Volume 17, Number 8
August 2, 2011
Deadly drug resistant bacteria outbreak at main CSS hospital
A scanning electron micrograph of an infected mouse lung shows a Klebsiella pneumoniae bacterium (pink) snared in a neutrophil extracellular trap (green), a web of decondensed chromatin released by neutrophils to catch and kill pathogens. For a higher resolution image, click here. Image by Volker Brinkmann and Abdul Hakkim, Journal of Cell Biology.
Once again, lives may have been lost because the government concealed a health crisis
by Eric Jackson
Klebsiella pneumoniae is among the most common gram-negative bacteria encountered by physicians worldwide. It is a common hospital-acquired pathogen, causing urinary tract infections, nosocomial pneumonia, and intraabdominal infections. K. pneumoniae is also a potential community-acquired pathogen.
US Centers for Disease Control
Emerging Infectious Diseases, 2002
The only levels of responsibility that the Social Security Fund can assume in this matter is if there were a case of negligence duly proven in the courts.
CSS deputy director Marlon De Souza
This administration has put the health of the Panamanian people in direct danger, by not buying the necessary cleaning materials, surgical supplies and other services, the consequence of which is the contamination of the hospital environment with hard-to-control bacteria.
John Höger Castrellón
surgeon, treasurer of COMENENAL,
former mayor of San Miguelito
The outcome was going to be the same.
CSS deputy director of health infrastructure
arguing that the infected patients who died would
have died from what put them in the ICU anyway
We regret the deaths at the CSS. Bacteria exist in all hospitals and places. They tell me that everything is under control. We support the CSS.
President Ricardo Martinelli
As it deals with technical information and to avoid unnecessary panic, no hospital in the world would release these reports to public opinion.
defending secrecy and lies
The basic story on which all appear to agree is that at least 50 people in the intensive care unit of the Social Security Fund (CSS) flagship hospital, the Arnulfo Arias Hospital Complex that's adjacent to the University of Panama, were infected with a drug-resistant strain of Klebsiella pneumoniae and that at least 16 of those who were infected died. These bacteria are "Gram-negative" --- that is, they do not retain crystal violet dye in the Gram staining protocol, which indicates certain properties of their cell walls, particularly the lipopolysaccharide (LPS) layer that triggers immune responses. These properties make such bacteria immune to many antibiotics in the best of circumstances, but Gram-negative bacteria also more readily swap genes with other microbes than do Gram-positive bacteria, which tend to create fast-mutating "moving targets" over the course of a disease outbreak. Of particular concern is when they acquire genes for extended spectrum beta-lactamases (ESBLs), which render them immune to many antibiotics.
There are at least two strains of drug resistant Klebsiella pneumoniae going around in the world. In July of 2010 the Pan-American Health Organization reported an outbreak of one of these strains in Argentina and some cases in other Latin American countries. This year there have been drug resistant Klebsiella pneumoniae outbreaks in several European countries, with a death rate of about 40 percent of those infected. There are a few antibiotics that can be used, and sometimes palliative care will save the patient as the infection runs its course. Sometimes the infections can be so bad that surgery is required to remove dead tissues, for example parts of the intestinal tract in an abdominal infection. The important things when there is an outbreak of drug resistant Klebsiella pneumoniae in a hospital is to isolate the patient and disinfect all areas where the patient has been. Because this can take the form of a contagious respiratory infection, it can get into ventilating systems and spread throughout a hospital that way, which can turn disinfection into a herculean task.
The public first heard about this outbreak not from the mainstream media but from the labor movement, with FRENADESO Noticias reporting on June 20th that a particularly deadly strain of bacteria was going around on several floors of the main CSS hospital complex and that people had died. Over the following days AMOACSS (the CSS doctors' association) and COMENENAL (the alliance and joint bargaining committee of physicians' organizations whose members work in the public health care system --- the CSS and the Ministry of Health hospitals and clinics, and the various hybrid facilities set up under government-controlled but ostensibly private foundations), weighed in with cautious statements about the situation. The CSS employees' caution derived in part from a June 13 edict from director Guillermo Sáez Llorens threatening to fire any CSS employee who talks to the press or anyone else outside of the institution about any matter affecting the CSS.
Political warfare between public health care system employees and managements? That's the norm, and certainly nothing new for President Martinelli. However, as the dates and details of this particular problem began to emerge, it began to appear that the Sáez Llorens gag order was not a random generic bit of labor bashing by an anti-union administration, but part of a desperate information control effort related to the Klebsiella pneumoniae outbreak. From CSS and Ministry of Health management statements, the pronouncements of organized labor and reports in both the mainstream and the left press (including pro-Martinelli media), there has emerged a timeline that goes something like this:
The Martinelli administration's defensive reaction to this problem at the hospital complex is colored by the president's long years of hostility to CSS employee unions. He was CSS director during the Pérez Balladares administration and his tenure was marked by battles with the unions. They all came to a head when 11 kidney patients died during or shortly after dialysis. The chemical containers from the machines all disappeared before investigators could inspect them, a wall of silence went up and the cause of the deaths was never officially established. Most probably some bad --- possibly expired or possibly improperly stored --- dialysis chemicals were used. Former First Lady Ana Mae Díz de Endara proclaimed that the basic cause of death was Martinelli's mismanagement, which prompted Martinelli to bring a criminal defamation charge against her. Former President Guillermo Endara came to his wife's defense and made some bigoted and apparently untrue remarks about Martinelli's sexual orientation, and Martinelli charged him with criminal defamation for that. In the end, Mrs. Endara was acquitted and Mr. Endara was convicted but quickly pardoned by Mireya Moscoso. However, long before those legal cases ran their courses Toro asked for Martinelli's resignation and it has been a cause of bitterness between Martinelli and both Pérez Balladares and the CSS unions ever since.
During the Moscoso administration, at least 28 patients received radiation overdoses while being treated for cancer on a machine at the Instituto Oncologico Nacional. A bunch of health care professionals were blamed and received penalties ranging from license suspensions to a prison term. However, the US-designed software for that machine was faulty, and the hospital had no operator's manual for the machine. The case was aggravated when, apparently from a group of international investigators, La Prensa obtained the medical records of the overdose victims and published them.
During the Torrijos administration a politically connected importer who had the contract to supply chemicals to the now defunct CSS medicine production lab bought what it thought was glycerin from a Spanish wholesaler. Some of the jugs of that lot actually contained toxic diethylene glycol (DEG), which had been labeled by its Chinese manufacturer, in Chinese, as "substitute" glycerin. The chemicals made their way through a Chinese exporter, a Spanish wholesaler and the Panamanian importer, with the labels getting changed at least twice before coming to the CSS lab, where the DEG was mixed into cough syrup. Although the official death toll is much lower, hundreds died and many more were made seriously ill. At least three of the patients who died from the Klebsiella pneumoniae infections were being treated for the toxic effects of tainted cough syrup that they ingested in 2006. In order to minimize government spending and personal political blame, the Torrijos administration cut off funds for the toxicology tests on the remains of those who were thought to have died from DEG poisoning, and those who claimed that they were sick from this cause. After a short while DEG degrades and it becomes impossible to positively identify in either living or dead tissues. President Torrijos took the position that without an absolutely positive toxicology report, a poisoning didn't happen. When a crowd of sick people descended on the Presidencia to protest, the SPI presidential guards beat them up. The most serious aggravating factor, which has never been the subject of any official investigation, was that in July of 2006 the CSS and Ministry of Health managements were told by health care workers that there was a problem with mysterious sudden deaths and illnesses, but this information was suppressed and not acted upon until late September of that year, leading to many more deaths than if the matter had been dealt with promptly and transparently. There are still ongoing criminal cases from that incident.
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