FW: PRO/EDR> NDM-1 carrying Enterobacteriaceae - Brazil: (RJ)

[Maffei, Joanne]

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Subject: PRO/EDR> NDM-1 carrying Enterobacteriaceae - Brazil: (RJ)


NDM-1 CARRYING ENTEROBACTERIACEAE - BRAZIL: (RIO DE JANEIRO)
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Date: Mon 16 Sep 2013
Source: UOL Notícias [in Portuguese, trans. Mod.RNA, summ., edited] <http://noticias.uol.com.br/saude/ultimas-noticias/estado/2013/09/16/rio-registra-primeiro-caso-de-superbacteria.htm>


Rio de Janeiro State reported the 1st cases of contamination by bacteria carrying the NDM-1 gene. These bacteria nullify the effects of almost all antimicrobial agents, including those which are more used to fight infections by multiresistant microorganisms. The cases were reported in [the pediatric ward of] HemoRio, the referral institution for treatment of patients with hematological diseases, and in hospitals in Campos dos Goytacazes in northern Rio de Janeiro State, and Duque de Caxias in the Baixada [region in the southeastern part of the state]. [No deaths have been recorded]. Rio de Janeiro is the 2nd state in the country to identify the superbug. Rio Grande do Sul had 5 cases reported in May [2013].

The 1st person to be identified with the resistant bacterium was a leukemic girl. She had been discharged from HemoRio and after a month of admission she was referred to the Children's Hospital for placement of a catheter. There she was subjected to routine surveillance cultures to identify possible colonization and the result was positive. The girl did not actually develop the infection. The hospital sought other children who came in contact with the patient and closed beds to allow isolation of those who were hospitalized and disinfection of wards. There are still patients in isolation but no new cases were diagnosed.

Alexandre Chieppe, Superintendent of Environmental and Health Surveillance of the State Department of Health, clarified that none of the patients identified in Rio were sick. "There were no cases of infection. People were colonized by the bacteria. There is no indication to interrupt the routine operation of hospitals," said Chieppe.

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[Originating in India, NDM-1 containing bacteria have spread to other parts of the world. As reported in the 25 Jun 2010 CDC Morbidity and Mortality Weekly Report. 2010; 59(24): 750; <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5924a5.htm?s_cid=mm5924a5>,
during the 1st half of 2010, 3 isolates of _Enterobacteriaceae_, an _E. coli_, a _Klebsiella pneumoniae_, and an _Enterobacter cloacae_, were identified at CDC to carry NDM-1, which confers resistance to all beta-lactams except aztreonam (a monobactam) but were also resistant to aztreonam. All 3 isolates were from patients who received recent medical care in India.

Yong and colleagues (Yong D, Toleman MA, Giske CG, et al:
Characterization of a new metallo-beta-lactamase gene, bla-NCm-1, and a novel erythromycin esterase gene carried on a unique genetic structure in _Klebsiella pneumoniae_ sequence type 14 from India.
Antimicrob Agents Chemother. 2009; 53(12): 5046-54;
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786356/>) found that the plasmid carrying NDM-1 also carries several other resistance genes and appears to easily transmit itself to other organisms. The authors state that "the dissemination of this plasmid among clinical bacteria would be a nightmare scenario."

This NDM-1 gene cassette of wide-spectrum antimicrobial resistance appears to have developed in the Indian subcontinent, where the use of antimicrobial agents is quite poorly controlled. Organisms carrying this resistance combination have already been introduced into western Europe, the USA, and Canada. The best methods of control are rapid recognition by standard microbiologic/nucleic acid methodology in patients having the appropriate medical/travel history and aggressive hand washing techniques.

The amazing overuse of our current antimicrobial armamentarium that I am currently observing in my clinical practice in the USA will no doubt serve as an efficient multiplier of these isolates, just as intravenous drug abuse and sexual promiscuity facilitated the explosion of HIV 30 years ago. This misuse, in my opinion, is directly related to the lack of control of antimicrobial usage in intensive care units and emergency care settings by intensivists and ER physicians who often react with a lack of wisdom and "cookbook"
protocols instead of using common sense and rational prescribing patterns. Once the patient moves out of the ICU or ER, the physicians do not even see the products of their unwise labors.

Of note, a 2012 paper (Hranjec T, Rosenberger LH, Swenson B, et al:
Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study. Lancet Infect Dis. 2012; 12(10):
774-80; abstract available at
<http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70151-2/abstract>)
suggests that aggressive empiric therapy may not be preferred. Despite the difficulties in design of such studies, the authors found that the odds ratio for the risk of mortality in the aggressive therapy group compared to the conservative therapy group was 2.5. - Mod.LL]

[Infection control interventions aimed at preventing transmission of carbapenemase-producing isolates include early recognition of carbapenem-resistant _Enterobacteriaceae_ (CRE) when cultured from clinical specimens, placement of patients colonized or infected with these isolates on contact precautions, and in some circumstances, conducting point prevalence surveys or active-surveillance testing among high-risk patients (CDC: Guidance for control of infections with carbapenem-resistant or carbapenemase-producing _Enterobacteriaceae_ in acute care facilities. MMWR 2009; 58(10): 256-60; available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm>).

Obtaining a history of travel, especially receipt of medical care, in countries where NDM is endemic, as well as identifying patients who previously were infected with or colonized by CRE, will aid the early recognition of patients carrying these organisms. Placement of these patients at the time of hospital admission on contact precautions is an important step in preventing further transmission. Whenever possible, these patients should have dedicated rooms, equipment, and staff. The microbiology laboratory should immediately alert clinical and infection control staff when CRE are identified. Detection of carbapenemase production is complicated because some carbapenemase-producing isolates may demonstrate elevated but susceptible carbapenem MICs (minimal inhibitory concentrations). Also, _Enterobacteriaceae_ can be resistant to carbapenems by mechanisms other than a carbapenemase, the most common of which is expression of an extended-spectrum cephalosporinase, such as an AmpC-type enzyme or an ESBL (extended-spectrum beta-lactamase), combined with porin loss.
Molecular methods, such as PCR or mass spectrometry, will be available in clinical microbiology laboratories to rapidly detect carbapenem-resistance in clinical isolates, it is hoped, in the near future.
- Mod.ML

A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/r/1pW_>.]

[see also:
NDM-1 carrying Acinetobacter - France: ex Algeria, ICU outbreak
20130802.1860993
2012
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NDM-carrying Enterobacteriaceae - USA (03): (CO) nosocomial
20121118.1414608
NDM-1 carrying Pseudomonas - France: (ex Serbia) 20121110.1402258
NDM-1 carrying Enterobacteriaceae - USA (02): feline 20120916.1294263
NDM-1 carrying Enterobacteriaceae - China (02): (HK) ex Guangdong
20120914.1291460
NDM-1 carrying Enterobacteriaceae - France: ex Cameroon
20120817.1249316
NDM-1 carrying Vibrio cholerae - India 20120801.1224333
NDM-1 carrying Enterobacteriaceae - USA: (RI) ex Viet Nam
20120621.1175799
NDM-1 carrying Enterobacteriaceae - China: (HK) ex Thailand
20120612.1165421
NDM carrying bacilli - Canada: (Alberta) nosocomial, fatal
20120520.1138608
NDM-1 carrying Acinetobacter - Czech Rep ex Egypt 20120219.1044883
NDM-1 carrying Enterobacteriaceae - Ireland: 1st rep, ex India
20120217.1044861
2011
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NDM-1 carrying Enterobacteriaceae - India (03): comment 20111230.3708
NDM-1 carrying Enterobacteriaceae - Guatemala: 1st rep, PAHO
20111128.3472
NDM-1 carrying Enterobacteriaceae - Italy: link to India
20111127.3466
Gram negative bacilli, MDR - South Africa: NDM-1, nosocomial
20111018.3117
NDM-1 carrying Enterobacteriaceae - India (02): nosocomial infections
20111006.3009
NDM-1 carrying Enterobacteriaceae - India, China: govt. response
20110412.1156
NDM-1 carrying Enterobacteriaceae - India: (New Delhi) water supply
20110411.1145
2010
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Gram negative bacilli, resistant, update (01): NDM-1, KPC
20101028.3908
NDM-1 carrying Enterobacteriaceae (04): Taiwan ex India 20101005.3604
NDM-1 carrying Enterobacteriaceae - worldwide ex India, Pakistan (02)
20100914.3325
NDM-1 carrying Enterobacteriaceae - worldwide ex India, Pakistan
20100817.2853
NDM-1 carrying Enterobacteriaceae - N America, UK ex India 20100815.2812] .................................................rna/ll/mj/ml/mj/jw
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