Cases of potentially lethal bug at CUH linked to one ward
Cork University Hospital saw outbreaks of superbug CPE throughout 2020. The vast majority of them emanating from a single ward. Picture File image
The vast majority of infections involving outbreaks of superbug CPE within Cork University Hospital in 2020 emanated from a single ward which had been long overdue a refurbishment.
Minutes of meetings of the hospital’s senior management taskforce regarding Carbapenemase-Producing Enterobacterales (CPE) from January until March deal with an initial outbreak in medical ward 1B, which has beds for 35 patients.
Throughout the year 1B, which also played host to an outbreak in October 2018, is repeatedly cited as being the epicentre for the illness, with the poor state of its infrastructure and a need for comprehensive refurbishment raised on multiple occasions, according to documents released under Freedom of Information.
That 2018 outbreak had seen the hospital face criticism for reopening 1B for admissions against the advice of its own infection prevention and control team. CUH also faced criticism for placing three patients with CPE in a room without a toilet, shower or hand hygiene facilities.
At a board meeting concerning CPE in early January 2020, the “urgent” need to fully refurbish 1B was outlined at a projected cost of €450,000 — however, this action was put back until April as the new budget wouldn’t have been outlined until then.
The hospital had in fact been free of CPE — a bug notoriously difficult to eradicate once it has taken hold —between September and December of 2019. However, of 28 positive cases of the bug in January 2020, 21 of them had spent time on ward 1B.
Meanwhile, a patient from the same ward subsequently tested positive having relocated to a nursing home in Mallow.
Inconsistencies with regard to hand hygiene, personal protective equipment and infection signage were likewise noted on the ward.
For much of the year, there was no dedicated CPE nurse working at the hospital making the successful quarantine of the illness more challenging.
Despite this, a decision was passed to “maximise” the ward in late January due to an increase in admissions to the hospital in general with flu season in full swing.
On February 3, management agreed to request €300,000 from the HSE’s lead for in-hospital infection Professor Martin Cormican for an overhaul of 1B.
A spokesperson for the hospital said that it is “satisfied” that ward 1B currently meets medical standards in terms of sanitisation.
As the crisis worsened into March and just before Ireland went into its first Covid-19 lockdown, bed blocking - the long term occupation of hospital beds — became an issue in 1B leading to a spike in the number of people on trolleys admitted through the Emergency Department, despite the ongoing refurbishment taking place.
While outbreaks were seen in other wards across the hospital throughout 2020, 1B remained the overriding issue with a further seven cases noted in mid-August.
On August 5 there was just one case of the illness in the hospital, in a ward separate to 1B. One week later, on August 13, that number had jumped to 13, six of them in 1B, with 61 close contacts noted, representing the bug’s peak for the year and leading to 1B’s closure to new admissions.
At the time CUH opted to perform an “aggressive” cleaning of all pipes using drain specialists DynoRod with a view to sanitising the plumbing.
Ward 1B was disbanded during the initial Covid lockdown, with the coronavirus blamed for a subsequent drop in screening for CPE.
During an unannounced inspection of CUH in November 2018, health watchdog, the Health Information and Quality Authority (Hiqa) criticised the hospital for its “overall approach” towards effectively managing the risk “to patients from infection and antimicrobial resistance”.
Inspectors said at the time that “more needs to be done locally by the hospital to effectively address the high risks identified during this inspection”.
Hiqa inspects CUH and notes that governance regarding healthcare-related infection needs to be developed.
First outbreak of CPE at CUH.
Outbreak of CPE declared at CUH’s ward 1B.
Seven cases found spread across wards by Hiqa during an unannounced inspection, despite assurances cases were quarantined in one place.
Hiqa notes failures in infection control governance which have “not been fully addressed” since its 2017 inspection.
December 2019 - No new CPE cases noted at CUH. Of 29 cases developed in CUH across 2019, 20 spent time in ward 1B.
Outbreak of the bug noted in 1B. Deep cleaning not possible as patients already occupying beds. Ward 1B ‘maximised’ to allow for a surge in hospital admissions. 1B noted as being in “urgent need” of refurbishment.
