Transcript for VitalSigns Teleconference: Antibiotic Resistant Germs

OPERATOR: Welcome. Thank you for standing by. Throughout today’s conference, all participants will remain in listen only mode, during the Q&A session, you can press star one if you would like to ask a question. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. Now I’ll turn over the course to Michelle Bonds. The Division Director for Public Affairs.

MICHELLE BONDS:  Thank you. Thank you all for joining us today for the release of the new CDC Vital Signs. This month’s vital signs is on antibiotic resistance and how CDC resources and containment strategy are helping protect people from untreatable infections. We are joined by Dr. Anne Schuchat, Dr. Jay Butler, Chief Medical Officer and Director of Alaska Division of Public Health and the Association of State and Territorial Health Officials also known as ASTHO. We have also joining us today is Dr. Arjun Srinivasan, Associate Director for Healthcare Associated Infections and Prevention Programs here to help respond to your questions as well. I would like to turn the call over to Dr. Schuchat.

ANNE SCHUCHAT: Thank you, Michelle. Thank you for joining us today to discuss the Vital Signs report. As you know each month we focus on the latest data about one of the critical health issues facing our nation and what can be done about it. Today, we’ll be talking about CDC’s containment strategy which can help stop the spread of unusual types of antibiotic resistance that haven’t yet spread widely. You have heard us talk about the emergence of resistant infections that are virtually untreatable with modern medicine. We don’t just rely on antibiotics to treat common infections. Antibiotics are the safety net for most cancer treatments, surgical procedures, and ICU care and organ transplants. Antibiotic resistance threatens this safety net. Today we’re talking about urgent efforts, the public health and clinical community is taking. There is good news and bad news to report. As you know the dangerous antibiotic, resistance is common. Taking a terrible human toll, 2 million Americans get infections from antibiotic resistance and 23,000 die from those infections each year. Today we’re talking about tackling a less common but highly important piece of the antibiotic resistance problem. Using CDC’s containment strategy to stop new and unusual antibiotic resistance from spreading. These unusual threats are the uncommon or highly resistant germs that have yet to spread throughout the U.S. we are working to get in front of them before they do become common in order to protect patients now and in the future. The good news is that we had hard data showing an aggressive approach works. Our report today summarizes our experience over the first several months of improved lab testing by CDC’s antibiotic resistance lab network. The report shows that in nine months in all states and Puerto Rico health departments in the AR lab network tested 5,776 samples of highly resistant germs. These germs were tested for unusual resistance. Those genes that were highly resistant or rare with special resistance that could spread. Of the 5,776, about one in four of the bacteria had a gene that helps it spread its resistance. And there were 221 instances of an especially rare resistance gene. These results prompted an aggressive response including many infection control assessments and colonization screens. The screenings showed that about one in ten, meaning one in ten could have continued spreading if left undetected. When screening tests were positive, vigilant infection control and additional screenings continued until the spread was stopped.

