FEATURE ARTICLES

3 Introduction to this issue

Bonnie Marshall (APUA News Staff)

4 Carbapenemases: a real threat

Dr. Moises Morejon Garcia, MSc (Hospital Universitario Manuel Fajardo, Havana, Cuba)

7 U.S. CDC is sounding the alarm on nightmare bacteria

Arjun Srinivasan, MD (U.S. CDC, Division of Healthcare Quality Promotion, Atlanta, GA)

10 Therapeutic approaches to carbapenem-producing Enterobacteriaceae: a brief update

Gabriel Levy Hara, MD (Hospital Durand, Buenos Aires, Argentina)

FOLLOW-UP: C. difficile

13 The epidemiology of community-acquired Clostridium difficile infection: a population-

based study

Sahil Khanna, MBBS, MS (Mayo Clinic, Rochester, MN)

APUA FIELD REPORTS & CHAPTER UPDATES

15 Impact of ESBLs and CREs—the Nigerian experience

17 ESBL-producing Enterobacteriaceae in Bulgaria

19 APUA-Kenya’s antimicrobial stewardship program

20 Acinetobacter baumannii epidemiology and

resistance in north Lebanon

18 Upcoming events

21 State & national responses to CRE & ESBL alarms

22 APUA headquarters in action: 2013 Leadership Award

and Directorship transition

23 APUA Learning Lab

24 Policy updates

25 News & publications of note

A light micrograph of the genus Klebsiella. These

non-motile, rod-shaped gram-negative bacteria live

normally in the human intestinal tract and commonly

cause opportunistic infections of the intestinal and

urinary tracts, lungs, and wounds. Highly prone to

developing antibiotic resistance, they are the most

common carriers of ESBL genes in healthcare

facilities and are the source of the KPC-type

carbapenemases that have spread globally.

Source: Med. Mic. Sciences Cardiff Uni, Wellcome Images

NEWSLETTER PUBLISHED CONTINUOUSLY SINCE 1983 BY THE ALLIANCE FOR THE PRUDENT USE OF ANTIBIOTICS

September 2013

Volume 31, No. 2

Nightmare bacteria and the worldwide threat to carbapenems

2 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA

Chief Executives Stuart B. Levy, President

Thomas F. O’Brien, Vice President

Kathleen T. Young, Executive Director

Board of Directors Stuart B. Levy, Chairman Sherwood Gorbach

Gordon W. Grundy

Bonnie Marshall

Mark Nance

Thomas F. O’Brien

Arnold G. Reinhold

Dennis Signorovitch

Philip D. Walson

Mary Wilson

Editorial Staff Stuart B. Levy, Editor

Bonnie Marshall, Associate Editor

Michelle Haan, Assistant Editor

Thu Do, Contributor

Christopher Logan, Contributor

Advisory Board Jacques F. Acar, France

Werner Arber, Switzerland

Fernando Baquero, Spain

Michael l. Bennish, USA

Otto Cars, Sweden

Patrice Courvalin, France

Jose Ramiro Cruz, Guatemala

Julian Davies, Canada

Abdoulaye Djimde, Mali

Paul Farmer, Haiti

Walter Gilbert, USA

Herman Goossens, Belgium

Sherwood l. Gorbach, USA

Ian M. Gould, Scotland

George Jacoby, USA

Sam Kariuki, Kenya

Ellen L. Koenig, Dominican Republic

Calvin M. Kunin, USA

Jacobo Kupersztoch, USA

Advisory Board (cont.) Stephen A. Lerner, USA

Jay A. Levy, USA

Donald E. Low, Canada

Scott McEwen, Canada

Jos. W.M. van der Meer, The Netherlands

Richard P. Novick, USA

Iruka Okeke, USA & Nigeria

Maria Eugenia Pinto, Chile

Vidal Rodriguez-Lemoine, Venezuela

José Ignacio Santos, Mexico

Mervyn Shapiro, Israel

K. B. Sharma, India

Atef M. Shibl, Saudi Arabia

E. John Threlfall, United Kingdom

Alexander Tomasz, USA

Thelma e. Tupasi, Philippines

Anne K. Vidaver, USA

Fu Wang, China

Thomas E. Wellems, USA

Bernd Wiedemann, Germany

APUA Project Partnerships: The Bill and Melinda Gates Foundation

The Pew Charitable Trusts

U.S. National Institute of Health (NIH)

Pan American Health Organization

(PAHO)

U.S. Agency for International Develop-

ment (USAID)

U.S. Department of Agriculture

U.S. Office of Homeland Security

National Biodefense Analysis and Coun-

termeasures Center

The World Bank

World Health Organization (WHO)

Centers for Disease Control and Preven-

tion (CDC)

U.S. Food and Drug Administration

Ministries of Health

U.S. Defense Threat Reduction Agency

Supporting Chapters: APUA—Abu Dhabi

APUA—South Korea

Australian Society for Antimicrobials

(APUA-Australia)

British Society for Antimicrobial Chemo-

therapy (APUA-UK)

APUA gratefully acknowledges unrestrict-

ed grants from corporate sponsors:

Leadership Level ($20,000+) Clorox Healthcare

Bayer Healthcare Pharmaceuticals

Optimer Pharmaceuticals

Alere Inc.

bioMérieux

Partner Level ($10,000+) Alcon Laboratories

GlaxoSmithKline

Supporter Level ($2,500+) Cubist Pharmaceuticals

Disclaimer APUA accepts no legal responsibility for the content of any submitted articles, nor for the violation of any copyright laws by any person

contributing to this newsletter. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed

or recommended by APUA in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of

proprietary products are distinguished by initial capital letters.

The APUA Newsletter (ISSN 154-1424) © 2013 APUA Since 1983, the APUA Newsletter has been a continuous source of non-commercial information disseminated without charge to healthcare

practitioners, researchers, and policy-makers worldwide. The Newsletter carries up-to-date scientific and clinical information on prudent

antibiotic use, antibiotic access and effectiveness, and management of antibiotic resistance. The publication is translated into three languages and

distributed to over 7,000 affiliated individuals in more than 100 countries. The material provided by APUA is designed for educational purposes

only and should not be used or taken as medical advice. We encourage distribution with appropriate attribution to APUA. See previous editions

of the Newsletter on the APUA website.

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Introduction to this issue

The beta-lactamase enzymes play a long and complex role in

the evolution of antibiotic resistance mechanisms. These

enzymes effectively inactivate the beta-lactam family of

antibiotics by hydrolyzing the four-atom beta-lactam ring that

is common to these agents.

The first beta-lactamase, called “penicillinase”, was discovered

in 1940 in E. coli, not

long after the discovery

of penicillin. With over

750 variants now

reported, the beta-

lactamases comprise

the most diversified of

the resistance mech-

anisms, and to com-

plicate matters further,

are variably categorized.

Functionally, they have

been classified into groups (Groups 1, 2, 3, 4) according to

their activity, i.e., which β-lactamase drugs they can hydrolyze

and their inhibition by clavulanic acid. They have also been

classified molecularly (Ambler Classes A-D), based on their

nucleotide and amino acid sequences and other compounds.2 In

this system, mechanisms for effective hydrolysis are dependent

either on the amino acid serine (Classes A, C, D) or on the

metal zinc (class B), hence the name, metallo-beta lactamase

(MBL). Among nosocomial pathogens, Classes A, B, and D are

of greatest clinical importance.

