H5N1

Carbapenemase-producing (OXA-48) Klebsiella pneumoniae ST392 in travellers previously hospitalised in Gran Canaria, Spain

ECDC has published Carbapenemase-producing (OXA-48) Klebsiella pneumoniae ST392 in travellers previously hospitalised in Gran Canaria, Spain. The executive summary:

Between January and April 2018, Sweden and Norway reported a cluster of returning travellers who carried or were infected with carbapenemase (OXA-48)-producing Klebsiella pneumoniae ST392. All cases were associated with hospital admissions in Gran Canaria. Isolates from cases showed tight clustering when analysed by whole genome sequencing.    

This cluster of 13 patients colonised or infected with OXA-48-producing K. pneumoniae ST392 is an example of cross-border spread of carbapenemase-producing Enterobacteriaceae (CPE) in the European Union/European Economic Area (EU/EEA). Cross-border transfers of patients or hospital admissions of patients with previous hospitalisation in another country are a daily occurrence in EU/EEA hospitals.   

The risk for individual travellers to acquire OXA-48-producing K. pneumoniae ST392 of the Gran Canaria cluster without healthcare contact is very low. However, if carriers of OXA-48-producing K. pneumoniae ST392 of the Gran Canaria cluster are admitted to a hospital in their country of origin, there is a high risk of transmission and subsequent outbreaks if OXA-48-producing K. pneumoniae ST392 carriage remains undetected and there are no adequate infection control and prevention measures.  

This example highlights the benefits of active surveillance (screening) for CPE carriage, including OXA-48-producing K. pneumoniae ST392, immediately at hospital admission in patients who are directly transferred from a hospital abroad. It also shows the value of cross-country sharing of epidemiological and whole genome sequencing data as well as the added value of collaborative analyses to determine the origin of this OXA-48-producing K. pneumoniae ST392 cluster. 

UK: Almost untreatable superbug CPE poses serious threat to patients, doctors warn

Via The Guardian: Almost untreatable superbug CPE poses serious threat to patients, doctors warn. Excerpt:

Doctors are warning that the rise of an almost untreatable superbug, immune to some of the last-line antibiotics available to hospitals, poses a serious threat to patients.  

The number of lab-confirmed cases of the bug, called carbapenemase-producing Enterobacteriaceae (CPE), rose from three to nearly 2,000 in the 12 years to 2015, according to Public Health England (PHE). But that may be far short of the real number because hospitals are not compelled to report suspected cases. PHE admits it does not know where the infections are coming from or how many people are dying.

Freedom of information requests made by the Bureau of Investigative Journalism reveal that at least 81 people infected with CPE have died since 2009 at 66 NHS trusts in England – although the bug may have been a complicating factor rather than the main cause of death in some cases. 

But the real figure is almost certain to be much higher. Many trusts did not respond to the requests or were unable to supply complete data. Out of 136 NHS hospital trusts that were asked for the numbers of infections and deaths between 2009 and 2016, 97 responded but nearly half did not have data on CPE or could not extract the details. 

In Manchester and London, dealing with CPE has cost NHS trusts almost £10m. There have also been confirmed outbreaks in Liverpool, Leeds, Sheffield, Birmingham, Nottingham, Colchester, Edinburgh, Belfast, Dublin and Limerick, among others.  

Elsewhere, Italy had only sporadic cases of CPE in 2009 but by 2014, the bugs were rife across the country. “If you look at Italy they’ve suspended bone marrow transplant programmes,” said Dr Matthew Laundy, consultant medical microbiologist at St George’s University Hospitals NHS Foundation Trust. “If you’ve got no antibiotics to treat CPEs you’re stuck.” 

 Experts are calling for reports of suspected CPE infections to be made mandatory. The numbers revealed by the Bureau are “shocking,” said Val Edwards-Jones, emeritus professor of microbiology at Manchester Metropolitan University. 

“It should absolutely be mandatory for trusts to report this,” she said. “If you go back to the 1990s MRSA [reporting] wasn’t mandatory. It was only when hospitals did proper surveillance and began looking at the bugs in the blood that we knew the scale of the problem. Then it was found that there were certain things that weren’t being done correctly.”

