“So MRSA has been a success story. And that also is true outside of the VA system to some extent as well,” Donskey said.

Unfortunately, while rates of MRSA infections have declined, rates of another HAI, Clostridium difficile, have increased across the country.

C. difficile is a bacterium that can infect patients whose normal balance of intestinal bacteria has been altered, especially the elderly or those with weakened immune systems. This imbalance of intestinal flora can be a result of long-term or broad-spectrum antibiotic treatment for other illnesses. With the other bacteria diminished, C. difficile takes over and its growth in the gut produces toxins leading to severe diarrhea and other serious intestinal illnesses.

“In the United States, rates of Clostridium difficile infections tripled during the past decade, from about 2002-2003 through the present,” said Donskey, whose research efforts focus primarily on C. difficile. “We’ve had a lot more serious infections and deaths due to C. difficile. We estimate that it kills about 14,000 Americans every year in hospitals, and probably more than that if you include long-term care facilities and outpatient settings. So C. difficile arguably has kind of outpaced MRSA. And with the success we’ve had with MRSA, C. difficile has emerged as the bigger problem at the moment.

Acinetobacter baumannii is another HAI-causing pathogen receiving attention as outbreaks among soldiers returning from Iraq and Afghanistan have been reported.

“The big increase has been associated with the emergence of a new epidemic strain that’s circulated around the United States that seems to be more prone to spread and potentially more virulent than previous strains,” Donskey explained. “So this is a common problem, and again, with the VA patient population, with a lot of elderly patients, a lot of long-term care facility patients, a lot of patients who need antibiotic treatment, our population is really set up for having issues related to C. difficile.”

While the rates of C. difficile infection have been on the rise, Donskey continued, “We don’t usually think of it as much as a multi-drug resistant strain as we do with other pathogens, because the standard treatments for C. difficile are still effective. This new strain, however, is more resistant to some of the antibiotics that we use in the hospital, like fluoroquinolones [a family of broad-spectrum antibiotics used in the treatment of HAIs and other serious infections], and this new strain may be allowed to spread more easily because of that. So antibiotic resistance does play a role in its spread, but we don’t have a real issue in terms of treatment.”

Acinetobacter baumannii is another HAI-causing pathogen receiving attention as outbreaks among soldiers returning from Iraq and Afghanistan have been reported. “The CDC [Centers for Disease Control and Prevention] has recently directed a lot of attention toward these carbapenem-resistant Acinetobacter baumannii,” said Donskey. Carbapenems are a group of antibiotics used to treat bacteria that are highly resistant to antibiotics; sometimes considered antibiotics of last resort for some infections. “Those organisms are certainly an important problem in certain areas of the country. There are some areas where they cause much less of a problem. There have been some reports of multi-drug resistant Acinetobacter within the VA system, [however] I’m not aware of a lot of problems related to Acinetobacter baumannii in the VA system as much as in other hospitals. Those have been particularly in the Northeast, although now they’re beginning to spread around the United States. So, Acinetobacter is certainly a problem, but it’s not a particular problem within the VA yet.”

“We’re watching very carefully with concern that resistant Acinetobacter and Klebsiella and other carbapenem-resistant organisms could spread within our population.”

Donskey added that among soldiers returning from the Middle East, “we have seen some outbreaks related to multi-drug resistant gram-negative organisms like Acinetobacter … So that has certainly raised a lot of concern recently, although to date we haven’t seen a lot of evidence that those organisms are spreading widely beyond that population.”

Klebsiella is another organism that is in a category similar to Acinetobacter. Donskey explained, “There is now a strain of Klebsiella pneumoniae which produces carbapenemases, which are enzymes that break down carbapenems, part of our last line antibiotics for treatment of organisms like Acinetobacter and Klebsiella. So there’s a lot of concern about the recent emergence and spread of carbapenem-resistant enterobacteriaceae, and primarily that’s Klebsiella that we’re concerned about … So they’re certainly a problem in many areas of the United States and around the world, but not a particular problem within the VA system more so than elsewhere.” However, he added, “We’re watching very carefully with concern that resistant Acinetobacter and Klebsiella and other carbapenem-resistant organisms could spread within our population.”

With the success of the measures aimed at reducing rates of MRSA infections, the VA continues to place heavy emphasis on mitigating the spread of other HAIs in addition to MRSA. In 2011, the MRSA Initiative program was expanded and the name changed to the MDRO (Multi-drug Resistant Organisms) Initiative to focus on other HAI-related pathogens, with the initial emphasis of the expansion on the reduction of the Clostridium difficile infections cited above by Donskey.

While the MDRO bundle of infection control strategies is similar to the MRSA Initiative, Donskey said, “probably the major component of that bundle is going to be improving environmental disinfection.”