I’ve had the pleasure of a few days in Geneva enjoying some fine Swiss hospitality, and fine science at ICPIC 2023. Here’s rapid reflection on scaling the risks attached to plasmid-mediated transmission of CPE, and what we can do about it (or not…!).
Continue readingCRE
CPE showing its teeth: mortality associated with carbapenem-resistant Gram-negative BSI
Now is a really good time to focus on carbapenem-resistant bacteria. We have spent much of the past 3 years focusing on one particular virus. But now that the clinical issues linked to SARS-CoV-2 are waning for our hospital patients, the threat of carbapenem-resistance in Gram-negative bacteria comes to the fore. An excellent study with far-reaching consequences has been published from Italy. Carbapenem resistance is bad news if you have a BSI: patients with carbapenem-resistant BSI were roughly twice as likely to die as patients with carbepenem-susceptible BSI.
Continue readingEstablishing the transmission rate of CPE in hospitalised patients
A helpful new study has combined shoe-leather epi and WGS to establish a transmission rate of CPE in hospitalised patients. Overall, 3 (2%) of 152 exposed patients ended up colonised with the same CPE from 47 index patient exposures. None of the 54 exposed staff ended up colonised with CPE. This transmission rate is a bit lower than I would have expected, but it’s also not zero!
Continue readingCPE: seek and ye shall find
We recently published a study in the Journal of Antimicrobial Chemotherapy relating the impact of introducing an enhanced testing* programme for CPE in London. (And yes, this is the first post for a while that isn’t on COVID-19!) Following an outbreak of NDM-producing Klebsiella pneumoniae affecting 40 patients in 2015 (published elsewhere, here and here), we ramped up our CPE testing programme. The number of patients carrying CPE increased substantially, from around 10 patients per month in June 2015 to around 50 per month in March 2018. However, the proportion of tests that were positive for CPE remained constant at around 0.4%, suggesting this was more effective carrier identification rather than a swelling pool of carriers per se; seek and ye shall find! Curiously, the majority of CPE identified were not linked in time and space with other CPE, suggested they represented a ground-swell of CPE coming into the hospital, rather than frequent in-hospital transmission. Also, the number of patients with CPE infections during the study period did not increase, which was reassuring.
Can you GES which carbapenemase caused this CPE outbreak?
An unusual and interesting outbreak of CPE was published recently in Clinical Infectious Diseases. Several key points: don’t rely solely on a PCR detecting the “Big 5” carbapenemases (NDM, KPC, OXA-48, IMP, VIM) – at some point you need to test for phenotypic carbapenemase activity; WGS can really help us in unravelling complex transmission routes; and covert plasmid propagation within and between species is a reality.
CPE has landed in East London
The team at Barts Health, one of the largest NHS hospital groups in the country, has published the findings of a point prevalence screen of all inpatients for carbapenemase-producing organism (CPO) carriage. Overall, 30 (3.1%) of the 977 patient tested were carrying 35 different CPOs (all but one of which were CPE). Risk factors for CPO carriage included hospitalisation abroad, any hospitalisation, and overseas travel (especially to India, Pakistan, and Bangladesh). These findings help us to understand an emerging picture of CPO in the UK.
Navigating guidelines for MDR-GNR
There’s a plethora of guidelines for MDR-GNR. But how do we choose between them? And how do we implement them effectively in our hospitals? I did a talk on this recently in London, here:
On the origin of multidrug-resistant Gram-negative bacteria (MDR-GNB)
The colour of the global crisis of antibiotic resistance is red (if te Gram stain is your reference). In rich countries we have ESBL-producing Enterobacterales (mainly E. coli), but the real problem are carbapenemase-producing strains (Klebsiella, Pseudomonas and Acinetobacter) that are already endemic in lower and middle-income countries. The unanswered question is “where did these resistant bacteria come from”? Animals or bathrooms? Continue reading
CPE infection prevention and control guidelines: an update
Since writing this 2015 review on gaps and controversies in the guidelines for the prevention and control of CPE (and other MDR-GNR) I’ve tried to keep it fairly up to date. So, here’s the latest iteration, including the 2015 CDC guidelines.
The infinite trio from South Africa
Last week I had the pleasure of attending the 8th FIDSSA Congress in Johannesburg (Federation of Infectious Diseases Societies of Southern Africa). I was invited to talk on infection control in the Netherlands, SDD and empiric antibiotic strategies in ICU. I never felt more distance between my habitat and that of my hosts. It surpassed the 3732 miles in the air. I learned a lot; from how it is to go into military conflict areas to identify Ebola cases, fighting a cholera outbreak after a tropical cyclone in Mozambique to the infinite trio, which stands for carbapenem resistant Klebsiella, Pseudomonas and Acinetobacter. Continue reading
Reflections on Infection Prevention and Control 