Hospital discusses whether or not to close 1B or simply list all inpatients as close contacts. Decision made to refurbish ward on February 24. Dirt on beds noted as a ‘big issue’.
18 beds blocked in 1B due to CPE. Ward 1B disbanded following Covid lockdown. Refurbishment of 1B to begin ‘as soon as possible’.
Poor screening levels for CPE attributed to Covid-19.
Index case of a fresh outbreak in ward 2A noted as having presented at CUH three times since January without being screened - cited as ‘missed opportunity’. Staffing shortages noted as ‘major concern’.
Fresh outbreaks leave 13 patients positive on August 13, with 61 contacts. Positive patients moved from ward 4B to 1B to allow for reopening of the former, with remainder to be ‘closely cohorted’. No cleaning product being used in toilets. DynoRod employed to sanitize sewage system. Concern raised regarding a shortage of infection control staff.
Two positive contacts noted outside CUH, one in a nursing home.
Screening levels for CPE rise to 1,549 in September, just within projected guidelines. ‘Long-standing issues’ with staff toilet noted as needing to be addressed in order to facilitate effective cleaning.
Carbapenemase-producing enterobacterales (CPE) are bacteria that usually live in the gut. They are resistant to most antibiotics making them an almost untreatable, and potentially deadly, superbug.
If CPE stays in the gut, it is largely harmless. However, if it spreads to the blood, kidneys, bladder or body tissues it can cause serious infection which may be fatal.
More than half of all patients who develop CPE bloodstream infections die. CPE has been called the “nightmare bacteria” by Tom Frieden, former head of the Centers for Disease Control and Prevention in the USA due to its stubborn antibiotic resistance.
Symptoms of CPE include a high temperature, aches and pains, chills, tiredness, weakness and confusion. Hospitals are key transmission zones for CPE.
The superbugs are more likely to spread to people who are already very sick, have compromised immune systems, recently had major surgery or had a medical device like a catheter or IV line inserted into their body.
Healthy people, including children and pregnant women, are at very low risk of CPE infection. The bug is shed in faeces and transmitted by direct and indirect contact with an infected person. Hand hygiene is a key form of defence against CPE.
Using your own soap, towel, sponge and razor if you are in hospital is advised, as is limiting contact with patients, keeping away from their bed space, avoiding sharing food, or items with patients and telling staff if facilities are not clean.
You don't need to limit contact with people or tell friends or family that you have CPE. It has been reported that people who are in contact with the bug have about a one in 20 chance of carrying the superbug and those who carry CPE have about a one in 20 chance of developing a CPE infection.
CPE infections have been a serious concern in Irish hospitals since the first recorded outbreak in 2009.
Prior to Covid, the National Public Health Emergency Team had worked on strategies to thwart the bug's growth in hospitals and care settings. Hospital wards have been closed due to CPE outbreaks.
A superbug is a word used for any bacterium that has developed a resistance to the antibiotics that are usually used to treat it. And any type of bacteria can potentially turn into a superbug.
The Centre for Disease Control (CDC) has warned that antibiotic resistance is one of the biggest public health challenges of our time. Each year in the US alone, at least 2.8 million people get an antibiotic-resistant infection and more than 35,000 of these people die with it.
Misusing antibiotics — such as taking them when you don’t need them or not finishing your prescribed course — is the single leading factor contributing to the problem, the CDC says.
Antibiotics which destroy disease-causing bacteria can be life-saving. However, if antibiotics are taken incorrectly, such as for a viral infection-like flu, it has no impact on that virus but instead attacks bacteria in the body, including 'good bacteria' that are vital to good health.
In an environment where the healthy bacteria ecosystem is displaced, 'bad' bacteria that are hardy enough to survive the antibiotic onslaught can grow and quickly multiply. And these drug-resistant strains may then spread to other people. Methicillin-resistant Staphylococcus aureus (MRSA) is another common superbug sometimes found in Ireland.
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