Thursday, February 28, 2013

APIC: The Persistence Of CRE


CDC Guidance For Control Of CRE


# 6974


Less than two weeks ago, in CDC HAN Advisory: Increase In CRE Reports In The United States, we looked at the growing concerns over the incidence of Carbapenem-resistant Enterobacteriaceae (CRE) colonization or infection across the nation.


Enterobacteriaceae comprise a large family of Gram-negative bacteria that range from harmless strains to pathogenic invaders, and includes such familiar names as Salmonella, Escherichia coli, Klebsiella and Shigella.


Carbapenem-resistant Enterobacteriaceae are varieties that have developed resistance to a class of antibiotics called carbapenems, which are often the drug of last resort for treating difficult bacterial infections.


And in mid February, in MMWR: Denver Hospital Outbreak Of NDM-Producing CRKP, we looked at an outbreak that occurred in 2012.


From APIC (Association for Professionals In Infection Control) we get a news release detailing just how persistent these CRE infections can be.


Superbug CRE may endure in patients one year after initial infection: study


Patients who tested positive for carbapenem-resistant Enterobacteriaceae (CRE) took an average of 387 days following hospital discharge to be clear of the organism, according to a new study published in the March issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).


The study was conducted in the Shaare Zedek Medical Center, a 700-bed university-affiliated general hospital in Jerusalem, Israel. The research team analyzed follow-up cultures from 97 CRE-positive patients who had been discharged from the medical center between January 2009 and December 2010.


The average time until cultures became negative was 387 days. At three months, 78 percent of patients remained culture positive; at six months, 65 percent remained positive; at nine months, 51 percent, and at one year 39 percent of patients remained positive, meaning they could potentially become re-infected or transmit the germ to others.


Risk factors for extended carriage included the number of hospitalization days, whether and how often the patient was re-hospitalized, and whether the patient had an active infection as opposed to colonization without signs of active disease.


This is one of the first studies to determine length of CRE duration after hospital discharge and provides vital insight into treating formerly CRE-positive patients upon readmission as to limit the spread of this virulent and often deadly pathogen.


The authors state, “Patients with multiple hospitalizations or those who were diagnosed with clinical CRE disease should be assumed to have a more extended duration of CRE coverage and should therefore be admitted under conditions of isolation and cohorting until proven to be CRE-negative. These measures will reduce the hospitalization of CRE-positive patients among the general patient population, potentially preventing the spread of CRE.”


CRE are extremely difficult-to-treat, multidrug-resistant organisms that are emerging in the United States. A CRE strain of Klebsiella pneumoniae recently spread through the National Institutes of Health hospital outside Washington, DC, killing six people. Because of increased reports of these multidrug-resistant germs, the Centers for Disease Control and Prevention recently alerted clinicians about the need for additional prevention steps to prevent transmission.

(Continue . . . )



The study is called (link not live yet):



Duration of carriage of carbapenem-resistant Enterobacteriaceae following hospital discharge

by Frederic S. Zimmerman, Marc V. Assous, Tali Bdolah-Abram, Tamar Lachish, Amos M. Yinnon and Yonit Wiener-Well

American Journal of Infection Control, Volume 41, Issue 3 (March 2013).



Other recent blogs on the threat of growing antibiotic resistance include:


ECDC: Multidrug Resistant Infections Increasing In Europe

EID: Environmental NDM-1 Detected In Vietnam

MMWR: NDM-1 Transmission In Rhode Island

Netherlands: Large Nosocomial KPC Outbreak


In March of 2012 (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.




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.




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

World Health Organization


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

No comments: