Multi-drug resistant organism identified at Middlemore Hospital

Media statement 20 December 2018 | A multi-drug resistant organism has recently been found in two patients during their admission to Middlemore Hospital, resulting in the Ministry of Health, in consultation with Counties Manukau Health, declaring certain wards a ‘transmission risk area’ (TRA).

The bacteria known as Carbapenemase Producing Enterobacterales/Enterobacteriaceae (CPE), which is resistant to nearly all antibiotics, was first identified by Counties Manukau Health in a surgical patient in November, followed by a second patient who acquired it on another ward about nine days later. 

The organism was found in both patients by routine screening of the patients’ gut organisms.  Neither patient had symptoms, or were unwell, with the organism. 

Infectious Diseases Consultant, Dr David Holland, says that while there is no need for alarm, it is important the public is aware of the situation.

The majority of patients and the visiting public are not at any risk, he says, and the hospital continues to operate as normal.

Dr Holland says Counties Manukau Health, in consultation with the Ministry of Health, is taking a pragmatic but active approach. 

Counties Manukau Health has intensified routine surveillance for antibiotic resistant bacteria at Middlemore Hospital. 

Also, to prevent the possibility of further transmission of CPE, all patients who have had an admission for 24 hours to surgical wards (excluding maternity) at Middlemore Hospital since 31 October, will be screened for resistant bacteria including CPE if they have been, or are, admitted to any health care or age related residential care facility since that time.

Dr Holland says other patients who may have been discharged home from these wards since 31 October do NOT need to take any special action as the simple presence of CPE in the gut/bowel does not require any treatment.

Describing what declaration of a TRA means to Counties Manukau Health, Dr Holland says: “the criteria set out in new guidelines from the Ministry of Health state that an area should be declared a transmission risk area if ‘there are two or more confirmed cases of the same CPE, and at least one case is locally acquired, and there is a plausible epidemiological connection between the cases’ or where acquisition from an environmental source is hypothesised, clustering in time and place without a direct patient-to-patient epidemiological link."

“This means that if there is a possibility of the organism being acquired in the hospital from a patient or environment source, either known or unknown, this triggers intensive investigation and reinforcement of infection control measures.”

Dr Holland says that at this stage Counties Manukau Health have not been able to establish a connection between the two patients or identified a source. 

“It’s important that we take every precaution to ensure we identify anyone else who may be carriers of CPE and, if possible, the source of these CPE,” he says.

 “We are working with the Ministry of Health regarding the situation at Middlemore Hospital. The Ministry will be sending an advisory to all DHBs asking them to forward messages to their Infection Prevention and Control services, advising them of the need to screen patients on admission if they were on a TRA ward at Middlemore after 31 October.

“The minimum recommended screening will involve a faeces specimen or rectal swab. Any positive result would result in further reinforcement of measures to prevent spread of the organism. There is no treatment necessary for simple presence of the organism in the bowel.”  

Dr Holland says that whilst CPE remains relatively rare in New Zealand, there has been an increase in the number of patients presenting at the hospital with these organisms in their gut over the last few years. 

“The bacteria can be in the gut for months to years and in that site will cause no harm,” he says. “There is no effective way to remove it from the gut and it may stay for longer if you take antibiotics.” 

He says CPE can cause infection in vulnerable people if it gets into the wrong place such as the urine or a surgical wound.

Dr Holland says the first line of defence against any bacteria is thorough and frequent handwashing, especially after going to the toilet, and before preparing and eating food.

Members of the public who are concerned that they may have been exposed to CPE or want to talk to a nurse about what this means, can contact the Healthline on 0800 611 116.


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Questions and Answers

Carbapenemase Producing Enterobacterales/Enterobacteraceae (CPE); also known as Carbapenem Resistant Organisms (CRO).  

What are Carbapenemase Producing Enterobacterales (CPE)?

CPE are bacteria that are members of the family Enterobacterales that are identified as carrying a carbapenemase gene. Enterobacterales are the largest family of gram-negative bacteria causing human infection.

Everyone has bacteria that live in the bowel that are generally harmless and can even help with digestion and general health. Your immune system keeps them in check and prevents them from spreading elsewhere in the body. However, sometimes these bacteria can cause infections and in certain situations they are antibiotic-resistant (this is where certain antibiotics no longer work against bacteria).

Some of these bugs have become CPE as they have become resistant to multiple antibiotics including the carbapenem antibiotics. These CPE are common in many overseas countries but are rare in New Zealand. There are very few antibiotics which can treat infections caused by these organisms, and in extreme cases no antibiotics are effective.

The majority of patients who are found to have CPE do not have symptoms and are known as carriers. If, however, a person develops an infection (such as urinary tract or bloodstream) for whatever reason and carries the CPE organism, then that organism may be involved in that infection. 

How do people get CPE?

CPE are more common in some countries than others. They are rare in New Zealand and currently almost all new isolates have been associated with foreign travel or residency.

Widespread use of antibiotics has caused the development of resistant bacteria such as CPE. CPE can spread between people through direct contact with each other or by touching items or surfaces that the person with CPE may have touched such as bed rails, toilets or equipment. As patients in hospital are much more vulnerable to infection, special precautions are taken to prevent the spread of CPE between them.

How could I have picked up CPE in New Zealand?

You may have attended hospital at the same time as a person who is a carrier or been overseas. CPE can be spread between people via direct contact with each other or through indirect contact with objects like touching toilets, bed rails, door knobs and other equipment at the hospital.

Is it easy to identify the symptoms of CPE?

No, the majority of people who are found to have CPE do not have symptoms and are known as carriers. Rarely, CPE can cause symptomatic infections such as urine, kidney or bloodstream infections in patients (such as critically unwell patients), and patients needing intensive care or while receiving chemotherapy.

Which patients are routinely tested for CPE?

CPE is a common bug in some overseas countries. If a patient has travelled to another country (except Australia) or been admitted to hospital in another country in the past 12 months and is being admitted to hospital in New Zealand, they should tell their doctor or nurse so that a CPE test can be done if deemed necessary. 

How is the test done?

A faeces sample of swab of faeces taken from a patient’s rectum is the quickest and easiest way to check for CPE, as it is usually detected in the bowel. The swab will be put in a special sample container to send to the hospital laboratory.

What is the risk associated with CPE?

As mentioned above, people who have acquired CPE usually just ‘carry’ it in their gut and suffer no consequences. However, if these people develop an infection for any reason then it is possible the CPE may be involved. The main risk is to vulnerable patients while they are in hospital. 

Again, CPE in NZ is very rare and the approaches taken with increased hygiene precautions and the use of gowns and gloves and vigilant hand cleaning are designed to prevent CPE getting a toe-hold in NZ and NZ hospitals. The risk to members of the public is still tiny but as a general measure good hygiene practices are advised while visiting patients in hospital.

What do I need to do to prevent the spread of CPE?

CPE is spread by contact so the best way to prevent the spread of CPE is to ensure that you maintain a strict approach to hygiene. This means washing your hands thoroughly at all times.

If I want to talk to someone, who can I call? 

If you have any questions and want to talk to a nurse, please contact us through Healthline on 0800 611 116.

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middlemore CRO CPE organism drug resistant inpatient infection

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