We're so very lucky to have lived in the "age of antibiotics." However, most of us were neither alive nor cognizant prior to 1943, so we don't have a concept of the morbidity and mortality prevented by antibiotics. In some regards, this pre-1943 period is the future we're facing. Author and science journalist Maryn McKenna has a wonderful article up on medium.com where she discusses this post-antibiotic past and future using a touching story of her great uncle along with facts such as "one out of every six recipients of new hip joints would die" without antibiotics. She also discussed this article on yesterday's CBC "Sunday Edition" radio broadcast (audio available here).
As if we need other things to add to our phobia lists, there's a new case-report published in JAC last Friday of an elderly Spanish woman with chronic renal disease and recurrent UTIs. She initially presented with pyelonephritis caused by a susceptible E coli. However, after 1 week of therapy she developed sepsis and renal failure that was unresponsive to meropenem and died. MDR E Coli was isolated, which was resistant to all tested antibiotics except fosfomycin, tigecycline and tetracycline. Further analysis identified numerous resistance and virulence genes (see figure above). Importantly, the authors state that this is "the first report of the co-production of KPC-3, VIM-1, SHV-12, OXA-9 and CMY-2 in a unique clinical multiresistant E. coli isolate."
With air pollution, it's risky to breathe and with water pollution it's risky to drink. I guess now it's risky to pee.
It's not quite the Zombie Apocalypse, but these carbepenem-resistant nightmare bacteria are clearly the next scariest thing. PBS's Frontline seems to think so. Producer/Writer/Director Rick Young has pulled together a 1-hour investigation into antibacterial resistant infections including (it appears) NDM-1 and the NIH CRE outbreak. From the promotional material it also seems that the program will touch on the lack of investment in drug discovery in addition to excess use, as causes of the epidemic. Remember, check your local listings.
We've covered CRE extensively over the past couple of years. Never so extensively as we did when the 2011 NIH KPC outbreak was first publicized last August following the whole-genome sequencing report in Science Translational Medicine. Almost a year has past since that report and kerfuffle, so it is nice to see that Tara Palmore and David Henderson have found the time to share their experiences controlling the outbreak and the media storm that followed the publication of the original manuscript. They decided to label the section on the public reaction the "Unintended Consequences of Publication." This title is very disturbing, as it highlights why many outbreaks like these are never reported - publication bias. I'm glad they weren't afraid to publish again, so that we can all learn for this difficult outbreak. The report is freely available in PDF over at CID. I'll stop writing and let you get on with your required reading.
Now that I have your attention, I wanted to point out a recent review in Lancet ID by Silvia Munoz-Price and colleagues. It's behind a paywall with a $31 charge, so hopefully you have access through your institution or can email one of the authors to request a copy. The co-authors do a wonderful job highlighting the emergence of KPC containing strains in the US (1996) and subsequent spread of these β-lactamases throughout the world. Importantly, they discuss treatment options (or lack thereof) and emphasize the important role that infection prevention will play for the foreseeable future. They also suggest that stewardship might be more relevant in plasmid (non-clonal) outbreaks.
There's a nice profile of Dr. Tara Palmore, a hospital epidemiologist at the NIH, in the Washington Post. The piece focuses on her role in bringing the KPC outbreak at the NIH Clinical Center under control via her collaboration with Dr. Julie Segre, a molecular biologist. Ten years ago it would be hard to imagine that a newspaper would publish an article about a hospital epidemiologist. The important role that infection prevention professionals play is finally coming to light.
I feel like I should expand on this recent post about why relying upon prompt laboratory detection of CRE carriers is unlikely to help contain spread (aside from during local outbreak responses). Why shouldn’t screening be a pillar of our prevention efforts, particularly given the inspiring stories of local and regional CRE control that utilized screening to detect carriers? Leaving aside the question of how important screening was among multiple simultaneous interventions, these tworeports are from academic tertiary care centers with robust on-site laboratory support and external funding to provide financial support for state-of-the-art screening approaches (such as rapid PCR detection of KPC producers).
The sad fact is that this level of clinical microbiology laboratory support is far from the norm. The trend over the past two decades has been toward consolidation and outsourcing of laboratory services, and reducing local resources available for diagnostic microbiology labs. I spoke about this trend, and some of the consequences, at the 5th Decennial conference a few years ago (you can view the slide set here). In the decade that has passed since we noted frequent errors in testing and reporting of blood culture results in a sample of 14 hospital laboratories, I doubt that much has improved. Yes, there are CAP proficiency surveys, but for several reasons these are not good indicators of actual laboratory performance. And while outsourcing microbiology to a regional lab may make short-term financial and technical sense for some hospitals, it also removes lab support further from the front line of patient care and infection prevention, prolongs turnaround times, and comes with a host of pre- and post-analytic problems.
If current fiscal and political trends continue, with additional cuts to public health infrastructure and CDC’s budget, it is difficult to imagine that we can do much in the short term to shore up our surveillance capabilities to respond to the CRE threat.
"You may ask yourself, well, how did I get here?" - the Talking Heads
It's been a busy week in antibiotic resistance. From Tuesday's MMWR early release identifying terrifyingly large increases in CRE until today, there has been non-stop media coverage. This morning, I had a long discussion with a colleague about CRE and it got me thinking about how we got to this point. As Maryn McKenna so astutely said this week: "it will be interesting to see whether the news sinks in this time." So, how did we get here?
1981: What we now call AIDS was recognized as a clinical syndrome. Thus began the cascade of infectious diseases research towards a full-scale and massively-funded response to the AIDS crisis. This has been an incredibly successful, if not yet complete effort. At the 2011 IDSA meeting, Cornell's Trip Gulick said that we now have 10,000 possible combinations of antiviral therapy agents for HIV. Thirty years after the virus was discovered in 1983, the progress has just been incredible. Sure, we've not yet achieved a significant number of cures and an effective vaccine remains just out of reach, but if you'd asked most of us in 1990 if we'd wanted to switch places with 2013, we would have said yes in a heartbeat.
2013: Most ID research efforts still target HIV and other viral pathogens. As we published last year, 2009 NIAID funding for HIV was $1.3 billion, while funding for all ESCKAPE pathogens was around $49 million. When we reported this disparity, it seemed quite obvious that we needed to fund more research of antibacterial resistant pathogens. However, nothing is ever that easy. One of the peer-reviewers of our paper made the excellent point that the "historically poor funding for antimicrobial resistance over the years along with the exit of pharma from the field has led to a lack of significant infrastructure. There may not be enough productive labs to send more money to at this point." So, even if the US wanted to fund more research, it may take time to train or retrain investigators to undertake the relevant research.
___
Now that I've shared some brief thoughts on why we are where we are, I have some further thoughts on where we should go. First, as I said earlier this week, we need a national response to CRE and antimicrobial resistance in general. This response needs to be horizontal in approach, as Mike Edmond and Dick Wenzel recommended several years ago. For it is quite clear that if we follow the vertical approach recommended by the CDC and others, swab for CRE and isolate, that this will bankrupt hospitals and ultimately fail.
This surveillance approach will bankrupt us, because CRE isn't the only "nightmare" in our hospitals. Back in 2010, when Dan was discussing MRSA on NPR, he said so eloquently: "MRSA is not the only bad bug out there. It's just the most famous." And along with MRSA, we have VRE and ESBL and C. difficile and Acinetobacter and MDR-Pseudomonas. You see, we might not be able to take this single-hospital outbreak approach and extrapolate it to the entire country and 10+ pathogens. And if there is one lesson we should be taking away from the NIH CRE outbreak it's not that new-fangled whole genome sequencing stopped the outbreak (because it didn't), it's that the outbreak spread and killed many patients despite herculean efforts to detect and eliminate it. Furthermore, if we target MRSA like many hospitals are now doing with chlorhexidine (CHG) baths, this approach could select for Gram-negative bacteria like CRE.