The early beta-lactamases were chromosomally mediated and

non-transferable. However, the newer, extended (or expanded)

spectrum beta-lactamases (ESBLs) are frequently plasmid-

encoded and first appeared in the mid-1980s. These enzymes

hydrolyze the extended-spectrum cephalosporin antibiotics

(such as cefotaxime, ceftriaxone, ceftazidime), and also

aztreonam, but not the carbapenem cephalosporins. With

increasing cephalosporin use, the ESBLs underwent sequential

mutations, raising the MICs (minimal inhibitory

concentrations) to these drugs more than 100-fold (Fig. 2).

Because transferable plasmids often specify resistance to other

antibiotic classes (e.g., aminoglycosides), multidrug resistance

has ensued and therapeutic options have become increasingly

limited. For serious infections caused by ESBL-producing

strains, the carbapenem family of antibiotics (imipenem,

meropenem, ertapenem, doripenem) have become the agents of

choice and, sometimes, the only remaining one. However, in

1993, the first carbapenemase-producing strain (Enterobacter

cloacae) was described in Paris. This was followed by a large

variety of carbapenemase-resistant Entero-bacteriaceae, or

“CRE”—generating the latest wave of

“superbugs.” High-level carbapenem-resistance

consists essentially of three types: the KPCs

(Klebsiella pneumoniae carbapenemases), the

MBLs (metallo-beta lactamase types), and the

OXAs (oxacillinase types). The spread of these

carbapenemases may now constitute the edge of

two concomitant epidemics: one within

community-acquired E. coli infections, and a

second within nosocomial Klebsiella

pneumonia—the most common ESBL carrier

found in healthcare facilities for the past 30

years.3

To escalate the problem further, the ESBLs have

become a diagnostic challenge. The transferable

genes are very difficult to differentiate from

those based on the chromosome, and some

appear susceptible to cephalosporins, but still

result in high failure rates. A convincing case

INTRODUCTION continued on page 6

by Bonnie Marshall (APUA staff)

Introduction to this issue • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 3

Figure 1. Penicillin resistance

Source: adapted from Ref. 4

Figure 2. Increasing MICs correlate with increasing cephalosporin use

and sequential TEM mutations.

Βeta-lactamase attacks the beta-lactam

ring of penicillin, disabling the

molecule. Source: http://bit.ly/1d6fc4l.

Carbapenemases: A real threat

Dr. Moises Morejon Garcia, MSc; APUA-Cuba President Hospital Universitario Manuel Fajardo, Havana, Cuba

Translated from Spanish

Although bacterial resistance is a natural evolutionary

phenomenon, the selective pressure exerted by antibiotic use in

the past 70 years has greatly accelerated this process. In their

evolution, bacteria have developed multiple mechanisms of

resistance—principally inactivating enzymes, mutations in

target sites and efflux pumps. The development and emergence

of inactivating enzymes began with the discovery and use of

the beta-lactams antibiotics—first penicillin in the 1940s and

subsequently, the cephalosporins in the 1960s. Over time, these

beta-lactam-inactivating enzymes expanded their spectrum of

activity—from penicillinases and cephalosporinases, to

extended-spectrum beta-lactamases (ESBLs) and most

recently, to the metallo-beta-lactamases (MBLs). These latter

enzymes, capable of hydrolyzing the carbapenems imipenem,

meropenem, ertapenem, and doripenem are virtually

incapacitating the last remaining treatments for multiresistant

gram-negative bacilli. The first reports of carbapenemase in the

1980s, and their subsequent spread across the globe, have

raised concern, and coincide with a decade in which no new

antimicrobial against gram-negatives is anticipated.

In the 1980s, Japan reported isolation of the first

carbapenemase from Aeromonas hydrophila.1 This was

followed by reports of the Seoul imipenemase (SME-1) from

Serratia marcescens in London (1982), and imipenemases

IMI-1 in California (1984) and NMC-A in France (1990), both

from Enterobacter cloacae.2

A report of the first Klebsiella pneumoniae carbapenemase

(KPC) in 1996 at a hospital in North Carolina raised concerns,

but outbreaks in 2001 in New York and New Jersey hospitals

created major alarm. These strains then spread across 27 U.S.

states to many Latin American countries, including Argentina,

Bolivia, Colombia, Venezuela, Uruguay, Brazil, Puerto Rico

and abroad (China, Israel, and France).3-5

In the 2000s, carbapenemase activity appeared in Southeast

Asia, Hong Kong and Singapore, while in Europe, the first

variant, IMP-2, appeared in a strain of Acinetobacter

baumannii. Meanwhile, reports of IMP increased in the U.S.,

Canada, and Brazil.6

A second family of carbapenemases, the Verona integron-

encoded metallo-lactamases (blaVIM-1), were isolated simul-

taneously in 1999 from strains of Pseudomonas aeruginosa and

Acinetobacter spp in Italy.7 Subsequently, a third metallo-

betalactamase family, SPM-1, was isolated from Pseudomonas

aeruginosa in Brazil.8 In Cuba, several reports of

carbapenemase-producing strains have sparked increased

vigilance.9,10

As the carbapenem antibiotics have been the primary therapy

against serious infections from multiresistant gram-negative

organisms, the emergence and increasing prevalence of the

carbapenemases jeopardize the effectiveness of this family of

antibiotics. According to the SENTRY global surveillance

report, rates in Latin America are higher than those in U.S. and

Europe.11

In 2008, the isolation of a new metallo-beta-lactamase, called

New Delhi metallo (NDM-1), raised global alarm due to its

isolation from Swedish and English patients who had

previously travelled to India and Pakistan. A surveillance study

between 2008 and 2010 in 29 European countries reported 77

cases of the NDM-1 enzyme in 13 of the countries,

predominantly in isolates of Klebsiella pneumoniae (54%).12

Subsequently, NDM-1 was found in Japan, Australia, Canada

and the USA.12

In November 2011, NDM-1 was first isolated in Latin

America—from a strain of Klebsiella pneumoniae. The

Guatermalan isolate prompted the Pan American Health

Organization (PAHO) to issue an alert for surveillance of these

health-care associated pathogens that seriously impact

morbidity and mortality.

The carbapenemases fall into two groups: the serine beta-

lactamases (serine-based) and the metallo-beta-lactamases

(zinc-based) (Table 1). The serine-based enzymes (enzymes of

Ambler class A or D) have less hydrolytic activity than the

4 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Garcia

metallo-enzymes, are not hydrolyzed by aztreonam, and can be

inhibited by beta-lactamase inhibitors.13

The metallo-beta-lactamases belong to Ambler class B of

(Group 3 in the Bush classification). These acquired carba-

penemases are the most clinically significant as they are

capable of hydrolyzing

all β-lactam antibiotics,

with the exception of

aztreonam, and are not

susceptible to beta-

lactamase inhibitors.

