You are not safe from bugs in hospitals. That’s the first thing you have to get into your head. And there is one superbug that is currently picked up principally in hospitals – that’s CPE, or Carbapenemase Producing Enterobaceriaceae.

Right now there are ongoing outbreaks of CPE in 11 hospitals, including eight of the major hospitals in the country.

In 2018 there were 536 new people with CPE identified in Ireland – up from 433 in 2017 and almost double the 282 in 2016.

CPE does not cause illness in most who catch it, but when people are at their most vulnerable because of other illness it can cause very serious infection that is difficult to treat.

If you’ve shared a ward or toilet with someone in a hospital who has been diagnosed with CPE you may have received a letter already telling you of the risks around that and giving you information about this superbug.

It won’t cause illness when it is in the gut, but if it gets into the bloodstream it’s another story however.

Professor Martin Cormican, the HSE lead for Antimicrobial Infection Control, who doesn’t mince his words when it comes to CPE, wants every person in Ireland to know that this bug can be picked up in hospitals.

CPE is out of control in some parts of the world and we don’t want that to happen here

It’s the goal of the HSE for 2019, he says, to let everyone know what’s happening and what has to be done by us all if a stop is to be put to CPE’s gallop.

And a serious stop is needed.

This superbug was declared a public health emergency in October 2017.

It is his experience as a bacteriologist that action has to be taken quickly before such a superbug gets out into the wider community, as it would be impossible to stop it then.

“CPE is out of control in some parts of the world and we don’t want that to happen here.”

CPE should not be confused with C.Diff (Clostridium difficile).

Those with CPE do not experience vomiting and diarrhea. If CPE gets into a person’s bladder or kidney it can cause urinary tract infection. In the lung it can cause pneumonia and if it gets into the bloodstream it can cause septicaemia, low blood pressure and shock.

Patients who get it from a hospital stay shouldn’t be made to feel guilty they have it

As CPE is found almost entirely in healthcare environments, especially in major general hospitals in Ireland, at present if someone has CPE and they have not travelled outside Ireland they most likely got it from the healthcare system.

“Therefore, they deserve to be looked after by the healthcare system,” Professor Cormican says.

“Patients who get it from a hospital stay shouldn’t be made to feel guilty they have it. People often say: ‘I felt like a leper, I wasn’t allowed to sit near anyone’.

"The key thing is respect for the person who is carrying CPE. Patients can’t be made to feel it’s their fault or that they are being punished in some way.” So why is it so difficult to treat CPE?

Car with bull bars

The professor has a car analogy to explain it. CPE is an E coli (think ordinary car) and E.coli doesn’t do any harm in the gut.

“We all have it in our gut and we’re supposed to have it, but E coli can become a CPE (think car with bull bars) when it mutates and acquires an antibiotic resistant gene. These genes are able to deflect the strongest antibiotics being used in the world today.”

While there are a few antibiotics that can treat it, they are not as satisfactory and therefore treatment is slow.

Bottom line

How is CPE spread and what can we do to stop that happening? Professor Cormican gets down to basics, with the word ‘poo’ featuring strongly.

“The bottom line is that if someone’s hands are not washed correctly (and they have CPE in their gut and faeces) and you (with no CPE) then touch something that those hands have touched but forget to wash your own hands before eating, then there is a good chance you will be ingesting micro particles of someone else’s poo – simple as that,” he says.

So how can we be ‘hygiene savvy’ if we are in hospital:

  • Don’t sit on other patients’ beds or touch areas like bed rails and lockers.
  • Don’t share things like newspapers or phones.
  • Wash your hands very, very thoroughly each time you go to the toilet.
  • Alcohol hand gel is also widely available in hospitals for use by patients, visitors and staff.
  • Art of handwashing

    “There is a specific technique to washing hands (see WHO handwashing video link). It involves hot water, a good lather of soap and time to do it properly.

    "Use bar soap and dry your hands on clean towels. Most people don’t clean their fingertips at all.

    "At talks, after showing a HSE video on handwashing I’ve had farmers and vets saying ‘no one showed me how to do that properly before’.”

    You don’t need antibacterial soaps either, he says.