My recommendations:
(1) Invest significantly in antimicrobial discovery. Apart from the need for new treatment options, optimal control of resistant pathogens may depend on availability of effective antibiotics.
(2) Invest in studies to improve compliance with hand hygiene – only 4 studies on this topic since 1980 per a recent Cochrane Review. Compliance is terrible, but currently the approach is to blame healthcare workers and not figure out how to help them easily clean their hands.
(3) Study universal gowning and gloving (several studies are ongoing). Dentists wear gloves with every patient, why not doctors?
(4) Undertake studies to further optimize environmental source control
(5) Actually study antimicrobial stewardship. Stop yelling at patients and clinicians to not use antimicrobials. Actually fund studies that use advertising and other other messaging techniques that have a chance to be effective.
Oh, and no more ridiculous hand hygiene song and dance videos...unless they include folks like the Talking Heads...
There is an early release MMWR out today describing the recent trends in carbapenem-resistant Enterobacteriaceae (CRE) using data from the CDC's National Healthcare Safety Network (NHSN) and the Surveillance Network–USA (TSN). CRE infections, such as UTIs or intra-abdominal infections, cannot be treated with currently available antibiotics. The results of the MMWR study are not surprising - there are more CRE now - yet I find them rather chilling.
The proportion of Enterobacteriaceae that were CRE rose from 1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN facilities. In Klebsiella species, the situation is dire with 10.4% classified as CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and 17.8% of long-term acute-care hospitals reported at least one CRE in their facility.
So things are pretty bad, at least 17.8% bad.
What can we do about this? This is what they say in the abstract: "Interventions exist that could slow the dissemination of CRE. Health departments are well positioned to play a leading role in prevention efforts by assisting with surveillance, situational awareness, and coordinating prevention efforts."
Which interventions? Certainly there are no evidence-based interventions, unless we call an uncontrolled quasi-experimental study evidence. The CDC authors made reference to VRE control efforts in the Siouxland, MRSA control efforts in The Netherlands and CRE control efforts in Israel. I think these are poor and overly optimistic comparisons for several reasons. For one, the first two efforts targeted Gram-positive bacteria and it's unclear if we can extrapolate these to control efforts targeting MDR-GNRs. For example, we have effective antibiotics for VRE and MRSA (quinupristin/dalfopristin-approved in 1999; linezolid-approved in 2000, daptomycin-approved in 2003) but not for CRE. Additionally, we can decolonize for MRSA but not CRE.
However, the most important aspect of the Netherlands and Israel examples were that they instituted NATIONAL RESPONSES aimed at MRSA and CRE. There are no such national efforts here in the US targeting CRE. This is what we have in the US per the MMWR report: "six states have made CRE reportable, and three additional states are actively pursuing this option." This is not a national response. This is a national tragedy. We can't expect CDC to say they can't handle the problem and we can't expect states to say they can't handle the problem. They are working their butts off with minimal support and no national will for a coordinated response. If we don't have a national response soon - it will be too late, but I'm not holding my breath.
I will leave you with an excerpt outlining the Israeli national CRE response from Mitch Schwaber's excellent report in CID. Do you think we have anything close to this going on here in the US? Me neither.
Update: Looks like NPR's "All Things Considered" will post an audio discussion of the CRE issue around 7pm ET here.
Why is it that the DOD can ask for more money to fight their wars but CDC can't? It seems to me that the fight against resistant bacteria is a war! - enp
I was interviewed by Peter Eisler of USA Today about a month ago concerning the recent NIH KPC Outbreak. His investigative report on carbapenem-resistant Enterobacteriaceae (CRE) was just published today and I found it a very good read. The report centers around a CRE outbreak that began four years ago at the University of Virginia Medical Center and continues there to this day. The article is particularly interesting when you focus on the quotes from all of the other HAI-prevention folks in the article. However, I also thought as I was reading it, what would Dan and Mike have highlighted if they'd posted on this same article?
I suspect that Dan would have wanted to highlight how difficult infection control becomes when gene/plasmids cross species during outbreaks and how this strongly impacts case definitions as you investigate. He might also point out how this limits the utility of whole genome sequencing, since the plasmids merrily skip from one species to another. I think that Mike might have pointed out that the vertical control barriers, like nasal PCR, set up to prevent MRSA transmission are not very effective at preventing the spread of non-MRSA pathogens like CRE. He might suggest that a continuous and relentless focus on horizontal measures, like hand-hygiene, would be most effective. Dan and Mike would both have been correct, but I have a different take...
My take is that CDC is on the wrong side of this debate and this has me very worried. Now, I don't remember exactly what was said about HIV during the 1980s, but I suspect there was a realization that something needed to be done and that significant investments would need to be made in its treatment and control. I'm not suggesting that CDC should flame fires of panic, but I wonder how long we can rely on the same old, largely ineffective, tools for outbreak control - patient isolation, subpar environmental control, inadequate hand-hygiene improvement bundles, lack of effective and novel antimicrobials - before CDC asks for help...and more funding.
So here are some select quotes from the article with my concerns bolded:
CDC:
"We're working with state health departments to try to figure out how big a problem this is," says the CDC's Srinivasan, noting that his agency can pool whatever incidence data states collect. "We're still at a point where we can stop this thing. You can never eradicate CRE, but we can prevent the spread. ... It's a matter of summoning the will."
The rest of us:
"In the Chicago area, where scores of CRE infections have been found since 2008, studies show that about 3% of hospital patients in intensive care carry the bacteria, says Mary Hayden, director of clinical microbiology and an infectious-disease doctor at Rush University Medical Center. Those same studies have found CREs being carried by about 30% of patients in long-term care facilities." "We have to think about a new approach, a regional approach, to controlling these organisms, because … no facility is an island," Hayden says.
"My concern is that there aren't a lot of methods in our tool kit that are significantly effective in curbing the spread of these infections," says Eli Perencevich, a professor and infectious-disease doctor at the University of Iowa's Carver College of Medicine. If unchecked, "these (bacteria) are going to greatly impact the kind of surgeries (and) treatments we can have," Perencevich says. "We're entering the post-antibiotic era; that's a very big problem."
"If you look at the current pipeline of antibiotics (in development) … none of them really is going to be active against these bacteria," says Gary Roselle, director of the Infectious Diseases Service for the Department of Veterans Affairs health care system. "The reality is, (CRE infections) are remarkably difficult to treat, they often have bad outcomes … and they're increasing nationally," adds Roselle. "I'm assuming this is going to get worse, and there likely won't be new antibiotics to treat it in the near future, so the focus has to be on prevention."
"So even if I had a perfect program to stop all patient-to-patient transmission in the hospital, the maximum impact I could have would be a 60% reduction in prevalence," says Brian Currie, the hospital's vice president for research and an assistant dean at the affiliated Albert Einstein College of Medicine.
"We have continued to have patients with CREs that are related to this (first) event," Costi Sifri, the hospital epidemiologist at UVA, says. "We haven't been able to close the door on this. ... I'm not sure you ever can."
Later today our colleague and fellow-blogger Eli will be one of the experts interviewed on NPRs Talk of the Nation. He will be discussing “the next steps in the fight against superbugs”. According to the preview, this segment will be aired during the second hour of the show. Tune in to hear Eli talk to the nation, revealing for the first time ever what the letters “KPC” really mean. If you miss it live, you can listen here once the show has aired.
It's been a quiet week out here on the edge of the blogging prairie. Some of us are recertifying, some are in the middle of huge grant deadlines and some are chairing a giant meeting planning committee with the meeting imminent. But, we still think about you every second and we miss providing you with up-to-date infection prevention information...
In the interim, we have created a little poll off to the right, which you can use to let us know how you like to read or follow the blog. Vote early and often.
