CRE -> CPE

Jon Otter (@jonotter) CRE , , , ,

CRE CPE 2

I have thought a lot (probably too much) about the best way to describe the issue of carbapenem resistance in Enterobacteriaceae. I decided ages ago that CRE (a la the CDC) is the way to go as a generic term to describe the problem. But the more I think about it, the more I am coming around to the idea that CPE (a la PHE) is better. And here’s why:

  • The real issue from a clinical and infection control viewpoint is CPE. Enterobacteriaceae that are resistant to carbapenems by means other than an acquired carbapenemase (i.e. CRE that are not carbapenemase producers) are important, but they don’t seem to have the same capacity to spread as carbapenemase producers.
  • It’s a really confusing situation in terms of terminology. From the “end user” staff member on the front line and patient, all that really counts is whether it is a CPE or not. It’s really rather confusing to tell a patient that the have a “CRE that is also a carbapenemase producer” – easier just to say “you have a CPE”. (I accept that you will also need to tell a patient if they have a CRE that is not a carbapenemase producer – but I think this way around is easier.)
  • CPE is already en vogue in the UK (mainly due to the PHE Toolkit) so using any other term risks confusion at the time of patient transfer. (Clearly, this point is reversed if you are working in the US!)

I still think that “CRO/CPO” is not the way to go, given the gulf in epidemiology between the Enterobacteriaceae and the non-fermenters (although, sometimes, begrudgingly, you have to go there). What I mean by this is that you will sometimes detect a carbapenemase gene from a PCR but don’t yet know whether it is from a non-fermenter or Enterobacteriaceae species. In this circumstance, this has to go down as a ‘CPO’.

So, there you have it, a personal U-turn. CRE -> CPE. But I wonder whether CDC and PHE and the international community will ever agree a common term…

State of the World’s antibiotics

Andreas Voss (@AVIPNL) Antibiotic resistance ,

Schermafbeelding 2015-09-24 om 20.07.42

The State of the World’s antibiotcs, 2015, was just released by the Center for Diseases Dynamics, Economics & Policy (http://www.cddep.org). For all those interested in antimicrobial resistance this report is a must read.

To cite from the publication, this State of the World’s Antibiotics report records the status of this important global resource and provides critical policy analysis on three issues:

  • global patterns and trends in antibiotic resistance and 
antibiotic use in human beings and animals
  • the existing antibiotic supply and the research and development pipeline
  • interventions that have been shown to help rationalize antibiotic use and are practicable in all countries.

While being wonderful, the reports include a figure from a 2013 Lancet ID publication, a colleague (@ChristinaGrauls) alerted me to. According to figure 2-2: Carbapenem retail sales in selected countries, 2005–2010, the retail sales and thus probable consumption of carbapenems per 1,000 population is identical for the Netherlands and the USA. Somehow, I find that hard to believe.

Mupirocin use drives mupirocin resistance…or does it?

Jon Otter (@jonotter) MRSA , , ,

mupirocin

I’ve blogged before that mupirocin resistance is an inevitable consequence of mupirocin use. Whilst I still think that this is true, my old colleagues from GSTT / KCL have just published an article suggesting that mupirocin resistance in MRSA has more to do with clonal variation than with mupirocin use.

The study is part of an ambitious project to sequence the genome of around 1000 MRSA isolates from across Central and South-East London (Guy’s and St. Thomas’, King’s, and Lewisham). Each isolate was then tested for phenotypic high (HMR) and low (LMR) mupirocin resistance, the genome was scoured for the genetic determinants known to be associated with mupirocin resistance, and clone was derived from the genome sequence. Risk factors for both HMR and LMR were then explored.

Continue reading →

Antibiotics and the Netherlands

Andreas Voss (@AVIPNL) Antibiotic resistance , ,

Schermafbeelding 2015-09-13 om 21.03.43

Antimicrobial resistance, control of antibiotic use and infection control are some of the things the Dutch presumably do well. Some of the Dutch infection control policies, such as “Search & Destroy” helped to stop the introduction of MRSA for a long time. I addition, the prevalence of other MDRO is low in comparison to many other countries. Still, more needed to be done, and consequently, the Dutch were (one of) the first that made antimicrobial stewardship teams (A-teams) compulsory for every hospital and presently plan introduction in other healthcare settings. Last but not least, the fight against antimicrobial resistance will be an important topic, while the Dutch hold the Presidency of the European Union in the first half of 2016.

Thus, what else could we ask for? A few weeks ago, I had at least one request: basic antibiotics.

Due to fading reimbursement policies and the constant pressure to sale drugs for decreasingly lower prices, the production for and/or distribution of several drugs within the Netherlands is no longer possible. Latest victim: i.v. penicillin, which is no longer available in my country (high-resource setting). While it seems difficult to argue for small spectrum antibiotics in the absence of one of the important ones, there is some good news: I no longer have to argue whether to use penicillin or a 3rd generation cephalosporin for certain indications. Ceph it is!