    “One of the problems with such soap is that the chemical in them – triclosan – promotes antibiotic resistance.”

    Antibiotics only when necessary

    This brings us to his other key message – don’t overuse antibiotics.

    “Each year 200,000t of antibiotics are used in the world between human and animal health. We have antibiotic-resistant bugs in the world now simply because we have over-used antibiotics. In Ireland we use a lot of antibiotics in human healthcare in comparison with other countries in Europe.

    The worry is around the fact that there aren’t many new antibiotics becoming available

    "CPE is, unfortunately, able to destroy meropenem – which has been the fall back antibiotic in this country for the last 10 years when Ampicillin or cefotaxime won’t work.”

    Professor Cormican says that there are antibiotics left to treat CPE, but there aren’t many and they can be difficult to use.

    “It’s just not as good as the treatment we used to have. The worry is around the fact that there aren’t many new antibiotics becoming available. The fear is that we will have a variant of CPE in the future that antibiotics won’t kill.”

    He traces the development of the bug.

    “First E coli became resistant to amoxicillin. Then we started using cephalosporins and they became resistant to these. That ‘superbug’ was called ESBL (Extended Spectrum Beta-lactamase Producing Enterobaterales). Then we started using meropenem to treat that and we have now ended up with CPE – a bug resistant to all three antibiotics.”

    The future

    Professor Cormican doesn’t want CPE to spread like he has seen the superbug ESBL do.

    “Twenty years ago when I came back here from the US, ESBL was more or less where CPE is now (only in hospitals), but now it’s everywhere – in animals, rivers, in people who have never been near the hospital.

    "Everything tells us that if we don’t control CPE in the next few years we’re going to end up with CPE being just as widespread as ESBL is now. That’s why it is so important to act.”

    The solution

  • Raise everyone’s awareness of the dangers of over-using antibiotics in human and animal health.
  • GP’s message should be not just ‘you don’t need the antibiotic’, but also that ‘taking an antibiotic you don’t need can cause you harm as it disturbs the garden of micro-organisms in our bodies’.
  • He mentioned the huge amount of research being done now into gut health.

    “We know now that the way this ‘garden’ feeds into our being healthy is much more complicated than we previously understood. We now know we need to leave the good bugs alone.”

    What hospitals are doing

    Old infrastructure isn’t helping with infection control in hospitals, he says.

    “You can have eight or 10 people sharing a space and a toilet. That’s why testing for CPE when patients are admitted is so important. We must prioritise getting those people (with CPE) into single rooms as soon as possible. In the meantime, risk can be reduced by being very careful about cleaning and hand hygiene in wards.

    While hospitals are getting better at testing for CPE on admission – this has doubled in the past year – it’s not sufficient.

    “Some hospitals are not doing enough. The monthly Health Protection Surveillance Centre (HPSC) figure show that.”

    As mentioned earlier staff are being guided to treat those who have CPE with respect.

    “There is a lot of guidance for staff now around that. Patients who get CPE can live a normal life at home, but they do need to be very careful with handwashing after using the toilet and keeping the toilet clean.”

    A new leaflet explaining CPE will soon be available in hospitals. Information is available on www.hse.ie/infectioncontrol.

    Fighting back

    Bernie O’Reilly is a member of Patients for Patient Safety Ireland – a collaboration between patients, next-of-kin and the HSE.

    She featured recently in an article about open disclosure, but she is also concerned, as a patient representative on the National Public Health Emergency Team set up in October 2017 to combat CPE, about stopping the spread of this dangerous bug.

    “Simple measures do save lives and hand hygiene is something everybody can do. We need a whole new awareness about looking out for ourselves by washing our hands properly. Wash your hands for as long as it takes to sing Happy Birthday, use lots of soap. The ideal set up in public places is automatic taps and paper towels.”

    Tips

    •Wash your hands properly after using the toilet.

    •Wash your hands properly before eating.

    •Don’t overuse antibiotics.

    •Keep animal faeces out of the house – no dirty boots and wash your hands.

    To watch a video on correct handwashing, visit www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/hcai/hand-hygiene-in-irish-healthcare-settings/hand-hygiene-videos.