H5N1

Extensively drug-resistant Klebsiella pneumoniae ST307 outbreak, north-eastern Germany, June to October 2019

A rapid communication to Eurosurveillance: Extensively drug-resistant Klebsiella pneumoniae ST307 outbreak, north-eastern Germany, June to October 2019. The abstract:

From June to October 2019, 17 patients (six infected, 11 colonised) with an extensively drug-resistant (XDR) Klebsiella pneumoniae strain were notified from four Western Pomerania medical facilities. The XDR K. pneumoniae produced carbapenemases NDM-1 and OXA-48, and was only susceptible to chloramphenicol, tigecycline and cefiderocol. Synergistic activity was observed for the combination of aztreonam plus ceftazidime-avibactam. Genomic analyses showed all isolates belonged to K. pneumoniae sequence type 307. Control measures and further investigations are ongoing.

ECDC: Surveillance of antimicrobial resistance in Europe 2018

ECDC has published Surveillance of antimicrobial resistance in Europe 2018. Excerpt from the executive summary: 

As in previous years, the AMR situation in Europe displays wide variations depending on bacterial species, antimicrobial group and geographical region. For several bacterial species–antimicrobial group combinations, a north-to-south and west-to-east gradient is evident. In general, lower resistance percentages were reported by countries in the north while higher percentages were reported in the south and east of Europe. The high variability in AMR across EU/EEA countries reinforces the scope for significant reductions through investments to strengthen current best practice.   

In 2018, more than half of the Escherichia  coli isolates reported to EARS-Net and more than a third of the Klebsiella pneumoniae isolates were resistant to at least one antimicrobial group under regular surveillance, and combined resistance to several antimicrobial groups was frequent. Resistance percentages were generally higher in K. pneumoniae than in E. coli. While carbapenem resistance remained rare in E. coli, several countries reported carbapenem resistance percentages above 10% for K. pneumoniae. 

Carbapenem resistance was also common in Pseudomonas  aeruginosa and Acinetobacter species, and at higher percentages compared with K. pneumoniae. For all four gram-negative bacteria, the countries reporting the highest carbapenem resistance percentages were also among the countries reporting the highest resistance percentages for other antimicrobial groups. For most gram-negative bacterial species–antimicrobial group combinations, changes in resistance percentages between 2015 and 2018 were moderate, and resistance remained at previously reported high levels.  

For Streptococcus pneumoniae, the resistance situation appeared stable, but with large inter-country variations. For Staphylococcus aureus, the decline in the percentage of methicillin-resistant (i.e. MRSA) isolates reported in previous years continued in 2018. Nevertheless, MRSA remains an important pathogen in the EU/EEA, as the levels of MRSA were still high in several countries, and combined resistance to other antimicrobial groups was common. 

Emergence of ceftazidime-avibactam-resistant Klebsiella pneumoniae during treatment, Finland, December 2018

Via Eurosurveillance: Emergence of ceftazidime-avibactam-resistant Klebsiella pneumoniae during treatment, Finland, December 2018. The abstract:

In December 2018, a ceftazidime-avibactam (CAZ-AVI)-resistant KPC-2-producing Klebsiella pneumoniae strain was isolated in Finland. CAZ-AVI resistance was observed 34 days after CAZ-AVI treatment in a trauma patient transferred from a hospital in Greece who had been colonised with bla_KPC-2-producing K. pneumoniae ST39, and later developed a bloodstream infection. The CAZ-AVI-resistant strain contained a novel 15 amino acid insertion in the KPC-2 protein causing structural changes proximal to the KPC-2 active site.

'We're holding up a floodgate': BC fights off superbugs brought home by medical tourists

Via CBC News: 'We're holding up a floodgate': B.C. fights off superbugs brought home by medical tourists. Excerpt:

The risks involved in medical tourism aren't just personal. Having surgery abroad could also mean bringing back a drug-resistant superbug and putting people in this country at risk, B.C. officials warn. 

That alert comes after the recent discovery that two patients at New Westminster's Royal Columbian Hospital had been colonized with the multidrug-resistant yeast Candida auris. Though neither patient is infected with the bug, the two join just a handful of cases that have been identified in B.C. since 2017.  

Dr. Linda Hoang, medical co-director for the Provincial Infection Control Network (PICNet), said most of these cases have come from travellers who have had treatment overseas, including medical tourists. 

It means patients need to do serious research on the facilities they're considering for surgeries or other treatments abroad, including looking for objective information about the presence of any drug-resistant microorganisms.  

"It's not only a problem in India or Southeast Asia. It is endemic in parts of the U.S. and parts of Europe," Hoang told CBC News.  

"It [antibiotic-resistant superbugs] is a global problem, and the only way to to be aware of them is to make sure that health-care professionals are informed and our residents are informed when they're seeking health care outside of British Columbia." 

It's a sobering reminder for those who travel abroad for medical treatments, whether it's to skip the surgery wait list in B.C., access therapies that aren't approved in Canada or save money on cosmetic therapy. Some of the top destinations for medical tourists from around the world include India, Mexico, Southeast Asia, Brazil and Turkey, according to the Medical Tourism Association.  

But facilities in other countries can sometimes take a more haphazard approach to prescribing antibiotics, and overuse can trigger the evolution of resistance to these crucial drugs.  

India a major source of bug 

The two colonized patients at Royal Columbian were isolated after the bug was discovered, and the hospital has been aggressively cleaning all areas they had visited, using UV light for disinfection, according to Fraser Health. 

C. auris was first identified in Japan in 2009, but it has popped up since then in countries around the world. 

It acts much like any other yeast species, causing infections in wounds, the bloodstream and the ears, but the real problem is how to treat it. 

"The only real reason why we're concerned or interested in monitoring Candida auris is because of that potential resistance profile, making it difficult to treat with the anti-fungal agent that we have," Hoang said. 

The biggest risk of infection right now seems to come from Indian facilities, Hoang said.

The bug was confirmed for the first time in B.C. in July 2017 in a patient who'd been treated in India. As it turned out, that traveller also came back with infections from multiple other drug-resistant organisms. 

B.C. doesn't track whether infected people travelled abroad as medical tourists or simply required medical treatment because of an emergency during their voyages. 

But patients who have had medical treatment outside B.C. for any reason are a major source of these superbugs, she said.

They include so-called CPOs — carbapenemase-producing organisms like Klebsiella, E. coli and Pseudomonas that have become resistant to broad-spectrum antibiotics, which Hoang describes as the "last resort" for treatment. 

In 2017-2018, PICNet recorded more CPO cases than ever before, and more than half of them were from people who had accessed health care overseas, Hoang said.

Climate change and antibiotic resistance

Via bioRxiv: Rates of increase of antibiotic resistance and ambient temperature in Europe: a cross-national analysis of 28 countries between 2000-2016. The abstract:

Background. 

Widely recognized as a major public health threat globally, the rapid increase of antibiotic resistance in bacteria could soon render our most effective method to combat infections obsolete. Factors influencing the burden of resistance in human populations remain poorly described, though temperature is known to play an important role in mechanisms at the bacterial level. 

Methods. 

We performed an ecologic analysis of country level antibiotic resistance prevalence in 3 common bacterial pathogens across 28 countries in Europe, and used multivariable models to evaluate associations with minimum temperature and other predictors over a 17-year period (2000-2016). We quantified the effects of minimum temperature, population density, and antibiotic consumption on the rate of change of antibiotic resistance across geographies. Findings. 

For three common bacterial pathogens and four classes of antibiotics, we found evidence of a long-term effect of ambient minimum temperature on rates of increase of antibiotic resistance across 28 countries in Europe between 2000-2016. 

Specifically, we show that across all antibiotic classes for the pathogens E. coli and K. pneumoniae, European countries with 10°C warmer ambient temperatures have experienced more rapid increases in antibiotic resistance over the 17-year period, ranging between 0.33%/year (95% CI 0.2, 0.5) and 1.2%/year (0.4, 1.9), even after accounting for recognized drivers of resistance including antibiotic consumption and population density. 

We found a decreasing relationship for S. aureus and methicillin of -0.4%/year (95% CI -0.7, 0.0), reflecting widespread declines in MRSA across Europe over the study period. 

Interpretation. 

Ambient temperature may be an important modulator of the rate of change of antibiotic resistance. Our findings suggest that rising temperatures globally may hasten the spread of resistance and complicate efforts to mitigate it.

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. 

Rise of carbapenem-resistant Enterobactericaeae: A threat to health in Europe

ECDC has published Rise of carbapenem-resistant Enterobactericaeae: A threat to health in Europe. Excerpt:

Infections with bacteria resistant to carbapenems, a group of highly effective antibiotics, pose a significant threat to patients and healthcare systems in all EU/EEA countries, warns ECDC in a Rapid Risk Assessment.  

Resistance to carbapenems has been reported with increasing frequency and geographical spread since the beginning of the 1990s. The global rise of carbapenem resistance in a certain family of bacteria called Enterobacteriaceae, or carbapenem-resistant Enterobactericaeae (CRE), represents a threat to healthcare delivery and patient safety.  

“We should be very concerned about the rise in carbapenem resistance in the EU/EEA as there are very few options for the treatment of patients with CRE infections” says Dominique Monnet, Head of ECDC’s Antimicrobial Resistance and Healthcare-Associated Infections Programme. 

“In recent years, the proportions of carbapenem resistance in Klebsiella pneumoniae – a type of Enterobacteriaceae – rapidly increased to high levels in Greece, Italy and Romania. The same could happen to other EU/EEA countries if appropriate measures are not taken. But the spread of CRE can likely be controlled in most countries through the implementation of appropriate prevention and control measures in hospitals and other healthcare settings.”  

CRE are often a cause of urinary tract infections and bloodstream infections in hospital settings. Such infections are associated with prolonged hospital stays, high treatment costs, treatment failures and high mortality, primarily due to delays in the administration of effective treatment and the limited availability of treatment options. 

Data from the European Antimicrobial Resistance Surveillance Network (EARS-Net) for 2016 show large differences in the national percentages of carbapenem resistant bloodstream infections caused by Klebsiella pneumonia, ranging from 0% to as high as 67%, depending on the country. Although prevalence is still low in most European countries, Romania, Italy and Greece, with 31%, 34% and 67%, respectively, are among the countries reporting the highest prevalences worldwide.  

In general, if the frequency of resistance to an antibiotic is high, it cannot be recommended for empiric treatment anymore due to the risk of failure. In case of CRE infection, there is no good antibiotic alternative for empiric treatment that does not carry serious side effects or other complications.

CIDRAP: MCR-1-carrying Shigella found in China

Via CIDRAP, Chris Dall writes: MCR-1-carrying Shigella found in China. Excerpt:

Scientists in China have for the first time identified the colistin-resistance gene MCR-1 in a species of bacteria that's one of the leading causes of diarrhea worldwide. 

In a study today in Applied and Environmental Microbiology, the scientists report that they identified the gene in a single isolate of Shigella flexneri found in pig stool samples from a farm in Guangxi province. The isolate was among more than 2,000 S flexneri isolates, mostly from stool samples of patients, screened by the scientists. 

Since the existence of the MCR-1 gene was first reported in Escherichia coli samples from pigs, pork products, and humans in China in 2015, it has been detected in more 30 countries. But it's mostly been found in E coli and other Enterobacteriaceae from animals and humans, mainly Klebsiella pneumoniae and Salmonella enterica. The gene has heightened concerns about antibiotic resistance because it confers resistance to a drug that is considered a last resort for treatment of infections caused by multidrug-resistant bacteria. 

Another concern about MCR-1 is its mobility. Because the gene is located on mobile pieces of DNA called plasmids, it can be shared within and between different species of bacteria, which means that other multidrug-resistant pathogens can acquire resistance to colistin. This raises the specter of bacterial infections that are impossible to treat with current antibiotics.  

The authors of the study say that finding the isolate in S flexneri from pig feces suggests it could be circulating on Chinese farms and beyond.

