Nationwide survey of ID physicians and pharmacists

Guest Post: Charlie Garland from the Healthcare Innovation & Technology Laboratory (HITLAB*) @ Columbia University Medical Center is conducting a nationwide survey of Infectious Disease physicians and pharmacists around treatment patterns for carbapenem resistant bacterial infections, and he would like your participation and expertise to help in this research.  

This survey will only require 10 – 15 minutes to complete, but the results will be extremely valuable.  We will gladly share the results of our research with each participant, which will help you and your colleagues to understand how your individual strategies compare to those of your peers – within your region, and across the US.

The link below will connect you to this survey, which will ask you:

·        A few demographic questions about the hospital at which you practice.

·        5 scenario-specific questions around treatment strategies that you would most likely employ in each case.

·        7 follow-up strategies, based on different patient responses to the initial Rx.

·        An option to enter your name/email if you’d like to receive the survey results (aggregated).

The information we gather will be de-identified and only reported in the aggregate.

Take the survey now: SHARE ID Treatment Survey https://www.surveymonkey.com/r/LC235N9

Please feel free to forward this link on to colleagues whom you believe would like to participate.  We are asking participation of infectious disease physicians, fellows, residents, interns, and pharmacists.

Kind regards,

Charlie Garland, HITLAB/Senior Fellow
Healthcare Innovation & Technology Laboratory
(@ Columbia University Medical Center)

*The Healthcare Innovation and Technology (HIT) Lab is a cross-disciplinary, academically based, research cooperative located at the Columbia University Medical Center in New York City. The HIT Lab consists of Columbia faculty, staff, students, alumni, and members of the Washington Heights community collaborating to improve healthcare through thoughtfully designed and implemented technology

Nothing to see here, please move along

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.

Regional Control of a large KPC outbreak: The Israeli Experience

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.

Reference: Schwaber MJ et al. CID April 2011

Note: Dan posted on the CDC Guidance for Carbapenem-Resistant Enterobacteriaceae a couple years ago.

VIM-producing carbapenem-resistant Klebsiella pneumoniae

CDC just released in MMWR a report of the first case of a Verona integron-encoded metallo-beta-lactamase (VIM) carbapenemase in an Enterobacteriaceae in the United States. The patient was initially hospitalized in Greece and then transferred to a US hospital.  CDC was notified in July and, fortunately, the screening of the 22 patients whose U.S. hospital stays overlapped with this patient were all negative. I would write more, but a nice post by Alex Kallen from the CDC puts this in the proper context.

Sept 24 MMWR article
Alex Kallen CDC post

NDM-1 containing Enterobacteriaceae

With yesterday's report suggesting a decline in MRSA, it is now time to switch gears and panic about other organisms. As Dan said so well yesterday, "MRSA isn't the only bug out there, it's just the most famous." Today's report is from Lancet ID by researchers in UK, Pakistan and India on a novel resistance mechanism in Gram-negative bacteria called the NDM-1. NDM-1 stands for New Dehli metallo-B-lactamase 1. I guess when you name it "1" you are expecting a "2" and maybe a "3". Even the Great War wasn't called WWI until World War II started or at least ended.

The report is very nice and includes background information discussing the rise of various resistance mechanisms in GNR including ESBLs (CTX-M-15) and KPCs. The group initially discovered the NDM-1 containing resistance gene in a patient in Sweden after the patient returned from a hospital admission in New Dehli. This new report includes descriptions of isolates collected in Chennai (south India), Haryana (north India), UK and other areas in India, Bangladesh and Pakistan. Little information is given as to how the samples were obtained. After initial screening, all isolates were tested for presence of the bla(ndm-1) by PCR.

As an example of the results, from Chennai there were 3521 isolates of Enterobacteriaceae screened with 141 (4%) resistant to carbapenems. 44 of the 141 were NDM-1 positive, which is about 1% of all of the isolates. Most were E coli (19), K pneumoniae (14) and E cloacae (7). By 2009, NDM-1 strains were the dominant carbapenemase-producers in the UK. In most isolates NDM-1 was carried on plasmids although 3 UK isolates carries the NDM-1 on their chromosome.

All of this is quite concerning. It is not this specific gene/mechanism that's troubling, it's the constant introduction and spread of many different types of resistant GNRs in our inter-connected world. Look at the figure. The chickenpox spread of NDM-1 that now covers India and the UK will soon spread to Germany, the US and beyond. While we have new classes of antibiotics recently introduced that are active against MDR-Gram positive bacteria, we have very few new classes in the pipeline that are active against GNR. When the US Surgeon General, Dr. William H Stewart said in the 1960's that it was "time to close the book on infectious disease" and/or "the war against infectious diseases has been won", he probably wasn't thinking about Gram negative bacteria.

Lancet ID article

link to newer NDM-1 post