Both metallo- and

serine-based enzymes

are found primarily in

Enterobacteriaceae and the non-fermenting bacilli

(Pseudomonas aeruginosa, Acinetobacter baumannii). These

create a therapeutic conundrum, as the antibiotic of choice

against these multidrug-resistant strains (piperacillin/

tazobactam, 3rd and 4th generation cephalosporins,

fluoroquinolones and aminoglycosides) has not yet been

determined. Intravenous (disodium) fosfomycin has proven

useful against KpC strains. Other possible options are

tigecycline, colistin and aztreonam, either alone, or more often

in combination.14-18

The increasing prevalence and global spread of these enzymes,

coupled with their impacts on treatment outcomes, obligate

countries to undertake surveillance monitoring.

In 2009, the Clinical and Laboratory Standard Institute (CLSI)

recommended the modified Hodge test (MHT) for detection of

carbapenemase—a method that permits detection, but does not

discriminate between

serine- and metallo-beta-

lactamases (Fig 1).19

Recommendations for

identifying metallo-beta

-lactamases utilize chel-

ating agents such as

ethylenediaminetetra-

acetic acid (EDTA) and

2-mercapto-propionic

acid (2-MPA). How-

ever, there is no

consensus on the best

substrate or the best

inhibitor of these

enzymes. Thus, there are two options: the IMP disk with

EDTA, and the epsilometric MBL detection assay (Etest MBL)

—using strips IMIK/IMI + EDTA—a less complex, but more

costly method that cannot be used in the carbapenemase-

producing strains of the oxacillinase (OXA) type, as it can give

false positives (often found in A. baumannii).20-22

It is worrisome that the genes encoding these enzymes are

carried on conjugative plasmids that possess considerable

potential for nosocomial spread to other pathogens. The overuse

of carbapenems is an important factor in the generation and

selection of carbapenemase-producing organisms. The proper

use of these agents will prolong their future at a critical time

when no new antimicrobials that target gram-negatives are

anticipated.

References

1. Masidda OG, Rossolini M, Satta G. The Aeromonas hydrophila

cphA gene: molecular heterogeneity among metallo-B-

lactamases. J Bacteriol 1991;173:4611-4617

2. Echeverri L M, Cataño JC. [Klebsiella pneumoniae as nosocomial

pathogens: epidemiology and resistance. Atreia 2010;23(3):240-

249.

3. Yigit H, Queenan AM, Anderson GJ, et al. Novel carbapenem-

hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant

strain of Klebsiella pneumoniae. Antimicrob Agents Chemother.

2001;45:1151-1161.

4. Bratu S, Brooks S, Burney S, et al. Detection and spread of

Escherichia coli possessing the plasmid-borne carbapenemase

KPC-2 in Brooklyn, New York. Clin Infect Dis. 2007;44:972-

975.

5. Bratu S, Mooty M, Nichani S, et al. Emergence of KPC-

possessing Klebsiella pneumoniae in Brooklyn, New York:

epidemiology and recommendations for detection. Antimicrob

Agents Chemother. 2005;49:3018-3020.

6. Andrade V. [Emergence of carbapenem resistance in

Pseudomonas aeruginosa producing metallo-B-lactamases].

Bioquimia 2005;30:53-58.

7. Lauretti L, Riccio ML, Mazzariol A, Cornaglia G, Amicosasnte

G, Fonatana R, et al. Cloning and characterization of blaVIM a

new integron-borne metallo-B-lactamase gene from a

Pseudomonas aeruginosa clinical isolate. Antimicrob Agents

Chemoter 1999;43:1584-1590.

8. Toleman MA, Simm AM, Murphy TA, Gales AC, Biedenbach

DJ, Jones RN et al. Molecular characterization of SPM-1 a novel

metallo-B-lactamase isolated in Latin America: report from the

SENTRY antimicrobial surveillance programme. J Antimicrob

2002;50:673-79.

9. Hart M, Espinosa F, Posada H, del Carmen M, Batista M, Luisa

M, Montes de Oca Z. Antibiotic resistance in Acinetobacter

baumannii strains isolated from January to March 2010 at the

Clinical Hospital "Hermanos Ameijeiras." Rev Cubana Med

2012; 49(3):218-227.

Carbapenemases—a real threat • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 5

(1) K. pneumoniae ATCC BAA 1705, positive

result; (2) K. pneumoniae ATCC BAA 1706,

negative result; and (3) a clinical isolate, positive

result on a 100mm plate.19

Figure 1. The Modified Hodge

Test

Table 1. Carbapenems

10. Pedros W, Ramos A, Nodarse R, Padron A, De armas E.

[Bacterial resistance to extended beta-lactamase producing

bacteria) Revista Cubana de Medicina Intensiva y Emergencias

2006;5(1):294-301.

11. Suarez CJ, Kattan JN, Guzman AM, Villegas MV. [Mechanisms

of resistance to carbapenems in P. aeruginosa, Acinetobacter and

Enterobacteriaceae and strategies for its prevention and control.]

Infect. 2006;10(2):85-93.

12. Struelens MJ, Monnet DL, Magiorakos AP, Santos O’Connor F,

Giesecke J, the European NDM-1 Survey Participants. New

Delhi metallo-beta-lactamase 1–producing Enterobacteriaceae:

emergence and response in Europe. Euro Surveill. 2010;15

(46):pii=19716.

13. Tafur JD, Torres JA, Villegas MV. [Mechanisms of antibiotic

resistance in gram-negative bacteria.] CIDEIM 2008;12:217-226.

14. Oliver A. [Carbapenem Resistance and Acinetobacter

baumannii]. Enferm Infecc Microbiol Clin 2004;22(5):259-61

259.

15. Hurtado IC, Trujillo M, Restrepo A, Garcés C, Tamayo C, Mesa

JG. Experience with tigecycline compassionate use in pediatric

patients infected with carbapenem resistant Klebsiella

pneumoniae. Rev. Chil. Infectol. 2012;29(3): 317-321.

16. Jimeno A. [Epidemic outbreak of Pseudomonas aeruginosa

carbepenem-resistant producing metallo-beta-lactamase] Rev

Clin Esp.2011.doi:10.1016/j.rce.2010.12.006.

17. Cordova E, Lespada MI, Gomez N, Pasteran F, Oviedo V,

Rodriguez C. [Clinical and epidemiological description of a

nosocomial outbreak of KPC-producing Klebsiella pneumoniae

in Buenos Aires, Argentina]. 2012;30 (7):376–379.

18. Casellas JM. [Antibacterial resistance in Latin America:

Implications for infections]. Rev Panam Salud Publica 201;30

(6):519-528.

19. US Centers for Disease Control and Prevention. http://

www.ndhealth.gov/microlab/Uploads/HodgeTest.pdf.

20. Meyer G, Ulrich S. [Phenotypes of beta lactamase-producing

Klebsiella pneumoniae in the Emergency Hospital of Porto

Alegre].Bras Patol Med Lab 2011;47(1):25-31.

21. Radice M, Marin M, Giovanakis M, Bay C, Almuzara M,

Limansky A et al. [Test criteria, interpretation and reporting of

susceptibility testing to antibiotics in gram negative

nonfermenters of clinical significance: recommendations of the

Subcommittee on Antimicrobial Argentina Society of

Bacteriology, Mycology and Parasitology Clinics, Argentina

Association for Microbiology.] Revista Argentina de

Microbiología (2011) 43: 136-153.

