Almost untreatable superbug CPE poses serious threat to patients, doctors warn

Doctors are warning that the rise of an almost untreatable superbug, immune to some of the last-line antibiotics available to hospitals, poses a serious threat to patients.

The number of lab-confirmed cases of the bug, called carbapenemase-producing Enterobacteriaceae (CPE), rose from three to nearly 2,000 in the 12 years to 2015, according to Public Health England (PHE). But that may be far short of the real number because hospitals are not compelled to report suspected cases. PHE admits it does not know where the infections are coming from or how many people are dying.

Freedom of information requests made by the Bureau of Investigative Journalism reveal that at least 81 people infected with CPE have died since 2009 at 66 NHS trusts in England – although the bug may have been a complicating factor rather than the main cause of death in some cases.

But the real figure is almost certain to be much higher. Many trusts did not respond to the requests or were unable to supply complete data. Out of 136 NHS hospital trusts that were asked for the numbers of infections and deaths between 2009 and 2016, 97 responded but nearly half did not have data on CPE or could not extract the details.

In Manchester and London, dealing with CPE has cost NHS trusts almost £10m. There have also been confirmed outbreaks in Liverpool, Leeds, Sheffield, Birmingham, Nottingham, Colchester, Edinburgh, Belfast, Dublin and Limerick, among others.

Elsewhere, Italy had only sporadic cases of CPE in 2009 but by 2014, the bugs were rife across the country. “If you look at Italy they’ve suspended bone marrow transplant programmes,” said Dr Matthew Laundy, consultant medical microbiologist at St George’s University Hospitals NHS Foundation Trust. “If you’ve got no antibiotics to treat CPEs you’re stuck.”

Experts are calling for reports of suspected CPE infections to be made mandatory. The numbers revealed by the Bureau are “shocking,” said Val Edwards-Jones, emeritus professor of microbiology at Manchester Metropolitan University.

“It should absolutely be mandatory for trusts to report this,” she said. “If you go back to the 1990s MRSA [reporting] wasn’t mandatory. It was only when hospitals did proper surveillance and began looking at the bugs in the blood that we knew the scale of the problem. Then it was found that there were certain things that weren’t being done correctly.”

Dr Michael Cooper, a consultant microbiologist and director of infection control at the Royal Wolverhampton NHS Trust, said: “If something’s not mandatory, it’s the places doing well that take care to report. You don’t get figures from the trusts with their head in the sand, the poor performers.

“Public Health England have no idea how many people are dying, they’ve no outcome data. This is a serious mistake.”

CPE is carried harmlessly in the gut, but may kill if it enters the bloodstream through a wound of a patient who is already sick or frail, which makes it a real danger in hospitals. About 40-50% of patients with a CPE bloodstream infection die. CPE is not untreatable, but it is difficult as antibiotic combinations or older, more toxic drugs have to be used.

CPE, dubbed the “nightmare bacteria” by Tom Frieden, former head of the Centers for Disease Control and Prevention in the USA, has developed resistance to the carbapenems, a group of “last resort” antibiotics that are used in serious infections when other drugs will not work. They include KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase).

Experts have warned that antibiotic resistance is a major threat to the world and could turn the clock back on medical advances by making some surgery, such as heart transplants, impossible.

There are high levels of CPE in India, Bangladesh, Pakistan, the Middle East, south and Central America, China, southeast Asia, Taiwan, Japan, some countries in southern Europe and the USA. In February the World Health Organisation named carbapenem resistant bugs a “critical priority” for which new antibiotics are urgently needed.

In 2014, the medical directors of both Public Health England and NHS England took what they called “the unusual step” of writing to all NHS Trust chief executives, urging them to take action to prevent the spread of CPE.

“CPE represents one of the most serious emerging infectious disease threats that we currently face, and the failure to control their spread now, while we still have the opportunity, could have substantial human health and financial consequences,” wrote Dr Paul Cosford and Sir Bruce Keogh.

However, Professor Alan Johnson, head of the department of healthcare-associated infection and antibiotic resistance at PHE, said patients should be reassured that infections caused by CPE can usually be treated with other antibiotics. Fewer than 2% of E coli or Klebsiella bloodstream infections are resistant to carbapenems, he said.

“We carry out enhanced surveillance on carbapenem-resistant bacteria to determine the numbers and different types of CPE. Although reports of CPE have increased recently, part of this may reflect increased laboratory testing of many sample types other than blood stream infections, as awareness of CPE has grown,” he said.

Manchester

New figures show that four times as many people have died as had previously been reported in an outbreak in Manchester.

In 2009, the first cases of a type of CPE called Klebsiella pneumoniae carbapenemase were detected. In 2014, the hospital trust confirmed that 14 people had died from this infection, contracted within the hospital, in the previous four years.

But the Bureau’s research shows that there have been 61 deaths in the last seven years, including a six-year-old boy with leukaemia who caught the infection while undergoing a bone marrow transplant.

Many of those affected were very ill and had underlying medical problems and so it is not known whether the infection directly caused their death. Some may have died with a CPE infection rather than from it.

