
Dr. Bell, I have you on your program to give insight into antibiotic resistance and healthcare
environment.>>Yes.
Thank you. I sort of apologize for heading back the Powerpoint
universe here. I have been asked to talk about is the healthcare
environment. We have been — we will be talking about environment
tomorrow and I think what some of what sherry described is the kinds of issues in healthcare
environment that I want to make a few points about.
Just to open the conversation which perhaps the committee reason interested in hearing
more about and Dr. CARTA was there to help me because this is an area I don’t know a
lot about. I want to talk about the healthcare environment
in terms of the dry environment and the wet environment.
The dry environment are non-critical surfaces like bed rails, bedside tables.
And these areas can be transiently contaminated by patient and by healthcare workers and we
know that this sort of contamination does contribute to transmitting pathogens an healthcare
settings. The wet environment are things like sink trains
and this is an area where it’s clear that contaminated fluids from colonized patients
pass through plumbing and there’s biofilm formation and drainage system which can serve
as a reservoir for antibiotic resistance organism and genetic elements like plasmids though
as I say this is — as I will say in a couple of moments this is an area that we still don’t
know a lot about. You think about transmission and pathogens
and healthcare settings, we start with a colonize patient.
You notice that there are a number of ways that transmission can occur from healthcare
workers again, the issue of gloves, it’s as sherry mentioned, there’s an interaction between
the healthcare workers and the environment bed rail, et cetera, as I was talking about.
Then there’s also of course the possibility of direct patient to patient transmission
as well as transmission from a colonized patient to the environment and then directly from
the environment so this is multi-factorial multi-sectoral process that needs to be addressed
at a number of different points. A little bit more for context, put this in some sort
of general sense of perspective. In the 1970s and ’80s, we are all focusing
on transmission of healthcare associated infections related to medical procedure and device utilization
especially in high acuity ICU care. This was clearly the area driving a large
proportion of healthcare associated infection. At that time given the burden with procedure
and devices, environmental surface contributed really less to the overall burden of healthcare
associated infections but with aggressive improvement and procedure and device related
care we have been able to achieve over the last several decades, non-critical surfaces
are now a larger part of the remaining burden of infection transmission that we feel like
this is the time that this really needs to be addressed in digs to continuing to improve
care. From some of the areas that we believe are
important for focus include optimizing terminal cleaning of patient rooms, understanding environmental
surfaces source for pathogens to something active going on there on the bed rails, identifying
opportunities for design improvements to reduce infection transmission from the environment.
We are looking at some of these issues from a research perspective, and doing that in
three different ways. First of all, some modeling, we find using
modeling can be quite useful in terms of understanding the role of non-critical surfaces and different
facilities. Measuring cleanliness.
It’s obviously — it’s not so clear what is clear enough, we can’t have sterile surfaces
everywhere. So evaluating methods for measuring the contamination
of non-critical surfaces and determining cleanliness thresholds associated with improved patient
outcomes. Just mention obviously something worth reiterating,
intermediate end points are really some utility but limited utility.
And improving cleanliness, understanding the current state of cleaning and disinfecting
of non-critical surfaces and evaluating methods to reduce contamination in order toll improve
out– in order to improve outcomes. We have as I’m sure many on this committee
know guidelines for infection and sterilization in healthcare facilities and environmental
infection control and we have been doing segmental updates of these guidelines with input from
our federal advisory committee, the healthcare infection control practices advisory committee,
HICP aC. This is transparent process that evaluates
peer reviewed evidence, solicits public review and feedback and follows rigorous conflict
of interest assessments we in this process are reviewing emerging technologies including
this — UV devices and surface treatments and assessing benefit and harm and our targeting
of final update on this segmental part of our guidelines for early 2018.
Again, say that there really is a changing landscape here in terms of environmental infection
control, which some of which I think is really driven by new technologies.
We see how infections are transmitted through soil surfaces.
There are these emerging technologies, no touch cleaning and disinfection and enhanced
wipe and mops an cloths and enhanced surfaces and codings and treatments that might be not