22. Munoz JL [Problematic bacteria] Rev Esp Quimioter 2008;21:2-

6.

6 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Garcia

can be made for the surveillance of ESBL activity. Many ESBL

resistances are a combination of sequential mutations. Because

the second and third mutations may result in very rapid rises in

MIC values, it is essential to detect the initial mutation early in

the process. Current clinical surveillance breakpoints are set

too high to detect these and thus will miss the first signal of an

impending resistance crisis.

The prevalence of carbapenemases is difficult to assess because

they very so widely from country to country (e.g., 3-5% in

France and >80% in India for ESBL-positive E. coli) and

because the possible “reservoir countries” have no surveillance

systems for detecting them.

This issue of the APUA Newsletter presents some of the

serious present-day challenges posed by the ESBLs and by the

newer carbapenemases in particular. The article by Garcia

overviews the emerging threat posed by the global spread of

carbapenemases, while that of CDC expert Srinivasan outlines

the seriousness of the problem in the US and government

interventions, including a “prevention toolkit” and

recommendations for providers and patients. Levy Hara

discusses the intricacies of CRE detection, as well as

antimicrobial treatment options. The articles by Ogbolu and by

Markovska/Keulyan present perspectives from sub-Saharan

Africa (Nigeria) and from Bulgaria, respectively.

References

1. Bush K, Jacoby GA, Medeiros AA (June 1995). A functional

classification scheme for beta-lactamases and its correlation with

molecular structure". Antimicrob. Agents Chemother. 39 (6):

1211–33.

2. Ambler RP (May 1980). The structure of beta-lactamases. Philos.

Trans. R. Soc. Lond., B, Biol. Sci. 289 (1036): 321–31.

3. Nordmann P, Naas T, Poirel L. (2011). Global spread of

carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis

17:1791-1798.

4. Amyes S, Beta-lactamases: clinical impact and epidemiology.

2009. http://hstalks.com/main/view_talk.php?

t=1538&r=442&j=754&c=252.

Garcia references, continued INTRODUCTION, continued from page 3

“Containing healthcare associated infections through antibiotic stewardship”: webinar by Drs. Stuart Levy and

Shira Doron, http://bit.ly/18cfJCj

“Beta-lactamases: clinical impact and epidemiology”: webinar by Prof. Sebastian Amyes, http://bit.ly/14IRZVJ

Recommended Viewing

Sounding the alarm on

nightmare bacteria

The Centers for Disease Control and Prevention (CDC) and the

nation’s healthcare providers are now battling what may be one

of the most pressing patient safety threats of our time—

carbapenem-resistant Enterobacteriaceae (CRE). In its March

2013 issue of Vital Signs,1 CDC sounded the alarm on the

spread of CRE—“nightmare bacteria”—in U.S. inpatient

medical facilities, stating that action is needed now to halt the

spread of these deadly bacteria. CDC is asking for rapid action

from healthcare leaders to ensure that CRE prevention

measures are aggressively implemented in your facility and by

those around you.

Enterobacteriaceae are a family of more than 70 different

bacteria including Klebsiella pneumoniae and E. coli that

normally live in the digestive system. Over time, some of these

bacteria have become resistant to a group of antibiotics known

as carbapenems, often referred to as last-resort antibiotics.

During the last decade, CDC has tracked one type of CRE from

a single health care facility to health care facilities in at least 42

states. In some medical facilities, these bacteria already pose a

By Arjun Srinivasan, MD Associate Director for Healthcare Associated Infection Prevention Programs,

U.S. CDC, Division of Healthcare Quality Promotion

routine threat to patients.

Here are other important facts to know about CRE:

About 4% of US short-stay hospitals had at least one

patient with a serious CRE infection during the first half of

2012. About 18% of long-term acute care hospitals had

one. This totals almost 200 facilities.

The most common type of CRE is also rising rapidly –

there has been a seven-fold increase in its presence during

the last 10 years.

Up to half of patients who get CRE bloodstream infections

will die.

CRE often spread between patients on the hands of health care

personnel. In addition, CRE bacteria can transfer their

resistance to other bacteria within their family. This type of

spread can create additional untreatable infections. Currently,

almost all CRE infections occur in people receiving significant

medical care in hospitals, long-term acute care facilities, or

nursing homes.

The Vital Signs report describes that

although CRE bacteria are not yet

common nationally, the percentage of

Enterobacteriaceae that are carbapenem-

resistant has increased fourfold in the past

decade. One type of CRE, a resistant form

of Klebsiella pneumoniae, has shown a

sevenfold increase in the last decade. In

the U.S., northeastern states report the

most cases of CRE. During just the first

half of 2012, almost 200 hospitals and

long-term acute care facilities treated at

least one patient infected with these

bacteria.

In the U.S., CRE infections are almost

never seen in healthy people. However,

Sounding the alarm on nightmare bacteria • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 7

Source: CDC’s “Healthcare-associated Infections: Tracking CRE”2

Figure 1. Carbapenemase-producing CRE in the United States

CRE’s ability to spread among people, coupled with their

ability to transfer resistance to other bacteria, raises the worry

that potentially untreatable infections could appear in otherwise

healthy people.

So how do we stop the rise of these deadly, resistant CRE

germs? Halting the rise of CRE will take a combination of

infection control measures and improved antibiotic use. CRE

have shown a propensity to spread quickly in healthcare

facilities and hence aggressive measures to find cases and apply

appropriate infection control measures are essential. But

infection control is only half the battle—we also have to focus

on antibiotic use. One study demonstrated that exposure to a

carbapenem increased a patient’s risk of developing CRE by

more than 15-fold. Reducing unnecessary use of antibiotics like

carbapenems could help slow the emergence of these deadly

bacteria. In 2012, CDC released a concise, practical CRE

prevention toolkit with recommendations for healthcare and

public health for controlling CRE transmission in hospitals,

long-term acute care facilities and nursing homes.

Key recommendations include:

enforcing use of infection control precautions (standard

and contact precautions)

grouping patients with CRE together

dedicating rooms, staff, and equipment to the care of

patients with CRE whenever possible

having facilities alert each other when patients with CRE

transfer back and forth

8 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Srinivasan

Figure 2.

CDC encourages all healthcare providers to:

Know if patients with CRE are hospitalized at your

facility, and stay aware of CRE infection rates. Ask if your

patients have received medical care somewhere else,

including another country.

Follow infection control recommendations with every

patient, using contact precautions for patients with CRE.

Whenever possible, dedicate rooms, equipment, and staff

to CRE patients.

Prescribe antibiotics wisely. Use culture results to modify

prescriptions if needed.

Remove temporary medical devices as soon as possible.

CDC also encourages patients to:

Tell your doctor if you have been hospitalized in another

facility or country.

Take antibiotics only as prescribed.

Insist that everyone wash their hands before touching you.

If rapid action is not taken today, we will miss our window of

opportunity, and CRE could become widespread across the

country. Let’s act now to protect patients from healthcare-

associated infections, including CRE.

For additional information on CRE, click here.