The bottom line is that resistance genes with the capacity to turn regular germs into nightmare bacteria have been introduced into many states. But with an aggressive response, we have been able to stomp them out promptly and stop their spread between people, between facilities and between other germs. CDC’s containment strategy calls for quickly identifying unusual resistance in patients, assessing infection control and the facility if unusual resistance is found. Sometimes testing contacts of patients with resistance to screen for spread, coordinating with other facilities and continuing infection control screenings until the spread is fully controlled. Today’s report describes how two types of resistance decreased from 2006 to 2015 using variations of this containment strategy. With independent or single facility approaches to control spread, a dangerous type of unusual resistance found in Enterobacteriaceae decreased by about 2% per year, but with the more aggressive approach using guidance like CDC’s CRE toolkit which was released in 2009 another type of unusual resistance in the same germ decreased by nearly 15% per year. The difference seen may be due in part to the more directed response to slow the spread of the second germ that nightmare bacteria CRE once it was identified. The Containment Strategy we have reported on today further builds on these efforts, encouraging health care facilities around public health authorities to respond to even single cases of an emerging antibiotic resistant pathogen. CDC estimates show if only 20% effective, the Containment Strategy can reduce the number of nightmare bacteria cases by 76% over three years in one area. That is the Containment Strategy will let us bend the curve or slow the spread of rising resistance. The Containment Strategy isn’t a new concept. But what is new is tremendously increased capacity in every state which is allowing more rapid detection of resistance and prompting a more aggressive response. The detection and response capacities from the newly established antibiotic resistance lab network and stronger state-based antibiotic resistance response efforts are improving prevention and response nationwide. Germs do more than spread and cause infections in people. They can also share their resistance with other germs –making some untreatable. Much like a fire, finding and stopping unusual resistance early when it is just a spark could help people. The new lab capacity allows us to detect smaller resistance fires and in some cases even resistant sparks so that they can be extinguished immediately. Detection is not enough on its own. When there’s a fire somebody needs to put it out. CDC supports more than 500 local staff across the country to combat antibiotic resistance wherever it emerges. Every state is now better able to stop the spread of antibiotic resistant bacteria and help keep these new threats from becoming common. Here’s how it worked at an Iowa nursing home when a patient got a urinary tract infection. Rapid testing by the healthcare facility and the CDC Antibiotic Resistance Lab Network detected unusual resistance. Over the following weeks the Iowa department of health and the nursing home did several on site assessments to identify any gaps in the infection control that might have let this germ spread. Because this patient had lived in the nursing home for several years, and had not recently had surgery or been hospitalized, the Containment Team tested 30 additional residents in the facility to determine if the threat had come from or spread to other people. Sure enough, five of the others were carrying the resistant gene. By following infection control protocols simple steps like consistent use of gloves and gowns workers at the facility were careful not to let the germs spread further. The facility and health department worked together to continue assessing the patients there until no other infection was found. because the facility was on guard rapidly, identified the germ and followed vigilant infection control and testing until the spread was stopped no further cases — stopped no further cases occurred. We’ll see more successes like Iowa’s and state and local leaders continue to champion this leader. Let me turn it over to Dr. Jay Butler who’s going to join us to talk about the perspective from the state.

JAY BUTLER: Thank you, Dr. Schuchat. Thank you for highlighting how they’re battling the antimicrobial resistance at the ground level, together with state and local and public health personnel who are truly on the front lines of the country’s detection and response effort. As past president of the Association of State and Territorial Health Officials which represents the health leadership in all 50 states, the eight territories and the District of Columbia, I can say that we’re already seeing the impact of the CDC resources and improving our ability to prevent infections and improving our capacity to detect and respond to antimicrobial resistance. I have a day job, I’m Chief Medical Officer for the state of Alaska. We saw the emergence of drug resistant pneumococcal nearly 30 years and community acquired methicillin-resistant staphylococcus aureus in 2000. We have also detected highly resistant gram-negative rods. I think it’s important to recognize that even in remote areas the threat of highly resistant gram negative pathogens is real because patients often transfer for care between our major cities and sometimes between states. I have seen firsthand the devastating effects of drug resistant infections plus what it takes to effectively tackle these new threats. Prior to my appointment as chief medical officer, I oversaw infection control at one of the community hospitals. I know the amount of work involved on the front lines in the intensive care unit and on the wards to prevent the spread resistant infections and the benefits of infection control programs and procedures that work. The report today suggests that what we do can make a difference. The support from CDC has also helped us develop greater lab and epidemiological response capacity. More providers are able to access local consultation and, in partnership with state hospital associations and tribal health organizations, we continue efforts to prevent infections and improve antibiotic use so that we can continue to tackle resistance we’re already familiar with organisms like MRSA, sometimes called “MERSA” plus the never before seen threats. And, I have heard from my state and local colleagues from across the nation that these resources have been a game changer in their states. Public health and health care work together to respond to first case of new threats. A critical role for CDC, state, tribal, and local health agencies is to help providers know how to best provide care based on the current science using antibiotics and the right clinical situations with the right drug at the right dose for the right duration and the right infection control policies and procedures to prevent spread of resistant organisms. We can’t wait until one case becomes ten or ten cases becomes a hundred. We can intervene early and aggressively to stop spread and to keep these threats out of our states. Unusual resistance is relevant to all of us. These organisms don’t care about state or city lines or the size of our team. The Containment Strategy provides resources that are useful to all of us. We don’t have to be in a big city or a huge metro area to make it work. We hope stories like the one that Dr. Schuchat shared from Iowa will be the new norm but it will require leadership at every level. Continued collaboration and communication between public health and health care leaders is critical to the successful implementation of the Containment Strategy across our country. This contributes to a comprehensive and the antimicrobial infrastructure that’s helping to protect all Americans against new resistance threats. I thank you for the opportunity to speak to you today and I’ll turn the microphone back to Dr. Schuchat.

