ECDC: Multidrug Resistant Infections Increasing In Europe

Consumption of antibiotics for systemic use in the community in EU/EEA countries, 2010 - Source

# 6721

 

November 18th is set aside each year by the ECDC and their partners as European Antibiotic Awareness Day. For the past 5 years they have mounted coordinated events to get the message out on the safe and sane use of antibiotics in the face of increasingly resistant bacteria.

 

You’ll find an excellent infographic, along with a number of other resources, available on the ECDC’s Antibiotics Awareness Day web page.

 

Coinciding with the 2012 observance, we have the release of new data on the consumption of antibiotics in the EU, along with numbers showing the rise in multi-drug resistant organisms.

 

A few excerpts from the ECDC news release, followed by links to the reports.  Follow the link for more.

 

 

Multidrug antibiotic resistance increasing in Europe

16 Nov 2012

On the occasion of the 5th edition of the European Antibiotic Awareness Day, ECDC releases new EU-wide data on antibiotic resistance and consumption. Antibiotic resistance still remains a major European and global public health problem and is, for a large part, driven by misuse of antibiotics. ECDC data show that over the last four years there has been a significant increasing trend of combined resistance to multiple antibiotics in both Klebsiella pneumoniae and E. coli in more than one-third of the EU/EEA countries. In several Member States, between 25 percent and up to more than 60 percent of Klebsiella pneumoniae from bloodstream infections show combined resistance to multiple antibiotics. Options for treatment of patients who are infected with such multidrug-resistant bacteria are limited to only few last-line antibiotics.

 

Antibiotic resistance is still a very serious threat to the health of European citizens, because it leads to increasing healthcare costs, extra length of stay in the hospital, treatment failures, and sometimes death. Speaking at a press event organised by ECDC and the European Commission in Brussels, ECDC Director Marc Sprenger said: “ECDC data show that over the last several years, there has been a Europe-wide increase of antibiotic resistance and of multidrug resistance in Gram-negative bacteria such as Klebsiella pneumoniae and Escherichia coli (E. coli). This means that, for patients who are infected with these bacteria, few last-line antibiotics, like carbapenems, remain available”.

 

Furthermore, ECDC data show that consumption of carbapenems – a major last-line class of antibiotics – increased significantly in EU/EEA countries from 2007 to 2010. This is the likely consequence of increasing multidrug resistance in Gram-negative infections, such as bloodstream infections or pneumonia, since carbapenems are often used to treat such infections. However, the percentage of carbapenem-resistant Klebsiella pneumoniae is already high and increasing in some countries in the EU.

 

He added: “There are, in contrast, some good news: in the past few years, meticillin-resistant Staphylococcus aureus (MRSA), has shown either a decrease or a stabilisation in most EU countries. Nevertheless, we must remain vigilant, as the percentage of Staphylococcus aureus resistant to meticilin remains above 25% in more than one fourth of the reporting countries, mainly in Southern and Eastern Europe”.

(Continue . . .)

 

News release
European Antibiotic Awareness Day 2012 – Latest data
European Antibiotic Awareness Day 2012 website
Antimicrobial resistance surveillance in Europe 2011

 

 

ECDC Infographic – Click to enlarge

 

For a look at the CDC’s Get Smart About Antibiotics Week here in the United States, you wish to revisit:

 

A Health Crisis In Slow Motion

»» 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

Referral: McKenna On Resistant Gonorrhea

 

Credit CDC

 

# 6487

 

A topic that Maryn McKenna and I have both blogged about at length over the past year – Increasingly Drug Resistant Gonorrhea - was the subject of a major announcement out of the CDC yesterday.

 

In the wake of rising treatment failures with the existing treatment protocol, Thursday’s MMWR contained new guidelines on the treatment of gonorrhea, making the oral antibiotic cefixamine no longer the first line drug of choice, and substituting injectable ceftriaxone along with oral doses of either azithromycin or doxycycline.

 

 

Last night, Maryn McKenna – Flublogia’s expert in all things antibiotic resistant  - wrote about this bulletin in her SUPERBUG BLOG, and so I would invite you to jump  over to her site to read:

 

Resistant Gonorrhea: CDC Says Just One Drug Left

• By Maryn McKenna 
• August 9, 2012 | 

 

This problem extends far beyond the growing incidence of resistant Neisseria gonorrhoeae. You’ll find Maryn’s 2010 book Superbug: The Fatal Menace of MRSA serves as a terrific wakeup call and primer covering a wide range of these resistance issues. 