From the nothing to see here column: We've heard new reports that the NIH KPC outbreak that was halted by whole-genome sequencing is back. On September 7th there was a new case of the KPC strain, the first since January and 19th overall. The blood stream infection resulted in the unfortunate death of boy from Minnesota, the seventh fatality attributable to the strain.
NOW SEE THIS: Registration for ScienceOnline2013 is now officially open. It's the seventh annual un-conference exploring science on the Web and takes place Jan. 30-Feb. 2, 2013, in Raleigh, NC. Registration for the first round of 100 slots is closed for today, but there are two more opportunities to register: Thursday, Sept 20, 2012 at 2:00 PM (EDT) and Friday, Sept 21, 2012 at 11:00 PM (EDT). By rumor I heard that these sessions last only minutes, so log on near those start times and keep refreshing your browser. All seems pretty exciting.
Note: This is the post I wanted to write regarding the NIH Clinical Center KPC outbreak last week until I noticed the posts and comments blaming the front line infection prevention staff.
"...we must guard against the acquisition of unwarranted
influence, whether sought or unsought, by the military-industrial complex (MIC). The
potential for the disastrous rise of misplaced power exists and will persist....As we peer
into society's future, we-you and I, and our government-must avoid the impulse
to live only for today, plundering, for our own ease and convenience, the precious
resources of tomorrow. We cannot mortgage the material assets of our grandchildren
without risking the loss also of their political and spiritual heritage." - President Eisenhower's Farewell Address January 17, 1961
In microbiology and clinical medicine, the MIC is the "lowest concentration of an antimicrobial that will inhibit the
visible growth of a microorganism after overnight incubation." I think it's time to recognize a new definition for MIC: the Microbiological Industrial Complex. The MIC encompasses the industry, associated lobbying efforts and government agencies that most benefit from the adoption of expensive and unproven testing and treatment. The MIC has had a tremendous impact on infection prevention practice through economic forces pushing for MRSA active surveillance mandates and perhaps mandatory flu vaccinations of health care workers. This MIC leads to the utilization of expensive (and largely unproven) interventions at great cost both economically and to the well-being of patients. The more we spend on expensive sequencing, the less we can spend on actual prevention. Hand hygiene might not be sexy, but it does more to prevent the spread of resistant infections than any PCR test.
The latest evidence of the insidious rise of the MIC is the initial discussion surrounding the NIH Clinical Center KPC outbreak. So far, the only paper describing the outbreak covered the miracle of whole-genome sequencing and how it helped halt the outbreak, which it most certainly did not. The outbreak was halted using a grab bag of unproven and expensive interventions including the hiring of 9 hand hygiene "police" that monitored infection control practice 24-7. Even NIH's Henry Masur speaking today on the Diane Rehm show said that sequencing "didn't conclusively prove" (what caused the outbreak). Both he and Jule Segre suggested they only stepped up their infection control efforts because of the whole genome sequencing evidence, which is almost certainly not true. They would have used infection control escalation even without expensive testing. (listen to the Diane Rehm show segment here)
To understand the power of the MIC, you don't have to look further than a recent MSNBC report, which noted that the NIH sequencing cost $40,000 and suggested that this technique could spawn a $1 billion industry in the US alone. In discussing the whole genome technique, Dr. Segre was noted to say "When you have patients in your ICU who just paid $100,000 for an organ
transplant,"...spending a few thousand dollars to protect them
from an outbreak of deadly bacterial infections "doesn't seem like too
much to ask."
It seems to me that since there is no evidence that whole genome identified the source of transmission here or elsewhere and even if it did it wouldn't have altered the course of the outbreak, we might better spend our infection control research and clinical dollars elsewhere. Unfortunately, the MIC has more money and more NIH backing. The NIH has a National Human Genome Research Institute but it doesn't have a "National Infection Prevention Institute", for example.
Almost a year ago, Mike peered through his crystal ball and accurately predicted the future of KPC prevention in the US. The NIH outbreak and report starts the countdown, and much like MRSA before it, the prevention efforts will be focused on expensive DNA surveillance efforts backed by large industry lobbying efforts and not investments in the research and expansion of basic and simple infection control efforts. It is easy to blame the healthcare worker for not washing their hands and look for a quick scientific panacea (DNA). Sadly, given that there have been only four high-quality hand hygiene improvement studies since 1980, we haven't provided clinicians with the proven tools to improve hand hygiene. If we continue to bow to the pressure of the MIC and avoid the harder tasks of infection prevention, we will be squandering our precious
resources of tomorrow (antibiotics), as Eisenhower warned 50 years ago.
Mike posted about this yesterday and I'm sure we'll have more posts concerning the deadly KPC outbreak that occurred last year at the NIH Clinical Center. Since the whole report is behind a paywall (why is that??), I thought I'd describe the interventions taken to control the outbreak and also let you peruse the description of the 18 cases and 11 deaths (See table below).
The kitchen sink: the problem
and the current solution
Infection control measures used:
1) Index patient placed on enhanced contact isolation on admission.
2) All ICU patients during the outbreak were placed on universal enhanced contact precautions during their entire stay
3) A wall was built in the ICU, so that all KPC+ patients could be placed in a new six-bed unit
4) Infection control compliance monitors were hired (peak use was 9 monitors) who ensured that all healthcare workers entering the rooms practiced enhanced contact precautions and hand hygiene. Suboptimal monitors were fired
5) A private firm was hired to decontaminate the ICU and all KPC+ patient rooms using hydrogen peroxide vapor
6) Staff were cohorted so that staff did not care for both KPC+ and KPC negative patients
7) When the KPC was found in a sink, they tore out the plumbing
8) Active surveillance culturing using rectal and throat swabs was utilized
What an amazing effort by Tara Palmore and others at NIH. Why did it take so long to control the outbreak? It's not their fault. I was in a similar situation with an acinetobacter outbreak in 2002. What I faced in 2002 and what Dr. Palmore faced last year is that there is almost no science behind infection prevention interventions. We literally don't know what works or where in works. What this outbreak demonstrates is what happens when you make little investment in infection control science in decades. We don't know how to prevent these outbreaks, so we throw the kitchen sink (literally in this case) at them hoping something works.
Not every hospital can afford to undertake all of the expensive construction and staffing interventions that the NIH did, especially since it isn't clear what works and what doesn't. Unless we make serious efforts in understanding the science behind hand hygiene compliance improvement, optimal use of contact isolation, environmental cleaning and other "unstudied" areas, this scene will continue to be repeated over and over again. These outbreaks are happening every day in the US and patients are dying (see below). We need science in infection prevention just as much as we need novel antibiotics. The lesson needs to be that we fund CDC and other agencies to direct the infection prevention studies necessary to prevent and terminate these terrible outbreaks.
The wrong lesson is to blame frontline infection prevention staff for fighting an outbreak with one hand behind their back and not being successful. We need to stop blaming clinicians and start funding the science to assist our infection prevention efforts. If we won't have novel antibiotics for 10-20 years, we better start getting serious about infection prevention.
Today's Washington Post contains an article that will send chills down the spine of every hospital epidemiologist and infection preventionist in the world. It describes an outbreak of carbapenem-resistant Klebsiella pneumoniae (KPC) at the hospital of the National Institutes of Health in Bethesda. Over a 6-month period last year, 17 patients became colonized or infected with KPC; of these 8 developed bloodstream infections. A total of 11 patients died; 6 of these deaths were attributed to the infection.
The outbreak was terminated using typical interventions (cohorting of patients and staff, active surveillance cultures, contact precautions, and enhanced cleaning protocols). Further details can be found in a report in Science Translational Medicine (abstract here, full text requires subscription). This report outlines how the outbreak was able to be tracked using whole genome sequencing, which allowed the epidemiologists to determine that the entire outbreak could be traced to a single patient. Traditional molecular typing with PFGE would not have provided enough discriminatory power to do this.
