Ghoulishly Deadly Bacteria

Can a butterfly's flight create the momentum to alter circumstances half a world away through a succession of occurrences starting with a slight movement of air that defies detection? If someone travels from a Canadian province to visit a site in India, becomes involved in a rickshaw accident, receives treatment in a hospital and becomes infected with a microbe, then unwittingly carries it with her back to Canada, that microbe has the opportunity to settle in to a new home.

And a man admitted to the Royal Alexandra Hospital in Edmonton became a host.

The host was 74 years of age, and not in the best of health. His body soon was overwhelmed by a horrible bacterium that had flourished a world away from his own home. It invaded his body and since his own ability to fight off infection -- possible in a young and healthy body without a compromised immune system -- was not successful against a microbe that possessed the biochemical wherewithal to evade antibiotics normally used for such circumstances, he died.

"Every hospital and health region is going to have to face it one way or the other. It should be a wake-up call for all of us" said Dr. Mark Joffe, senior medical director of infection prevention and control for Alberta Health Services, of the bacterium Acinetobacter baumannii and Klebsiella pneumoniae and Escherichia coli (E.coli), a new class known as carbapenem-resistant Enterobacteriaceae (CRE), and spoken of as "nightmare bacteria".

Dr. Joffe is also president of the Association of Medical Microbiology and Infectious Disease Canada, an organization that represents physicians, clinical microbiologists and medical researchers. It was Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention who evidently coined the phrase "nightmare bacteria" in speaking of CRE: "They are resistant to all or nearly all antibiotics; they kill up to half of people who get serious infections with them; and they can spread their resistance to other common bacteria."

Their dire threat to the health and safety of populations the world over cannot be overstated. England's chief medical officer, Sally Davies, spoke of antibiotic-resistant bacteria as "a catastrophic threat", warranting urgent worldwide action. "If we don't act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can't be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection. That's why governments and organizations across the world, including the World Health Organization and G8 need to take this seriously."

Most antibiotics, inclusive of carbapenems, characterized as representing "one of the last drugs on the shelf", don't destroy CRE organisms. The bacteria, explained Michael Mulvey, chief of antimicrobial resistance and nosocomial (hospital acquired) infections at Canada's National Microbiology Laboratory in Winnipeg, are related to many common gut-dwelling microbes, but they are at the very same time "highly promiscuous", carrying their genes for drug resistance on plasmids, sharing them with other microbes.

One type of CRE contains an enzyme, Klebsiella carbapenemae, known in short as KPC which breaks down carbapenem antiobiotics, the antibiotics described as the last remaining "on the shelf" solution to combating the onset of these dread microbes -- at least until such time as improved, more powerful and bacterial-specific antibiotics can be discovered by medical scientists. The problem is, of course, that these malignant microbes are capable of evading, changing, transforming themselves into ever more deadly streams, and in the process bringing other bacteria onstream as deadly pathogens.

Another type of CRE named New Delhi metallo-beta-lactamase (NDM-1) has surfaced in the Indian subcontinent allowing bacteria to evade carbapenems. NDM-1 circulates in hospitals, and has been detected in waste water from pharmaceutical plants. And this is where the microbial plot thickens, isn't it? In Britain and the United States, CRE infections have caused thousands of deaths. According to the U.S. Centers for Disease Control and Prevention, CRE causes about 9,300 health-care-related infections yearly in the U.S., with 600 dying of the infections.

In 2010, a KPC-carrying microbe was present in an intensive care unit in a Montreal hospital, spreading to nine patients, killing four. In another outbreak in Montreal, sixteen patients picked up KPC-infected organisms resulting in pneumonia, urinary tract and wound infections. Still, it is not yet mandatory for doctors and health care facilities to report CRE outbreaks to a central source, or the federal Public Health Agency of Canada which urges the provinces and territories to set up mandatory reporting of diseases.

Some Canadian hospitals have taken to isolating patients who have been hospitalized prior to their presentation in Canadian hospitals, at one abroad, until a check for CRE can be completed. The Alberta woman who had been involved in that rickshaw accident in India underwent surgery in India after her thigh bone had been fractured in the accident. The wound in her leg developed an infection refusing to respond to treatment. "Eventually she discharged herself and flew back to Edmonton."

The woman was immediately booked for surgery by doctors at the Royal Alex, carving away the inflamed tissue and saving her limb and her life. But on admission the woman was placed in a room on a surgical ward with three other patients, violating the hospital's own policy of isolation and screening those treated outside Canada in foreign medical facilities. It was only after surgery that the infection control team at the hospital became cognizant of the threat, and isolated her.

Too late, however, to stop the antibiotic resistant microbes she carried with her from triggering a two-month outbreak in the hospital. Those deadly microbes spread to five patients, including the man who was there for surgery after complications had developed, post lung-operation. His body was shortly overwhelmed by the bacteria known to cause pneumonia and blood-stream infections in critically ill patients.

When he "developed septic shock and organ failure, was transferred to the intensive care unit and died a few hours later", the message was stark, if belated. This case marked the first time where a Canadian met death from such a bacteria brought back to Canada from a foreign hospital. The hospital had to screen over 400 patients to determine whether any others had picked up one of the pathogenic organisms.

According to Dr. Joffe, the bacteria most likely were "spread on unclean hands or possibly on a shared piece of equipment that was not cleaned between one person and the next. These bacteria don't fly, they don't jump, they don't hop. So to get from one person to another they have to be carried there." The first line of defence is vigilance and isolation in these identified circumstances.

The second is that medical professionals fully understand their obligation to due diligence; clean, sterile conditions, including the most basic of instructions; hand washing.