 

We’ve known this day was coming, of course. Over the past year I’ve written about the warning signs in:

 

ECDC Response Plan To Multi-Drug Resistant Gonorrhea

WHO: Urgent Action Needed On Resistant Gonorrhea

CDC Grand Rounds: Multidrug-Resistant Gonorrhea

Going, Going, Gonorrhea

The Path Of Increased Resistance

 

 

History has taught us – that given enough time – bacterial pathogens often manage to evolve resistance to whatever antibiotics we use against them.

 

With few new classes of antimicrobials in the developmental pipeline, the fear is that a few years down the road, our ability to treat even the simplest of infections may be compromised.

 

Director-General Margaret Chan of the WHO warned earlier this year during a keynote address to the Conference on Combating Antimicrobial Resistance in  Copenhagen, Denmark that our World Faces A `Post-Antibiotic Era’.

 

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.

 

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 World Health Organization recently 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

»» Read More

EID: Environmental NDM-1 Detected In Vietnam

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

 

# 6440

 

In a study reminiscent of one we saw published in April of last year (see Lancet Study: NDM-1 In New Delhi Water Supply), the CDC’s EID Journal has a letter by R. Isozumi et al. that appears (ahead of print) in their August issue, that reveals the detection of the NDM-1 gene in a river in Hanoi.

 

bla_NDM-1–positive Klebsiella pneumoniae from Environment, Vietnam

Rie Isozumi , Kumiko Yoshimatsu, Tetsu Yamashiro, Futoshi Hasebe, Binh Minh Nguyen, Tuan Cuong Ngo, Shumpei P. Yasuda, Takaaki Koma, Kenta Shimizu, and Jiro Arikawa

 

By way of explanation, bla_NDM-1 is the gene responsible for creating the NDM-1 (New Delhi metallo-β-lactamase) enzyme that can make many types of bacteria resistant to a wide spectrum of antibiotics.

 

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).

 

Over the past few years we have seen a worrisome expansion of β-lactamase enzymes in bacteria, and they are slowly eroding the value of much of our antibiotic arsenal.

 

Those that inhibit the antimicrobial actions of the (formerly resistant) Carbapenem class of antibiotics – called carbapenemases – are of particular concern. Carbapenems are often used as the drug of last resort for treating difficult bacterial infections, including Escherichia coli (E. coli) and Klebsiella pneumoniae.

 

So when the gene responsible for the NDM-1 enzyme begins to show up in the environment, doctors and researchers take notice.

 

The author’s of today’s EID Journal report state their reasons for concern:

 

The possible appearance of bacteria harboring bla_NDM-1 in Vietnam is of concern because cultural and economic links between Vietnam and India are strongly established, including extensive person-to-person exchanges that could enable easy exchange of pathogens. In addition, Vietnam faces a serious problem of antimicrobial drug resistance because drugs are freely available and used in an indiscriminate fashion. Thus, once bla_NDM-1–positive bacteria colonize persons in Vietnam, they would be able to spread easily and pose a serious public health threat.

 

To look for environmental bla_NDM-1, researchers examined water samples taken from 20 locations within 10 km of Hanoi, Vietnam. Samples were collected from rivers, lakes, and standing water in the streets.

The authors report finding the NDM-1 enzyme producing gene in two locations – 3km apart – in the Kim Nguu River, which flows through the city.  They write:

 

We harvested several species of bacteria from the 2 seepage samples positive for bla_NDM-1: Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, P. fluorescens/putida, and P. luteola. 

 

They also report finding 2 other βeta-lactamases (bla_TEM-1 and bla_CTX-M-3) that were highly resistant to another class of antibiotics called aminoglycosides (which include neomycin, streptomycin & tobramycin)

The authors conclude by saying:

Wide-scale surveillance of environmental and clinical samples in Vietnam and establishment of a strategy to prevent further spread of bla_NDM-1 are urgently needed.

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. that awakened the world to the  emergence and growing prevalence of the NDM-1 enzyme.

 

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

 

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.

 

Last March, Director-General of the World Health Organization Margaret Chan warned that the World Faces A `Post-Antibiotic Era’. One where even common infections may become untreatable.

 

While we aren’t there yet, reports such as the one today in the EID Journal add to the growing concern that someday, that fear may become a reality.

»» Read More

Referral: McKenna On Resistant UTIs

 

 

# 6429

 

Maryn McKenna, everybody’s favorite scary disease girl, has a double whammy for us this morning.  A blog post, and an extended investigative report in The Atlantic, on the suspected link between resistant UTIs and the routine feeding of antibiotics to poultry.

