Credit EID Journal
#17,910
While novel emerging viruses often get the bulk of our attention, they are not the only global health threats on the horizon. We are also faced with a growing array of multidrug resistant organisms (MDROs) - both bacterial and fungal - that already claim hundreds of thousands of lives each year.MDROs such as Candida auris, C. difficle, CRE, and MRSA cause significant morbidity and mortality in hospitalized patients, can be spread to other patients, staff, and even visitors, and are particularly problematic in nursing homes and LTCFs (Long Term Care Facilities).
Although most bacterial infections are still treatable - AMR (antimicrobial resistance) isn't some obscure future threat - as it already impacts millions of lives each year around the globe.
- In 2019, the CDC estimated that: More than 2.8 million antibiotic-resistant infections occur in the United States each year, and more than 35,000 people die as a result.
- While globally the WHO estimates bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths (1).
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 prove deadly.
Of particular concern are reports of CRE (Carbapenem-resistant Enterobacteriaceae) colonization or infection.
- 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.
- While 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.
In recent years HvKp - a hypervirulent form of Klebsiella pneumoniae - most commonly reported in Asia, has drawn our attention. This highly invasive bacterial infection is increasingly showing signs of antibiotic resistance (see CIDRAP Hypervirulent, highly resistant Klebsiella identified in China).
- In December of 2020, in EID Journal: COVID-19 and Fatal Sepsis Caused by Hypervirulent Klebsiella pneumoniae, Japan, 2020, we looked at an account of an elderly COVID patient in Japan who was co-infected with HvKp, a hypervirulent form of Klebsiella pneumoniae.
- In 2019, we looked at an outbreak Extensively drug-resistant (XDR) Klebsiella pneumonia in Europe involving (XDR) K. pneumoniae, affecting four hospitals in the northeast of the state of Mecklenburg-West Pomerania.
- And in 2020 the CDC listed K. pneumoniae carbapenemase (KPC) - which was first identified in the United States around 2001- as the most common carbapenemase in the United States.
Unlike `classic' K. pneumoniae (C-Kp) - which is an opportunistic
infection that often causes pneumonia, urinary tract infections and bacteremia in immunocompromised or frequently hospitalized individuals - hvKp has the ability to
cause serious infections in previously healthy individuals
Not quite 3 years ago (March 2021) the ECDC published a risk assessment on the Emergence of Hypervirulent Klebsiella pneumoniae ST23 Carrying Carbapenemase genes in EU/EEA countries, in response to two clusters of HvKp reported in Ireland since 2019.
Yesterday the ECDC published their first update to that risk assessment, which finds that HvKp has spread from 4 EU/EEA nations to 10, and the number of cases has increased nearly 12-fold since that first report.
Given the limits of surveillance and reporting, these numbers are likely an undercount.
Citing recent reports point to increasing geographic distribution, healthcare association and multidrug resistance, the ECDC warns:
The probability of further spread and establishment of hvKp carrying carbapenemase genes in healthcare settings in EU/EEA countries with consequent significant impact on morbidity and mortality is therefore currently considered to be high.
First the executive summary and a link to the full (17-page) report. I'll have a bit more after the break.
Risk Assessment: Emergence of hypervirulent Klebsiella pneumoniae ST23 carrying carbapenemase genes in EU/EEA countries - first update
Risk assessment
14 Feb 2024
Since the last ECDC rapid risk assessment in 2021, the number of European Union/European Economic Area (EU/EEA) countries reporting cases of hypervirulent Klebsiella pneumoniae (hvKp) sequence type (ST) 23 has increased from four to 10 countries, and the number of isolates submitted for analysis by these countries has increased from 12 to 143 isolates.
Executive summary
Furthermore, there is now evidence of sustained spread of the globally dominant hvKp ST23-K1 lineage carrying carbapenemase genes between healthcare facilities in Ireland over a period of five years, despite enhanced control efforts. Clusters of hvKp ST23-K1 isolates signifying potential within-country transmission were also detected in France, Latvia, and Lithuania; however, these have so far not been confirmed as being most likely due to within-country transmission with epidemiological data. Similar spread in and between healthcare facilities may already occur in other EU/EEA countries with less established surveillance.
The emergence of K. pneumoniae isolates with combined hypervirulence and resistance to last-line antibiotics such as carbapenems is of concern as, in contrast to ‘classic’ K. pneumoniae strains, hvKp strains can cause severe infections in healthy individuals, often complicated by dissemination to various body sites. Previously, hvKp strains were primarily found in Asia, were mainly community-acquired, and were only rarely resistant to antibiotics. However, recent reports point to increasing geographic distribution, healthcare association and multidrug resistance. With the convergence of virulence and antimicrobial resistance in hvKp strains, there is a possibility of potentially untreatable infections in previously healthy adults.
An even higher morbidity and mortality must be expected if carbapenem-resistant hvKp strains spread in healthcare settings and affect a vulnerable patient population. Sustained transmission of hvKp ST23 carrying carbapenemase genes between healthcare facilities in an EU/EEA country has been confirmed. The probability of further spread and establishment of hvKp carrying carbapenemase genes in healthcare settings in EU/EEA countries with consequent significant impact on morbidity and mortality is therefore currently considered to be high.
It is important to detect hvKp early and prevent further dissemination in healthcare settings in EU/EEA countries to avoid further establishment of hvKp carrying carbapenemase genes as a healthcare-associated pathogen. Options for response include alerts to clinicians and clinical microbiology laboratories, the establishment of sufficient laboratory capacity to detect hvKp isolates including whole-genome sequencing, the submission of all suspected hvKp isolates with or without additional antimicrobial resistance to national reference laboratories, and enhanced infection prevention and control measures in healthcare facilities. Prospective data collection on hvKp isolates, including epidemiological and clinical data on cases of infection, carriage and associated risk factors, would improve the understanding of national spread and transmission routes and determine the need for further surveillance
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While today the topic is on the rising threat from HvKp, we humans are engaged in an endless `arms race' with countless thousands of constantly evolving pathogens (viral, bacterial, fungal, and parasites) whose very survival depends on evading our medical armamentarium.
A few recent related blogs include:
UKHSA Warns On Rising Reports of Extremely drug-resistant Shigella
China's Growing Antibiotic Resistance Problem
CDC EID Journal: Two Reports On Tecovirimat Resistance in Mpox Patients
AJIC: The impact of the COVID-19 Pandemic on Hospital-Acquired Infections
EID Journal: Two Recent Studies on Candida auris Associated Hospitalizations
UKHSA: Gonorrhoea and Syphilis at Record Levels in 2022
While I cover AMR topics occasionally 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.
