H5N1

Bacteria becoming resistant to hospital disinfectants, warn scientists

Via The Guardian: Bacteria becoming resistant to hospital disinfectants, warn scientists. Excerpt:

Hospitals will need to use new strategies to tackle bacteria experts have warned, after finding a type of hospital superbug is becoming increasingly tolerant of alcohol – the key component of current disinfectant hand rubs. 

Handwashes based on alcohols such as isopropanol have become commonplace as a method of infection control. But while the move has been linked to benefits, including a fall in rates of hospital infections of methicillin-resistant Staphylococcus aureus (MRSA), new research suggests it might also have had unexpected consequences. 

Scientists say they have discovered that superbugs known as vancomycin-resistant enterococci, or VRE, appear to be becoming more tolerant to alcohol.  

“This is a wake-up call to infection control hospital teams around the world that if you want to control the emergence of VRE you need to do more than just rely on your alcohol-based disinfectants,” said Prof Timothy Stinear, co-author of the research from the University of Melbourne, noting that these could include improved adherence to current regimens – such as thorough cleaning with alcohol hand rubs – the use of other disinfectants like chlorine-based products, and greater screening of patients for infections. 

One of the most common species of VRE is Enterococcus faecium, with infections on the rise in England and Australia. VRE infections, said Stinear, can be serious and sometimes even prove deadly. “The problem with VRE is that it can colonise the gut and then go into patients’ bloodstream and cause sepsis, bloodstream infection, and it is very difficult to get rid of because it is resistant to almost all antibiotics,” he said. Among the problems, Stinear added, is that it can lodge in heart valves and prosthetic device implants.

“It only impacts the most susceptible people – so healthy people do not get VRE infections,” Stinear said, noting that people receiving chemotherapy, organ transplants or who undergo dialysis are among those at risk. 

Writing in the journal Science Translational Medicine, Stinear and colleagues report how they took Enterococcus faecium bacteria recovered from patients – so-called “isolates” – and exposed these in the lab to an isopropanol-based solution for five minutes. In total 139 such samples were used, collected from two hospitals in Melbourne between 1997 and 2015. Alcohol-based handrubs were systematically introduced in Australia from the early 2000s, with the volume used increasing tenfold by 2015. 

The results reveal that Enterococcus faecium bacteria have become more tolerant to alcohol over that time.

CIDRAP: Canada reports rising MRSA, VRE but drop in antibiotic use

Via CIDRAP, Chris Dall writes: Canada reports rising MRSA, VRE but drop in antibiotic use. Excerpt:

A new report from the Canadian Antimicrobial Resistance Surveillance System (CARSS) shows rising antibiotic resistance in two major healthcare-associated pathogens, along with noteworthy decreases in antibiotic use in humans and animals.  

The CARRS-2017 Report is the third published by the Public Health Agency of Canada (PHAC) and includes surveillance data on antimicrobial resistance and use, both in humans and animals, through 2016. The report is based on available surveillance data from the PHAC's nine surveillance systems and laboratory reference services. This year's report includes new data on antibiotic-resistant infections and antibiotic use in community settings.  

Worrisome trends 

The two pathogens of concern are methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The CARRS report shows that the overall rate of MRSA infection in sentinel hospitals in Canada increased from 2.84 cases to 3.13 cases per 10,000 patient-days from 2011 through 2016, with a decrease in healthcare-associated MRSA (HA-MRSA) cases (from 1.93 cases in 2011 to 1.69 in 2016) and an increase in community-associated cases (from 0.56 cases to 0.96 cases per 1,000 admissions).  

Most concerning was a fivefold increase in HA-MRSA bloodstream infections (BSIs) in the country's pediatric hospitals—from 0.08 to 0.43 cases per 10,000 patient-days between 2011 and 2016. 

The rate of VRE infections in Canada, meanwhile, rose from 0.41 cases per 10,000 patient-days in 2015 to 0.44 cases in 2016. While that's a reduction from a high of 0.61 cases in 2012, it still represents a significant rise since 2007, when the rate was 0.10 cases per 10,000 patient-days. 

