Action required urgently on CRE ‘superbugs’

Interviews conducted by the <strong><em>Medical Independent</em></strong> (<strong><em>MI</em></strong>) and documents obtained through Freedom of Information legislation show that Ireland is facing a major battle to ensure CRE does not become endemic in the hospital system and ultimately in other healthcare settings. Carbapenemase-producing <em>Enterobacteriaceae</em> (CPE), a subset of CRE, are causing particular concern.

Amid the perennial aberrations of Irish healthcare — the trolley crisis, the long waiting lists — CRE and the wider issue of multi-drug resistant organisms seems to have slipped from the agenda at the Department of Health and the upper echelons of the HSE, if they were ever there to begin with.

One would only require a cursory glance at statistics from Ireland’s National Carbapenemase-Producing Enterobacteriaceae Reference Laboratory to have a sense of the scale of the increase in CPE cases over recent years. There were 48 cases in 2013, 81 in 2014, 140 in 2015 and 369 in 2016.

On 24 August 2016, Tallaght Hospital, Dublin, notified the local HSE public health department of an outbreak that quickly developed into a major crisis and Ireland’s largest hospital CRE outbreak to date, described as “unprecedented” for Ireland in an internal HSE document in November. Yet the Minister for Health Simon Harris — some three weeks after outbreak notification, on the night of 14 September — was moved to ask his department officials to enquire “if there is an outbreak” of CRE at Tallaght Hospital. Days — weeks — had gone by when the hospital could not even replace mattresses that failed an audit; could not accord dedicated staff to CRE patients due to financial and staffing pressures.

In this maelstrom of poor communication channels, Tallaght Hospital did not inform Dublin Midlands Hospital Group about the outbreak until 14 September.

The highly inadequate staff resourcing of the Health Protection Surveillance Centre (HPSC) also deserves special mention, with just 0.5 whole-time equivalent (WTE) consultant microbiologists, in an era where multi-drug resistant organisms carry such a huge threat to health systems globally.  The HPSC, it should also be remembered, is without a permanent Director since the retirement of Dr Darina O’Flanagan in May 2016.

A plan outlining a much more focused and resourced approach to CRE is currently with the HSE Leadership Team. The cost of not implementing these measures will be far too much.

The Department and HSE must heed the warnings of leading professionals in Irish microbiology, including President of the Irish Society of Clinical Microbiologists Dr Eleanor McNamara, Professor of Bacteriology at NUI Galway Prof Martin Cormican and Clinical Lead for the HSE programme on healthcare-associated infections and antimicrobial resistance Dr Rob Cunney.

As Dr McNamara put it, the window of opportunity to stop CRE from becoming endemic in the hospital system is “diminishing rapidly”.