KPC is a horrible organism. As shown here, over half of colonized patients developed bloodstream infection and three-quarters of those died. This bug makes MRSA look like a teddy bear. We desperately need new antibiotics to combat this organism as many strains are resistant to all available antibiotics.
Late last week, the CDC issued new guidance for control of CRE. You can read my 2009 post for thoughts on their initial guidance. This update expands on that guidance, providing tailored recommendations for different settings, ranging from regions where no CRE have been reported to those in which CRE are common. The guidance also emphasizes regional control and the role of long term care (and “long term acute care”) in the epidemiology of CRE.
I think the new guidance is on the mark, and should be helpful as we struggle with how to respond to these bad bugs. As was the case back in 2009, my main concern relates to the screening recommendations. Not all CRE are created equal, and the test methods available to most laboratories are not good at differentiating among the really nasty (e.g. KPC- and NDM-producers) and the moderately nasty (e.g. chromosomal cephalosporinase + porin protein mutation). The former have much greater outbreak and local-regional spread potential, which is why the modified Hodge Test (MHT) has been used to single them out. But the MHT is not always easy to interpret, can have falsely positive and negative results, and seems to perform especially poorly in detecting certain carbapenemases (e.g. NDM). The CLSI has issued lower MIC breakpoints to better detect CRE, but these breakpoints are (appropriately) designed to guide therapy for individual patients, not to provide detailed information about resistance mechanisms for infection prevention or public health purposes. Lower breakpoints means more CRE detected, most of which do not carry mobile resistance elements like KPC and NDM. Do we respond to them in the same way (they are still resistant, after all….)?
I favor making CRE (at least those due to carbapenemases) reportable, as a couple states have done, along with periodic regional prevalence surveys to help facilities and public health departments understand local and regional epidemiology of CRE (and to help detect emerging new resistance mechanisms). These surveys would need to rely on culture, with referral of all isolates that have a CRE phenotype to state or regional labs that can do the molecular work to determine the underlying mechanism(s).
In a recent piece on CNN, Elizabeth Cohen discusses the recent KPC outbreak in SoCal. She offers some advice to patients and families as to how they can help prevent these 'superbug' infections under the heading "sorting fact from fiction." Let's go through this: 1) Wash hands - check 2) Remove unnecessary catheters - check and ....3) Eat Yogurt.?!? What the? To be fair, when she was challenged by the other news person, she backed off and said yogurt prevented some infections and not specifically KPCs, but why include it in the graphic? Was yogurt the fiction to the hand hygiene fact? Is the data even suggestive that yogurt "prevents" C. diff? Maybe this is a case of powerpoint making us stupid because she felt the need to have at least three bullet points per slide?
A study in Altern Ther Health Med from 2005 found no benefit of a non-dairy probiotic on the gut microflora including Klebsiella. The CNN article quotes my long lost co-fellow Mitch Schwaber, who was the author of the Israeli KPC outbreak that we highlighted last week. Hopefully Mitch will be in Dallas and I can ask him about the yogurt...
Mike posted yesterday about KPCs in LA, and now there is a report of a KPC outbreak in Ireland. I have read several reports of the outbreak, which involved 5-7 patients (two infected, three colonized) at the Mid-Western Regional Hospital in Limerick, and there is one consistent aspect to what is reported: It's the health care workers fault. See the article "Hospital Staff Warned" in the Irish Times.
The articles state that "steps had been taken to improve hand hygiene standards among hospital staff but warned that a zero-tolerance approach was being enforced in respect of anyone who failed to comply with these standards" and that "This will include disciplinary action and or notification to relevant professional registration bodies if warranted in any particular case."