In addition, the report shows that the rate of VRE BSI in sentinel adult hospitals more than doubled from 2011 to 2016, climbing from 0.12 cases per 10,000 patient-days to 0.26 cases. "This finding points to the need for ongoing monitoring of this microorganism in Canada," the authors of the report write.  

The report also found that drug-resistant gonorrhea is becoming an increasing problem in Canada, matching a trend that has been observed worldwide. From 2014 through 2015, the proportion of cultured Neisseria gonorrhea isolates that were resistant to at least one antibiotic rose from 52% to 60%, with increases observed in the proportion of isolates resistant to azithromycin (from 1.3% in 2010 to 4.7% in 2015) and in the proportion of isolates with decreased susceptibility to the cephalosporin antibiotics cefixime or ceftriaxone (from 1.1% and 2.7% in 2014, respectively, to 1.9% and 3.5% in 2015). 

Since 2001, the rate of gonorrhea infections in Canada has more than doubled. But the country has not yet reported any treatment failures resulting from resistance to azithromycin and decreased susceptibility to cephalosporins—the currently recommended dual therapy for gonorrhea. 

On a positive note, the CARSS-2017 Report showed that the rate of healthcare-associated Clostridium difficile infection (CDI) in Canada continued to decline, falling from 6.64 cases per 10,000 patient-days in 2015 to 4.05 cases in 2016. Surveillance of sentinel hospitals beginning in 2015 showed that 37% of all CDI reported in patients admitted to those hospitals was community-associated.

Superantibiotic is 25,000 times more potent than its predecessor

Via Science: Superantibiotic is 25,000 times more potent than its predecessor. Excerpt:

The world’s last line of defense against disease-causing bacteria just got a new warrior: vancomycin 3.0. Its predecessor—vancomycin 1.0—has been used since 1958 to combat dangerous infections like methicillin-resistant Staphylococcus aureus. But as the rise of resistant bacteria has blunted its effectiveness, scientists have engineered more potent versions of the drug—vancomycin 2.0. Now, version 3.0 has a unique three-pronged approach to killing bacteria that could give doctors a powerful new weapon against drug-resistant bacteria and help researchers engineer more durable antibiotics. 

“This is pretty special,” says Scott Miller, a chemist at Yale University who was not involved in the new work. “It’s really the culmination of a decades-long effort.”  

Vancomycin, long considered a “drug of last resort,” kills by preventing bacteria from building cell walls. It binds to wall-building protein fragments called peptides, in particular those that end with two copies of the amino acid D-alanine (D-ala). But bacteria have evolved. Many now replace one D-ala with D-lactic acid (D-lac), sharply reducing vancomycin’s ability to bind to its target. Today, that resistance has spread so that dangerous infections like vancomycin-resistant enterococci (VRE) and vancomycin-resistant Staphylococcus aureus (VRSA) are becoming more common. According to the U.S. Centers for Disease Control and Prevention, about 23,000 Americans die from 17 antibiotic-resistant infections each year (although it’s difficult to parse out how much is due to vancomycin resistance).

To solve the D-lac problem, researchers led by Dale Boger, a chemist at the Scripps Research Institute in San Diego, California, began synthesizing new versions of vancomycin that bind to peptides ending in D-ala and D-lac. They succeeded in 2011. Meanwhile, other groups developed new ways of killing bacteria with vancomycin: One alteration found a novel way to halt cell wall construction, whereas another caused the outer wall membrane to leak, leading to cell death.  

Now, Boger and his colleagues have assembled all three weapons into one single vancomycin analog. The new antibiotic is at least 25,000 times more potent against microbes such as VRE and VRSA, they report this week in the Proceedings of the National Academy of Sciences. 

Moreover, when Boger’s team tested vancomycin-resistant bacteria against the new three-part analog, the microbes were unable to evolve resistance even after 50 rounds. Many antibiotics begin to fail after just a few rounds. This suggests the new compound may be far more durable than current antibiotics, Boger says. 

"Organisms just can't simultaneously work to find a way around three independent mechanisms of action,” he says. “Even if they found a solution to one of those, the organisms would still be killed by the other two."

Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile

Via The Lancet: Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. The summary:

Background 

Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. 

Methods 

We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. 

Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370.  

Findings 

31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). 

The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. 

Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). 

Interpretation 

A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk.

Canada: More on superbug resistance

Via The Globe and Mail: The war against superbugs: Can drug-resistant bacteria be beaten? Excerpt:

So what’s being done to fight MRSA (methicillin-resistant Staphylococcus aureus), CRE (carbapenem-resistant Enterobacteriaceae), VRE (vancomycin-resistant Enterococcus) and other antibiotic-resistant superbugs that – fuelled by overuse and misuse in agriculture and human health care – threaten to force modern medicine back to an archaic time? 

Around the world, governments are crafting legislation to accurately track and control how antibiotics are prescribed and taken, pouring hundreds of millions of dollars into the development of new drugs, and even altering regulations around clinical trials to ensure potential antibiotics get tested faster. But will it be enough?

Preparing superbug strategies 

Facing the real possibility of entering a post-antibiotic era this century, British Prime Minister David Cameron urged former Goldman Sachs chief Jim O’Neill last year to provide a global economist’s view of the problem: Concluding that drug-resistant superbugs could kill some 10 million people annually and cost up to $100-trillion by 2050, O’Neill called for a global fund to develop new antibiotics. 

The European Union had already backed its 2011 Action Plan against Antimicrobial Resistance with combined investment of €650-million ($890-million) that includes both conservation and stewardship of existing antimicrobials (including bacteria-killing antibiotics and drugs that target a wider range of microbes such as fungi) and investment into new drugs. 

In January, U.S. President Barack Obama committed an unprecedented $1.2-billion to fight antibiotic resistance: More than half of the money would be invested in new drug development, while giving the Centers for Disease Control and Prevention $280-million to halt the spread of drug-resistant superbugs. 

On March 27, in a report that involved the departments of health, agriculture and defence, Obama elaborated: Along with investment in drug development, he would use the threat of financial penalties to encourage the reporting of antibiotic overprescribing by doctors who take part in Medicare or Medicaid. 

For its part, Health Canada has just released a Federal Action Plan on Antimicrobial Resistance and Use, promising the creation of an antimicrobial resistance surveillance system, launching a $20-million, five-year project to help understand and mitigate antimicrobial resistance under the federal Genomics Research and Development Initiative, and committing to increase research investment through the Canadian Institutes of Health Research-funded Canada-Britain partnership and other CIHR-funded projects. 

On March 31, Health Canada and the Public Health Agency of Canada also released a report from the newly created Canadian Antimicrobial Resistance Surveillance System (CARSS), following a round-table discussion that included leaders from the food industry, veterinary and human medicine, pharmacy and an expert in drug-resistant microbes. 

The report concluded that when it comes to superbug infection rates, there has been no significant improvement despite existing surveillance programs, and the surveillance picture in Canada is far from complete. The authors did say CARSS will provide a better understanding of the issues by “directing the expansion of surveillance activities to areas of greatest need.” 

That said, experts worry the Canadian plan lacks the timelines and budget to have a meaningful impact.

Superbugs: The Globe and Mail takes note

Via The Globe and Mail, an editorial: Superbugs: They caught them at the hospital. Excerpt

The omnipresent hand-sanitization stations in the entrances of Canadian hospitals probably may strike you as a sensible option for the prudent visitor, or as an oasis for hypochondriacs. The truth is, they are neither. Those squirts of isopropyl alcohol are a critical part of an existential battle against the steady rises of antibiotic-resistant bacteria and hospital-acquired infections in this country. 

