VRE outbreak at major West Australian hospital

Royal Perth Hospital, Western Australia’s oldest teaching hospital, was forced to close one of its intensive care units last October in the wake of Australia’s worst outbreak of the antibiotic-resistant “superbug” known as VRE (Vancomycin Resistant Enterococci).

Within weeks, patients at other Perth hospitals were also infected. The hospitals affected included Swan District, which services outer suburban and rural areas around Perth, and Bentley, in the southern suburbs, where a number of elderly patients who had been transferred from Royal Perth (RPH) tested positive for the disease. Infections also occurred at RPH’s Shenton Health Campus, which cares for patients undergoing rehabilitation. Many of those affected had been transported to the main RPH campus for day treatment.

To date, over 140 cases of VRE have been identified statewide, although no deaths have been reported. A Health Department spokesman David Smith said most cases arose from RPH and that more than 1,000 people may have come into contact with carriers of VRE. According to recent media reports, no new cases have been detected at RPH for several weeks. It is troubling, however, that the screening of people in the community and other medical facilities who may have had contact with VRE at RPH continues to find new carriers.

VRE is of particular concern because it is resistant to the antibiotic vancomycin, one of the strongest antibiotics available. A relatively harmless bacteria when found, as is common, in the human gut, enterococci can become fatal if it travels into the bloodstream. There is no known cure—patients can only be stabilised in the hope that their own immune systems eventually prevail.

Outbreaks of VRE first occurred in Europe in the mid-1980s. Cases then began to appear in America, Canada and Japan. The first Australian case was detected in 1994 at Austin Hospital, Victoria. In 1996, several cases were diagnosed in hospitals in Sydney, Brisbane, Perth, Melbourne and Newcastle.

Many medical experts say VRE has developed due to the overuse or incorrect use of antibiotics that has, over time, made enterococci resistant. Antibiotics attack a bacterial infection. There is always the chance that within the population of bacteria, some members will continue to grow in the presence of the antibiotic. Those germs that are not killed, then, are free to multiply without competition from the sensitive strains. Microbiologists argue that the more antibiotics we use, the more we contribute to this pool of resistant germs. Eventually these strains build up and an outbreak of antibiotic resistant disease can take hold.

Hospitals, and particularly intensive care units are veritable breeding grounds for resistant germs, as this is where the heaviest and most concentrated use of antibiotics takes place. When this is combined with patients who have compromised immune systems and intravenous tubes that allow easy bacterial entrance to the bloodstream, the chances of contracting VRE are higher. Under these conditions, a very strict hygiene regime is critical.

In an attempt to play down concerns and reassure patients and the public, West Australian Health Department acting chief officer Dorothy Jones issued a statement in October saying that WA hospitals were as safe as other Australian hospitals. “Antibiotic resistance is a fact of modern health care. Unfortunately in busy teaching hospitals where you have a lot of people with complex illnesses you tend to see these things from time to time,” she said.

Jones and other officials have yet to explain how the outbreak occurred, however.

A breakdown in hygiene protocols may well have contributed. Miscellaneous Workers Union spokesman David Kelly pointed to the privatisation of cleaning services at RPH. Kelly said private contractors were used to clean non-ward areas, while staff cleaning the wards were also engaged in catering and orderly services. Kelly said staff who are required to do several jobs at once might be playing a part in the spread of the VRE.

“When non-ward cleaning was privatised the standards went down the toilet. From our point of view the jury is still out on the effectiveness of multi-skilled workers who are cleaning the wards because the reports to us are that they are run off their feet.”

To date, RPH management has not commented publicly on the question of private cleaners, yet it has decided to restore in-house cleaning.

Some health professionals have raised wider concerns. In November, RPH emergency department head Ron Hirsch said staff shortages, particularly of nurses, had led to some workers having to shortcut hand-washing procedures due to lack of time and access to sinks. “Busy emergency department staff are often quite unable to comply with the hospital infection control guidelines which have been specifically designed to prevent such outbreaks ... such as gaining access to wash basins to perform the simple but vitally important functions of hand washing after patient contact.”

Industrial action by WA nurses over the past year has served to highlight the crisis in staffing levels, wages and conditions as well as aging equipment—the legacy of a protracted running down of the public health system by state and federal governments, Labor and Liberal alike.

In last year's state elections, deep going opposition to public health cuts was a factor in the defeat of the Liberals and the return of Labor under Premier Geoff Gallop. In Gallop’s first budget last September, however, public hospitals received between $85 and $120 million less than required to maintain basic services.

Late last month, in an attempt to placate angry health professionals and the public, the Labor government promised another $70 million. Gallop was forced to acknowledge that some of the “extra money is needed to fight the antibiotic VRE germ that swept Royal Perth Hospital”.

National prevention strategies are also being hampered by a lack of funds.

Professor Turnbridge, a Microbiology and Infectious Diseases Director at North Adelaide’s Womens and Childrens Hospital said the federal government had agreed last year that an expert advisory committee would examine the problem of antibiotic resistant germs but the committee was yet to receive any money for critical aspects such as the surveillance of VRE.

“The absence of a national notification system for resistant bacteria such as VRE ... meant there was no official data. This makes monitoring difficult. There is general agreement there should be a laboratory in each state that acts as one network,” Turnbridge said.