WHO: High levels of antibiotic resistance found worldwide, new data shows

A WHO news release: High levels of antibiotic resistance found worldwide, new data shows. Excerpt:

WHO’s first release of surveillance data on antibiotic resistance reveals high levels of resistance to a number of serious bacterial infections in both high- and low-income countries. 

WHO’s new Global Antimicrobial Surveillance System (GLASS) reveals widespread occurrence of antibiotic resistance among 500 000 people with suspected bacterial infections across 22 countries. 

The most commonly reported resistant bacteria were Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pneumoniae, followed by Salmonella spp. The system does not include data on resistance of Mycobacterium tuberculosis, which causes tuberculosis (TB), as WHO has been tracking it since 1994 and providing annual updates in the Global tuberculosis report. 

Among patients with suspected bloodstream infection, the proportion that had bacteria resistant to at least one of the most commonly used antibiotics ranged tremendously between different countries – from zero to 82%. Resistance to penicillin – the medicine used for decades worldwide to treat pneumonia – ranged from zero to 51% among reporting countries. And between 8% to 65% of E. coli associated with urinary tract infections presented resistance to ciprofloxacin, an antibiotic commonly used to treat this condition. 

“The report confirms the serious situation of antibiotic resistance worldwide,” says Dr Marc Sprenger, director of WHO’s Antimicrobial Resistance Secretariat. 

“Some of the world’s most common – and potentially most dangerous – infections are proving drug-resistant,” adds Sprenger. “And most worrying of all, pathogens don’t respect national borders. That’s why WHO is encouraging all countries to set up good surveillance systems for detecting drug resistance that can provide data to this global system.” 

To date, 52 countries (25 high-income, 20 middle-income and 7 low-income countries) are enrolled in WHO’s Global Antimicrobial Surveillance System. For the first report, 40 countries provided information about their national surveillance systems and 22 countries also provided data on levels of antibiotic resistance.

ECDC: Guidance on CRE infection prevention and control

ECDC has published Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Click or tap through to download the complete document.

On the occasion of the 10th European Antibiotic Awareness Day, the European Centre for Disease Prevention and Control (ECDC) published a new guidance on how to prevent the entry and spread of carbapenemase-producing Enterobacteriaceae (CRE) into healthcare settings. The guidance features a series of tables and a flowchart with information on how to assess and manage patients who may be “at-risk” for carrying CRE when they are admitted to a healthcare setting. These easy-to-use tables and flowchart can hopefully be helpful to healthcare workers to easily identify those “at-risk” patients and implement appropriate infection prevention and control measures in a timely manner. 

Carbapenem-resistant Enterobacteriaceae (CRE), in which Escherichia coli and Klebsiella pneumoniae predominate, are responsible for a large number of patient deaths and high hospital costs. Patients who are “carriers” of CRE are considered “at-risk” for importing these multidrug-resistant bacteria into healthcare settings and spreading them to other patients.  

The purpose of this guidance is to assist frontline healthcare workers in identifying “at-risk” patients easily when admitted to a healthcare setting and implementing infection prevention and control (IPC) measures in a timely manner, on admission, to prevent CRE from spreading in the facility. 

The following risk factors may put patients “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months; b) dialysis dependence or cancer chemotherapy in the last 12 months; c) known previous carriage of CRE in the last 12 months; and d) epidemiological linkage to a known carrier of CRE. 

If patients who are admitted to a healthcare setting are known CRE carriers or potential carriers, preliminary supplemental measures such as pre-emptive isolation, active screening for CRE and contact precautions should be implemented on admission. Patients who are confirmed positive for CRE will need supplemental measures, and their status should be communicated to the receiving facilities in case they are transferred between healthcare settings. 

The ECDC guidance outlines the epidemiological profiles that place patients “at-risk” for CRE carriage, as well as the IPC measures and the flowchart summarizing the decision-making process, in printable table format, to assist frontline workers and IPC teams in their evaluation and decision-making when admitting patients to healthcare settings. 

This guidance outlines evidence-based best practices for the prevention of CRE. Measures for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources