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Oct 21, 2023

Nursing Homes Are a Breeding Ground for a Fatal Fungus

Deadly Germs, Lost Cures Drug-resistant germs, including Candida auris, prey on

Deadly Germs, Lost Cures

Drug-resistant germs, including Candida auris, prey on severely ill patients in skilled nursing facilities, a problem sometimes amplified by poor care and low staffing.

Maria Davila with her husband, Anthony Hernandez. She is one of numerous patients at a Brooklyn nursing home with a highly contagious drug-resistant infection.Credit...Jeenah Moon for The New York Times

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By Matt Richtel and Andrew Jacobs

Maria Davila lay mute in a nursing home bed, an anguished expression fixed to her face, as her husband stroked her withered hand. Ms. Davila, 65, suffers from a long list of ailments — respiratory failure, kidney disease, high blood pressure, an irregular heartbeat — and is kept alive by a gently beeping ventilator and a feeding tube.

Doctors recently added another diagnosis to her medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it arrived in the United States four years ago, with half of patients dying within 90 days.

At least 38 other patients at Ms. Davila's nursing home, Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been infected with or carry C. auris, a germ so virulent and hard to eradicate that some facilities will not accept patients with it. Now, as they struggle to contain the pathogen, public health officials from cities, states and the federal government say that skilled nursing facilities like Palm Gardens are fueling its spread.

"They are the dark underbelly of drug-resistant infection," said Dr. Tom Chiller, who heads the fungal division at the Centers for Disease Control and Prevention, speaking about skilled nursing facilities, particularly those with ventilated patients, but not Palm Gardens specifically.

Such nursing homes are playing a key role in the spread in New York, where 396 people are known to be infected and another 496 are carrying the germ without showing symptoms, according to public health officials. In Chicago, half of patients living on dedicated ventilator floors in the city's skilled nursing homes are infected with or harboring C. auris on their bodies, said Dr. Allison Arwady, the acting commissioner of the city's Department of Public Health.

Much of the blame for the rise of drug-resistant infections like C. auris, as well as efforts to combat them, has focused on the overuse of antibiotics in humans and livestock, and on hospital-acquired infections. But public health experts say that nursing facilities, and long-term hospitals, are a dangerously weak link in the health care system, often understaffed and ill-equipped to enforce rigorous infection control, yet continuously cycling infected patients, or those who carry the germ, into hospitals and back again.

"They are caldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria," said Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths. "You’ll never protect hospital patients until the nursing homes are forced to clean up."

[Read our other stories in our series on drug resistance, Deadly Germs, Lost Cures.]

The story is far bigger than one nursing home or one germ. Drug-resistant germs of all types thrive in such settings where severely ill and ventilated patients like Ms. Davila are prone to infection and often take multiple antibiotics, which can spur drug resistance. Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing.

These issues have also vexed long-term, acute-care hospitals, where patients typically stay for a month or less before going to a skilled nursing home or a different facility.

A recent inquiry by the New York State Department of Health found that some long-term hospitals grappling with C. auris were failing to take basic measures, such as using disposable gowns and latex gloves, or to post warning signs outside the rooms of infected patients. At one unnamed facility, it said, "hand sanitizers were completely absent."

Officials at the 240-bed Palm Gardens did not respond to repeated requests for comment. Over the past year, the number of patients who were infected with or were carrying C. auris there grew to 38 from six, according to a nurse there and public health officials. The tally has now fallen into the high 20s after some patients died or moved elsewhere.

transcript

There once was a man named Albert Alexander. He was a policeman — "[American accent] Hey." — in England. "[British accent] Hello." One day on patrol, he cut his cheek — "Ouch!" — which led to a terrible infection. See, this was back in 1941, before patients had antibiotics. These were the days when a little scratch could kill you. "Or you got an ear infection and you died. A cat bite and you died. Or you stepped on a stick and you died. All of a sudden, antibiotics come along and bang." The antibiotic era had begun. Soon a slow and painful death became a seven-day course of antibiotics and a $10 copay. And Albert? Albert was the first patient in the world to receive the antibiotic — penicillin. And it worked. "We just came up with a lifesaving, life-extending drug, one of the greatest developments in human history. Except not." That's Matt Richtel, a science reporter for The New York Times. For the past year, Matt's been talking to health experts to find out if we are reaching the end of the antibiotic era. Modern medicine depends on the antibiotic. "And having used it so much, we’re now putting it at risk. Is our fate sealed?" "First off, I don't think people respect bacteria enough." This is Ellen Silbergeld, one of the leading scientists studying antibiotic resistance. "Bacteria rule the world. We are just a platform for bacteria. Within the human body, there are more bacterial cells than there are human cells. So we are, in fact, mostly bacteria." "Alexander Fleming —" the man who discovered penicillin "— in his Nobel speech said, hang on, be aware. When you start killing this stuff off, it's going to fight back." "Did we pay any attention to that? No." "The C.D.C. got our attention today with a warning about what it calls ‘nightmare bacteria.’" "These are bacteria that are resistant to most, if not all, antibiotics." When we take antibiotics to kill infections, some bacteria survive. It used to be they’d replicate, and eventually resistance would grow. But now, they’re way more efficient and share drug-resistant genes among themselves. So every time we take an antibiotic, we risk creating stronger, more resistant bacteria. And stronger, more resistant bacteria means less and less effective antibiotics. And this is a problem because we take lots of antibiotics. "Money gets made over the sale of antibiotics." Big money. Globally, the antibiotics market is valued at $40 billion. And in the U.S., the C.D.C. estimates that about 30 percent of all prescribed antibiotics are not needed at all. That's 47 million excess prescriptions. And in many places outside of the U.S., you don't even need a prescription. "You can walk into a pharmacy. A pharmacist will diagnose you and give you antibiotics. I tend to think of it as a story of Darwinian forces multiplied by the pace and scale of global capitalism. In an interconnected world — travel, import, export — we’re moving the bugs with us." "I can go to a meeting in China or Vietnam or some place —" This is Lance Price, the director of the Antibiotic Resistance Action Center. "I can become colonized by untreatable E. coli. And I might not have any symptoms. But you can get colonized. And you can become this sort of long-term host." So you could be healthy and still spreading bad bacteria without even knowing it. "Drug-resistant bacteria have never been able to travel the world as fast as they do today." And that's just part of the problem. "You should know that about 80 percent of antibiotic production in this country goes into agriculture." "Why on earth did somebody think putting antibiotics in agriculture was a great idea?" "We’ve said, hey, look, cram these animals together. Don't worry too much about hygiene or trying to keep them healthy. Just give them antibiotics. And then in a couple weeks, you’re going to have full-grown animals that you can chop up and eat. Right? And you can make money off of that." "Nobody was making the connection between feeding animals antibiotics and the fact that the food would be carrying drug-resistant bacteria." So Ellen did a study. She compared different kinds of store-bought chicken. And she found that poultry raised with antibiotics had nine times as much drug-resistant bacteria on it. "Now, let's talk about the vegetarians. I just want you to understand, you’re not safe. You know all these outbreaks that take place among the lettuce and the things like that. Have you ever wondered how that happened? It's because animal manure is used in raising crops. Organic agriculture lauds the use of animal manure." "Unless you’re just a complete, ‘I’m a vegan, and I only hang out with vegans, and I eat sterilized vegetables,’ you know, it's very likely that you’re picking up the same bacteria." Resistant bacteria seep into the groundwater, fly off the back of livestock trucks and hitch a ride home on the hands of farm workers, all of which makes trying to pinpoint exactly where resistant bacteria is originating extremely difficult. And even when it seems like there is a clear source, things still aren't so simple. "No one wants to be seen as a hub of an epidemic." Say your grandmother makes you a rump roast. And then that rump roast makes you sick. Well, if you live in France, or Ireland, or pretty much anywhere in the E.U., packaged meat has a tracking label. You can figure out exactly what farm that meat came from. But in the U.S., not even the top public health officials can do that. "Most countries have animal ID laws. We don't." Pat Basu, former chief veterinarian for the U.S.D.A.'s Food Safety and Inspection Service, basically one of the top veterinarians in the country. "Let me start at the beginning. We got a case where we had resistant bacteria causing illness in people. There were sick people that C.D.C. identified." "More than 50 people in eight counties have gotten an unusual strain of salmonella linked to pork." "This is not your grandmother's pathogen anymore. This is a new bug." Health officials traced the outbreak back to the slaughterhouse and identified six potential farms where the outbreak could have come from. But then the investigation shut down. "The individual farmers have to agree voluntarily to share the data with these investigators who go out. We couldn't go any further back. It was a dead end." 192 people sick, 30 hospitalizations and zero access for health officials to investigate the farms. "The secrecy is maintained because there are big economic forces behind it. Farms are scared of losing their ability to get antibiotics. Hospitals are scared of driving away patients." "Well, as a physician, I do get very upset. I get very upset, as a patient, that information is being withheld." This is Kevin Kavanagh, a doctor and a consumer advocate for patients. "Drug-resistant bacteria is a huge problem. If it occurs at a restaurant, if it occurs in a cruise ship, you know about this immediately —" "A salmonella outbreak —" "within days or hours of an outbreak occurring." "This morning, Chipotle is keeping dozens of its restaurants in the Pacific Northwest closed —" "But yet, in a hospital, it can take you months or even over a year until this data appears on a governmental website or reported by the C.D.C." In the U.S., hospitals are under no obligation to inform the public when a bacterial outbreak occurs. "Defend and deny. They are very concerned about the short-term economic benefits, rather than looking at long-term problems." "There's always this response like, well, but there's still a drug, right? Like, this isn't the end." Remember Albert Alexander? — "Hello. Ouch!" — the first patient to be given penicillin? Well, his story didn't end there. Five days after he started recovering, the hospital ran out of the new drug, and Mr. Alexander died. Today, we don't have to worry about antibiotics running out. We have to worry about using them so much that they stop working altogether. "— want to know why a metro health department didn't shut down a restaurant —" "It's a very resistant bacteria —" "We really need to change the way we use antibiotics. Because the way we use antibiotics is destroying them." "It's putting at risk the entire system of care that we depend on for lengthening our lives and improving the quality of our lives." The British government commissioned a study which predicted a worst case scenario where more people will die by 2050 of these infections than will die of cancer. "That's a generation from now." "It takes 10 years to identify, develop, test and bring to market a new antibiotic. And it takes a billion dollars." "This is a common issue for humanity." "Very similar to global warming." "You can't control it as a single company. You can't control this as a single government." And because the bacteria are now working together so efficiently — "Unless the world acts consistently together, it doesn't make a difference."

The New York health department issued a statement in response to queries from The New York Times: "The Department of Health has made controlling the spread of C. auris a high priority and has conducted extensive training and education on infection control policies and procedures for Palm Gardens and other nursing home providers throughout this region. The health and well being of nursing home residents is our primary concern and we take complaints regarding quality of care very seriously."

Scientific research on nursing homes and drug resistance is sparse, but some recent studies offer evidence of the problem. A study published in June in the Journal of Clinical Infectious Diseases found that patients and residents in long-term care settings have alarmingly high rates of drug-resistant colonization, which means they carry the germs on their skin or in their bodies, usually without knowing it, and can pass them invisibly to staff members, relatives or other patients. Elderly or severely ill people with weakened immune systems who carry the germ are at high risk of becoming infected. (Health officials in New York state said 14 percent of those now infected started out carrying it and then developed symptoms).

The study, which focused on Southern California, found that 65 percent of nursing home residents in that region harbored a drug-resistant germ, as did 80 percent of residents of long-term acute-care hospitals, where their "status is frequently unknown to the facility." By comparison, only 10 to 15 percent of hospital patients carried such germs, the study found.

The phenomenon is global. A study published in 2017 found that elderly residents of long-term care facilities in Britain were four times as likely to be infected with drug-resistant urinary tract infections as elderly residents living at home. Soaring levels of resistance were found in long-term care facilities in Italy, a 2018 paper found. And a 2019 study found that long-term care facilities in Israel are "a major reservoir" of carbapenem-resistant Enterobacteriaceae, or CRE — a major family of drug-resistant germs — contributing to their "rapid regional dissemination."

Experts said the problem is pronounced in the United States, given changing economics that push high-risk patients out of hospitals and into skilled nursing homes. The facilities are reimbursed at a higher rate to care for these patients, they said, providing an economic incentive for poorly staffed or equipped facilities to care for vulnerable patients.

C. auris, which is resistant to major antifungal medications, was first identified in 2009 in Japan and, as of July 31, had infected 796 people in the United States, largely in New York, Chicago and New Jersey, since its arrival here in 2015, according to the C.D.C. Another 1,540 people have been identified as carrying the germ on their skin or in their bodies without showing symptoms.

On Palm Gardens’ second floor, where Ms. Davila and other ventilated patients reside, signs posted outside nearly every room warn visitors and staff members to wear gloves, gowns and masks — a state requirement for those infected with C. auris.

But during two recent visits to Palm Gardens by a Times reporter, accompanying Ms. Davila's husband as his guest, orderlies and nurses moved in and out of her room without the required protection.

"The nurses and janitors are just spreading this thing from room to room," her husband, Anthony Hernandez, said on a visit in August, shortly after a nurse, who was wearing gloves but no mask or gown, poured liquid nourishment into his wife's feeding tube. During a brief interview in the lobby, Pamela Delacuadra, the center's director of nursing, said employees had initially struggled with the infection-control protocols required for C. auris.

"It was overwhelming at first but with help from the health department, we’ve gotten much better," she said.

Ms. Davila's medical records, reviewed by The Times, do not identify the specific date when she got C. auris. But a chart written by a Palm Gardens doctor in December 2018 includes a note listing her as a carrier of the fungus. She was put in isolation for C. auris patients, and her records subsequently referred to her as having the infection and taking antifungal medications for it.

Palm Gardens occupies a nondescript seven-story brick building in a working-class neighborhood in central Brooklyn. Magenta banners promote its dialysis center and adult day care services, as well as a "respiratory pavilion" for patients on mechanical life support.

A high-level official from a local hospital that has seen a number of C. auris patients from nursing homes said Palm Gardens was a major source. He declined to be named because his employer had not authorized any comment.

Palm Gardens's performance is poorly rated by the federal government; it received two stars, a below-average rating for staffing and overall care, from the Centers for Medicare and Medicaid Services, an agency that ranks nursing home care on a scale from one star to five. In 2018, the agency investigated the deaths of two ventilator patients at Palm Gardens, finding that employees had failed to turn their ventilators back on after performing mechanical checks. The patients died within minutes of each other, the report said.

C.M.S. declined to comment on Palm Gardens.

The ownership of Palm Gardens is controlled by someone identified as Shimon Lefkowitz, according to public filings.

Mr. Lefkowitz did not respond to efforts to reach him through Palm Gardens. Calls to several law firms that represent Palm Gardens in lawsuits were not returned.

Not all Palm Gardens residents with C. auris contracted the germ there, and it is not clear how many did. One patient who died was infected at Maimonides Medical Center in Brooklyn, according to the man's family.

Skilled nursing homes and long-term care facilities have been playing an increasingly important role in caring for seriously ill patients who used to stay longer in hospitals.

Advances in medical technology have made it possible to prolong the lives of desperately ill patients, while changes in Medicare reimbursement rates created a financial incentive for the expansion of such facilities, said Neale Mahoney, an economist at the University of Chicago who studies the industry's growth. There are now about 400 long-term care hospitals across the country, up from about 40 in the early 1980s, he said.

Since 2012, the number of skilled nursing homes with ventilator units rose to 436 from 367 — a significant jump but still a fraction of the nation's 15,000 nursing homes — according to C.M.S.

"Ventilator units are the poster child, the best example of a place that has challenges," said Dr. Alexander Kallen, an outbreak expert at the C.D.C.

The federal government reimburses facilities for ventilator patients at significantly higher rates than for other patients, according to C.M.S. Ventilated patients can bring in $531 a day compared to $200 for a standard patient. That's about $16,000 a month compared to $6,000.

The reimbursement rates reflect the significant care required for vulnerable patients, and the cost of equipment.

C.M.S. contends the majority of skilled nursing homes do well with staffing and overall care. Yet roughly 1,400 nursing homes received a one-star rating for staffing in 2018 from the agency.

"It is impossible for them to do a good job with the way their staffing is," said Dr. Mary Hayden, a professor at Rush Medical College who studies the rise of drug-resistant infections in health care, adding of the challenges of curbing drug-resistant infection: "The way they’re set up, they can't do it."

Ms. Davila carried C. auris with her on her journey through the health care system.

In early August, after a routine blood test found her white cell count plummeting, she was taken by ambulance to Methodist Hospital in Brooklyn for a blood transfusion. Doctors discovered an infection and put her on two different antibiotics. Heavy use of antibiotics, while often necessary, can kill off the nonresistant infections and allow resistant ones to thrive.

Her condition stabilized after two weeks and she returned to Palm Gardens. It was one of at least a dozen trips she had taken to the hospital since she first arrived at Palm Gardens.

Her sharp decline began in 2017 after pain from a suspected hernia sent her to the hospital. A lifelong smoker, Ms. Davila had emphysema, which led to a litany of complications and infections, according to a review of her medical records.

Now she spends her days frozen in bed, serenaded by a Latin music radio station and the mechanical whir of her respirator.

Mr. Hernandez doubts his wife will recover. "If I can take her home to die that would be a blessing," he said.

He pulled the blanket higher, turned up the radio and told his wife he loved her. Momentarily alert, she fixed her eyes on his and then mouthed: "I love you, too."

Benjamin Ryan contributed reporting.

Andrew Jacobs is a reporter with the Health and Science Desk, based in New York. He previously reported from Beijing and Brazil and had stints as a Metro reporter, Styles writer and National correspondent, covering the American South. @AndrewJacobsNYT

Matt Richtel is a best-selling author and Pulitzer Prize-winning reporter based in San Francisco. He joined The Times staff in 2000, and his work has focused on science, technology, business and narrative-driven storytelling around these issues.

@mrichtel

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