Trends in carbapenemase-producing enterobacteriaceae, France, 2012 to 2014

Via Eurosurveillance: Trends in carbapenemase-producing enterobacteriaceae, France, 2012 to 2014. The abstract:

In 2014, a total of 2,976 Enterobacteriaceae isolates with decreased susceptibility to carbapenems were received at the French Associated National Reference Center for Antibiotic Resistance (NRC) and were characterised for their molecular resistance mechanism to carbapenems and compared with results obtained during 2012 and 2013.

The overall number of enterobacterial isolates with decreased susceptibility to carbapenems received at the NRC rapidly increased (more than twofold in two years) with a growing proportion of carbapenemase producers (23.1% in 2012 vs 28.6% in 2013 vs 36.2% in 2014). 

Between 2012 and 2014, the main carbapenemase type was OXA-48, with an increase in OXA-48 variants (mostly OXA-181) and NDM producers, whereas the number KPC producers decreased. We identified a potential spread of OXA-181 producers in the tropical region of Africa. Finally, OXA-48 and OXA-48-related enzymes remained the predominant carbapenemases in France. 

The number of carbapenemase-producing Escherischia coli isolates was multiplied by fivefold between 2012 and 2014, suggesting a possible dissemination in the community.

Beijing smog is rich in antibiotic resistance genes

Via Microbiome, a report with some disquieting implications: The structure and diversity of human, animal and environmental resistomes. "ARGs" stands for "antibiotic resistance genes." Excerpt from the results section:

Antibiotic-polluted environments have the highest abundances of ARGs 

Environments affected by pollution from pharmaceutical manufacturing were not only rich in ARGs but also carried the highest relative abundance of ARGs of all investigated environments (Fig. 1a). In particular, we identified exceptionally high relative abundances of the sulfonamide resistance gene sul2 and aminoglycoside resistance genes aph(6)-Id and aph(3”)-Ib together with a set of resistance genes to quinolones (qnr) and beta-lactams. The exact quantitative estimates of resistance genes should, however, be interpreted with caution since DNA from 7 out of 11 metagenomes from pharmaceutically polluted environments were amplified before sequencing, which can potentially introduce bias. 

The relative abundances of ARGs in wastewater/sludge were also higher (0.17 copies per 16S rRNA on average) compared to most other environmental habitats (sediment, water, soil and mine; 0.002–0.02 copies per 16S rRNA on average) all of which are likely less impacted by human faecal residues. 

Air from Beijing smog (see below), pharmaceutically polluted (38.9 different ARG types) and wastewater/sludge (19.4 different ARG types) environments carried more diverse sets of ARGs than did metagenomes from other external environments (1.6–3.3 different types of ARGs), animals (11.8 different ARG types) and humans (1.0–16.6 different ARG types). Note that these estimates only refer to genes identical or highly similar to known ARGs. 

Urban air has high abundance and diversity of ARGs 

Microbial communities from Beijing smog harboured the highest richness of known ARGs (64.4 different ARG types), as well as the highest bacterial richness of all environments. The relative abundance was however on the same level as the human gut and wastewater/sludge (0.3 copies of ARGs per 16S rRNA). 

To investigate if the high ARG richness was a general feature of air microbiomes, we compared the resistome profile of Beijing smog samples to indoor and outdoor air samples (generated on the 454 sequencing platform) from houses, office buildings and hospitals located in New York and San Diego. After normalizing for the very large differences in sequencing depth between the two datasets (using down-sampling), the air microbiomes from the US cities showed comparable relative abundances of ARGs. 

However, the richness of ARGs was higher in Beijing smog than in the air samples from US cities with the exception of office indoor air samples. Notably, the Beijing smog metagenomes contained several resistance genes to carbapenems, a class of last resort antibiotics, including IND, GES, IMP, OXA-50, OXA-51 and OXA-58 beta-lactamase gene types.

See this report in today's South China Morning Post for details on these findings. And as if that weren't bad enough, Beijing's air quality index stations are today reporting counts mostly in 300s (hazardous).

ECDC: Occurrence of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in Europe

ECDC has published Occurrence of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in Europe. Click or tap through for several related links.