References

1. Centers for Disease Control. “Stop

Infections from Lethal CRE Germs

Now.” CDC Vital Signs Report. 2013.

2. Centers for Disease Control.

“Healthcare-associated Infections:

Carbapenamase producing CRE in the

United States.” 2012. http://

www.cdc.gov/hai/organisms/cre/

TrackingCRE.html.

3. Centers for Disease Control. “Risk

of CRE Infections.” CDC Vital Signs

Report. 2013.

asking patients whether they have recently received care

somewhere else (including another country)

using antibiotics wisely

When implemented fully, CDC recommendations have been

proven to work. Medical facilities in several states have

reduced CRE infection rates and halted CRE outbreaks by

following CDC’s prevention guidelines.

The U.S. is at a critical point in its ability to stop the spread of

CRE. These infections can be controlled if rapid, coordinated,

and consistent facility and regional efforts are implemented by

doctors, nurses, lab staff, medical facility leadership, health

departments/states, policymakers and the federal government.

Currently, the Federal Government is:

Monitoring the presence of, and risk factors for CRE

infections through the National Healthcare Safety Network

(NHSN) and Emerging Infections Program (EIP).

Providing CRE outbreak support such as staff expertise,

prevention guidelines, tools, and lab testing to states and

facilities.

Developing detection methods and prevention programs to

control CRE. CDC's "Detect and Protect" effort supports

regional CRE programs.

Helping medical facilities improve antibiotic prescribing

practices.

Sounding the alarm on nightmare bacteria • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 9

Therapeutic approaches to carbapenem-

producing Enterobacteriaceae: a brief update

Gabriel Levy Hara, MD

Infectious Diseases Unit, Hospital Durand, Buenos Aires, Argentina

Carbapenems are one of few available last-resort therapeutics

for the treatment of serious infections caused by the

Enterobacteriaceae and by gram-negative non-fermenting rods

(GNB). Regrettably, in recent years, the prevalence of

carbapenemase-producing Enterobacteriaceae (CPE) has

increased rapidly in most parts of the world, leaving the

medical profession—and their patients—with limited, if any,

therapeutic options.

Classification of carbapenemases

These enzymes are encoded by bla genes carried on plasmids

and/or integrons that could easily disseminate among different

gram-negative species. Classes A, B, and D are the most

important carbapenemases.

Class A

Within the diversity of Class A enzymes, the KPC-types

(Klebsiella pneumoniae carbapenemases) are the most

frequently identified among clinical isolates. While often

present in Klebsiella pneumoniae, KPC can also be found in

other Enterobacteriaceae, as well as the non-fermenting GNB.

They are generally broadly active against all β-lactam

antibiotics, despite the fact that organisms containing them may

test susceptible to many carbapenems (with the exception of

ertapenem) by standard antimicrobial susceptibility tests

(ASTs).

Class B

Metallo-beta-lactamases (MBLs) are mostly VIM- and IMP-

types. However, the most recent to appear, the NDM-type, is

currently the most dangerous, both because of the high-level of

carbapenem resistance typically exhibited among

Enterobacteriaceae harboring this enzyme (e.g., MICs for

imipenem and meropenem are ≥32 mg/L), and because of its

rapid worldwide dissemination.

Class D

These enzymes are usually OXA-48-like producers. Their

recognition can be difficult because they exhibit no resistance

to broad-spectrum cephalosporins and only decreased

susceptibility to carbapenems. In such a case, the

microbiologist must be aware that Enterobacteriaceae (mainly

E. coli producing OXA-48-like enzymes only, and not co-

possessing ESBLs) demonstrate low MIC values for imipenem

and meropenem (e.g, 0.25-1 mg/L) and exhibit susceptibility to

the extended-spectrum cephalosporins.

Detection of carbapenemase-producers

As noted above, the detection of CPE can be difficult because

their MIC values do not always reflect resistance. This is a

concern, both in terms of early detection and adoption of

infection control measures, as well as for early prescription of

effective antibiotic therapy. CPE can be suspected based on

antimicrobial susceptibility test (AST) results obtained by

diffusion methods or by automated systems by paying close

attention to the MICs or inhibition diameters for carbapenems.

Reference methods, such as broth microdilution and agar

dilution, are preferred, since these are more sensitive than disk

diffusion, Etest, and automated methods. Susceptibility to

ertapenem can be used for the initial screening of

carbapenemase production. When possible, more appropriate

phenotypic (e.g., modified Hodge test) and molecular methods

(e.g., PCR-based or microarray) should be utilized for

confirming the presence of resistance enzymes.

Antimicrobial treatment options

Optimal treatment for CPE infections is not well established, as

most published reports have evaluated only a few patients,

retrospectively. Nonetheless, rapidly growing evidence

suggests that combined therapy can significantly reduce

mortality in severe infections. Considering the different

susceptibilities to potentially effective drugs, it is essential to

choose an antibiotic based on the AST results for each and

every specific clinical situation. Patients who are colonized

only, and who demonstrate no clinical infection, should not be

treated, and current practices for prevention of dissemination of

CPE (e.g., isolation, hand hygiene, etc) should be strictly

observed.

10 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Levy Hara

The following drugs are potentially useful for CPE treatment:

Colistin

Colistin is frequently the only agent to achieve adequate serum

levels for treatment of CPE bloodstream infections (BSIs).

Globally, the sensitivity of GNB to colistin varies from 70% to

100%. Regrettably, in some countries and in certain city

hospitals, resistance is increasing due to the clonal spread of

strains. The emergence of multi drug-resistant (MDR) and

extreme drug-resistant (XDR) pathogens has led to a

significant increase in utilization of colistin—a formerly

uncommon drug. While our knowledge of the PK/PD issues of

colistin has improved, it is not yet fully established.

To avoid confusion related to different formulations, it should

be noted that 100 mg of

colistin sulfate base is

equivalent to 240 mg of

colistin methanesulfonate

(CMS) and to 3 million

units (MU) of CMS (the

non-active pro-drug of

colistin). Current dosing

schemes (commonly, 3

MU of CMS every 8h)

reach only suboptimal

concentrations—i.e., below the MIC breakpoint of 2 mg/liter—

at least during the critical first 2 to 3 days of therapy.1,2 These

levels can greatly increase mortality in critically ill patients, as

well as promote selection of resistant strains. In one study, a 20

-fold difference in the AUC0-24* between patients was

observed.2 Creatinine clearance was an important covariate in

the population PK model applied. Recent studies showed that a

loading dose of 6 to 9 MU, followed by maintenance doses of

4.5 to 6 MU every 12h—always adjusting to renal function—

could be more effective than previously prescribed regimens of

3 MU every 8h, without an increase of nephrotoxicity.2-4 In

different studies, nephrotoxicity varied from 10%-15% and, in

most cases, was transient and probably related to dosage and

duration of treatment. A recent survey of the use of colistin

showed that barely 21.2% of institutions worldwide are

currently using loading doses.

Tigecycline

The clinical use of this glycylcycline, a bacteriostatic agent, is

limited for several reasons. First, a scarcity of controlled

studies demonstrate its efficacy in the treatment of infections

due to MDR and XDR bacteria. Secondly, the PK/PD profile of

tigecycline suggests that it is not appropriate for treatment—at

least as monotherapy—of serious disease. Its protein binding

is 71 - 89%, and with a standard dosing regimen of 50 mg bid,

the peak serum concentrations range from 0.6 - 0.9 mg/l. In

contrast, the MICs for the majority of KPC-producing K.

pneumoniae isolates range between 1 to 2 mg/L. Higher doses

are badly tolerated due to gastrointestinal toxicity (e.g., nausea

and vomiting). Finally, there is a concern regarding the

development of resistance via upregulation of cellular efflux

pumps during therapy. However, as discussed below, there is

some good evidence for the efficacy of tigecycline in

combination with colistin and carbapenems in the treatment of

severely ill patients.

Aminoglycosides

Resistance to this class is increasing

among CPE. In the regrettably few

infections produced by susceptible

strains, these drugs have been

efficacious options as part of

combined therapeutic regimens.

Fosfomycin

Like colistin, this older drug has been

revitalized for the treatment of some

MDR and XDR GNB, and displays in vitro activity against

many CPE, including colistin-resistant strains. Some reports

suggest that fosfomycin should always be used in high doses

(e.g., 4 grams, 4X/day in a normal renal functioning patient)

and in combination regimens (see below).

Combination therapy

Recently published evidence supports the use of combination

therapy in patients with CPE infections. Tzouvelekis et. al.

performed a systematic search to evaluate the efficacy of

different treatment approaches.6 Among 34 small studies, a

total of 298 patients were identified: 244 with blood stream

infections (BSIs), and 32 with pneumonia. One hundred and

forty three patients received monotherapy (only one drug was

active in vitro against the infecting organism); 99 received

combination therapy (at least two drugs active in vitro), and the

remaining 56 received inappropriate therapy (no drug active in

vitro). Combination therapy was superior to monotherapy, and

those patients treated with carbapenems as part of the regimen

had the lowest failure rate (8.3%). In contrast, treatment with

tigecycline or colistin as single active agents resulted in failure

rates (35.7% and 47.2%, respectively) comparable to that

observed for patients improperly treated (45%). Combinations *Area Under the serum Concentration curve over a day

“Patients who are colonized only, and who

demonstrate no clinical infection, should

not be treated, and current practices for

prevention of dissemination of CPE

(isolation, hand hygiene, etc.) should be

strictly observed.”

Therapeutic approaches • The APUA Newsletter Vol. 31. No. 2• © 2013 • APUA • 11

12 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Levy Hara

of carbapenem plus colistin (5.5% of failures) or carbapenem

plus an aminoglycoside (6.2%) exhibited better outcomes than

when these drugs were used alone or as part of other

combinations. Finally, combinations of tigecycline (24% of

failures), colistin (32%), and aminoglycosides (33.3%) in

regimens not including a carbapenem, exhibited higher failure

rates.

A recently published multicenter retrospective cohort study of

125 patients with BSIs caused by KPC-K. pneumoniae also

showed higher mortality rates in patients treated with

monotherapy (54.3% vs. 34.1% with combined drug therapy; P

= 0.02). Combination therapy with tigecycline, colistin, and

meropenem was independently associated with survival (OR:

0.11; 95% CI: .02–.69; P = 0.01). With MIC values of ≤4 mg/l

for meropenem, inclusion of this drug in a combined regimen

led to a survival rate of 86.6%, and with even higher MIC

values, the survival rate was 75%.7

Carbapenems display time-dependent bactericidal killing when

free drug concentrations remain above the MIC for 40–50% of

the time between doses. The probability of attaining 50%

T>MIC* target for an isolate with a MIC of 4 mg/l is 69% for

the traditional dosing regimen (e.g., 30 min infusion of 1g

every 8 hours for meropenem) and increases to 100% for the

high-dose/prolonged infusion regimen (e.g., 3 hour infusion of

2g every 8 hours for meropenem). Even for an MIC of 8 mg/l,

the high-dose/prolonged-infusion carries a high probability

(85%) of bactericidal activity.8

In the February 2013 issue of the Journal of Chemotherapy, an

International Working Group** published some pivotal

recommendations for the detection, treatment and prevention of

CPE.9 For all the above reasons, the recommendations of this

Working Group support the use of carbapenems, provided that:

the carbapenem MIC for the infecting organism is >4 mg/l

(and possibly up to 8 mg/l)

a high-dose, prolonged-infusion regimen is administered

(e.g. 2g meropenem every 8h, or 1g imipenem every 6-8h)

they are used in combination with another active

compound, preferably colistin or an aminoglycoside.

Considering the deficit of new drugs on the near horizon, our

most immediate option for preventing more deaths from CPE

will be the enforcement of infection control practices combined

with diligent antimicrobial stewardship.

*(Time above MIC) = the percentage of a dosage interval in which the

serum level exceeds the minimal inhibitory concentration.

**This group included representatives from the Argentinian Society of

Infectious Diseases (SADI), the International Society of

Chemotherapy (ISC), the Pan American Association of Infectious

Diseases (API), the Pan American Health Organization/World Health

Organization (PAHO/WHO), the Infection Control African Network

(ICAN), Mediterranean Society of Chemotherapy (MSC) and the

Federation of European Societies for Chemotherapy and for Infections

(FESCI). This article briefly summarizes the key points of their

recommendations.

References

1. Plachouras D, Karvanen M, Friberg L, Papadomichelakis E,

Antoniadou A, Tsangaris I et al. Population pharmacokinetic

analysis of colistin methanesulfonate and colistin after

intravenous administration in critically ill patients with infections

caused by Gram-negative bacteria. Antimicrob Agents

Chemother 2009; 53: 3430-6.

2. Garonzik SM, Li J, Thamlikitkul V, Paterson DL, Shoham S,

Jacob J, Silveira FP, et al. Population pharmacokinetics of

colistin methanesulfonate and formed colistin in critically ill

patients from a multicenter study provide dosing suggestions for

various categories of patients. Antimicrob Agents Chemother

2011; 55: 3284-94.

3. Dalfino L, Puntillo F, Mosca A, Monno R, Spada ML,

Coppolecchia S et al. High-dose, extended-interval colistin

administration in critically ill patients: is this the right dosing

strategy? A preliminary study. Clin Infect Dis. 2012; 54:1720-6.

4. Pogue JM, Lee J, Marchaim D, Yee V, Zhao JJ, Chopra T et al.

Incidence of and risk factors for colistin-associated

nephrotoxicity in a large academic health system. Clin Infect Dis

2011; 53:879-84.

5. Wertheim H, Van Nguyen K, Levy Hara G, Gelband H,

Laxminarayan R, Mouton J, Cars O. Global survey of polymyxin

use: A call for international guidelines. J Global Antimicrob

Resist (2013) in press, http://dx.doi.org/10.1016/

j.jgar.2013.03.012.

6. Tzouvelekis LS, Markogiannakis AM, Psichogiou PT, Tassios

PT, Daikos GL. Carbapenemases in Klebsiella pneumoniae and

other Enterobacteriaceae: an evolving crisis of global

dimensions. Clin Microbiol Rev; 25: 682-707.