 

First stop, is Maryn’s SUPERBUG BLOG, where she previews her investigative article – produced with the Food & Environment Reporting Network.

 

Investigation: Drug Resistance, Chicken And 8 Million UTIs

By Maryn McKenna  July 11, 2012

 

If Maryn’s blog post is a tasty Hors d'oeuvre, then the main course is served up in The Atlantic.

 

How Your Chicken Dinner Is Creating a Drug-Resistant Superbug

By Maryn McKenna

Jul 11 2012, 5:16 PM ET 1

Continuing to treat urinary tract infections as a short-term, routine ailment rather than a long-term food safety issue risks turning the responsible bacteria into a major health crisis.

(Continue . . . )

 

 

Both pieces are highly recommended.

 

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

»» Read More

MMWR: NDM-1 Transmission In Rhode Island

 

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

 

 

# 6397

 

From the today’s MMWR , we’ve a report on the importation and likely nosocomial transmission of a CRE (carabapenem-resistant Enterobacteriaceae) infection containing NDM-1.

 

NMD-1, or New Delhi metallo-ß-lactamase-1 – is an enzyme which confers broad antibiotic resistance to various types of bacteria. Even more troubling, it rides on a plasmid (a snippet of portable DNA) that can be shared by different types of bacteria.

 

The good news is that NDM-1 cases in the United States are still rare enough that they merit extensive reportage in the CDC’s MMWR. The bad news is, they continue to spread around the globe and our treatment options against them are extremely limited.

 

A few excerpts from today’s MMWR report follow (slightly reparagraphed for readability). 

 

 

Carbapenem-Resistant Enterobacteriaceae Containing New Delhi Metallo-Beta-Lactamase in Two Patients — Rhode Island, March 2012

 

June 22, 2012 / 61(24);446-448

U.S. and international efforts to control carabapenem-resistant Enterobacteriaceae (CRE) are critical to protect public health. Clinicians caring for patients infected with such organisms have few, if any, therapeutic options available. CRE containing New Delhi metallo-beta-lactamase (NDM), first reported in a patient who had been hospitalized in New Delhi, India, in 2007 (1), are of particular concern because these enzymes usually are encoded on plasmids that harbor multiple resistance determinants and are transmitted easily to other Enterobacteriaceae and other genera of bacteria (2).

 

A urine specimen collected on March 4, 2012, from a patient who recently had been hospitalized in Viet Nam, but who was receiving care at a hospital in Rhode Island, was found to have a Klebsiella pneumoniae isolate containing NDM.

 

The isolate was susceptible only to tigecycline, colistin, and polymyxin B. Point-prevalence surveys of epidemiologically linked patients revealed transmission to a second patient on the hematology/oncology unit.

 

These two cases bring to 13 the number of cases of NDM reported in the United States. After contact precautions were reinforced and environmental cleaning was implemented, no further cases were identified.

 

<SNIP Lengthy Narrative On Patients, Lab Tests, and Isolation Methods>

 

Reported by

Erica E. Hardy, MD, Leonard A. Mermel, DO, Dept of Medicine, Kimberle C. Chapin, MD, Dept of Pathology, Warren Alpert Medical School of Brown Univ; Cindy Vanner, Rhode Island Dept of Health. Ekta Gupta, MD, Dept of Medicine, Boston Univ School of Medicine, Massachusetts. Corresponding contributor: Leonard A. Mermel, lmermel@lifespan.org, 401-444-2608.

Editorial Note

Since the first report in 2009, cases involving NDM-producing Enterobacteriaceae have been reported in every continent except South America and Antarctica (7). Among 29 cases in the United Kingdom, at least 17 involved patients who had traveled to India or Pakistan, among whom 14 had been hospitalized in one of those countries (8).

 

Although medical care in the Indian subcontinent was associated with many early reports, recent cases have been described involving persons who traveled to endemic regions* but were not hospitalized (7). The plasmid-carrying NDM is highly transmissible to other bacteria, and bacteria carrying NDM can colonize the gastrointestinal systems of humans for prolonged periods and can spread through contamination of water sources and environmental surfaces (7).

 

Not surprisingly, nosocomial spread also has been documented outside of the Indian subcontinent. Of 77 cases of infection or colonization with CRE containing NDM in Europe, 13 might have been hospital-acquired in Europe (9). Spread of NDM in other parts of Asia also has been reported, including four patients in South Korea without travel history (10), similar to recent reports elsewhere (7).

 

(Continue . . . )

 

 

In summary, the report offers the following:

 

What is already known on this topic?

