CHP: Review Of NDM-1 In Hong Kong

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

# 6719

 

The Centre for Health Protection publishes a weekly Communicable Disease Watch, where they highlight recent infectious disease events in and around Hong Kong.

 

Today, they include a review of the resistance enzyme NDM-1 (New Delhi metallo-ß-lactamase-1) which was first detected in a patient in Sweden (albeit with Indian origins) four years ago, but has subsequently spread to many countries around the world.

 

This enzyme confers resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems. Carbapenems are often our drug of last resort against a variety of bacterial infections.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

The rise of antibiotic resistance - including this emerging NDM-1 enzyme - has long been linked to the overuse and misuse of antibiotics. A practice that is still widespread in many parts of the world, but is particularly rampant on the Indian sub-continent.

 

Citing a lack of doctors and low family incomes, the Indian government (see India: Still Looking For A Policy On Antibiotics) has been slow to stop the sale of antibiotics to the public without a doctor’s prescription.

 

It’s been more than 2 years since The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. that sounded the alarm on the emergence and growing prevalence of the NDM-1 enzyme on the Indian sub-continent.

 

Since that time, we’ve seen a slow, but inexorable spread of NDM-1 carrying bacteria around the globe. A few of my past blogs on the subject include:

 

Carbapenemases Rising

NDM-1: One Year Later

WHO Unveils 6-Point Plan To Preserve Antibiotic Effectiveness

Eurosurveillance On Antimicrobial Resistance

 

 

Today’s report from the HPC indicates that they have identified 17 patients carrying the NDM-1 enzyme over the past four years, with one case each in 2009 and 2010, three cases in 2011, and 12 cases so far in 2012.

 

Many of these cases were colonized and detected through routine screening, but were asymptomatic. As this report indicates:

 

Infections varied from colonisation or mild to potentially life threatening or fatal. The level of risk depends upon which body part is infected and general health of the patient.

 

I’ve included some excerpts, but follow the link to read:

 

 

Source CHP Communicable Disease Watch

Among the 17 cases, 13 (76%) were male, and the median age was 64 years (ranged from 11 months to 94 years). Fourteen (82%) were Chinese, 2 Indian and 1 Burmese.

 

Among 16 imported cases, all except one had history of admission to hospitals while staying abroad. Twelve were hospitalised in Mainland China (8 in Guangdong province, 2 in Hunan province, 1 in Fujian province and 1 in Henan province), one in India, one in Myanmar and one in Thailand. Six (40%) of them had operations done during their hospitalisation.

 

The one without history of admission to hospital was a 66-year-old male patient of Indian ethnicity and he had travelled to India before onset of symptoms. Four cases had signs of infection (2 had chest infection, 1 urinary tract infection and 1 leg infection). 

 

Thirteen were asymptomatic colonisation detected by screening or contact tracing. One had the bacteria yielded from both sputum and rectal swab specimens. Two cases passed away due to underlying illness and aspiration pneumonia respectively.

 

In September 2012, CHP identified an import-related NDM-1 case affecting a 64-year-old man. A rectal swab was taken for this patient as part of the contact tracing exercise for another imported NDM-1 patient (78-year-old man) from Myanmar. They had stayed in the same cubicle of a hospital ward in Hong Kong.

 

The rectal swab was tested positive for NDM-1. Pulsed-field gel electrophoresis patterns of the two NDM-1 strains were subsequently found to be identical by the Public Health Laboratory Services Branch (PHLSB) of CHP.

This suggests that the 64-year-old case was epidemiologically linked to the 78-year-old imported case. Thirteen other patients stayed in the same cubicles as the case patients for more than 48 hours were screened by rectal swabs and all were tested negative.

 

 

This week is antibiotic awareness week (see A Health Crisis In Slow Motion) here in the United States, as it is in many places around the world. The erosion of the effectiveness of our antimicrobial arsenal increases with each year, and leads many doctors and scientists to worry that we’ll eventually lose the ability to treat even common infections.

 

For a far more complete discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA. And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

»» Read More

A Health Crisis In Slow Motion

 

 

# 6715

 

Although truly the miracle drugs of the 20th century, antibiotics are a fragile armamentarium, and over the past 70 years we’ve learned just how quickly bacteria can evolve to evade their antimicrobial effects.

 

Antimicrobial resistance is a huge and growing threat to public health – perhaps the greatest threat of all. 

 

Yet it is largely unappreciated by the public because its progression has been gradual, the loss of antibiotics incremental, and so far at least . . . there have always been replacement drugs available when an antibiotic has failed.

 

But the number of new antibiotics in the pipeline are desperately few, and the frequency of newly emerging resistant bugs has increased in recent years. 

 

Last March, the Director General of the World Health Organization, Margaret Chan - in a keynote address to the Conference on Combating Antimicrobial Resistance in Copenhagen - painted a bleak picture of the future of antibiotic availability if action is not taken.

 

The D-G’s entire remarks may be viewed on the WHO’s website at Antimicrobial resistance in the European Union and the world, but I’ve excerpted a few choice statements below.

 

If current trends continue unabated, the future is easy to predict. Some experts say we are moving back to the pre-antibiotic era. No. This will be a post-antibiotic era. In terms of new replacement antibiotics, the pipeline is virtually dry, especially for gram-negative bacteria. The cupboard is nearly bare.

 

<SNIP>

 

A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.

 

Some sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy, and care of preterm infants, would become far more difficult or even too dangerous to undertake.

 

This week (Nov. 12th-18th) marks the CDC’s fifth annual Get Smart About Antibiotics Week, which coincides with observances in many regions around the world, including  European Antibiotic Awareness Day, Australia's Antibiotic Awareness Week and Canada's Antibiotic Awareness Week.

 

The theme of this campaign is the smart usage of antibiotics, and educating the public on the fact that these drugs won’t cure a viral infection, and their overuse leads to resistance.  

 

Get Smart. Take a look at this chart to find out which upper respiratory infections are usually caused by viruses — germs that are not killed by antibiotics. Talk with your doctor about ways to feel better when you are sick. Ask what you should look for at home that might mean you are developing another infection for which antibiotics might be appropriate.

 

For some ideas about what to do for these types of illnesses without taking antibiotics, the CDC has a Symptom Relief webpage.

 

Still, many people expect an antibiotic when they go to their doctor with a respiratory infection (and many doctors continue to prescribe them).

 

 

Maryn McKenna has more on the public’s often errant perception of proper antibiotic use, and on highly divergent physician prescribing habits across the country. Follow the link to read:

 

The Persistence of Resistance And Some Reasons Why

• By Maryn McKenna
• November 13, 2012 |  

 

 

The `go to’ person on all things antibiotic resistant in the blogosphere is undoubtedly Maryn McKenna, author of Superbug: The Fatal Menace of MRSA and editor of the Superbug Blog. Both of which I highly recommend.

 

I, on occasion, do wade into the shallower depths of the antimicrobial pool in this blog. A few recent examples include:

 

EID Journal: Challenges To Defining TDR-TB

India: Still Looking For A Policy On Antibiotics

MMWR: NDM-1 Transmission In Rhode Island

ECDC Response Plan To Multi-Drug Resistant Gonorrhea

CDC Grand Rounds: Multidrug-Resistant Gonorrhea

 

 

The problems of antimicrobial resistance go far beyond the overuse, or misuse of antibiotics by the American public. Other threats include:

 

• The FDA estimates US livestock get 29 million pounds of antibiotics per year, or roughly 80% of all antibiotics used in this country. 
• The indiscriminate sale and use of antibiotics in places like India, Latin America, and parts of Eastern Europe (see India: Still Looking For A Policy On Antibiotics).
• The (illegal) trade in fake, out-of-date, or otherwise compromised antibiotics from online pharmacies (see Interpol & FDA: Operation Pangea V)
• And the excretion into the environment of bioactive antibiotic metabolites (see Pandemics & The Law Of Unintended Consequences).

 

 

It will take a multi-pronged, international effort to slow the growth of antibiotic resistance. Agencies like the FDA, CDC, WHO, and ECDC are working towards finding solutions, but there are many competing interests and much bureaucratic red tape.

 

Progress is often slow. 

 

Other than supporting the wise use of antibiotics internationally, admittedly as individuals we can’t do much about the use of antibiotics in India, or on the farm, or sold over the internet.

 

But we can be smart about how we use these drugs. Part of the solution is not being part of the problem.

 

We either exercise proper stewardship over the remaining drugs we have (and hope that new ones can be developed) or we face a very grim future where minor infections - once easily defeated -  will once again claim millions of lives.

»» Read More

India: Still Looking For A Policy On Antibiotics

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

# 6502

 

Although the antibiotic resistance enzyme now known as NDM-1 (New Delhi metallo-ß-lactamase-1) was first detected in a patient in Sweden (albeit with Indian origins) four years ago, it didn’t capture much attention until the publication of an eye-opening research paper in The Lancet in August of 2010.

 

Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

Dr David Livermore, Prof Timothy Walsh, et al.

doi:10.1016/S1473-3099(10)70143-2

Published Online: 11 August 2010

 

This study linked the recent importation of a handful of NDM-1 infections into the UK, US, and other countries  to `medical tourism’ on the Indian Sub-continent (see NDM-1: A New Acronym To Memorize).

 

NDM-1 is an enzyme confers resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems. Carbapenems are often our drug of last resort against a variety of bacterial infections.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

 

The rise of antibiotic resistance has long been linked to the overuse and misuse of antibiotics.

 

Citing a lack of doctors and low family incomes, the Indian government allows the unfettered sale of antibiotics to the public without a doctor’s prescription.

 

Indian officials swiftly reacted to the Lancet paper, but rather than taking immediate action against a growing public health menace, they took umbrage instead.

 

They condemned of the use of `New Delhi’ in the naming of this resistance gene and called the paper a `conspiracy theory’.  They issued broad denials of its prevalence in India or that medical tourism to their nation was responsible for its spread.

 

It is worth noting that the naming convention for pathogens that invoked India’s ire has long used the pathogen’s place of discovery or emergence. India was certainly not singled out.

 

After intense pressure from the International community and scathing editorializing in Indian newspapers, the Indian Health Ministry announced in October 2010 that they would impose new restrictions on the sale of 90 antibiotics that were currently sold over-the-counter.

 

But that plan was eventually abandoned. Two years later, the sale of antibiotics remains rampant and unregulated in India.

 

This article appeared last week in The Hindu.

 

 

Wanted: a policy on antibiotics

R. Sujatha

It needed a scare like NDM-1 for the country to wake up to a policy to regulate antibiotics. But after announcing with much fanfare that a policy would be in place, the government withdrew the decision. We have arrived at a crossroads and there is no solution to the crisis yet.

(Continue . . .)

 

 

The story goes on to say that next week doctors from around the country will meet in Chennai to try to come up some kind of  `road map’ for the government to use to implement an antibiotic policy. 

 

Whether they will succeed, and whether the government will follow through, remains to be seen.

 

Meanwhile, as policy makers dither, the NDM-1 enzyme continues its evolution and spread.

 

Six months after the first Lancet article in April, 2011, the same researchers published a another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested.

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

And most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

Once again the reaction out of India was one of denial (see Hopefully, It’s Just A Stage They Are Going Through). 

 

Last fall, despite ongoing denials from the Indian government, we saw a number of stories that helped to corroborate the findings of these two much-maligned-in-India Lancet studies.

 

First stop, the The Economic Times.

Ganga Ram study finds high levels of superbug NDM1

5 Oct, 2011, 1114 hrs IST, Durgesh Nandan Jha, TNN

NEW DELHI: India might have vehemently opposed an antibiotic-resistant superbug being named New Delhi Metallo-beta-lactamase 1 (NDM1), but a study in a leading city hospital has found a worryingly high prevalence of the deadly gene.

(Continue . . . )

 

 

The study, conducted over a 5-month period, examined 10,889 samples from patients. The NDM1 resistance gene was found in 8.1% of E. coli samples and 38.02% of samples of K. pneumoniae.

 

In the article, Dr S P Byotra, chairperson of medicine at the Ganga Ram Hospital, is quoted as saying:

 

"The idea behind this study is to stop denying the crisis NDM1 poses and work out strategies to check its spread. Antibiotic usage needs to be monitored strictly and good infection-control methods should be put in place at hospitals."

 

Another related article, that appeared in the International Business Times, quotes Former Indian Council of Medical Research chief and chairman N.K. Ganguly as saying that the multi-drug resistant New Delhi metallo-beta-lactamase-1 or NDM-1 comes from hospital waste that goes into Delhi's sewage water.

 

Presence of Antibiotic-Resistant Bacteria in Delhi Confirmed

October 5, 2011 1:26 PM EST

 

 

Last March (see Chan: World Faces A `Post-Antibiotic Era’), World Health Organization Director-General Margaret Chan – delivering the  keynote address to the Conference on Combating Antimicrobial Resistance in Copenhagen, Denmark - painted a bleak picture of the future of antibiotic availability if action is not taken.

 

The D-G’s entire remarks may be viewed on the WHO’s website at Antimicrobial resistance in the European Union and the world, but I’ve excerpted a few choice statements below, after which you’ll find a link to the World Health Organization’s latest publication on antibiotic resistance.

 

Excerpts from D-G Chan’s March 14th, 2012 speech.

 

Antimicrobial resistance is on the rise in Europe, and elsewhere in the world. We are losing our first-line antimicrobials. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.

 

<SNIP>

 

If current trends continue unabated, the future is easy to predict. Some experts say we are moving back to the pre-antibiotic era. No. This will be a post-antibiotic era. In terms of new replacement antibiotics, the pipeline is virtually dry, especially for gram-negative bacteria. The cupboard is nearly bare.

 

<SNIP>

 

A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.

The evolving threat of antimicrobial resistance - Options for action

Authors:
World Health Organization

 

 

To be fair, India isn’t the only country with NDM-1 cases or growing carbapenem resistance. But the Indian sub-continent does appear to be a focal point – a situation often linked to their lax controls on the sale and use of antibiotics.

 

Short of seeing a hyper-virulent pandemic someday, I can think of no public health crisis with a bigger potential impact than the growth of antibiotic resistant pathogens.

 

While I dabble in the subject from time to time, without a doubt  the `go to’ blogger on all things antibiotic resistant is Maryn McKenna, author of Superbug: The Fatal Menace of MRSA. 

 

 

If you aren’t a regular visitor to her Superbug Blog, you should be.

 

If and when the Indian government imposes meaningful restrictions on the sale of antibiotics, I’ll report it. 

 

One just hopes that happens before the point becomes moot.

»» Read More

Study: Antimicrobial Prescribing Practices During The 2009 Pandemic

Photo Credit – CDC

 

# 6479

 

One of the most common dilemmas that doctors face is whether or not to prescribe an antibiotic for a patient presenting with an FRI (Febrile Respiratory Illness) often defined as a fever > 38C accompanied by a cough, sore throat, or runny nose.

 

While these illnesses are often caused by a simple viral infection, there is always the possibility that the patient may have (or may subsequently develop) a bacterial infection.

 

Since there is little in a patients physical appearance that can help distinguish between a viral and a bacterial respiratory infection, many doctors will decide to err on the side of caution and prescribe an antibiotic, “just in case”.

 

The problem is that the over-prescribing of antibiotics is viewed as one of the main forces driving the continual growth of antibiotic resistance.  

 

Guidelines (created by the CDC in cooperation with other medical organizations) have been developed to assist the doctor in the prescribing of antibiotics for upper respiratory infections (Adult Treatment Guidelines, Pediatric Treatment Guidelines).

 

The CDC has also prepared patient education information on when antibiotics are appropriate (see the CDC’s GET SMART ABOUT ANTIBIOTICS website).

 

 

But in the end, it often comes down to the primary care provider’s gut feeling whether or not to prescribe an antibiotic. According to a study that appeared yesterday in the Annals of Internal Medicine, Epidemiological Context – not just patient appearance - can be one of the factors that influences this decision.

 

The study is called:

 

The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory Illness: A Cohort Study

Courtney Hebert, MD; Jennifer Beaumont, MS; Gene Schwartz, MD; and Ari Robicsek, MD

 

The authors undertook a 5.5 year retrospective cohort study on the prescribing of antibiotics to patients seen by a network of Midwest primary care providers during influenza seasons between 2006 and 2011.

 

Their results, compiled from 28,301 patient encounters with signs of an FRI – seen by 69 physicians across 26 practices - is illuminating.

 

• They found that during the pandemic flu season (April to June 2009 - Sept 2009 to March 2010) antibiotic prescribing dropped significantly over that seen during non-pandemic flu seasons (39.2% versus 47.5%)
• Furthermore, they found the odds that a doctor would prescribe an antibiotic decreased as the number of FRI cases that they had seen in the previous week increased.

 

In other words, the more viral illness that a doctor perceives to be circulating in their community, the less likely that doctor is to prescribe an antibiotic.

 

Perhaps more surprising was the range of antibiotic script writing by doctors across this limited geographic region.

 

Overall, antibiotics were prescribed in just under half (45.2%) of all FRI cases, but among individual clinicians that number ranged from a low of 17.9% to a high of 83.7%.

 

While there may be other factors not readily apparent from these numbers, there does appear to be a surprising diversity of opinion among clinicians over the appropriateness of prescribing of antibiotics for FRIs.

 

Although limited in both size and scope, this study suggests that finding ways to keep doctors better informed on what illnesses are currently circulating in their community might help moderate the unnecessary prescribing of antibiotics.

 

You’ll also find an accompanying editorial in the same issue of Annals Of Internal Medicine, that stresses it is important to not only determine which external factors affect clinician’s decisions, “but how and why”.

 

The Context of Antibiotic Overuse

Sara Ackerman, PhD, MPH; and Ralph Gonzales, MD, MSPH

 

 

For more on the importance of proper antibiotic usage, you may wish to revisit these earlier blogs.

 

Chan: World Faces A `Post-Antibiotic Era’

Get Smart About Antibiotics Week

IDSA: Educational Guidelines Lower Antibiotic Use

 

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

»» Read More

NDM-1: A Matter Of Import

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

# 6390

 

It’s been nearly 2 years since The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. on the emergence and growing prevalence a new enzyme – dubbed NDM-1 (New Delhi metallo-ß-lactamase-1) - on the Indian sub-continent that can confer resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems.

 

Carbapenems are newer generation beta-lactam antibiotics (a class that includes penicillins, cephalosporins, cephamycins, and carbapenems) that are usually reserved as an antibiotic of last resort.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

While the numbers were small, the authors identified a handful of patients in the UK who had recently travelled to the Indian Subcontinent and who returned with this resistant bacteria.

 

The reaction from officials out of India was both swift and disappointing. Rather than taking immediate action against a growing public health threat, they took umbrage instead.

 

They condemned of the use of `New Delhi’ in the naming of this resistance gene, called the paper a `conspiracy theory’, and issued broad denials of its prevalence in India or that medical tourism to their nation was responsible for its spread.

 

Under mounting pressure from the International community and editorializing in Indian newspapers, the Indian Health Ministry announced in October 2010 that they would impose new restrictions on the sale of 90 currently over-the-counter antibiotics.

 

But as the Deccan Chronicle reported as recently as last month, in an article called Medical body demands ban on 33 drugs in India (published May 20, 2012), little progress has been made:

 

Sale of antibiotics without prescription is rampant

Despite the government regulations restricting the sale of drugs without a prescription, medical stores continue to do so in the absence of active government monitoring. In particular, antibiotics can be obtained at medical stores just by naming them. Doctors say such an unchecked sale of antibiotics is harmful from the public's perspective.

 

Even though the policy framework of the Directorate General of Health Services seeks to regulate the unauthorised sale of antibiotics, the practice is rampant.

 

 

Six months after the first Lancet article - in April, 2011 - the same researchers published another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested.

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

 

And most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

 

Today the VOA (Voice of America) carries a report on the growing concerns over the spread of Drug Resistant bacteria across India. A problem exacerbated not only by the unregulated sale of antibiotics over the counter, but also by a lack of waste treatment facilities in that country of more than 1 billion people.

 

Concerns Mount Over India's Role In Incubating Drug-Resistant Bacteria

Kurt Achin

May 16, 2012

Medical research is once again pointing to India as a dangerous crucible of bacterial strains that resist many forms of antibiotic treatment. Cheap, under-regulated antibiotics and a severe shortfall of sanitation infrastructure fuel the problem.

 

<SNIP>

 

Unsanitary conditions in India are blamed for creating an environment for superbugs - both in emerging megacities, and in rural locations where toilet infrastructure is nearly nonexistent.

Nitya Jacob, head of water issues at New Delhi's Center for Science and Environment, co-authored a recent study called “Excreta Matters.”

"India has a capacity to treat only about a fifth of its sewage and I think about 40 percent of that capacity is concentrated in just two cities of Delhi and Bombay," said Jacob.

Superbug researcher Kumarasamy says the Indian government needs to act urgently to prevent the spread of drug-resistant diseases.

(Continue . . .)

 

More detail on the Excreta Matters study, referenced above, can be found on the Centre For Science and Environment website.

 

 

Meanwhile, as governments dither and regulations go unenforced - superbugs like NDM-1, acinetobacter, and a myriad of carbapenamases including: IMP, VIM, OXA, CMY, and most notably KPC (K. pneumoniae carbapenemase) - continue their pernicious spread around the world.

 

A story out of Edmonton, Canada last week illustrates this point, showing just how easily superbugs can be imported, and then spread:

 

Health officials admit superbug lead to death of patient at Royal Alex

Updated: Wed Jun. 06 2012 19:18:56
Julia Parrish, ctvedmonton.ca

Weeks after two types of drug resistant bacteria were brought into Edmonton by a woman who had surgery overseas, health officials have confirmed those `superbugs' lead to the death of another patient at the Royal Alexandra Hospital.

(Continue . . . )

 

 

Short of seeing an extremely high mortality influenza pandemic, I can think of no looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be an extremely urgent public health concern.

 

For more on these issues, you may wish to revisit:

 

Carbapenemases Rising

Chan: World Faces A `Post-Antibiotic Era’

WHO: The Evolving Threat Of Antimicrobial Resistance

 

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

»» Read More

Referral: McKenna Times Four

 

 

# 6367

 

 

Maryn McKenna has two new blogs up, both dealing with the dangers of antibiotics in livestock, and a new article in SELF Magazine, and all three are very much worth taking the time to read this morning.

 

As an added bonus, Maryn will also be conducting a twitter chat tomorrow (details below), so block out an hour of your time and start thinking about your questions.

 

While I scrounge around looking for something for my own blog this morning, I would invite you to jump over to Maryn’s site to read:

 

Court Scolds FDA Over Ag Antibiotic Use

• By Maryn McKenna June 5, 2012 

 

 

The Superbugs In Your Dinner (Bonus: Twitterchat!)

• By Maryn McKenna  June 6, 2012 | 
• 6:00 am

 

 

As her second blog explains, Maryn has a major new article up on SELF Magazine, and tomorrow Maryn will hold a twitter chat.  The details from Maryn’s blog follow:

 

Now: Bonus! With SELF’s help, Lisa and I are going to conduct a Twitterchat tomorrow (Thursday, June 7), starting at 4 pm ET and going for an hour. To participate, follow me (@marynmck), Lisa (@adamslisa) or SELF (@SELFMagazine), or watch for the hashtag #superbugs. Send us your questions in advance or during the chat. We really want to hear from you.

 

 

And finally, for anyone who has not yet read Maryn’s eye-opening 2010 book Superbug: The Fatal Menace of MRSA, a link to my review.

»» Read More

HPA: Healthcare-Associated Infection (HCAI) Survey

 

# 6340

 

The UK’s HPA has released a comprehensive survey of antimicrobial use, and HCAI (Healthcare-Associated Infections), across 114 hospitals (99 NHS acute trusts and 5 independent sector organizations), providing us with a snapshot of conditions between September and November 2011.

 

Although the full global burden of HCAIs or HAIs (Hospital Acquired Infections) is unknown and underappreciated, even in countries with modern healthcare facilities they constitute a major threat to life and health.

 

The following is an oft quoted assessment from the CDC on HAI’s (Hospital Acquired Infections) in the United States back in 2010.

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

The subject of HAIs is often addressed by Maryn McKenna on her excellent Superbug Blog, and was a major focus of her book SUPERBUG: The Fatal Menace Of MRSA. Both are highly recommended.

 

The HPA is working to reduce the incidence of HAIs in the UK, and according to their latest report, progress has been made. The greatest reductions have been made in MRSA bloodstream infections and C. difficile infections.

 

Of special note, Enterobacteriaceae (includes E. coli, Klebsiella spp.,Enterobacter spp. and others) were the most frequently reported organisms associated with HCAI, infecting roughly .9% of the patient population, and making up nearly 1/3rd of all infections.

 

Links to the 140 page preliminary report, 144 page appendices, and a 16  page FAQ at the link below.

 

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011: preliminary data

Authors:

HPA

Publication date: May 2012

Synopsis

The Health Protection Agency (HPA) coordinated the fourth National Point Prevalence Survey (PPS) on healthcare-associated infection (HCAI) and first National PPS on antimicrobial use (AMU) in England. This survey is not directly comparable to previous surveys.