ANNE SCHUCHAT: Thank you so much Dr. Butler. It’s critical that we’re able to support nationwide enhancements to labs and infection control and response infrastructure. The Containment Strategy was part of our vision when we launched the landmark antibiotic resistant solutions initiative in 2016. Though again at a very high level the Containment Strategy includes rapid detection in health care facilities, infection control in those supported by the health department, colonization screenings when needed to make sure that unrecognized spread has not already occurred. Coordination between health care facilities in the area and then infection control assessments and colonization screening until the spread is controlled. Before we take your questions, I do want to say that our work to stop antibiotic resistance is ongoing. In addition to confronting the new kinds of threats we talked about today, we are also working with partners across the country to prevent infections with established threats like MRSA. We’re very committed to preventing infections through tactics like vaccines, infection control and improving antibiotic use. The Containment Strategy complements these effective strategies and leverages our new capacities nationwide. But the hard truth is that as fast as we have run to slow resistance, some germs have outpaced us. We have had some success but it just isn’t enough to turn the tide. We need to do more and we need to do it faster and earlier with each new antibiotic resistance threat. I’ll turn things back over to Michelle then.

MICHELLE BONDS: Thank you, Dr. Schuchat. We now have Dr. Schuchat, Dr. Srinivasan and Dr. Butler to answer your questions. Operator, we are ready for questions.

OPERATOR: If you’d like to ask a question on the phone lines please press star one and record your name at the prompt. Again, press star one, please check to be sure that your line is unmuted and record your name, when prompted. Parties, please limit yourself to one question and one follow-up question. Our first question comes from Richard Harris with NPR.

RICHARD HARRIS: Thanks very much. My understanding is that some of these early efforts were funded by the Affordable Care Act, money that went to the CDC which has since evaporated. I’m wondering whether funding for what you’re talking about here is secure.

ANNE SCHUCHAT: Thank you for that question. The antimicrobial resistance solution resources are more recent than that and we have been very appreciative of congress’ support for this effort. Across the U.S. government there’s a real commitment to tackling antimicrobial resistance and in fact we’re working with other countries on the global dimensions of the problem. But with the resources that we have had since is 2016 we have been able to build up the lab network and we really feel there’s bipartisan support to continue this.

RICHARD HARRIS: So you’re saying the efforts need to be intensified. Would that then mean more state support and state effort on this or just more of the same, just turning up the tap a bit?

ANNE SCHUCHAT: We have now been able to support the state health departments and their laboratory and response teams. What we need is clinicians and labs in hospitals and health care facilities to be aware of this opportunity, to look for the resistant infections and recognize they can get help from the states because the more you look unfortunately the more you find. Many clinicians and facilities may not have been aware of this or they may not have been looking because they weren’t able to keep up with the response strategy. But now with some 500 staff across the country to help, and with the laboratories in every state, as well as, seven regional antimicrobial resistant labs that can actually do the testing for colonization specimens we think there’s abilities for us to respond. So I think in intensifying we want additional awareness by the clinicians in the hospital facilities and long term care facilities and really taking advantage of this network that we have established.

MICHELLE BONDS: Next question.

OPERATOR: Next we have Susan Scutti with CNN. Your line is open.

SUSAN SCUTTI: Hi. So the report also discusses asymptomatic carriers of CRE germs. Did the CDC report look at how many people may be currently walking around carrying this highly resistant germ without showing symptoms?

ANNE SCHUCHAT: No, this study didn’t — the surveillance didn’t do that. But we did find when we had an individual with a clinical infection from the highly resistant germ and we tested their context, one in ten of those was also carrying — asymptomatically carrying that resistant germ or the resistant gene. So we can’t say that one in ten people in general are because this is really — the testing was prompted by identifying the resistance in an individual. You know, I can say though that silent carriage disease is happening and that’s one of the reasons we think this aggressive containment strategy is important. When there’s a single case, it is an opportunity to uncover the reservoir of these resistant germs and to snuff it out before it’s spreads and becomes widespread.

SUSAN SCUTTI: My follow-up question, if you were to come into contact with an asymptomatic carrier, how likely is it that you would develop a CRE infection.

ANNE SCHUCHAT: We don’t know that. This kind of containment strategy and the data that we gather from it will help us learn. Certainly our outbreak investigations have helped us understand some, but we don’t have that kind of transmission dynamic data yet.

MICHELLE BONDS: Next question.