Canadians have yet to fully grasp how serious the problem is, and the federal government needs to do more to bring them up to speed – and to track where the war is, and is not, being won.

The Chief Public Health Officer reports that more than 200,000 Canadians acquire infections in hospital every year, and that more than 8,000 die from them. That is a startling rate of 22 deaths each day. It’s more alarming when you realize that the dead did not bring the disease that killed them to the hospital; it was there waiting for them on another patient, on the hands of a nurse or doctor, or on an improperly cleaned door handle. 

More than half of these fatal infections involve a growing number of antibiotic-resistant bacteria, such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE) and Clostridium difficile (C. difficile). Last month, a hospital in British Columbia revealed it had had an outbreak of Carbapenem-resistant Enterobacteriaceae (CRE) – a new superbug that is invulnerable to existing drugs and fatal in most cases. 

Health officials around the world worry that the steady rise of superbugs could lead us back to a “post-antibiotic” era, in which conventional surgeries and treatments would be impossible. The cancer treatment chemotherapy, for instance, drastically reduces the immune systems of patients, who then require antibiotics to fight infections. But if the infections are immune to the antibiotics, then the side effects of chemotherapy could render it too dangerous to be a useful treatment.

Hong Kong: Update on cluster of Vancomycin Resistant Enterococci cases in Tuen Mun Hospital

The Centre for Health Protection has issued a news release: Update on cluster of Vancomycin Resistant Enterococci cases in Tuen Mun Hospital.

The spokesperson for Tuen Mun Hospital made the following update today (January 19) regarding an earlier announcement on a cluster of Vancomycin Resistant Enterococci (VRE) carriers in a Medicine and Geriatrics Ward:      

In accordance with the prevailing infection control guidelines, the hospital has performed contact tracing. One more 87-year-old female patient is confirmed as VRE carrier but without clinical symptoms. She is now under medical surveillance and isolation with stable condition. 

The hospital will continue the enhanced infection control measures and closely monitor the situation of the ward. The case has been reported to the Hospital Authority Head Office and the Centre for Health Protection for necessary follow-up.

Rare superbug found in Hong Kong has never been detected in Asia before

Via South China China Morning Post, a July 29 report: Rare superbug found in Hong Kong has never been detected in Asia before. Excerpt:

A rare superbug detected in a slaughterhouse in Sheung Shui has never before been found among livestock in Hong Kong or Asia, a University of Hong Kong study has confirmed. 

The microbiologist who led the study told the South China Morning Post it had raised concerns that pig farmers in Hong Kong or on the mainland were misusing antibiotics to treat their animals, leading to the development of such drug-resistant superbugs. 

"It indicates that there may have been widespread use by some farmers of antibiotics to keep their pigs healthy," Ho Pak-leung said. "This is one explanation as to why [the Sheung Shui] pork contains the drug-resistant bug." 

Humans can catch the superbug through eating uncooked pork or coming into contact with infected livestock, Ho said. 

But the risk of Hongkongers becoming infected remains low - as long as they only consume pork that has been thoroughly cooked, he said. 

The superbug, vancomycin-resistant Enterococcus faecium(VRE), was detected in one of 137 batches of pork samples collected in January at a slaughterhouse in Sheung Shui. 

Genetic analysis confirmed the bug to be of the sequence type ST6, never before detected in any animal bred for consumption in Asia. Another strain of VRE, ST414, is more common in Hong Kong and causes several deaths a year during hospital outbreaks, Ho said. 

VRE infections tend to occur in already debilitated patients, and usually break out within a contaminated institution, such as a hospital. Mortality rates for VRE infections have been calculated at between 40 and 70 per cent. It can be contracted and carried by a healthy person for years without any symptoms, only to attack when the carrier becomes sick or is injured. 

The infected pork in Sheung Shui could not be traced because the slaughterhouse gathers animals from both local and mainland farms. 

Ho said: "The reason for its occurrence is still unknown. We cannot rule out the possibility that there may be a VRE outbreak in some farms."