Mike has written before about the dangers of this adversarial approach to infection prevention, so I won't belabor the point. However, when the authorities state that they are already doing everything right since MRSA and C. diff prevention efforts are all you need to control KPC, I get a bit worried. There is no evidence that this one-size-fits-all approach works for infection prevention. Yes, compliance with infection prevention is important, but there must be other approaches besides punishing the health care worker that will protect our patients.
The larger problem is that little to no research funding is available to study the epidemiology and optimal prevention methods for Gram-negative (or Gram-positive) bacteria. Before we blame the health care worker, perhaps we could ask why there is almost no funding for infection prevention research and implementation and why there are no new antibiotic classes in the pipeline. You do get what you pay for...
In the previous post, we learned from Eli that MRSA is going away. But there's no rest for hospital epidemiologists. The LA Times reports today that in the last 6-months of 2010 there were more than 350 cases of carbapenemase-producing Klebsiella pneumoniae infections reported from healthcare facilities in LA County. The epicenter appears to be long-term care facilities. Given the lack of treatment options for these pathogens, this is a very disturbing development.
The oubreak DID NOT occur here.
However, it IS St. Patrick's Day.
Hello everybody. I hope you're all having a great St. Patrick's Day and a great Match Day. Not sure those two days should be combined, at least for the safety of the future of the medical profession, but for some reason, that decision is not left up to me...
There is a report out electronically in CID (scheduled for April 1) by Mitch Schwaber et al. that describes the containment of a country-wide, carbepenem-resistant Klebsiella pneumoniae outbreak in Israel. The outbreak of a highly-resistant strain, typically susceptible only to gentamicin and colistin, began in 2006 in multiple Israeli hospitals. The resistance was mediated by KPC-3 and local efforts to control the outbreak were largely unsuccessful. By March 31, 2007 there had been 1275 patients in 27 hospitals affected (13,040 beds).
In March 2007, the Israel Ministry of Health implemented a 3 component intervention: 1) Mandatory reporting of every patient with a carbepenem-resistant Enterobacteriaceae (CRE); 2) mandatory contact isolation of all known CRE carriers within self-contained nursing units in single rooms or cohorts with dedicated equipment AND dedicated nursing; and 3) creation of a nationwide task-force with statutory authority to intervene as necessary to control the outbreak.
Did it all work? Well, they probably wouldn't have published this if it didn't work. They'd still be working too hard trying to stop the problem! From the peak of 185 cases (56 cases/100,000) in March 2007 (92% of CREs were Klebsiella) infections fell to a low of 45 (12 cases/100,000) in May 2008, a 79% decline. I have pasted the incidence curve below. So it worked, but there are still too many CREs. If they let their guard down, the outbreak could easily reoccur.
As far as the study design, the usual caveats apply. Despite great statistical control, they did not include a non-equivalent control group, etc, so perhaps these findings could be partially explained by regression to the mean or other biases, such as non-recorded interventions. Do I think that is what is going on here? No. I think the nationwide effort probably worked and their analysis and interpretation are correct. This overwhelming response might be needed more often in the future given the lack of new antimicrobials, poor overall support for infection control (everywhere, not just in Israel) and continued overuse of the antimicrobials we do have.
…will bring up the “Find and Replace” tool in Microsoft Word. Illinois legislators, you may want to use this tool today, so you can get yourselves a shiny new law to deal with the latest emerging antimicrobial resistance threat.
Hint: you’ll want to find “MRSA”, and replace with “KPC”. Make sure to go to “search options” and click on “Match Case”, or you’ll mess it all up.
We're so very lucky to have lived in the "age of antibiotics." However, most of us were neither alive nor cognizant prior to 1943, so we don't have a concept of the morbidity and mortality prevented by antibiotics. In some regards, this pre-1943 period is the future we're facing. Author and science journalist Maryn McKenna has a wonderful article up on medium.com where she discusses this post-antibiotic past and future using a touching story of her great uncle along with facts such as "one out of every six recipients of new hip joints would die" without antibiotics. She also discussed this article on yesterday's CBC "Sunday Edition" radio broadcast (audio available here).