ads good a surface for bacteria. There’s also emerging technologies for monitoring
cleaning and disinfection and lots of opportunities for improvement in facility design and lay
out so this is a good time to be taking another look at this issue.
Just a word about wetted environment and then I will stop there.
There have been several outbreak investigations recently and not so recently that have detected
an organism or a plasmid of interest on — from sink drains in patient rooms.
So biofilms in plumbing serve as reservoir for gram negative infection, for example CRE.
It’s very difficult to prove causality if we finds in the drain that is not to say that
that’s actually the cause of the infection. So there are a lot of unanswered questions
how do these pathogens persist in drains and other wet environment and potential for genetic
exchange and what’s the role of dissemination of these pathogens to patients.
Considering a number of potential mechanisms, and then options for minimizing the risk.
And so I’m going to stop here which is good because I’m choking.
I’m happy for myself or Dr. CARTO to answer any questions.>>Thank you very much.
We have time for a couple of questions. Dr. Marty.>>Thank you so much for those presentations
both of which were excellent. I want to address the hospital acquired infections
a little bit. And one thing you didn’t talk about was texture
of surfaces such as shark skin that repel the growth of bacteria and certain metal surfaces
such ads copper surface, would you include those in various things you would like the
add to the discussion?>>I think so.
I certainly know about copper surface being something we have been interested in looking
at. I don’t know about the shark skin.
Do you know?>>So the way we work as Dr. Bell said is
for us to recommend something we have to have evidence.
So at the same time we look at what is being done in terms of evidence, we’re — (inaudible)
the impact of some of those — so I also want to clarify there are new products that promise
a lot. So we also have vendor’s day, day that all
the manufacturers come and tell us what they’re doing.
It doesn’t mean — it is good alternative for us to be aware of everything.
So so we are aware of all the different options, the groups we fund are passing some of the
options based on their decision, but I think it’s like I said we need the look at a multi-approach.
For this problem.>>I didn’t want to emphasize any product
but rather — doing things beyond the simple — the obvious solutions we looked at in the
past.>>Thank you so much.>>One thing — the last slide is also looking
at the — not just the surface or everything but also the toilet, sinker, where they’re
located how they work. So beyond what we’re finding we may need to
change the way ICUs are built. So we have much more complex.>>Time for one more question.>>Thanks for that.
So any of these technologies I’m guessing the answer is no.
Substantially good and ready for prime time in a way that exciting or I’m guessing none
of them are, which can go in as a robot and clear the whole place.
I’m guessing by lack Ohio nothing is there yet, that’s the first part, the second question
is infection control practices within hospitals, is there guidance for them apart from having
to evaluate the evidence themselves but guidance from CDC on saying not manufacturer but just
to say that these things should really be part of your infection control program and
therefore was paid for because if they don’t get that language, — so I think not so much
that we don’t have a lot of enthusiasm, it’s that there’s a lot out there right now, a
lot of claims but as Denise said we feel like all in this different gadgets and things that
need to be evaluated before they can sound good, they can look good based on what a company
says and that just is not enough so we are actually funding a few of our network partners
to really rigorously evaluate some of these so that we can provide the kinds you’re talking
about. This also is part of our plan to update our
guidelines. I said would be ready in early 2018.
That’s sort of the point. As you say everybody is like being bombarded
with all these — we have the robots and we have the gas and we have the copper this and
there really is, it’s very, very important for these to be evaluated rigorously and we
do feel like that’s our responsibility and that’s what we’re shooting for is what it
boils down to.>>Sara, time for one short question.>>As hospital epidemiologist I have to say
we must maintain focus on infection controlled practice with hand hygiene at the very top
of the list. So where I think the new technologies are
intriguing and interesting, never be viewed as a substitute for —
>>Absolutely. That’s one thing we’re concerned about are
unintended consequences that people feel I have this new machine so I don’t have to wash
my hands. So I think that’s part of what’s so tricky
and why we’re trying to approach it in a deliberative way as we have been saying.
>>Thank you very much. We have come full circle.
Thanks to sherry Dornberger for sharing her story, we come back to hand washing, which
is appropriate and this is also a segue into our discussion tomorrow about the environment
in general.

Author:

Leave a Reply

Your email address will not be published. Required fields are marked *