​The global rise of carbapenemase-producing Enterobacteriaceae (CPE) is alarming and is an increasing threat to patient safety, in Europe and globally. It results in higher healthcare costs, prolonged hospital stays, treatment failures and sometimes death.  

In 2012, the European Centre for Disease Prevention and Control (ECDC) launched the the “European Survey on Carbapenamase-Producing Enterobacteriaceae''' (EuSCAPE) project with the aim to gather data on the occurrence of CPE in Europe and build laboratory capacity for their diagnosis and for surveillance. 

On the occasion of the 9th European Antibiotic Awareness Day, on 18 November 2016, The Lancet Infectious Diseases published the results of characterisation, including carbapenemase production, of 1397 carbapenem-resistant Enterobacteriaceae isolates collected in 455 European hospitals from 36 countries during the EuSCAPE project, giving the first complete snapshot of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in Europe. 

The survey showed that on average in Europe, 1.3 patients per 10 000 hospital admissions had a carbapenemase-producing K. pneumoniae or E. coli infection, with the highest incidence found in southern and southeastern Europe. In K. pneumoniae, the most frequently detected carbapenamases were KPC enzymes, followed by OXA-48-like, NDM and VIM, while in E. coli, there were OXA-48-like enzymes followed by NDM and KPC.  

The EuSCAPE project contributed to the improvement of the capacity and ability to detect CPE in European countries by creating a European network of national reference/expert laboratories able to provide information for monitoring incidence and spread of carbapenemases and CPE. 

These results highlight the need to develop a system for public health surveillance of CPE across healthcare systems in Europe as a tool to inform risk assessment and control programmes.

ECDC on Antibiotic Awareness Week

ECDC has published Combating resistance to last-line antibiotics in the EU still a priority. Click or tap through for several important related links.

​Survey results released by the European Centre for Disease Prevention and Control (ECDC) show that the situation continues to worsen with regard to the spread of carbapenemase-producing Enterobacteriaceae (CPE) in the EU, with 8 countries reporting an interregional spread and 3 countries an endemic situation. This means that in these 3 countries most hospitals are repeatedly seeing patients that cannot be treated with carbapenems, a last-line antibiotic group. 

On the occasion of the 8th European Antibiotic Awareness Day, ECDC is releasing the results of the European Survey of Carbapenemase-Producing Enterobacteriaceae (EuSCAPE) on the spread in Europe’s hospitals of bacteria resistant to carbapenems. On the other hand, the survey also shows that national capacity for the containment of CPE in the EU is increasing.   

Vytenis Andriukaitis, European Commissioner for Health and Food Safety said: “The ECDC results published today show that the threat of antibiotic resistance is increasing day by day.  If left unchecked, it has the capacity to turn the clock back on medicine by a hundred years.  

"We are working together with the Member States and our international partners to ensure that we strengthen the prevention and control of antimicrobial resistance across all sectors in a "one-health" approach and to secure the availability of new antimicrobial agents for the future”.   

ECDC is also releasing its latest data on antibiotic resistance (EARS-Net) and consumption (ESAC-Net) in Europe. Resistance continues to rise for most bacteria and antibiotics under surveillance; however, there are some exceptions like meticillin-resistant Staphylococcus aureus (MRSA). For the first time, data show a significant decrease in antibiotic consumption in the community in five European countries: Denmark, Luxembourg, Slovenia, Spain and Sweden. Nevertheless, antibiotic consumption in the hospital sector, overall and for carbapenems, is still increasing.   

ECDC Acting Director, Dr Andrea Ammon said: “The further spread of CPE, meaning bacteria resistant to carbapenems, a last-line group of antibiotics, is a cause for major concern in the EU as alternative options for the treatment of infected patients are limited. ECDC is encouraged to see that many EU countries have taken action to combat CPE, with national plans and other measures. However, there is more work to be done at all levels, local, national and European”. 

Dr Ammon added: “Decreasing antibiotic consumption in 5 countries shows that Europe is moving towards a more prudent use of antibiotics in the community. Prudent antibiotic use in both the community and in hospitals is critical to make sure that we are getting the most out of existing drugs”.   