OPERATOR: Next we have Kate Sheridan with Newsweek. Your line is open.

KATE SHERIDAN: Hi there, very quick question for you. I was wondering if we knew how many of the 221 cases unfortunately resulted in a fatality or a death? Do we have any information on mortality from these nightmare bacteria?

ANNE SCHUCHAT: We don’t from this particular report. In the past though, when we looked at the CRE or the nightmare bacteria studies suggest up to 50 percent can result in death. So these can be very serious infections. What we say almost untreatable or very, very difficult to treat.

KATE SHERIDAN: Great, thank you.

MICHELLE BONDS: Next question?

OPERATOR: Next we have Marilyn Marchione with the Associated Press. Your line is open.

MARILYN MARCHIONE: Hi, thanks so much. I wonder if you can explain a little more about who was screened. Is this other patients or family members or both and how they were tested? Nasal swabs and what was done about any who tested positive?

ANNE SCHUCHAT: Thank you. Let me begin and see if we need to supplement my quick response. When an individual case was identified, the assessment of contacts was focused on the health care facilities. It may not have been just at one facility if they have been transferred there might have been contact with other patients at other facilities. But this didn’t involve testing family members. The testing because these are — these were generally bowel bacteria, the testing was done by rectal swabs and the laboratory testing for the colonization specimens was done in one of the seven regional labs. Really centers of excellence that could happen the high volume and the new molecular diagnostic tests. The CDC had developed lab tests for the unusual kinds of resistance, what we called Carbapenems resistance, that is not the KPC type, but there were some molecular probes used to test.

MICHELLE BONDS: Next question.

MARILYN MARCHIONE: I’m sorry, what was done if anyone tested positive?

ANNE SCHUCHAT: Let me let Dr. Srinivasan expand on that.

ARJUN SRINIVASAN: So the samples are tested for a number of the resistance genes and the key as Dr. Schuchat is mentioning is to uncover the really unusual ones because whenever you have something that’s really unusual it presents the greatest opportunity to control it and to prevent it from spreading to other people. So what’s done is some specific genetic testing that looks for the presence of all of these resistance genes and then that information then goes back to the hospital through the state. So that both the laboratory and the state is aware of what’s going on. And then the response team in the state can help the facility respond. So it’s really specific genetic testing for these unusual types of resistance.

ANNE SCHUCHAT: And then in that facility there would be contact precautions or the contacts who had the resistance genes without symptoms were handled specially so that they in turn couldn’t spread. Maybe you want to talk about the infection control around the asymptomatic patients.

ARJUN SRINIVASAN: Right, absolutely. So, you know, obviously the provider is at the center of this. So that is the person taking care of the patient. They’re the primary focus of the information. They get these results back and then it really becomes a team effort. One of the messages that we want to send with this is that no provider has to go it alone. This is not something where you should feel like you’ve uncovered this situation and now you don’t have resources to help you handle it. So the provider gets this result and then they have their infection control team at the hospital that can come and show them this is the way that you care for that patient safely. Do you wear gowns and gloves to enter the room, is there special cleaning that needs to happen in the room so that the environmental services staff can be aware. The health department comes in to support the infection control team at the facility to help them understand what are the latest best practices? Are there ways that we can prevent the spread more effectively? So it’s all done together. It’s done collaboratively. And it keeps happening. That’s the key message here. This is not a one and done. You don’t go and then say okay, well, we assume that this has gone the way we hope it does. We keep at it, so the infection control team and the hospital, the providers, the health departments continue to look, continue to assess and if necessary, continue to test until they know that the spread is controlled.

ANNE SCHUCHAT: So as you can see this can be a lot of work. That’s one of the reasons the resources to the state health departments were so vital. Because we do think it’s worth the effort, but we know its resource intensive. So the teams that are assessing and reassessing are supported through the antimicrobial resistance dollars that we’ve gotten. Next question.

OPERATOR: Next, Amy Birnbaum from CBS Evening News. Your line is open.

AMY BIRNBAUM: Hi, thank you for taking my question. Of the 221 of those highly resistant, how did that compare to previous years? Is there any way to compare or to figure out what the spread of these highly resistant bacteria are?

ANNE SCHUCHAT: No, this was the beginning of the surveillance and so it’s just the first nine months. I can tell you that I was surprised by the numbers that we found. This was more than I was expecting. But it’s the beginning of looking. We hope though that this won’t be an inevitable march upward, but that by finding them early when there’s only one in the facility we can stop this from becoming very, very common. So we don’t have any trend data.

