WHEN THE DIRECTOR of the Social Security Fund (CSS), Guillermo Sáez-Llorens, appeared before the National Assembly on August 13, to answer questions on his management. He dodged, couldn't recall, stonewalled or passed the buck to his deputies.

Says La Prensa: There, on the podium, standing before the deputies, officials and a whole country following him expectantly, he was questioned about the deaths from the bacterium Klebsiella pneumoniae resistant carbapenemase (KPC), reported in the Hospital Arnulfo Arias MadridComplex and uncovered by the media in July 2011.

"When I heard about the KPC was precisely on the news and then I took action," said Sáez-Llorens.
But who was responsible for communicating? Should the CEO of CSS have known of an alert issued to the hospital? Did he breach his duties as a public servant?, were questions that he did not want to answer
However says La Prensa documents to which it had access access show that authorities at the Hospital Complex were alerted months before before the presence of the killerbacteria in the hospital was confirmed.

The first note, dated June 1, 2010, was sent by José Luis Moreno, coordinator of the Committee of Nosocomial Infections, to Alonso Alvarado, then medical director of the Complex, to bring it to the attention of some cases of hospitalized patients with KPC.
The document noted that control of all cases with these microorganisms must be managed with contact precautions to prevent the crossing of these strains to patients, visitors and staff of the entity.

"Of the five patients, all had more than 15 days of hospitalization and were managed in different areas of the hospital. Of the patients who died with this organism both had multiple risk factors and organ failure, prolonged hospitalization and critical management in the intensive care unit for the underlying condition, "the letter said.

Six months later, on December 20, 2010, Moreno sent another note to the Medical Director of the Hospital, now under the responsibility of Roberto Mitre, which details the confirmation of the KPC enzyme strain in two of the patients requiring "strict" compliance with standard prevention measures.

"This is a voice of warning to health personnel attending the patient directly. It is important that preventive measures be taken to prevent this strain causing nosocomial infection in view of that action must be taken against the drug resistant strain circulating in the community, "the letter concludes.

Despite these microbiological alert notifications, cases were increasing, and on May 15, 2011, the Committee of Nosocomial Infections (among its functions is advisor to the Medical Director of the Complex) had 23 patient detected with KPC Moreno again called on Mitre, to implement basic biosecurity measures.

On June 3, 2011, Moreno sent to his superiors the last warning notr as coordinator of the Committee of Nosocomial Infections and five days later, ie on June 8, was relieved of duty by order of the authorities CSS.

The letter denotes a certain desperation in Moreno, as the problem had increased in the hospital setting.

He mentioned that the Committee was "increasingly concerned" about the detection of Klebsiella pneumoniaeresistant strain to antibiotics and, despite all the measures and verbal and written recommendations, these did not have enough impact on health staff despite the apparent increase in cases.

"It is important that this information be disclosed and at local levels take greater interest in services primarily involved with this strain, in efforts to unite in control of it because it is a serious situation," was highlighted.
Until then no media had reported on the KPC, and the CSS authorities were silent about what was happening with patients. Only when the situation peaked in July 2011, was there official communication.

The first to provide information was the deputy national executive and Services Health Benefits of CSS (now head of office), Liska Richards, who said on July 28 that KPC patients who had died had more than one disease and their defenses were"too low".

From that date, the CSS began to implement measures such as the transfer of patients to Hospital December 24, and requiring medical personnel meet the standards of biosecurity and paying attention to disinfecting rooms
However, on several occasions during that period, medical associations urged the Hospital responsible to buy grooming equipment and gloves, as the existing supplies served only for regular work.

The complaints about lack of cleaning implements and other equipment were supported by the Pan American Health Organization (PAHO) in a report prepared for the health crisis
PAHO staff made a reconnaissance visit, the August 3, 2011, the main areas of the hospital where patients were in the KPC isolation, to verify conditions.

International agency experts detected that not all of the essential inputs were in the areas of patient care to enable the precautionary measures, such as soap, paper hand dryers, alcohol gel, gowns and gloves.

Nor was there equipment for the care of patients, including stethoscope, sphygmomanometers and individual thermometers.

PAHO referred to there was lack of standards of cleanliness and knowledge of the staff of the recommendations for cleaning equipment and flat surfaces. Similarly, there were no monitoring patterns to verify nursing procedures. Antiseptics were not in their original bottles and did not have identification and expiration date.

The PAHO report also determined that the KPC grew betweenMarch and April 2011 and peaked in July re

On deaths from the bacteria, PAHO noted that the August 3, 2011had a cumulative total of 71 patients with KPC isolation and of that amount were 37 dead August 11, 2011.

Of these patients, a percentage between 46.5% and 60.5%, wasdistributed in different rooms or medical services, as in intensive care units at the time of making the first positive sample.

According to death certificates included in the clinical record, the cause of death in 72.9% of the 37 patients had an infectious origin.

In the process of the investigations the existence of other multi-resistant bacteria, such as Clostridium difficile, Enterobacter KPC, Acinectobacter, Pseudomonas were detected.

MINSA INFORMED

The statements of officials are in the prosecutors’ files shows that the Ministry of Health (MoH), , had been informed of the bacteria since 2010

Under oath, Eduardo Lucas Mora, then general manager of Health MoH confirmed he knew of the presence of the KPC at the Hospital on December 20, 2010, by the Central Reference Laboratory in the CSS.

Mora said in his statement that such the alarm system was immediately activated and the MoH t sent circulars to all public and private hospitals with recommendations to follow.

He stated that weekly monitoring reports that each hospital should be referred to the Department of Epidemiology MoH
He said that CSS National Epidemiology Epidemiology sent a note to the MoH to report the presence of two strains producing KPC and had taken measures to control and monitor the situation.

The former director general of Health highlighted, according to his statement, that no mention of the KPC was subsequentlymade until the received epidemiological report in week 22 - 29 May to 4June 2011, in which 33 cases and three deaths were reported

After that scenario, he said the MoH, together with a mission of PAHO, visited the Hospital to aprise the situation. He said that help from the international organization was offered to support CSS consultants so that further analysis could be done.done.

Nevertheless, he said, SSC did not respond to his offer. However, Mora concluded that once the outbreak was detected control measures were not appropriate
Repeated questionnaires were sent to the director of the CSS, Guillermo Sáez-Llorens, but he said nothing, says La Prensa.
SUFFERING FAMILIES
The number of people killed by KPC in the Arnulfo Arias Madrid Complex varies depending on the authority. But three years after the health crisis, relatives of victims still react with anger, frustration and pain asking why a health facility, produced suffering and death?
La Prensa lists cases of people with relatively minor problems, ending up dead. One man from Taboga who had a cut on his toe, was discharged. d. The next day he was taken back to hospital and stayed and ended up dead. His brothers are still waiting for explanation from the authorities of the CSS and for punishment for those responsible.

In a mixed order, the Tenth Circuit Prosecutor requested for trial of six for the alleged crime of manslaughter, and a temporary stay for another five.

At a hearing July 28, 2014, prosecutor Vielka Vargas Byrne established that for those accused , members of the Infection nosocomial, there is sufficient evidence to open a criminal prosecution for the crime of manslaughter.