 

The aims of the PPS were to determine the burden of HCAI and AMU in acute hospitals and to use the results to identify priority areas for the future.

Key points

• The prevalence of healthcare-associated infections (HCAI) was 6.4% in 2011 compared to 8.2% in 2006.
• The most frequent HCAIs detected were respiratory tract, urinary tract and surgical site infections.
• The prevalence of antimicrobial use (AMU) was 34.7%. This is the first time AMU was measured nationally. This provides a baseline for future monitoring.
• The prevalence of HCAIs, AMU and device use was highest in intensive care units, which relates in part to the complexity and vulnerability of patients in this setting.

Download full publication

English National Point Prevalence Survey on Healthcare-Associated Infections and Antimicrobial Use, 2011 - Appendices (PDF, 3.3 MB)

 

PPS Frequently Asked Questions (PDF, 654 KB)

 

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011 (PDF, 1.9 MB)

 

While there is much to be gleaned from these reports, a few highlights from the FAQ include:

 

 

3.1 What is the overall prevalence of HCAI in English hospitals?

The overall prevalence of HCAI in acute hospitals was 6.4%.The prevalence in NHS acute trusts was 6.5% Independent sector organisation had a lower prevalence of HCAI of 2.2%.

It is not appropriate to compare the prevalence between these hospital types because they represent distinct case mixes, patient populations and specialties. Further the numbers included were very small in paediatric and independent hospitals and these results should be interpreted with caution.

3.2 Does a prevalence of 6.4% mean that if I go in to hospital I have a one in sixteen chance of getting a HCAI?

No. This means that at any time one in sixteen inpatients in hospital will have a HCAI. A prevalence survey counts the number of patients with HCAI at any point in time.

People with HCAI tend to stay in hospital longer and those patients who stay in hospital for longer periods of treatment tend to be more seriously ill and therefore more at risk of contracting HCAI. The large majority of patients are successfully treated in hospital and go home without acquiring a HCAI.

3.3 Can you tell me what my chance is of contracting HCAI during my hospital stay?

No. This is not shown by the current prevalence survey. In order to calculate how likely a person is to get a HCAI an incidence study would be required. This would look at all patients who were treated within the hospital on a regular basis over a defined time period.

 

 

 

 

The other focus of this survey was to determine the level of AMU (Antimicrobial Usage) in acute care hospitals in England.  The report found:

 

The overall prevalence of AMU was 34.7%. The prevalence of AMU was greatest in the independent sector hospitals (46.7%) compared with NHS organisations at 34.3%. The prevalence of AMU in adults was 35.3% and in paediatrics 28.7%. AMU prevalence was greatest in ICU at 60.8%.

The total number of antimicrobials prescribed in the survey was 25,942 for 18,219 (34.7%) patients, which equates to 1.4 AM per patient prescribed antimicrobials. AMU were most frequently prescribed for community acquired infections (53.0%). Thirteen percent of patients were on an antimicrobial (AM) for surgical prophylaxis; 30.3% of surgical prophylaxis was administered for greater than one day.

 

The majority of AMU was for respiratory tract infections (30.9%). The second most common reason for AMU was skin, soft tissue, bone and joint infections (19.0%).

 

The use of a standardized survey technique should go a long ways towards developing better year-to-year comparisons of HCAIs and AMU in UK facilities, and will facilitate comparisons with other EU countries that have adopted similar surveys.

»» Read More

Chan: World Faces A `Post-Antibiotic Era’

 

 

# 6226

 

World Health Organization Director-General Margaret Chan - in a keynote address to the Conference on Combating Antimicrobial Resistance this week in Copenhagen, Denmark - painted a bleak picture of the future of antibiotic availability if action is not taken.

 

The D-G’s entire remarks may be viewed on the WHO’s website at Antimicrobial resistance in the European Union and the world, but I’ve excerpted a few choice statements below, after which you’ll find a link to the World Health Organization’s latest publication on antibiotic resistance.

 

Excerpts from D-G Chan’s March 14th, 2012 speech.

 

Antimicrobial resistance is on the rise in Europe, and elsewhere in the world. We are losing our first-line antimicrobials. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.

 

For patients infected with some drug-resistant pathogens, mortality has been shown to increase by around 50%. Let me give an example of what this means for a disease of global significance.

 

Among the world’s 12 million cases of tuberculosis in 2010, WHO estimates that 650,000 involved multidrug-resistant TB strains. Treatment of MDR-TB is extremely complicated, typically requiring two years of medication with toxic and expensive medicines, some of which are in constant short supply. Even with the best of care, only slightly more than 50% of these patients will be cured.

 

Many other pathogens are developing resistance to multiple drugs, some to nearly all. Hospitals have become hotbeds for highly-resistant pathogens, like MRSA, ESBL, and CPE, increasing the risk that hospitalization kills instead of cures. These are end-of-the-road pathogens that are resistant to last-line antimicrobials.

 

If current trends continue unabated, the future is easy to predict. Some experts say we are moving back to the pre-antibiotic era. No. This will be a post-antibiotic era. In terms of new replacement antibiotics, the pipeline is virtually dry, especially for gram-negative bacteria. The cupboard is nearly bare.

<SNIP>

A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.

 

Some sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy, and care of preterm infants, would become far more difficult or even too dangerous to undertake.

 

 

Director Chan called for greater restrictions in the use of antibiotics, and a crackdown on counterfeit drugs which not only can endanger the patients taking them, they can feed growing resistance.

 

This week the WHO released a 120 page book that provides options and strategies for combating this global threat.

 

The evolving threat of antimicrobial resistance - Options for action

Authors:
World Health Organization

Publication details

Number of pages: 120
Publication date: 2012
Languages: English
ISBN: 978 92 4 1503181

Downloads

• The evolving threat of antimicrobial resistance - Options for action
  English, pdf, 2.10Mb

Overview

Antibiotic resistance development is a natural process of adaption leading to a limited lifespan of antibiotics. Unnecessary and inappropriate use of antibiotics favours the emergence and spread of resistant bacteria. A crisis has been building up over decades, so that today common and life-threatening infections are becoming difficult or even impossible to treat. It is time to take much stronger action worldwide to avert an ever increasing health and economic burden. A new WHO publication "The evolving threat of antimicrobial resistance - Options for action" describes examples of policy activities that have addressed AMR in different parts of the world. The aim is to raise awareness and to stimulate further coordinated efforts.

 

 

As an aside, without a doubt  the `go to’ blogger on all things antibiotic resistant is Maryn McKenna, author of Superbug: The Fatal Menace of MRSA.  If you aren’t a regular visitor to her Superbug Blog, you should be.

 

While not in the same league, you’ll also find some of my humble offerings at the links below:

 

NDM-1: One Year Later

WHO Unveils 6-Point Plan To Preserve Antibiotic Effectiveness

Eurosurveillance On Antimicrobial Resistance

ECDC/EMEA: Joint Report On Resistant Bacteria

Carbapenemases Rising

WHO: The Threat Of Antimicrobial Resistance

NDM-1: A New Acronym To Memorize

»» Read More

WHO: The Evolving Threat Of Antimicrobial Resistance

 

 

# 6207

 

 

The World Health Organization has today published a 120-page guide designed to raise awareness on what may well be public health’s biggest challenge over the next couple of decades; the growing threat of antibiotic resistant organisms.

 

 

Publication details

Number of pages: 120
Publication date: 2012
Languages: English
ISBN: 978 92 4 1503181

Downloads

• The evolving threat of antimicrobial resistance - Options for action
  English, pdf, 2.10Mb

Overview

Antibiotic resistance development is a natural process of adaption leading to a limited lifespan of antibiotics. Unnecessary and inappropriate use of antibiotics favours the emergence and spread of resistant bacteria. A crisis has been building up over decades, so that today common and life-threatening infections are becoming difficult or even impossible to treat. It is time to take much stronger action worldwide to avert an ever increasing health and economic burden. A new WHO publication "The evolving threat of antimicrobial resistance - Options for action" describes examples of policy activities that have addressed AMR in different parts of the world. The aim is to raise awareness and to stimulate further coordinated efforts.

 

While I’ve only briefly skimmed this publication, it appears to be a pretty good introduction and overview of the problem, and contains a good deal of data gathered from around the world.

 

Last year, you may recall, the the theme of World Health Day was combating drug resistance.

 

World Health Day – 7 April 2011

Antimicrobial resistance: no action today, no cure tomorrow

 

While we often hear of potential threats to our health that – quite frankly – are rare and unlikely, antimicrobial resistance is neither.

 

It already has a major impact on our health care system, and that impact is growing by the day.

 

We literally risk losing our front line drugs against a variety of aggressive and deadly pathogens.

 

Unless we face the problem now, and change our cavalier attitude on the use of antibiotics, we face a future where effective lifesaving antibiotics may be increasingly difficult to find.

»» Read More

Get Smart About Antibiotics Week

 

 

# 5966

 

 

Short of seeing a Category 5 pandemic, I can think of no health threat that has a greater potential to threaten the general public than does the global rise in antibiotic resistant bacteria.

 

As Maryn McKenna so eloquently explained in her book Superbug: The Fatal Menace Of MRSA, not only are many of our older antibiotics losing their effectiveness, the number of replacement antibiotics under development is distressingly limited.

 

While it may sound alarmist, there are many scientists who fear that one day we may find ourselves facing a post-antibiotic world, where many of the infections we can treat today will no longer respond to the antibiotics we have remaining.

 

In April of this year, Margaret Chan – Director General of the World Health Organization – in a speech for World Health Day 2011, issued this stark warning:

 

In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated.

 

 

Since much of this resistance has come about from inappropriate use of antibiotics (in humans, and on the farm), the immediate focus is on ways to curb their improper use.

 

This week the CDC is promoting their GET SMART about antibiotics campaign, while countries across Europe are promoting European Antibiotic Awareness Day tomorrow, November 18th.

 

 

Today, a round up of some antibiotic resistance resources for you to explore.

 

 

First stop, a short video from the CDC on the appropriate use of antibiotics.

 

 

The CDC has also introduced a number of new fact sheets and other promotional material for 2011 on antibiotic resistance.

 

Fact Sheets New 2011

• Antibiotics: Will they work when you really need them? [412 KB, 2 ages]

                                                                 

• Delivering safe care for patients: all healthcare providers play a role [503 KB, 2 pages]
  
• Antibiotic stewardship – the ultimate return on investment [460 KB, 2 pages]
  
• Preserving antibiotics for the future [420 KB, 2 pages]
  
• Resistance anywhere is resistance everywhere [475 KB, 2 pages]
  
• Antibiotic use in long-term care facilities [600 KB, 2 pages]
  

 

Across the pond, the ECDC has posted a short (8 minute) documentary on antibiotic resistance, and some short PSA announcements which can be viewed at this link.

 

You’ll find additional European initiatives and information on the European Antibiotics Awareness Day website.

 

In support of the CDC & ECDC awareness campaigns, Clinical Infectious Diseases  and The Journal of Infectious Diseases  have made a number of recent articles on antibiotic resistance freely available for the month of November.

 

Clinical Infectious Diseases articles:

Editorial commentary: Outpatient Antibiotic Use in the United States: Time to "Get Smarter"

Behavior Change Strategies to Influence Antimicrobial Prescribing in Acute Care: A Systematic Review

The Interface Between Antibiotic Resistance and Virulence in Staphylococcus aureusand Its Impact Upon Clinical Outcomes

Rapid Diagnostics and Appropriate Antibiotic Use

Strategies for Reduction in Duration of Antibiotic Use in Hospitalized Patients

The Journal of Infectious Diseases articles:

Editor's Choice: Antibiotic Choice May Not Explain Poorer Outcomes in Patients With Staphylococcus aureus Bacteremia and High Vancomycin Minimum Inhibitory Concentrations

Editorial commentary: At What Cost Echinocandin Resistance?

Acinetobacter baumannii Resistant to Colistin Alters Its Antibiotic Resistance Profile: A Case Report From Spain

The Combination of a Tumor Necrosis Factor Inhibitor and Antibiotic Alleviates Staphylococcal Arthritis and Sepsis in Mice

Divergent Mechanisms for Passive Pneumococcal Resistance to &szlig-Lactam Antibiotics in the Presence of Haemophilus influenza

 

 

And for good measure, a sampling of some of my antibiotic resistance essays from the past year.

 

India: The NDM-1 Story Continues

CDDEP: Mapping Resistance

NDM-1: One Year Later

ECDC/EMEA: Joint Report On Resistant Bacteria

Carbapenemases Rising

»» Read More

South African Statement On NDM-1 Cases

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

# 5915

 

Over the past week a story emerged from South Africa regarding (initially 9, now 10) patients in a private hospital who were diagnosed with an NDM-1 bacterial infection.

Crof, at Crofsblog covered these reports here, here, and here.

 

Three of these patients have reportedly died, but local authorities have pointed out that all three had `co-morbidities’ that probably played a major role in their deaths.

 

NDM-1 gained prominence a little over a year ago with the publication of a Lancet article (see NDM-1: A New Acronym To Memorize) that tied India and Pakistan to the emergence and spread of an enzyme that confers resistance in common gram negative bacteria like E.coli and Klebsiella against most antibiotics.

 

Today the South African Department of Health has posted a statement regarding these recent cases. While calling NDM-1 a `national concern’, it provides little in the way of specifics on this outbreak, and instead seeks to reassure that everything is under control.  

 

 

Emergence of NDM-1 in South Africa a national issue

Joint media statement issued by the National Department of Health and Life Healthcare

20 October 2011

 

The emergence of the Klebsiella pneumoniae producing NDM-1 enzyme in South Africa is a matter of national concern. It should be noted that the institution-based outbreak is contained through the effective measures implemented thus far. The possibility of further spread is limited.

 

NDM-1 was identified at Life The Glynnwood Hospital in Benoni, where 10 patients treated were confirmed to have NDM-1. An outpatient at Charlotte Maxeke Hospital in Johannesburg was earlier also confirmed with this multidrug resistant strain of bacteria. There are presently still three patients in Glynnwood Hospital with the NDM-1 bacterium who are in a stable condition.

 

Representatives of the national, provincial and district departments of health met with Life The Glynnwood management and with representatives of Life Healthcare (of which the hospital forms part) as well as with other key roleplayers on Wednesday (19 October) to assess the situation and determine the way forward.

 

Life The Glynnwood was commended for identifying the NDM-1 strain promptly and implementing effective interventions to respond to the outbreak and prevent its spread. These measures include effective treatment and isolation of affected patients, strengthening infection control measures, screening of around 400 patients and staff as well as commissioning an independent clinical audit.

 

A co-ordinating outbreak response team was formed that will meet regularly to monitoring and redirect response to the outbreak when needed. A monitoring system within public and private sector will also be set up.

 

A formal report is being compiled and will be submitted to the Minister of Health. The parties will furthermore work together in formalising a NDM-1 treatment protocol for clinicians. They will also document lessons learned from the experience at Life The Glynnwood to share with other roleplayers. These actions will be of immense value to other hospitals which may be faced with a similar situation in future.

 

Prof Adriano Duse, an appointee of the Department of Health and the Head of Clinical Microbiology and Infection Control at Wits University as well as the National Health Laboratory Services (NHLS) will continue to be the spokesperson on the NDM-1 outbreak.

»» Read More