An investigation into the outbreak found in 2015 that CPE bacteria were living in the hospital kitchen sinks and handwash basins, which had drains that allowed splashback. Hugh Pennington, a leading microbiologist who chaired official inquiries into E coli outbreaks in 1996 and 2005, said such basins elsewhere in the NHS should be replaced. “It’s all about sound plumbing. It’s not rocket science. If your sink is going to spread the bug, get rid of it.”

Almost untreatable superbug CPE poses serious threat to patients, doctors warn

Epidemic of untreatable back and neck pain costs billions, study finds

Low back and neck pain is an increasingly widespread and expensive condition worldwide, costing the US alone $ 88bn a year – the third highest bill for any health condition – despite evidence most treatments do not work.

Millions of people worldwide suffer from low back and neck pain, most of it unexplained, although some professionals think it may be worsened by sitting at desks all day, carrying bags and general bad posture. Episodes of acute pain are very common, but experts say that medical investigations only make things worse and the best cure is often to take painkillers, exercise gently and wait for the pain to pass.

The rising bill for treatment in the US has been uncovered in a new study by the Institute of Health Metrics and Evaluation (IHME) at the University of Washington, which looked at public and private spending on all diseases in 2013. Diabetes was in first place on $ 101.4bn and heart disease was second with $ 88.1bn. But neck and lower back pain treatment costs were close behind, at $ 87.6bn. The team split cancer into 29 separate conditions, which meant that none of them made the top 20, although combined the costs of treatment came to $ 115bn.

The most remarkable thing, said Joseph Dieleman, lead author of the paper published in the Journal of the American Medical Association, was the increase in treatment costs for lower back and neck pain, running at 6.5% a year against 3.5% overall. “In absolute terms, there was an increase from $ 30bn in 1996 to $ 88bn in 2013,” he told the Guardian.

The numbers of people suffering low back and neck pain in the US had not changed much, he said, but the spending had soared. Three things were driving the rise, said Dielman: individuals with pain going more often to outpatients’ clinics, increases in the costs and quantity of treatments given to people admitted to hospital, and a larger older population.

Surprised by what they found, Dieleman and his colleagues now plan to do similar work looking at the costs of treatment of low back and neck pain and other diseases in England, Norway and Switzerland.

What they already know is that low back and neck pain is a huge worldwide problem. The latest Global Burden of Disease (GBD) study, also produced by the IHME and published by the Lancet, showed it was “the leading global cause of disability in 2015 in most countries”. In the UK, a third of all long-term sickness absence from work, and nearly a fifth of any sick leave, is caused by musculoskeletal disorders, which is mostly lower back and neck pain, according to the Work Foundation.

“It’s about 30% of GP consultations,” said Karen Steadman, health, wellbeing and work lead at the foundation. A lot of patients have other health complaints at the same time – so-called co-morbidities. “About a third have co-morbid depression,” she said.

Dr Andrea Furlan, a co-ordinating editor of Cochrane Back and Neck – one of the collaborating groups of scientists who assess the worldwide evidence for which treatments work – said back or neck pain affect maybe eight out of 10 people at some point. “Almost everybody in the world will have some kind of back pain in their life,” she said.

Acute lower back or neck pain, which can last for a few days up to a couple of months, can be extremely debilitating, she said. Furlan knows this, as quite apart from being based at the Institute for Work and Health in Toronto, Canada, she has experienced it herself. “It was so painful I had to lie on the floor,” she said. “I was sure I had ruptured a disc or ligament.”

But she also knew she should not get it investigated. “The first thing you have to remember is don’t x-ray, don’t MRI and don’t CT scan – no investigation. I was desperate to have one

“Thank goodness I didn’t [get it investigated] because that’s where things go wrong. I’m 47 years old. When you do an investigation, there is a chance you are going to find something wrong in the spine. Then somebody will want to intervene.”

Injections, electrical nerve stimulation, opioid drugs and a whole host of other interventions are not recommended for lower back and neck pain. The Cochrane group have found no evidence in favour of using these or many other interventions; in the UK, guidance from the National Institute for Health and Care Excellence advises healthcare staff not to offer them.

There are people who will be “red flagged” for investigation because of their age, a fever or other issues, but most people will be advised to keep working, keep moving, keep exercising and taking painkillers and wait to get better. “Rest for acute back pain is the worst thing you can do,” said Furlan. After three weeks, her own pain was gone.

It is important to try to prevent acute pain from becoming chronic pain – the sort that does not permanently go away. Treatment can make things worse, but there is also a mental health element to much chronic pain. Those at risk of developing chronic pain are “yellow flagged”, said Furlan, and risk factors include depression and a lack of social or workplace support. Those with chronic pain will need interventions, which may include professional physiotherapy but also relaxation exercises, meditation and mindfulness.

The epidemic of lower back and neck pain is not surprising, said Furlan. “The spine is a part of the body that is so fragile. People have no idea,” she said. “It is unbelievable what the spine does.” It is also supporting increased weight and changed posture in the many people who have become obese in recent years – plus carrying heavy bags around and tension in neck muscles as people work at computers does not help.

Ending the epidemic, however, is going to be hard.

Epidemic of untreatable back and neck pain costs billions, study finds