New Delhi metallo-beta-lactamase (NDM)–producing Klebsiella pneumoniae are resistant to extended-spectrum antimicrobials, including carbapenems. The resistance mechanism is highly transmissible and its presence substantially limits treatment options. NDM-producing Enterobacteriaceae have been identified in the United States, primarily among patients with exposure to health care in endemic countries.

 

What is added by this report?

An NDM-producing organism was isolated from a patient being treated in the United States after having been hospitalized in Vietnam. Implementation of CDC-recommended carbapenem-resistant Enterobacteriaceae (CRE) control practices, including surveillance cultures of epidemiologically linked contacts, identified likely transmission to one other patient on the same ward of the U.S. hospital. Additional control measures were applied and additional surveillance and clinical cultures have not identified further transmission.

 

What are the implications for public health practice?

An aggressive approach to control of CRE, including highly transmissible carbapenemase-producing organisms, is essential to slow the spread of these organisms in the United States. In an outbreak, use of surveillance cultures to identify asymptomatic transmission potentially is an important part of these efforts.

 

 

I  wrote about this emerging public health threat less than a week ago, in NDM-1: A Matter Of Import. The following link will provide a list of some of my past blogs on the NDM-1 enzyme.

 

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.

 

Last March, Director-General of the World Health Organization Margaret Chan warned that the World Faces A `Post-Antibiotic Era’.

 

One where even common infections may become untreatable.

 

While we aren’t there yet, reports such as this one add to the growing concern that someday, that fear may become a reality.

»» Read More

ECDC Response Plan To Multi-Drug Resistant Gonorrhea

 

 

# 6379

 

 

Last week in WHO: Urgent Action Needed On Resistant Gonorrhea, I updated a story that Maryn McKenna and I have both written about on several occasions over the past couple of years; the worrisome rise in antibiotic-resistant gonorrhea around the globe.

 

Early last month Maryn wrote Drug-Resistant Gonorrhea: How We Lost Track and last year she penned The Clap Came Back: Multidrug-Resistant Gonorrhea, both of which are highly recommended reading.

 

You’ll find a couple of my earlier offerings here, and here.

 

Today the ECDC has released a series of reports, including a 23-page technical document with their response plan to control and manage the threat of multidrug-resistant gonorrhea in Europe.

 

 

 

Released today as well is a 41-page document called Gonococcal antimicrobial susceptibility surveillance in Europe – 2010, that finds a worrisome trend:

 

Euro-GASP 2010 identified a significant increase in the proportion of tested isolates that show decreased susceptibility to cefixime, from 4% in 2009 to 9% in 2010, using a cut-off of >0.125 mg/L. Rates of ciprofloxacin and azithromycin resistance remain high (53% and 7%, respectively).

 

Along with the two report, the ECDC has released their surveillance report Sexually transmitted infections in Europe 1990-2010, tracking the spread and prevalence of five STI’s (syphilis, congenital syphilis, gonorrhoea, chlamydia and lymphogranuloma  venereum (LGV)) across the EU over the past 2 decades.

 

Details and links follow:

 

 

 

Concerns about future treatment of gonorrhoea in Europe: ECDC issues response plan

11 Jun 2012

ECDC

With more than 32 000 cases, gonorrhoea was the second most commonly reported sexually transmitted infection (STI) in Europe in 2010. As data from the ECDC report Gonococcal antimicrobial susceptibility surveillance in Europe 2010 illustrates, gonococci have become more resistant to common agents for treatment and show reduced susceptibility to newer antibiotics. “This indicates the risk that gonorrhoea may become an untreatable disease in the near future”, stresses ECDC Director Marc Sprenger.

In response to these signals, ECDC today also publishes its Response plan to control and manage the threat of multidrug-resistant gonorrhoea in Europe.

 

Results from the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP)  show that the percentage of isolates with decreased susceptibility to the recommended drug for treatment of gonorrhoea (cefixime) rose from 4% in 2009 to 9% in 2010. Decreased susceptibility was detected in 17 countries in 2010, seven more than in the previous year.

 

“Decreasing susceptibility to recommended antimicrobials and increasing numbers of treatment failures across Europe ask for careful monitoring of the European gonococcal population as the as the loss of the current recommended treatments could result in untreatable gonorrhoea”, says ECDC Director Marc Sprenger.

