As if the new “Delta” variant of the COVID virus (and there are others on the horizon) is not concerning enough, health officials in two separate areas of the country are reporting concerns about the emergence of a "superbug" that poses threats to the elderly and here at home, Rhode Island Department of Health (RIDOH) officials have cited an increase in another infection first found in Philadelphia some 45 years ago that may also have its origin in the pandemic.
First, let's talk about the superbug. The CDC cites the top five "superbug" infections that are resistant to antibiotics that they consider to be urgent threats to public health. They are;
Acinetobacter (bacteria) - Carbapenem-resistant Acinetobacter causes pneumonia and wound, bloodstream, and urinary tract infections. Nearly all these infections happen in patients who recently received care in a healthcare facility.
Candida auris (fungus) - C. auris is an emerging multidrug-resistant yeast. It can cause severe infections and spreads easily between hospitalized patients and nursing home residents.
Clostridioides difficile (bacteria) - C. difficile or C-diff causes life-threatening diarrhea and colitis (inflammation of the colon), mostly in people who have had both recent medical care and antibiotics.
Enterobacterales (bacteria) - CRE is a major concern for patients in healthcare facilities. Some Enterobacterales are resistant to nearly all antibiotics, leaving more toxic or less effective treatment options.
Neisseria gonorrhoeae (bacteria) - N. gonorrhoeae causes the sexually transmitted disease gonorrhea that can result in life-threatening ectopic pregnancy and infertility and can increase the risk of getting and giving HIV.
This blog is going to focus on Candida auris, as it is the "superbug" infection making the news in the wake of the initial COVID-19 pandemic.
The Candida auris fungus
The Candida Auris fungus, a "superbug" that has spread among patients in hospitals and long-term care facilities in Texas and Washington, D.C. according to the CDC. This fungus preys on those with weakened immune systems and evidence now suggests that the spread is the result of person-to-person transmission, which is a first according to health authorities.
This fungus was first seen in the United States in 2013 and is resistant to treatment. Candida Auris is "resistant to multiple antifungal drugs that we have, and it's also resistant to all the things that we use to eradicate bacteria and fungal strains in the hospital," Dr. Neeta Ogden, an internal medicine specialist, told a CBS News reporter.
In Texas, there were 22 cases identified from January to April 2021 with two of the cases being resistant to all three major classes of antifungal medications with five resistant to two of them. All seven cases were patients in care, five in hospital settings, and two in long and short-term care facilities. And like COVID, it tends to kill those with pre-existing conditions.
Meanwhile, in Washington, D.C. during the same time period, there were 101 cases of fungal infections with three isolated as being resistant to all three major classes of antifungal medications. Those cases occurred at a long-term care facility for severely ill patients.
Candida auris infections are not new to the institutional care world, as these bugs have been reported in facilities worldwide. Those at the highest risk for infection are those who have been hospitalized for a lengthy period of time and have breathing tubes, feeding tubes, and venous catheters. This fungus causes wound and bloodstream infections that can prove fatal.
Those familiar with these infections state that hospitals, long-term care facilities, and local governmental health agencies are reluctant to release information on this out of fear of being viewed as infection hot spots. In fact, Candida auris is so invasive that special equipment is often needed to eradicate it, including removing the ceiling and floor tiles.
According to a recent public health report cited by the news site Vox, most states refuse to report such outbreaks due to fears as to how the public will perceive this. Even the CDC, under its agreement with states, is not allowed to make public the location or name of hospitals involved in such outbreaks. State governments have in many cases declined to publicly share information beyond acknowledging that they have had cases.
Vox also reports that each state is responsible for reporting these outbreaks and because they are concerned about being seen in a negative light, they tend not to share these numbers with the CDC. As a result, there is no public tracking system with real-time information as to who is experiencing these outbreaks. As the result, patients and family members have no idea what they may be exposed to at a hospital.
Unfortunately, public health officials support this process, stating that such a reporting system would be counter-productive if people with serious illnesses are too frightened to go to the hospital and stay home until the illness becomes critical. In such cases, patients who may have been saved earlier could die, And, concerns that some hospitals could be blamed for an outbreak that is not their fault. “Patients move between facilities while receiving care,” a CDC spokesperson told Vox, “and may have picked up a superbug from another facility or the community.” So one hospital might gain a bad reputation for another hospital’s unnoticed or unreported superbug.
Why Superbugs Have Developed
The five superbugs we listed above are but a handful of a number of them that are found to exist annually. According to the CDC, superbugs infect more than 2 million people nationally every year and of them, at least 23,000 will die. The problem lies, according to some researchers, with the overuse of antibiotics.
Records show that antibiotics are the most prescribed medications for the public. In addition to their use by humans, they are given to livestock to prevent disease and to promote growth. Many do not understand that antibiotics are effective only against bacterial infections and have no effect against viral infections. This information, however, has not stopped the over-prescribing of these drugs for use by both humans and animals. But just how does this result in the development of superbugs (see illustration below)?
According to biologists, when antibiotics are used as indicated, they can destroy the targeted bacteria, but when used for a viral illness, they destroy the "good" bacteria in the body that help fight infections, digest food, and stay healthy. Once that happens, the hearty "bad" bacteria that may be present survive and rapidly multiply. These bad bacteria develop a resistance to antibiotics which can result in their ability to spread to others. Eventually, these bacteria thrive making once effective medications less or even ineffective.
Here in Rhode Island, no cases of a "superbug" have been publically reported, but state health officials expressed concerns early last week about the increase in the diagnosis of Legionnaire's disease in the state. According to the Rhode Island Department of Health, during the years of 2014 to 2020, an average of 10 cases was reported during June and July however so far this year, 30 cases have been reported, with 29 of those reported in the last week alone. Of this group, 28 needed hospitalization. There has been no known common source of infection to date.
Legionnaire's disease was first discovered in 1976 following an American Legion convention in Philadelphia, attended by some 4000 members, at the historic Bellevue-Stratford hotel. After the convention ended and attendees returned home, they began to fall ill with 12 legionnaire's dying and nearly 40 being hospitalized with a mysterious respiratory infection that included fevers as high as 107 degrees, headaches, severe coughs, and chest pains. The illness wasn't confined just to the attendees of the convention as a bank teller and a bus driver also became ill.
Labs worked around the clock to find the cause of the disease and finally isolated it in the Bellvue-Stratford's water and cooling system, and later, in showers, fountains, and hot tubs. This bacterium thrives in warm, stagnant waters where rust and limescale act as nutrients. Victims contract the illness by breathing in contaminated aerosolized droplets, such as is emitted by steam and hot water released from cooling and heating systems. The disease most often affects the elderly, those with weakened immune systems, and those with co-morbid lung disease. While most people who contract the disease will need to be admitted to the hospital, they typically make a full recovery, especially if the disease is caught early.
How COVID is Implicated
So how exactly has COVID been implicated in the rise of the "superbugs" and Legionnaire's disease? It appears that it's not directly due to the virus, but in how hospitals and the country, in general, have responded to the pandemic. The CDC targeted cases at a Florida hospital and investigated how some patients admitted for COVID treatment became infected with Candida auris.
Before the pandemic, this hospital always conducted Candida auris screenings on patients upon admission and if found to be positive, were placed in a special unit. Even with this precaution, the Candida auris outbreak began in July of 2020 when four patients were infected, three through the bloodstream and one from a urinary tract infection. In August, things got much worse with 35 more infected with Candida auris with eight of these patients dying. However, it is not clear if the fungus was the primary cause of death.
The hospital and the CDC performed a joint investigation to see if infection controls played a part in the outbreak. This investigation focused on personnel, storage of supplies, and disinfection standards. Several weaknesses were found:
The investigation discovered numerous weaknesses that occurred because of the high number of admissions during the height of the COVID pandemic including:
Mobile computers and medical equipment were not always disinfected between uses.
Medical supplies were stored in open bins in hallways and not in cleaned and controlled storage rooms.
Health care personnel were observed missing opportunities to perform hand hygiene due to the number of patients coming for care.
Health care staff wearing multiple layers of PPE were found to heighten the risk of microbe transmission, where heat and moisture allowed the bacteria to grow.
Staff practice of reusing PPE also was found to increase microbe transmission.
The study found when the hospital removed supplies from hallways, enhanced cleaning and disinfection practices, and ceased base layer and reuse PPE practices, no further Candida auris transmission was detected on subsequent surveys.
In Rhode Island, the lockdown and closure of businesses may have contributed to the emergence of Legionnaires disease. RIDOH Director Dr. Nicole Alexander-Scott told WPRI News, “We know that Legionella bacteria grow best in complex water systems that are not well maintained. When this water becomes aerosolized in small droplets, such as in a cooling tower, shower, or decorative fountain, people can accidentally breathe in the contaminated water. This is of particular concern now as some buildings’ water systems have been offline for a prolonged period due to the COVID-19 pandemic and are just now returning to service.”
Those who are involved in infection control point out that the answer is not creating new drugs as the process is lengthy and burdensome and new superbugs may render them useless anyway, but in keeping them away by using disinfection aggressive strategies.
Next Week: COVID Variants Will Continue To Plague Us