MICHELLE BONDS: Next question.

OPERATOR: Next, we have Betsy McKay with the Wall Street Journal. Your line is open.

BETSY MCKAY: Hi, thanks. I wanted to ask about these 221 samples. I know you didn’t have mortality data to share, but can you tell us anything more about what types of patients these were, what conditions? You know what types of health care facilities they were in or anything else about them that would give us some idea of where these unusual — uncommon types are being identified.

ANNE SCHUCHAT: The 221 were in 27 different states. So this wasn’t just a problem in one or two states where we have been following up outbreaks. The kinds of infections that they had included pneumonia, urinary tract infections and blood stream infections. We don’t have data right now on the underlying conditions or the age range or sex, but we do think that these germs are out there and they’re a problem. We have seen, you know, young people with cystic fibrosis succumb to these types of resistance germs. We have seen the elderly, we’ve seen a variety of individuals, but this particular report is just the surveillance.

ARJUN SRINIVASAN: The only thing I’ll add, Becky, is that these weren’t just in hospitals. I think that’s an important point. We know that the health care system is connected by patients. And when patients move the resistant bacteria move with them. So these isolates were sent in from hospitals, but some of them were also sent in from nursing homes and especially nursing homes where they take care of sicker patients, in particular nursing homes where they have patients who might be on ventilators for long periods of time. Indeed, what we found is that these types of unusual resistance and the spread of unusual resistance poses even more of a challenge in some of those nursing home settings. That’s an area where we’re really actively going to work with that community, with our providers in that setting, state and local partners to better understand how we can optimize the control of the spread of resistance in those types of settings where it’s very challenging.

MICHELLE BONDS: Next question.

OPERATOR: Next we have Lynne Peterson with Trends in Medicine. Your line is open.

LYNNE PETERSON: Hi, I actually have two questions. I’ll ask them both at the same time. One is what’s the role of negative pressure rooms? I know some hospitals are looking at creating those. Is that going to be useful for these patients? And secondly, in the patients — if this is treatment resistant, antibiotic resistant, how do the patients recover?

ANNE SCHUCHAT: Thanks. There’s no role for a negative pressure rooms for this kind of infection. And the issue with recovery of course many of the patients don’t recover. And that’s one of the reasons that we’re so concerned about these resistance genes. And other supportive care may help them get through it, but we’ll be learning more as we continue to follow this. Next question.

OPERATOR: We have John Tozzi with Bloomberg News. Your line is open.

JOHN TOZZI: Hi, thanks for taking my question. I’m just wondering if the surveillance network has detected any instances of the NCR1 resistance gene and if so, what the frequency of that is like.

ANNE SCHUCHAT: The system has detected the NCR1 gene. In terms of the frequency I think somebody could get back with you later. But absolutely, one of the nice things about this approach is we’re not limiting the surveillance system to the five or six threats we are aware of right now. It’s a nimble, flexible system. Recently we talked about Candida auris, that’s one of the germs that the system is looking for now. The NCR1 as well. So when we find a new threat or another country finds a new threat, we incorporate it into the system.

MICHELLE BONDS: Last question, please.

OPERATOR: Our final question today comes from Molly Walker with Medpage Today.

MOLLY WALKER: Thank you for taking my question. Going back to the first question where you talked about clinicians and the importance of letting them know, do you have any outreach plan directly to clinicians other than this press call?

ANNE SCHUCHAT: Yes. Let me let Dr. Srinivasan explain the outreach we are planning, but we certainly appreciate your help in getting the news out.

ARJUN SRINIVASAN: Yeah, absolutely. We have a number of clinical societies that we work with actively. The list would be too long to mention here, but rest assured we are making direct outreach to providers directly, through hospital associations, through all of you, to make sure that providers know that these — what they need to do, that these resources are available and I said, that they don’t have to go it alone.

MOLLY WALKER: Thank you.

MICHELLE BONDS: All right. Thank you all for joining us today. I’d like to especially thank Dr.’s. Anne Schuchat, Dr. Arjun Srinivasan and Dr. Butler for joining us today as well as all the reporters. For follow-up questions please call the press office at 404-639-3286 or send an e-mail at media at cdc.gov. Thank you for joining us today and this concludes our call.

OPERATOR: Thank you for your participation. You may disconnect your lines at this time.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES