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Old 01-16-2017, 04:51 PM   #1
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Default Nevada health dept. reports death of a woman from CRE

CRE (carbapenem-resistant enterobacteriaceae) has been in the U.S. since about 2001, but most people still don't know much about it. However, the news of this death, which is getting attention from the MSM, may help spread awareness. This isn't something to lose sleep over, yet. But people need to understand that we've kind of created this situation ourselves by expecting, sometimes demanding, that doctors prescribe some type of antibiotic to cure whatever ails them. The era of "antibiotics can cure anything" is over.

What makes this case unique is that the infectious agent showed resistance to every type of antimicrobial drugs available in the U.S.

I'm making this post a kind of primer about CRE by including information from 3 sources. The first is an article that gives a simplified version of the case. The 2nd is the MMWR article, which is more technical but informative. The 3rd is from a CDC teleconference held in 2013(?) that discusses what is known about CRE and how the CDC is dealing with it.

So far, this remains a hospital-acquired infection. Unlike MRSA, it's not showing up in the general population, yet. But, if you're an in-patient or out-patient of a hospital or nursing home, or are even just visiting someone, it's critical that you wash your hands thoroughly. In spite of all of our high-tech medical care, simple hand washing is still the first and best line of defense.


A Nevada woman dies of a superbug resistant to every available antibiotic in the US
Quote:
By Helen Branswell

If it sometimes seems like the idea of antibiotic resistance, though unsettling, is more theoretical than real, please read on.

Public health officials from Nevada are reporting on a case of a woman who died in Reno in September from an incurable infection. Testing showed the superbug that had spread throughout her system could fend off 26 different antibiotics.

“It was tested against everything that’s available in the United States … and was not effective,” said Dr. Alexander Kallen, a medical officer in the Centers for Disease Control and Prevention’s division of health care quality promotion.

Although this isn’t the first time someone in the US has been infected with pan-resistant bacteria, at this point, it is not common. It is, however, alarming.

...The case involved a woman who had spent considerable time in India, where multi-drug-resistant bacteria are more common than they are in the US. She had broken her right femur — the big bone in the thigh — while in India a couple of years back. She later developed a bone infection in her femur and her hip and was hospitalized a number of times in India in the two years that followed. Her last admission to a hospital in India was in June of last year.

The unnamed woman — described as a resident of Washoe County who was in her 70s — went into hospital in Reno for care in mid-August, where it was discovered she was infected with what is called a CRE — carbapenem-resistant enterobacteriaceae. That’s a general name to describe bacteria that commonly live in the gut that have developed resistance to the class of antibiotics called carbapenems — an important last-line of defense used when other antibiotics fail. CDC Director Dr. Tom Frieden has called CREs “nightmare bacteria” because of the danger they pose for spreading antibiotic resistance.

...In the woman’s case, the specific bacteria attacking her was called Klebsiella pneumoniae, a bug that often causes of urinary tract infections.

Testing at the hospital showed resistance to 14 drugs — all the drug options the hospital had...

A sample was sent to the CDC in Atlanta for further testing, which revealed that nothing available to US doctors would have cured this infection.

...“If we’re waiting for some sort of major signal that we need to attack this internationally, we need an aggressive program, both domestically and internationally to attack this problem, here’s one more signal that we need to do that,” said Lance Price, who heads the Antibiotic Resistance Action Center at George Washington University.

There is international recognition of the threat, which an expert report published last year warned could kill 10 million a year by 2050 if left unchecked. In September, the UN General Assembly held a high-level meeting on antibiotic resistance, only the fourth time the body had addressed a health issue.

...“People have asked me many times ‘How scared should we be?’ … ‘How close are we to the edge of the cliff?’ And I tell them: We’re already falling off the cliff,” Johnson said. “It’s happening. It’s just happening — so far — on a relatively small scale and mostly far away from us. People that we don’t see … so it doesn’t have the same emotional impact.’’

The MMWR notes that incidences of complete resistance are uncommon. I'm tempted to add "so far" to that comment.


CDC MMWR: Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016


Quote:
Jan. 13, 2017

On August 25, 2016, the Washoe County Health District in Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-resistant Enterobacteriaceae (CRE) that was resistant to all available antimicrobial drugs. The specific CRE, Klebsiella pneumoniae, was isolated from a wound specimen collected on August 19, 2016. After CRE was identified, the patient was placed in a single room under contact precautions. The patient had a history of recent hospitalization outside the United States. Therefore, based on CDC guidance (1), the isolate was sent to CDC for testing to determine the mechanism of antimicrobial resistance, which confirmed the presence of New Delhi metallo-beta-lactamase (NDM).

...Antimicrobial susceptibility testing in the United States indicated that the isolate was resistant to 26 antibiotics...

...First, although CRE are commonly sent to CDC as part of surveillance programs or for reference testing, isolates that are resistant to all antimicrobials are very uncommon. Among >250 CRE isolate reports collected as part of the Emerging Infections Program, approximately 80% remained susceptible to at least one aminoglycoside and nearly 90% were susceptible to tigecycline (2).

I believe this teleconference was held in 2013.


CDC: Vital Signs Telebriefing on Carbapenem-Resistant Enterobacteriaceae


Quote:
Tuesday, March 5

...CRE are nightmare bacteria. They pose a triple threat. First, they're resistant to all or nearly all antibiotics. Even some of our last-resort drugs. Second, they have high mortality rates. They kill up to half of people who get serious infections with them. And third, they can spread their resistance to other bacteria. So one form of bacteria, for example, carbapenem-resistant klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also.

...the long word, carbapenem-resistant enterobacteriaceae, is a family of more than 70 different kinds of bacteria. It includes some very common ones, like klebsiella and E. coli, that are normally present in our intestines. Sometimes, however, these bacteria can get into the wrong places like the blood or the bladder. When this happens, people can get severe infections called urinary tract infections. Some types of enterobacteriaceae have become resistant to antibiotics, even high-powered, last resort, last line of defense of antibiotics, called carbapenems. Antibiotic resistance is what turns normal enterobacteriaceae into drug resistant or CRE. Now there are many different types of resistance that are carried by different plasmids that go by names like KPC or VIM or NDM, or CRKP. These are all types of CRE.

...The risk of CRE infection is highest among patients who are getting complex or long-term medical care. This mostly means patients in regular hospitals or long-term acute care hospitals, or nursing homes.

...We know that in the first half of 2012 alone, nearly 200 hospitals and long-term acute care facilities treated at least one patient who was infected with these bacteria. We've tracked CRE from a single healthcare facility in one state in 2001 to healthcare facilities now in 42 states or more. In some of those places, these bacteria are now a routine challenge for patients and clinicians.

Overall, CRE has increased from one percent to four percent in the past decade and the most common type of CRE has increased from two percent to 10 percent during that time. That's a very troubling increase. It's a four or five-fold increase in the proportion of these serious infections that are from highly-resistant organisms.

...Last year, CDC released a tool kit with updated recommendations to tackle CRE, and we're very gratified to see that places that have implemented those tools have seen dramatic reductions in their CRE rates.

...Many antibiotics have been shown to increase the risk of getting CRE. For example, in one study giving a patient one antibiotic, a carbapenem, increased their risk of getting CRE 15-fold.

...We know that it's widespread, in that 42 states have had at least a single case. When we compare it with other drug resistant bacteria, such as MRSA, it has not yet spread to the community.

...What they've found is this is something that's basically almost exclusively limited to patients who have extensive exposure to healthcare. We feel like we have information through these collaborations with the health department that makes us confident in saying this is a problem for our healthcare facilities, but it's not yet an issue that we face out in the community.

...What we do know is that some hospitals have been the site of outbreaks simply because they've received a patient in transfer from another facility, and that patient already had CRE. And then started a cluster, or outbreak in that hospital.

...What, if anything, can people just in the community as a whole do to protect themselves, if anything, maybe even if they happen to be visiting loved ones in the hospital, are there any special measures that they can take? And the follow-up question to that is, what are the warning signs if this super bug does enter the community? And if it were to get into the community, how quickly would we know that it was there?

...The first thing is to recognize that not all fevers require antibiotics. The more we use antibiotics unnecessarily, the more we promote the spread of drug resistance. So understanding that for most routine infections, they're viral and antibiotics won't help. In the hospital, ensuring that you, your visitors and your caretakers wash their hands before touching you is also very important. Because that's the main way these organisms spread.

...I think that taking antibiotics carefully, not demanding antibiotics when your healthcare provider tells you that you don't need them, those are all things that people can do. Careful attention to washing hands is also absolutely critical when you're in the hospital, when you're out of the hospital. That's something that we know is a simple thing that every one of us can do to prevent the risk of infection spreading.

...The most serious infections are those that are what we call invasive, meaning they're invading a part of the body that is usually sterile, like the blood stream. And what we find is that for things like urinary tract infections which can become invasive, it's very important to remove urinary catheters quickly, as quickly as possible, because having the catheter in place makes it virtually impossible to get rid of the infection.

...I understand there were some here in New York, particularly in New York City. And if you know where the clusters were, how large were they? Did they involve multiple hospitals, one hospital, two hospitals?

...The one that was at NIH in 2011 was not small. That involved 17 people. And I understand that the person who transferred the bacteria, the CRE, had come from New York.

...clinicians in New York are very familiar with CRE. It's prevalent in a number of hospitals in the New York area. So it's been an issue that they have been combating and dealing with for many years now. And in fact, a lot of the information that we have about how CRE spreads, how lethal the infections are, comes from reports that have been published by people, by clinicians in New York. Because they've been dealing with this for so long.

...I’m referring to the fact that broadly in the New York area, we know that clinicians frequently encounter CRE.
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Old 01-16-2017, 05:35 PM   #2
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So the End of the Antibiotic Era is in sight.
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Old 01-16-2017, 05:37 PM   #3
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It's been in sight for a long time - just a matter of 'when'. It's not in the community - "yet". It may actually be. People often beat a bacterial infection on their own - think of small cuts or abrasions that look yucky for a few days. It's possible some of the bacteria causing those infections DO carry the resistance but because they haven't been challenged with antibiotics, no one has picked up on them.
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Old 01-16-2017, 07:08 PM   #4
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Quote:
Originally Posted by Mama Alanna View Post
So the End of the Antibiotic Era is in sight.
What Sue said is true. We don't think it's in the community yet. The CDC has all kinds of monitoring in place to watch for it. But only 6 states mandate reporting of CRE infections or deaths. But, unless every person who develops some sort of sepsis gets cultured, or autopsied after dying, who's to say how many of cases of sepsis are actually due to some form of CRE?

For people who aren't in the medical field, I think the biggest problem is cultural. For most of us, our parents were born when the first simple antibiotics were initially developed and used. After generations of watching people die or become disabled by what we now consider to be simple infections, those new antibiotics were considered by their parents to be nothing less than miracle pills.

Our parents carried that belief with them when they had kids. As more and more different antibiotics were created, it seemed only natural for doctors to prescribe miracle pills for almost everything. So, we baby boomers have spent most of our lives routinely getting dosed up on antibiotics for every boo-boo, sniffle, or cough we might have.

It's really only been in the past decade or so that research started showing that there's a price to pay for all those miracles in a pill. Yes, antibiotics kill 'germs'. But, over the almost 80 years that antibiotics have been used, those germs have adapted and evolved to the point that it's getting harder and harder for an antibiotic pill to do it's magic thing and make us all better.

Essentially, we've created our own monsters. I feel badly for our kids and grandchildren. It's mostly their generations that will have to pay the price for our unknowingly over-use of those magic pills. I expect to see more and more types of drug-resistant infectious agents like MRSA and CRE to develop in the near future. I also believe that it won't take all that long for resistant infections to become community wide, mostly because people still don't understand the importance of simple hand washing. It amazes me that signs have to be posted in doctor's offices, clinics, and hospitals to remind people to wash their hands.

We also need research (and funding for it) that looks for alternate methods of dealing with bacterial infections instead of relying solely on antibiotics. Without that kind of research, our kids and grandchildren will be back where our parents started - in an era where even simple infections can become deadly.
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Old 01-16-2017, 07:18 PM   #5
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And this is properly the subject of a distinct thread but we've become 'medically lazy' about a host of other conditions & illnesses... because we've become accustomed to quick & dirty cures or long term treatments that mitigate most, if not all, the negative effects.
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Old 01-16-2017, 08:59 PM   #6
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Gram-negative sepsis is bad juju in old folks. The KES group (klebsiella, enterobacter, serratia) are ugly little bastards that have always been hard to kill.

But uncommon.

The real nightmare would be drug-resistant E. Coli. UTIs in women? Usually E. Coli. UTIs in people with catheters (used to be everyone in the damn hospital, and still a lot of folks these days)? Usually E. Coli. Most common cause of gram negative sepsis? E. Coli.

Imagine if every little "bladder infection" in a sexually active woman was potentially life threatening. Every fever in a nursing home patient, ditto. And, since sepsis happens to the old and infirm, that's going to increasingly be Baby Boomers—most of us on this board, I'll warrant.
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Old 01-16-2017, 09:44 PM   #7
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Oh, bite your tongue, dharma. If E.Coli were to become drug-resistant, I'd be dead. I do everything to avoid UTI's including no longer handling any raw chicken, including that supposedly grown without antibiotics.
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Old 01-16-2017, 10:00 PM   #8
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Quote:
Originally Posted by dharma View Post
Gram-negative sepsis is bad juju in old folks. The KES group (klebsiella, enterobacter, serratia) are ugly little bastards that have always been hard to kill.

But uncommon.

The real nightmare would be drug-resistant E. Coli. UTIs in women? Usually E. Coli. UTIs in people with catheters (used to be everyone in the damn hospital, and still a lot of folks these days)? Usually E. Coli. Most common cause of gram negative sepsis? E. Coli.

Imagine if every little "bladder infection" in a sexually active woman was potentially life threatening. Every fever in a nursing home patient, ditto. And, since sepsis happens to the old and infirm, that's going to increasingly be Baby Boomers—most of us on this board, I'll warrant.
From what I've been reading, I think E. Coli is in the on-deck circle. It's just a matter of time.

Sorry Andrea.
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Old 01-17-2017, 07:14 PM   #9
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Ah, my dementia is worsening. I failed to add the punchline to my post: KES group bacteria frequently "swap genes" with other gram negatives, including E. Coli. That means increasing drug resistance (there's already some) in E. Coli is a major risk going forward.

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