Dr Zsuzsanna Jakab, WHO Regional Director for Europe said: “This year, on the first World Antibiotic Awareness Week, WHO/Europe releases its first report on antibiotic resistance in five non-EU countries of the European Region. Complementing the EU overview, data show that antibiotic resistance in non-EU countries is comparable with their EU neighbours. This is a first step to get a better insight of antibiotic resistance in the whole Region and provides guidance to countries that are building or strengthening their national surveillance. We call on all European countries to join WHO/Europe and ECDC’s networks and complete the picture.” 

To mark European Antibiotic Awareness Day, activities promoting prudent use of antibiotics under the banner “European Antibiotic Awareness Day and the global health challenges of antibiotic resistance” are being organised in more than 40 countries across Europe. ECDC is a partner of the World Health Organization for the first World Antibiotic Awareness Week with the slogan, “Antibiotics: Handle with Care”.   

The European Antibiotic Awareness Day, the United States “Get Smart About Antibiotics” Week, the Canadian Antibiotic Awareness Week and the Australian Antibiotic Awareness Week, as well as activities in New Zealand and Japan, are being launched simultaneously during the week of 18 November in an effort to show global solidarity in addressing antibiotic resistance.

Canada: Surrey Memorial hospital reporting unprecedented patient backups

Via CBC News, a report from my own back yard: Surrey Memorial hospital reporting unprecedented patient backups. Click through for the full report, including a video and a copy of the memo mentioned. Excerpt:

Surrey Memorial hospital is experiencing unprecedented congestion, according to an internal bulletin to staff obtained by CBC News.   

The memo reports, "the highest volume ever of patients in Emergency needing admission without assigned beds," as well as multiple infection outbreaks across the hospital including Clostridium difficile (C. difficile), influenza, CPE bacteria and respiratory conditions.  

The hospital says it is facing challenges getting patients discharged and has set up a site Operations Command Centre to investigate new strategies to deal with the overcrowding.  

"Every patient on every unit is being reviewed daily for potential discharge," says the bulletin. 

It asks staff to share their ideas for better "patient flow" and support management strategies for dealing with the congestion. 

The Fraser Health Authority says Surrey Memorial Hospital used to see about 300 patients a day, but now sees 300 to 400 patients daily. 

B.C. nurses respond 

 B.C. Nurses Union president Gayle Duteil says the Fraser Health Authority failed to  plan for a situation it should have anticipated. 

"They have not hired enough nurses to care for the patients that are coming through their doors in droves," she said.  

"This is winter surge for sure, but it happens every winter. We are working short. Nurses are working without proper staffing and there are shortages of nurses across the hospital today." 

Canada: BC microbiologist calls for better superbug alert system

Via The Globe and Mail: B.C. microbiologist calls for better superbug alert system. Excerpt:

Canadian hospitals need better warning systems when it comes to CPE, a potentially lethal superbug that has established a foothold in British Columbia, says a medical microbiologist who helped launch a provincial surveillance program for the bacteria. 

“One of the main challenges for the hospitals in B.C., as well as [elsewhere in] Canada and the rest of the world, is to maintain infection control and CPE alerts,” Dr. Linda Hoang, a medical microbiologist with the British Columbia Centre for Disease Control (BCCDC), said in a recent presentation.

“And also clear communication between facilities – so if one hospital is going to send a patient to another facility, there needs to be very close communication and alerts to warn the other hospital that a CPE case is on its way.” 

Dr. Hoang’s recommendations – made in a BCCDC presentation on Jan. 28 and subsequently posted online – echo those of other infection-control experts who have called for improved communication and even a national registry to monitor cases of CPE, or carbapenemase-producing enterobacteriaceae. 

CPE are bacteria that have developed a resistance to carbapenems, powerful antibiotics often referred to as the “drugs of last resort.” Healthy people can carry CPE without showing any symptoms. But the bacteria can cause problems when they travel into parts of the body where they do not belong, such as the urinary tract or bloodstream, and cause an infection. CPE infections can be fatal for up to 50 per cent of people who acquire them. 

CPE are an emerging global threat and a pressing reality in B.C., where a cluster of cases emerged in 2013 and where an outbreak was declared earlier this week. Fraser Health Authority, one of five regional health authorities in the province, cited “sustained transmission” of the bacteria on a unit at Royal Columbian Hospital, whose shared patient rooms make it more difficult to prevent transmission. Fraser Health said it had taken steps to control the outbreak, including separating patients who have been “colonized” with the bacteria and additional cleaning.