Reconsidering the burden of CRE screening

Jon Otter (@jonotter) CRE , , , , ,

 

swabs

Shortly after the PHE Toolkit was published, I blogged some crude sums to size the burden of CRE admission screening a la Toolkit. I’m pleased to report that colleagues at Imperial have done a much better job of this, published in a letter in the Journal of Infection. The study provides some evidence that the recommendation in the PHE CRE Toolkit to perform pre-emptive isolation of suspected carriers whilst obtaining three negative screens is simply not feasible. The team then compare an alternate strategy – of applying the Tookit triggers to admissions to high risk specialties only (intensive care, nephrology, cardiothoracic surgery, neurosurgery and oncology).

Continue reading →

Endoscope Reprocessing Survey

Andreas Voss (@AVIPNL) Cleaning, Disinfection, endoscopy

What-do-you-think

Recent reports of multidrug-resistant infections related to contaminated endoscopes, which have intricate mechanisms and channels that are especially difficult to clean, have raised awareness about the necessity for meticulous reprocessing of all types of endoscopes to prevent the transmission of pathogens to patients.

In response to concerns from various countries about inadequately reprocessed endoscopes and to prevent further transmittal of infections by endoscopes, the ISC Infection Prevention & Control Working Group prioritized this issue in a meeting earlier this year and created a survey on current Endoscope Reprocessing Practices that could be used to compare such practices of institutions around the globe.

We would ask you to share the link to the on-line survey and encourage as many of your colleagues from various health care facilities to complete this. To complete this survey you need to be involved in Endoscope reprocessing activities or know the guidelines and structure of your institutions with regard to Endoscope reprocessing.

Thank you for your participation and for sharing the link!

Link to survey: https://www.surveymonkey.com/r/6ZSGF5L

This checklist was created by the following members of ISC IPC working group. Andreas Voss, Alex Friedrich, Peter Collignon, Moi Lin Ling, Brenda Ang, Wing Hong Seto, Paul Tambyah, Eli Perencevich, Marin Schweizer, Leanne Frazer, Achilleas Gikas, Tom Gottlieb, Joost Hopman, Nikki Kenters, Inge Huijskens, Kalisvar Marimuthu, Rehab El-Sokkary, Yogandree Ramsamy, Margaret Vos, Ermira Tartari, Debkishore Gupta.

We need to work together to reduce CRE and other pathogens

Jon Otter (@jonotter) CRE , , , ,

Some fascinating modelling from the CDC Vital Signs programme suggests that a co-ordinated, multi-facilitiy approach will be much more effective than each hospital doing its own prevention interventions.

The team first estimated the burden of key infections in the US: CRE, multi-resistant  P. aeruginosa, invasive MRSA and CDI combined were responsible for 310,000 infections in 2011, which would increase 10% to 340,000 over 5 years. However, with an ‘aggressive’ national intervention, this could be reduced to below 200,000 by 2019. It would be a huge undertaking to implement and co-ordinate a national campaign in the US, where there is so much heterogeneity in the way that hospitals are structured and funded. But if anybody can do it, the CDC can!

Continue reading →

It’s transmission doc, but not as we know it

Jon Otter (@jonotter) Whole genome sequencing , ,

A groundbreaking study just published in PLOS Genetics provides new insight into the transmission dynamics of bacteria in the ICU setting using WGS. The ambitious authors performed WGS on virtually all bacterial isolates from ICUs in a US hospital for a year. The first surprise was that 12% of the bacteria considered clinically relevant were previously undescribed.

The next – and perhaps biggest – surprise was that whilst transmission of the usual suspect pathogens (MRSA, VRE etc) was rare, 9% of the other bacteria were shared by multiple patients, often with overlapping admissions (see the figure below). This suggests that there is a fair bit of transmission going on under the radar in the ICU setting.

Figure: Clonal lineages extending across multiple patients.

WGS ICU timeline

This study reminds me of one published in CID a few years ago showing that outbreaks of resistance probably occur regularly and usually undetected across multiple species.

So, is it time to start using WGS for all bacteria identified in the clinical laboratory? Not quite yet I don’t think: the analytical methods have not yet caught up with the sequencing technology. But this study is a glimpse of the future, no doubt about it.

Should we throw out the chlorhexidine with the bathwater?

Jon Otter (@jonotter) Decolonisation , , ,

Noto chg

Following hot on the heels of a series of studies showing that daily bathing using chlorhexidine reduces the risk of HCAI, a recent study suggests that chlorhexidine daily bathing does not reduce HCAI. The headline finding is that chlorhexidine bathing did not reduce HCAI. Before throwing out the chlorhexidine with the bathwater, it’s worth considering the limitations of the study.

Continue reading →

Is CRE lurking in nursing homes?

Jon Otter (@jonotter) CRE , , , , ,

Nursing home CRE

They say that things come in threes, so following hot on the heels of blogs about MRSA and other MDROs in nursing homes, I was struck by a recent outbreak report of CRE associated with nursing homes the Netherlands.

Following the admission of a patient from a Greek ICU, a nosocomial transmission of CRE (ST258 KPC K. pneumoniae) occurred. By the way, this occurred despite the hospital recognising the risk of CRE at the time of admission from the Greek ICU, perform an admission screening and implementing pre-emptive contact precautions. Then the index patient was transferred to a nursing home, where subsequent transmission occurred to four other patients.

Continue reading →