Read more

• Press release "Concerns about future treatment of gonorrhoea in Europe: ECDC issues its reponse plan"
• Sexually transmitted infections in Europe 1990-2010 surveillance report
• Gonococcal antimicrobial susceptibility surveillance in Europe 2010
• Response plan to control and manage the threat of multidrug-resistant gonorrhoea in Europe

 

 

The problem of antibiotic resistance isn’t restricted to Neisseria gonorrhoeae, of course. The list of resistant bacteria is long and continues to expand, including such high profile pathogens as MRSA, NDM-1, KPC, EHEC.

 

While the end of the antibiotic era is not yet at hand, the fear is - without new drugs and the proper stewardship of the ones we already have - we may be drawing closer to that day.

 

A few of my blogs on the subject include:

 

UK: `New MRSA’ Strain Spreading

CMAJ: Local Acquisition Of NDM-1 In Ontario

India Looks For (And Finds) NDM-1

Carbapenemases Rising

WHO: The Threat Of Antimicrobial Resistance

NDM-1: A New Acronym To Memorize

 

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.

»» Read More

WHO: Urgent Action Needed On Resistant Gonorrhea

 

 

# 6368

 

 

A subject that Maryn McKenna and I have both covered several times over the past year has been the worrisome rise in antibiotic-resistant gonorrhea around the globe. 

 

Early last month Maryn wrote Drug-Resistant Gonorrhea: How We Lost Track and last year she penned The Clap Came Back: Multidrug-Resistant Gonorrhea, both of which are highly recommended reading.

 

Last year in The Path Of Increased Resistance I wrote about the history and recent rise of resistant gonorrhea around the globe and an MMWR report (Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000—2010) chronicling its spread over the past decade.

 

Briefly, I wrote:

 

Despite 70 years of effective antibiotic treatment for this sexually transmitted disease, it remains the second most common STD in the United States.  The CDC  estimates that more than 700,000 persons in the U.S. contract gonorrhea each year, although less than half of those infections are reported to CDC.

 

In 2009, the CDC recorded 301,174 cases of gonorrhea.

 

The introduction of penicillin in the 1940s represented the first truly effective treatment for this scourge.  And for roughly 30 years, penicillin and tetracycline both proved effective weapons against this disease.

 

But by the 1970s penicillin/tetracycline resistant forms of Neisseria gonorrhoeae began to appear in the United States, and by the 1980s had become common. In response, the CDC began recommending cephalosporins as the first-line treatment for gonorrhea.

 

In 1993, the CDC also recommended the use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) to treat gonorrhea, as they were relatively cheap, effective, and allowed for a 1 dose treatment.

 

But in less than a decade, fluoroquinolone-resistant N. gonorrhoeae (QRNG) emerged out of Asia and began showing up in Hawaii and then California (see MMWR Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae --- Hawaii and California, 2001)

 

In 2007, the CDC announced Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections, leaving just one class of antibiotics - the cephalosporins -still recommended and available for the treatment of gonorrhea.

 

Last month the CDC Grand Rounds: Multidrug-Resistant Gonorrhea webcast provided expert presentations from:

Edward Hook III, MD
William Shafer, PhD
Carolyn Deal, PhD 
Robert D. Kirkcaldy, MD, MPH

 

All of which serves as prelude to a news release today from the World Health Organization on the growing global threat of resistant gonorrhea.

 

WHO: Urgent action needed to prevent the spread of untreatable gonorrhoea

Note for the media

6 June 2012 | Geneva - Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according WHO. Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics – the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected with gonorrhea, which is transmitted sexually.

Dwindling treatment options

“Gonorrhoea is becoming a major public health challenge, due to the high incidence of infections accompanied by dwindling treatment options,” says Dr Manjula Lusti-Narasimhan, from the Department of Reproductive Health and Research at WHO. “The available data only shows the tip of the iceberg. Without adequate surveillance we won’t know the extent of resistance to gonorrhoea and without research into new antimicrobial agents, there could soon be no effective treatment for patients.”

Correct use of antibiotics needed

In new guidance issued today, WHO is calling for greater vigilance on the correct use of antibiotics and more research into alternative treatment regimens for gonococcal infections. WHO’s Global Action Plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoea also calls for increased monitoring and reporting of resistant strains as well as better prevention, diagnosis and control of gonococcal infections.

Health implications are important

Gonorrhoea makes up one quarter of the four major curable sexually-transmitted infections¹. Since the development of antibiotics, the pathogen has developed resistance to many of the common antibiotics used as treatment, including penicillin, tetracyclines and quinolones.

 

“We are very concerned about recent reports of treatment failure from the last effective treatment option – the class of cephalosporin antibiotics – as there are no new therapeutic drugs in development,” says Dr Lusti-Narasimhan. “If gonococcal infections become untreatable, the health implications are significant.”