Canada: A CPE outbreak in a BC hospital

Fraser Health, the agency responsible for healthcare east of Vancouver, has issued a news release: Fraser Health informs public about CPE cases at Royal Columbian Hospital.

Fraser Health is informing the public of an outbreak of Carbapenemase-Producing Enterobacteriaceae (CPE) on a medicine unit at Royal Columbian Hospital. Infection prevention and control measures are already in place; however, because of sustained transmission of the bacteria on this unit, we are now declaring an outbreak and have implemented further measures. 

This includes separating patients, who are known through our screening protocol to be colonized, providing them with dedicated staff and equipment and clearly dividing the affected unit between patients who are carrying the bacteria and those who are not. As RCH is an older facility with most rooms being occupied by multiple people, this is a necessary and effective control measure. 

“We have been preparing for increased cases of CPE for some time and have adopted aggressive infection control protocols to detect and isolate these cases in our hospitals,” says Dr. Elizabeth Brodkin, Executive Medical Director for Infection Prevention and Control at Fraser Health. “Our patients and families can be confident that all measures are in place to protect them while they are in our care.” 

Over the past 10 years, there has been a global increase in the appearance of CPE. As international travel becomes more accessible, the prevalence of this bacteria in our region has also increased. Fraser Health has implemented a screening process for all patients admitted into our hospitals, particularly those being treated in intensive care units. The screening process involves asking whether or not patients have been admitted into a hospital or received renal dialysis outside of Canada within the past six months. Anyone who answers yes to the screening question will be tested for CPE. 

Health care providers working with patients who are carriers of CPE are taking extra measures to prevent spreading the organism to other patients. This includes the use of gowns and gloves during care and cohorting patients that are colonized with CPE. It is very important for visitors and health care providers to practice good hand cleaning at all times to help keep them and our patients safe. 

Unlike some other infections, CPE colonization develops slowly, which means it will take several weeks before we can declare the outbreak over. In the meantime patients and visitors should not be discouraged from coming to the hospital for care or to visit.

Canada: When do you have a superbug "outbreak"?

Via The Globe and Mail, a report by Wendy Stueck: 'Outbreak' or not? How superbugs test a hospital's practices on informing the public. Excerpt:

In the global cast of drug-resistant bacteria, carbapenemase-producing enterobacteriaceae – more commonly known as CPE – can be thought of as the brooding villains. They are resistant to nearly all antibiotics, they can spread resistant traits to other organisms, and as many as 50 per cent of people who get a serious CPE infection die.

Yet when Fraser Health Authority detected 41 patients carrying the potentially lethal bug in its hospitals in the last half of 2013, it was under no obligation to report that to the public. The reason? In Canada, individual health facilities to determine what constitutes an outbreak. Fraser Health has called the incidents a “cluster,” saying B.C. hospitals and infection control practitioners are still discussing guidelines on what determines an outbreak. 

The question of when a cluster becomes an outbreak – and whether and when the public should be told – is pertinent not only to Fraser Health, which serves more than 1.6-million people in the Fraser Valley east of Vancouver. It highlights the challenges for Canadian hospitals when it comes to getting ahead of CPE, which began to show up in Canada around 2010. 

Health facilities are grappling with questions around the best ways to screen and test for the bacteria, the costs associated with increased testing and even whether screening can do harm. A June conference on antimicrobial-resistant organisms in Calgary, for example, includes a session that will discuss whether screening can result in patients receiving reduced care due to “leperization” and isolation. 

Fraser Health, meanwhile, is dealing with a new reality – asking patients admitted to its sites whether they have traveled outside Canada within the last six months. Those who answer yes are tested for CPE. The authority currently has about a dozen cases and expects CPE to be an ongoing issue. 

“We have not provincially decided on the definition of what an outbreak means,” Elizabeth Brodkin, Fraser Health’s medical director of infection prevention and control, said last week in discussing the cases. “So I wouldn’t use the term outbreak. We saw a cluster, which clearly we needed to respond to. And the measures we put in place were very satisfactory in bringing the numbers down.”