Monday, October 07, 2019

ECDC CDTR: Extensively drug-resistant (XDR) Klebsiella pneumoniae - Germany

Credit CDC - Vital Signs


Although novel viral respiratory pathogens - like influenza and MERS-CoV - pose the greatest risk of a sudden pandemic, growing antibiotic resistance is no less of a threat to human health, albeit on a longer time scale. 
Pandemics tend to produce a sharper, more dramatic impact, but over time antimicrobial resistance (AMR) could prove far deadlier.
Each year we draw a little closer to a long-predicted, but highly plausible `post-antibiotic era', where even common infections become resistant to most antibiotics, and something as simple as a scraped knee, or elective surgery, could be deadly. 
Completely resistant infections have been - thus far - extraordinarily rare, with a few - often last resort drugs - still being effective.
In 2017, however, the MMWR published a report on a fatal infection - of a patient who had previously been hospitalized in India, and then later in Nevada - which proved resistant to all 26 types of antibiotics approved for use in the United States.
The organism in question was identified as a pan-resistant CRE (Carbapenem-resistant Enterobacteriaceae), specifically Klebsiella pneumoniaeK. Pneumoniae’s opportunistic qualities – attacking those with weakened immune systems - makes it an important, and difficult to control, hospital acquired infection.
Four months ago in ECDC Rapid Risk Assessment: Large Outbreak of NDM-producing CRE in Tuscany Region, Italy, we looked at a multi-hospital outbreak of Carbapenum resistant CRE in the Tuscany region of Italy. While difficult to treat, these infections were not - as in the case of the fatal case in Nevada - pan resistant.
The ECDC put the risk of further spread within Italy as `high', while the risk of cross border spread was deemed `moderate'.
This morning the ECDC's Communicable Disease Threats Report (CDTR) describes a new CRE outbreak - this time in Germany - of an extensively drug-resistant (XDR) K. pneumoniae, affecting four hospitals in the northeast of the state of Mecklenburg-West Pomerania.

Extensively drug-resistant (XDR) Klebsiella pneumoniae

Opening date: 3 October 2019
Latest update: 4 October 2019

± Germany ±

Epidemiological summary

The Robert Koch Institute reports an outbreak of extensively drug-resistant (XDR) K. pneumoniae , carrying the genes encoding for the OXA-48 and NDM-1 carbapenemases and resistant to colistin.
As of 2 October 2019, 17 cases in four hospitals in the northeast of the state of Mecklenburg-West Pomerania have been reported: six cases of infections and eleven cases of carriage of the bacterium. The involved K. pneumoniae strain is resistant to all penicillins, cephalosporins, carbapenems, quinolones, aminoglycosides as well as fosfomycin and colistin, but susceptible to chloramphenicol, tigecycline (limited susceptibility) and cefiderocol (antibiotic in development, not yet approved for use in the EU/EEA).

Source: RKI | Regional health authority

ECDC assessment

This outbreak affecting four hospitals in Germany is another event highlighting the worsening situation and the high risk for further spread of highly-resistant, hospital-adapted strains of carbapenem-resistant Enterobacteriaceae in the EU/EEA. The extensively drug-resistant (XDR) profile of this outbreak strain is of concern due to the very few remaining treatment options.

EU/EEA-wide enhanced control efforts are needed as was recently outlined in an ECDC rapid risk assessment on carbapenem-resistant Enterobacteriaceae (27 September 2019).
Timing is, as they say, everything. And this report comes barely 10 days after the ECDC's publication of an updated 17-page RRA (Rapid Risk Assessment) on CRE in the EU.

Risk assessment
Carbapenem resistance in Enterobacteriaceae such as Klebsiella pneumoniae and Escherichia coli poses a significant threat to patients and healthcare systems in all European Union/European Economic Area (EU/EEA) countries. Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high mortality, primarily due to delays in administration of effective treatment and the limited availability of treatment options.
Hypervirulent carbapenem-resistant K. pneumoniae strains have been reported presenting an additional threat with a potential for global dissemination. The spread of high risk clones and plasmids carrying carbapenemases in healthcare settings is a major cause of the spread of CRE in EU/EEA countries.
Recent events of cross-border importation after patient transfer and large regional outbreaks as well as the worsening epidemiologic situation of carbapenemase-producing CRE in the EU/EEA highlight the high risk for further spread of CRE and the need for enhanced control efforts. Options for control are outlined in the respective section below.
- EN - [PDF-774.27 KB]
While most infections are still treatable - AMR isn't some obscure future threat -  as it already impacts millions of lives each year around the globe.

In 2015 the CDC estimated that – in the United States alone – at least 23,000 people die each year due to antibiotic resistant infections (see CDC’s Vital Signs: A Coordinated Approach To Curb The Spread Of Antibiotic Resistance).


While I cover AMR topics from time to time in this blog, I can heartily recommend CIDRAP's Antimicrobial Stewardship Project as the best place to learn about the growing global threat of AMR.
You'll also want to check out the CIDRAP-ASP Youtube Channel, which has more than 24 hours of lectures and webinars on Antimicrobial stewardship.
Some of my more recent blogs on the threat of antibiotic resistance include:
WHO Update - Carbapenem-resistant Pseudomonas aeruginosa Infection – Mexico
UK Launches 5-year Action Plan Against Antimicrobial Resistance
WHO Report: Wide Differences In Antibiotic Use Between Countries

The Lancet: Attributable Deaths & Disability Due To Infections With Antibiotic-Resistant Bacteria - EU 2015

mBio: The Gathering Storm: Is Untreatable Typhoid Fever on the Way?
WHO: First Global Antimicrobial Surveillance System (GLASS) Report