One of the biggest concerns facing long-term care (LTC) today beyond COVID is Carbapenem-resistant Enterobacteriaceae and the continued emergence of resistant bacterial infections in all of our populations. As a LTC medical director, reducing drug-resistant bacteria and infections in LTC facilities is my primary objective. It’s also the hallmark of a comprehensive infection prevention and control program.

 

Unfortunately, this threat persists across the country and these resistant bacteria continue to threaten the health and safety of our residents. According to the CDC, more than 70% of LTC residents receive one or more courses of antibiotics annually, and 50 to 70% of them are improperly prescribed, which compounds this problem. There are more than 2.5 million drug-resistant infections each year, which have contributed to the deaths of 35,000 Americans. And while it’s difficult to accurately capture the total economic impact of antibiotic resistance, the CDC estimates that the cost to treat these infections is more than $4.6 billion annually.

 

There is good news to report: The CDC has identified effective infection prevention and control efforts in reducing these infections and related deaths.

 

A history of resistance

 

As I said, this is not a new concern. It’s a major concern – and you should act quickly to address it – but it’s been a serious (and growing) issue for years. Drug resistance began with simple Penicillin resistance and evolved through the evolution of Penicillinase in several bacterial species. It then developed into a much bigger issue with resistance to Methicillin, which is a specialized form of Penicillin created to combat the very resistance you’re reading about right now.

 

Eventually the same bacteria developed the ability to defeat the Methicillin and we have been blessed/cursed with the existence of Methicillin Resistant Staph aureus – known as MRSA for most of the period of my medical career. Fortunately, for the most part, many of these resistant bacteria have continued to be sensitive to several other commonly used antibiotics which have helped us through the hard times.

 

But more concerning resistance patterns have begun to develop in other bacteria, including a resistance to Vancomycin. My educational process taught me that Vancomycin was the “biggest, baddest” antibiotic that was available and should only be used when absolutely necessary such that we don't give the ability for bacteria to become resistant. Unfortunately, through the continued march of progress, we have used Vancomycin and the bacteria have outsmarted us and learned how to avoid Vancomycin. Vancomycin resistant Enterococcus (VRE) remains a very real and persistent threat to people of all ages, but especially the elderly.

The most recent frontier to be worried about is that of resistance to the Carbapenems- these next-generation beta-lactam antibiotics have been developed as the next best thing to take care of the big, bad bacteria that give us trouble. As we have seen so many times before, the bacteria are smarter and have learned how to get around these powerful antibiotics.  

 

There is a reported infection rate of 0.3 to 2.93 CRE infections per 100,000 person years. The mortality rate of up to 50% is especially concerning. It is variable and unclear as to whether "other antibiotics" will still be available and effective for these terrible infections.

 

What can be done to combat this resistance? Effective use of antibiotics when appropriate, screening for resistance patterns, implementing an antibiotic stewardship program, quick isolation of the infected and provision of supportive care when needed.