Antimicrobial resistance

Antimicrobial resistance is caused by the unrestricted access to antimicrobials, overuse and poor quality of antibiotics, as well as natural genetic mutations within disease organisms. In addition, gonorrhoea strains tend to retain genetic resistance to previous antibiotics even after their use has been discontinued. The extent of this resistance worldwide is not known due to lack of reliable data for gonorrhoea in many countries and insufficient research.

Gonorrhoea

Untreated gonococcal infection can cause health problems in men, women and newborn babies including:

• infection of the urethra, cervix and rectum;
• infertility in both men and women;
• a significantly increased risk of HIV infection and transmission;
• ectopic pregnancy, spontaneous abortion, stillbirths and premature deliveries; and
• severe eye infections occur in 30-50% of babies born to women with untreated gonorrhoea, which can lead to blindness.

Gonorrhoea can be prevented through safer sexual intercourse. Early detection and prompt treatment, including of sexual partners, is essential to control sexually transmitted infections.

¹ The four major curable sexually-transmitted infections are syphilis, gonorrhoea, chlamydial infection and trichomoniasis.

 

Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae

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Authors:
World Health Organization, Department of Reproductive Health and Research

Publication details

Number of pages: 36
Publication date: 2012
Languages: English
ISBN: 978 92 4 150350 1 - Web only

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• Global action plan

 

In a related story, Director-General Margaret Chan of the WHO warned this year during a keynote address to the Conference on Combating Antimicrobial Resistance in  Copenhagen, Denmark that our World Faces A `Post-Antibiotic Era’.

 

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.

<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 World Health Organization recently 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

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CDC Grand Rounds: Multidrug-Resistant Gonorrhea

 

 

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As I’ve mentioned previously, once a month the CDC  presents a Public Health Grand Rounds webcast, that focuses on a single public health issue. In April of last year I gave considerable blog space to CDC Grand Rounds: Sodium Reduction. 

 

Later today (1 pm EDT) the CDC will live stream their latest Grand Rounds presentation, this time on the growing threat of multi-drug resistant gonorrhea.

 

Tuesday, May 15, 2012 1 p.m. – 2 p.m., EDT

Watch live webcast

 

 

 

This is a subject that both Maryn McKenna (see Drug-Resistant Gonorrhea: How We Lost Track and The Clap Came Back: Multidrug-Resistant Gonorrhea) and I have written about in the past.

 

A couple of my offerings include:

 

The Path Of Increased Resistance

True in the 1940s, but sadly, no longer the case – Photo Credit scdhec.gov

 

and . . .

Going, Going, Gonorrhea

 

 

Here is the CDC’s announcement for today’s Grand Rounds:

 

 

Public Health Grand Rounds

 The Growing Threat of Multidrug-Resistant Gonorrhea

This session of Grand Rounds will explore the development of antibiotic resistance in Neisseria gonorrhoeae as a growing public health concern because the United States gonorrhea control strategy relies on effective antibiotic therapy. Since antibiotics were first used for treatment of gonorrhea, N. gonorrhoeae has progressively developed resistance to the antibiotic drugs prescribed to treat it: sulfonilamides, penicillin, tetracycline, and ciprofloxacin. Currently, CDC STD treatment guidelines recommend dual therapy with a cephalosporin antibiotic (ceftriaxone is preferred) and either azithromycin or doxycycline to treat all uncomplicated gonococcal infections among adults and adolescents in the United States.

 

Given the ability of N. gonorrhoeae to develop antibiotic resistance, it is critical to continuously monitor gonococcal antibiotic resistance and encourage research and development of new treatment regimens for gonorrhea.

(Continue . . . )

 

 

Today’s presenters include:

 

Edward Hook III, MD
Professor of Medicine and Epidemiology
University of Alabama, Birmingham

William Shafer, PhD
Professor of Microbiology and Immunology
Emory University

Carolyn Deal, PhD
Chief, Sexually Transmitted Diseases Branch
National Institute of Allergy and Infectious Diseases
National Institutes of Health

Robert D. Kirkcaldy, MD, MPH
Medical Officer
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

 

 

If you miss the live broadcast, you’ll be able to view this latest Grand Rounds presentation on the CDC’s Streaming Health Youtube Channel in about 48 hours.

»» Read More

Video: Maryn McKenna On Antibiotic Resistance

 

 

 

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Short of seeing a 1918-level or worse pandemic, I’ve little doubt that the rise of antibiotic resistant bacteria will be the number one public health story of the next couple of decades.

 

While MRSA was the big concern 3 or 4 years ago, today we are seeing the rise and geographic spread of NDM-1, extremely drug-resistant TB (XDR-TB), along with an expanding array of Carbapenemases  – bacteria that are resistant to the Carbapenem class of antibiotics.

 

 

Journalist, author, and everybody’s favorite scary disease girl Maryn McKenna produced a terrific book on the subject of antibiotic resistance in 2010, called SUPERBUG: The Fatal Menace Of MRSA. 

 

You can read my review of it HERE. Maryn is also the author of Beating Back The Devil, the inside story of the CDC’s Epidemic Intelligence Service.  

 

All of which puts Maryn on the top of the list of people you’d want to include in any documentary on antibiotic resistance. As it happens, UJI Films is working on exactly that; a film scheduled to be release later this year called RESISTANCE.

 

We’ve a bit of a preview this morning, by way of a 4-minute excerpt from the film featuring Maryn. You’ll also find several other short film clips on the resistancethefilm Youtube Channel, as well.

 

 

»» Read More

Indonesia: MOH Suspects H5N1 May Be Gaining Antiviral Resistance

 

 

 

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In Indonesia the antiviral Tamiflu ® (Oseltamivir) has been distributed fairly liberally over the past 6 years whenever there has been a suspected case of H5N1.

 

Households, whole neighborhoods - sometimes entire villages - have been placed on prophylactic antivirals in what is  commonly called a `Tamiflu Blanket’. The idea is to stop or prevent household or community transmission of the virus.

 

And the fact that we’ve seen only a few clusters of the H5N1 virus over the years is suggestive that this policy may have been at least partially successful.

 

But the fear when you use antivirals is that over time, the targeted virus will develop resistance.

 

That happened in 2008 with the old seasonal H1N1 virus (which was supplanted by pandemic H1N1 in 2009), and in recent months we’ve seen small indications that it may be occurring in some strains of the new H1N1 virus (see NEJM: Oseltamivir Resistant H1N1 in Australia).

 

So far, most of the H5N1 cases we’ve seen have appeared to be sensitive to oseltamivir, although a few resistant cases have been documented in Indonesia and Egypt.

 

See CIDRAP’s  2007 article Tamiflu-resistant H5N1 strain surfaces in Egypt and 2005 article Tamiflu resistance in avian flu victims sparks concern.

 

 

One of the striking features about Indonesia’s H5N1 cases is the  high CFR (Case fatality rate) of 82% – even with antiviral treatment – which is more than double that seen in Egypt (35%).

 

Today, Indonesia’s Health Minister Endang Rahayu Sedyaningsi is quoted in the media as worrying that oseltamivir may be losing effectiveness against the Indonesian strains of bird flu.

 

A hat tip to Diane Morin on FluTrackers for finding the following article which appears in Media Indonesia. The original link to the Indonesia (Bahasa) language version is HERE.

 

The following is a machine translation.

 

Indonesia Health Minister Suspected Bird Flu Immune Drug

Authors: Cornelius Eko Susanto

Friday, January 20, 2012 22:47 pm

JAKARTA - MICOM: Health Minister Endang Rahayu Sedyaningsih suspect in Indonesia has occurred the possibility of resistance (drug resistance) to the drug oseltamivir.

 

The hypothesis was made ​​based on the presence of some positive victims of bird flu in Indonesia are still died despite oseltamivir have been given early on.

 

"I suspect resistance to oseltamivir has been happening in Indonesia. That is why the death rate of bird flu patients here reaches more than 80% when oseltamivir was given, "said Minister of Health at a press conference after the ministerial coordination meeting to discuss bird flu on Friday (20 / 1), in Jakarta.

 

Himself said, there may exist specific genes in the H5N1 virus in Indonesia that caused the H5N1 virus in Indonesia is more virulent than the H5N1 viruses that exist in other countries.

 

"Honestly, I was curious as a former researcher with the possibility of the existence of this gene," he said.

 

If there is resistance to oseltamivir, Indonesia no longer has a drug to counteract the spread of the H5N1 virus. Because, oseltamivir is the only drug that can kill the flu virus, although with certain prerequisites and conditions.

 

In the market, oseltamivir sold under the brand Tamiflu. (Tlc/OL-5)

 

Based on this article, this theory appears predicated on anecdotal observations; mostly the high CFR. What is needed now is genetic sequencing of these isolates to look for known resistance markers.

 

One of the big concerns over Indonesia’s prolonged refusal to share samples of the H5N1 virus was that the virus would mutate or change without the world being aware what was happening.

With new virus sharing agreements put into place last year, hopefully the world will get a good look at the viral evolution in Indonesia and be able to document if any serious changes have occurred.

 

Stay tuned.

 

»» Read More

NPR Science Friday: McKenna On Resistant TB

 

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Later today (Friday, January 13th) Maryn McKenna will be a guest during the first hour (2 –3 pm EST) on NPR’s Science Friday to discuss the recent detection of a dozen cases of tuberculosis in India said to be `totally resistant’ to current antibiotic treatment.

 

 

 

Friday, January 13th, 2012

New Tuberculosis Strain Thwarts All Antibiotics

Physicians in India have discovered a strain of tuberculosis they call ‘TDR’ for ‘Totally Drug-Resistant’--meaning there is no antibiotic available to fight it. Maryn McKenna, author of Superbug , discusses the possible origins of the strain, and what options--if any--doctors have to treat it.

Guests

Maryn McKenna
Author, "Superbug: The Fatal Menace of MRSA," (Free Press, 2010)
Blogger, Wired
Atlanta, Georgia

 

 

Maryn, who is Flublogia’s resident expert on everything drug resistant, has written twice this week about this new development in her Superbug Blog, links to which you’ll find below:

 

 

Totally Resistant TB: Earliest Cases in Italy

• By Maryn McKenna
• January 12, 2012

India Reports Completely Drug-Resistant TB

• By Maryn McKenna 
• January 9, 2012  | 

»» Read More

ECDC Comment On Drug Resistant TB In India

 

 

 

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While more than a little discomfiting, in recent years we’ve grown accustomed to hearing about MDR-TB (multi-drug resistant tuberculosis), and XDR-TB (extensively drug resistant Tuberculosis). 

 

These varyingly resistant forms of Tuberculosis have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients. Patient compliance for long-term treatment has long been a major obstacle.

 

Until now – as difficult as treatment might have been - there has always been some combination of antibiotics that could be used to treat even the most resistant of TB cases.

 

All that appeared to change a few weeks ago when it was announced in an ahead-of-print letter to the journal Clinical Infectious Diseases that a four cases of TDR (totally drug resistant) tuberculosis had been identified in India. A follow up news report indicated that there are now at least 12 known cases in one hospital alone.

 

For more background on this announcement, I would invite you to read Maryn McKenna’s recent blog entry called India Reports Completely Drug-Resistant TB.

 

Today the ECDC has published their own comments on this development, along with links to other TB-related documents, on their website.

One of the points being made in the comments section (excerpted below) is that the term TDR-TB is as yet not well defined, and may be misleading.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

Successful treatment of TB is possible but requires full support from the health care system by offering optimal diagnostic services, high-quality drugs for the full time of treatment and support to the patient in fulfilling the treatment. To make this happen, strong TB diagnostic services and processes that ensure the rational use of TB drugs (1,2,3) are essential in order to be able to test all suspected TB cases for drug-resistance and to identify resistance as soon as possible to enable appropriate therapy. Furthermore, ensuring treatment outcome monitoring of all cases is vital.

 

Follow the link below to read the entire comment.

 

 

New drug resistant form of tuberculosis reported in India

12 Jan 2012

In a recent scientific article (Udwadia, F et al. Clin. Infect. Dis. 2011, Dec 21, Eprint) four cases of so-called total drug resistant tuberculosis (TB) were reported from India. According to the article, these patients have shown resistance to all the first line TB drugs and to seven second line anti-TB drugs.

With the existing forms of multi-drug and extensively drug resistant TB (M/XDR-TB) this so-called total drug resistant TB would indicate that none of the known TB combination regimens would be effective for such patients.

Read more:

Read the ECDC comment on this in our full

Public Health Development “New drug resistant form of tuberculosis reported in India”

 

ECDC Tuberculosis Programme

Tuberculosis, a global challenge: discover the ECDC Spotlight

Get the facts: read the ECDC special report “Progressing towards TB elimination”

Download the report “Tuberculosis surveillance in Europe 2009”

Discover the Spotlight “Tackling tuberculosis in children: towards a TB-free generation

Keep in touch with ECDC on facebook

Read the ECDC/WHO co-authored article “Tackling the spread of drug-resistant tuberculosis in Europe”

 

 

 

This story is just beginning to unfold, and I’m sure we’ll hear a lot more about it – and whether or not this new form of tuberculosis is indeed, as the study authors dubbed it - `totally resistant’ – in the coming months.

»» Read More