7. Tumbarello M, Viale P, Viscoli C, Trecarichi EM, Tumietto F,

Marchese A et al. Predictors of mortality in bloodstream

infections caused by Klebsiella pneumoniae carbapenemase-

producing K. pneumoniae: Importance of combination therapy.

Clin Infect Dis 2012; 55:943-50.

8. Akova M, Daikos GL, Tzouvelekis L, Carmeli Y. Interventional

strategies and current clinical experience with carbapenemase-

producing Gram-negative bacteria. Clin Microbiol Infect 2012;

18: 439–448.

9. Levy Hara G, Gould I, Endimiani A, Ramón Pardo P, Daikos G,

Hsueh PR, et al. Detection, treatment and prevention of

carbapenemase-producing Enterobacteriaceae: Recom-

mendations from an International Working Group. J Chemother

2013; 25: 129-140.

In a population-based study from Olmsted County, Minnesota

between 1991-2005, 41% of all CDI cases were community-

acquired, 50% were hospital-acquired, and 9% were nursing

home-acquired.5 In accordance with the existing literature, the

majority of cases (53%) occurred in the elderly (age ≥65

years). The overall age- and sex-adjusted incidence of CDI was

25.2 per 100,000 person-years and there was a significant

increase in both hospital-acquired (19.3-fold) and community-

acquired (5.3-fold) cases over the study period.5

In this study, patients with community-acquired CDI were

younger, had fewer co-morbid conditions, were less likely to

have an underlying malignancy, and were less likely to develop

severe disease. Interestingly, of all CDI patients, 13% had no

documented antibiotic exposure in the preceding 90 days.

Compared to hospital-acquired CDI patients, those with

community-acquired CDI were

significantly less likely to be exposed to

antibiotics (94% vs. 78%) or gastric acid

suppression medications (47% vs. 22%).5

CDI cases were predominantly female

(75.3%); one-fifth had severe CDI; 20%

had treatment failure and a significant

proportion required hospitalization for

CDI. Community-acquired CDI patients

who required hospitalization were

significantly older (median age difference 20 years), had more

comorbid conditions and were more likely to have severe CDI.6

Within the pediatric population of Olmsted County (1991 -

2009), the majority of cases (75%) were community-acquired.

The overall age and sex-adjusted CDI incidence was 13.8 per

100,000 persons, which increased 12.5-fold over the study

period. The incidence of community-acquired CDI was 10.3

per 100,000 persons and increased 10.5-fold over the study

period.7 Of all community-acquired cases, 85.5% had an

outpatient or an emergency-department visit in the three

months prior to onset of CDI. Severe, severe-complicated, and

recurrent CDI occurred in 9%, 3%, and 20% respectively.

Community-acquired C. difficile

infection—old bug, new insights

Sahil Khanna, MBBS, MS

Mayo Clinic, Rochester, Minnesota

Clostridium difficile infection (CDI) is the most common

hospital-acquired infection and the most common cause of

infection diarrhea in the hospital—with ~500,000 - 1,000,000

infections and ~14,000 deaths annually in the United States.1, 2

While the traditional risk factors for CDI include increasing

age, antibiotic exposure and hospitalization, recent data have

shown that CDI is also present in the community—in patients

who may lack these traditional risk factors.2

According to guidelines from the Infectious Diseases Society

of America, CDI is defined as “hospital-acquired” if symptom

onset occurs more than 48 hours after admission to, or less than

4 weeks after discharge from, a

health care facility.3 CDI is

considered “community-acquired”

if symptom onset occurs in the

community or within 48 hours of

admission to a hospital, provided

that symptom onset was more

than 12 weeks after the last

discharge from a hospital. CDI is

defined as “indeterminate” if symptom onset occurs between 4

and 12 weeks following a hospital dismissal.3

Community-acquired CDI is probably an under-diagnosed and

under-recognized sub-group of patients—likely due to a lack

of awareness of the existence of CDI outside the healthcare

setting. Studies have shown that the proportion of community-

acquired CDI ranges from 27 - 41% in adults and up to 75% in

pediatric patients.2,4 CA-CDI has been described in populations

previously considered to be at low risk, including peri-partum

women, children and young adults.4 Many of these patients

lack traditional risk factors for CDI, such as antibiotic exposure

or recent hospitalization.5

Community-acquired C. difficile • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 13

This article is a follow-up to APUA’s April 2013

Newsletter on C. difficile infections in healthcare

institutions. For important new updates on C. difficile

management, see page 26.

“...Up to one-third of households

and half of water and swimming

pool samples may be contam-

inated with C. difficile.”

There were fewer treatment failures in those treated with

vancomycin compared to metronidazole.7

The lack of traditional risk factors in a subset of patients with

community-acquired CDI suggests alternate novel risk factors

for CDI and newer modes of transmission in the community.

Studies have suggested that up to 94% of patients may have had

health-care exposure predisposing them to CDI.8 Potential risk

factors for community-acquired CDI include contaminated food

consumption, and personal contact (person-to-person,

environment-to-person, and potentially animal-to-person. C.

difficile strains have been identified in retail meat and meat

products, including beef, chicken and pork. Similarities have

been reported in animal feed isolates with those reported to

cause CDI in

humans.9, 10

Person-to-person

spread is important

both within and

outside hospitals.

Recently published

guidelines have

suggested that

visitors to hospital

rooms harboring CDI patients should practice the same

isolation precautions as healthcare personnel.11 Additionally,

there is a potential for increased exposure to colonized or

infected persons in the community, such as health care workers,

and studies have shown that family members of patients with

recent infection have a higher risk of CDI.12 Infants and

children may be asymptomatically colonized with C. difficile,

and exposure to a colonized infant may be a risk factor for

recurrent CDI in mothers in the post-natal period.

Environmental contamination has been found in daycare

centers, and up to one-third of households and half of water and

swimming pool samples may be contaminated with C.

difficile.12 In these settings, strict hand hygiene precautions with

soap and water (not alcohol-based hand rubs) is the cornerstone

to the prevention of CDI.3, 11

As the incidence of community-acquired CDI increases, CDI

should be considered in all outpatients with acute diarrhea, even

in the absence of traditional risk factors such as hospitalization

or antibiotic exposure. A majority of patients, however, have

some form of healthcare exposure, which suggests that

outpatient and emergency room visits may also place patients at

a higher risk for CDI. Additionally, community-acquired CDI

may have serious consequences. Given the additional risks and

costs associated with hospitalization, physicians should be

aware of risk factors (increasing age, comorbid conditions and

disease severity) that predict the need for hospitalization.

Patients with community-acquired CDI should be managed

aggressively, with close clinical follow-up to prevent adverse

outcomes.6

References

1. Khanna S, Pardi DS. Clostridium difficile Infection: New Insights

Into Management. Mayo Clin Proc 2012; 87: 1106-1117.

2. Khanna S, Pardi DS. The growing incidence and severity of

Clostridium difficile infection in inpatient and outpatient settings.

Expert Rev Gastroenterol Hepatol 2010; 4: 409-416.

3. Cohen SH, Gerding DN, Johnson

S, et al. Clinical practice guidelines for

Clostridium difficile infection in adults:

2010 update by the Society for

Healthcare Epidemiology of America

(SHEA) and the Infectious Diseases

Society of America (IDSA). Infect

Control Hosp Epidemiol 2010; 31: 431-

455.

4. Centers for Disease Control and

Prevention. Severe Clostridium difficile-

associated disease in populations

previously at low risk--four states, 2005.

MMWR 2005; 54: 1201-1205.

5. Khanna S, Pardi DS, Aronson SL, et al. The Epidemiology of

Community-Acquired Clostridium difficile Infection: A

Population-Based Study. Am J Gastroenterol 2012; 107: 89-95.

6. Khanna S, Pardi DS, Aronson SL, Kammer PP, Baddour LM.

Outcomes in community-acquired Clostridium difficile infection.

Aliment Pharmacol Ther 2012; 35: 613-618.

7. Khanna S, Baddour LM, Huskins WC, et al. The Epidemiology of

Clostridium difficile Infection in Children: A Population-based

Study. Clin Infect Dis 2013; 56: 1401-1406.

8. Centers for Disease Control and Prevention. Vital signs:

preventing Clostridium difficile infections. MMWR 2012; 61: 157-

162.

9. Jhung MA, Thompson AD, Killgore GE, et al. Toxinotype V

Clostridium difficile in humans and food animals. Emerg Infect

Dis 2008; 14: 1039-1045.

10. Weese JS, Reid-Smith RJ, Avery BP, Rousseau J. Detection and

characterization of Clostridium difficile in retail chicken. Lett

Appl Microbiol 2010; 50: 362-365.

11. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for

diagnosis, treatment, and prevention of Clostridium difficile

infections. Am J Gastroenterol 2013; 108: 478-498; quiz 499.

12. Otten AM, Reid-Smith RJ, Fazil A, Weese JS. Disease

transmission model for community-associated Clostridium

difficile infection. Epidemiol Infect 2010; 138: 907-914.

14 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Khanna

“As the incidence of community-acquired CDI

increases, CDI should be considered in all out-

patients with acute diarrhea, even in the

absence of traditional risk factors such as

hospitalization or antibiotic exposure.”

Plasmids believed to be responsible for the dissemination of

ESBLs are largely members of the IncF replicon/

incompatibility group6 and parallels the pattern observed

worldwide for CTX-M-15-carrying plasmids,7-9 as well as the

spread of plasmid-mediated ampC genes (blaCMY and

blaDHA).10,11 Nigerian ampC strains demonstrate low-level re-

sistance to third-generation cephalosporins, but are associated

with high-level resistance to quinolones. The blaCTX-M genes

are associated with plasmids that also carry other resistance

genes: the tet(A) gene, aminoglycoside resistance genes (aac

(3)II and aac(6’)-Ib4),

and PMQR (plasmid-

mediated quinolone re-

sistance qnr genes, aac

(6’)-Ib-cr), and the efflux

pump gene, qepA.1

Carbapenems have re-

cently been introduced to

patient management in

Nigeria, but are rarely used by physicians, due largely to high

cost. We previously (in 2009) found extremely high levels of

resistance to all antibiotics tested and the presence of numerous

mobile genetic elements carrying resistance to ß-lactams.6

While the focus of the study was on ESBL resistance, we did

identify potential carbapenem resistance, indicating a reservoir

of carbapenem-resistant strains. Most recently, we have found

high-level carbapenemase production in gram-negative clinical

isolates, with carriage of various known carbapenemases and

potential for variants of existing carbapenemases or unknown

carbapenemase (submitted). It is surprising that such a number

of highly carbapenem-resistant isolates were observed, of

which more than half were carbapenemase-producers and pan-

drug resistant.

ESBLs have been detected not only in clinical isolates, but also

in commensal bacteria from humans and animals in Nigeria

and in isolates from products of the food chain and sewage,

demonstrating a variety of sources and reservoirs for these re-

APUA Field Report: Nigeria • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 15

The distribution and epidemiology of extended-spectrum beta-

lactamases (ESBLs) in various pathogens have been intensively

studied in developed countries, but data are extremely limited

from sub-Saharan Africa, including Nigeria. Antibiotic use in

Nigeria is unregulated; there are no regional or national surveil-

lance data on bacterial resistance to antibiotics, and only a few

localized institutional studies have reported the prevalence or

level of antibiotic resistance, particularly to β-lactams. In Nige-

ria, extended-spectrum cephalosporins and fluoroquinolones

are widely used as broad-spectrum antibiotics and remain the

drugs of choice to treat

infections caused by var-

ious gram-negative path-

ogens.1 Gram-negative

bacteria cause a signifi-

cant number of infections

in Nigerian hospitals and

represent the majority of

both wound and urinary

isolates, which form the

largest group of clinical specimens received in microbiology

laboratories.

A diversity of ESBL enzymes have evolved and been detected

in gram-negative pathogens over the last 30 years, with the

CTX-M group becoming the dominant ESBL identified world-

wide.2 In Nigeria, Aibinu et al.3 reported 20% carriage of

ESBLs in Enterobacter species in the capitol, Lagos—a rate

similar to that found in gram-negatives from four teaching hos-

pitals of the southwest region.1 The predominant ESBL geno-

type detected is CTX-M-15.4,5 CTX-M-3 was also reported in

2011 with TEM, SHV and OXA variants. Plasmidic or chro-

mosomal ampC genes (ACT-1, DHA-1 and CMY-2) have also

been identified, co-existing with ESBL genes such as CTX-M-

15, TEM-1, SHV-1 and OXA-1.1 Additionally, other plasmid-

mediated β-lactamases (VEB-1, OXA-10) have been found in

Providencia species, although they are believed to be less com-

mon.12 It remains to be seen whether they are of clinical signif-

icance in other genera of Enterobacteriaceae.

Impact of ESBLs and CREs—the

Nigerian Experience

David Olusoga Ogbolu, PhD, FMLSCN Ladoke Akintola University of Technology, Ogbomosho, Nigeria

“There is high-level resistance to many antimicrobials,

including cephalosporins and carbapenems, among

Enterobacteriaceae in Nigeria. This has led to

increased and widespread use of reserved antibiotics

such as carbapenems, with consequent ineffectiveness

and escalation to pan-drug resistance.”

7. Coque TM, Novias A, Carattoli A, Poirel L, Pitout J, Peixe L,

Baquero F, Canton R, Nordmann P. Dissemination of clonally

related Escherichia coli strains expressing extended-spectrum β-

lactamase CTX-M-15. Emerging Infectious Diseases 2008; 14:

195-200.

8. Marcade G, Deschamps C, Boyd A, Gautier V, Picard B, Branger

C, Denamur E, Arlet G. Replicon typing of plasmids in Esche-

richia coli producing extended-spectrum β-lactamases. J Antimi-

crob Chemother 2009; 63: 67-71.

9. Villa L, Garcia-Fernandez A, Fortini D, Carattoli A. Replicon

sequence typing of IncF plasmids carrying virulence and re-

sistance determinants. J Antimicrob Chemother 2010; 65: 2518-

2529.

10. Leflon-Guibout V, Blanco J, Amaqdouf K, Mora A, Guize L,

Nicolas-Chanoine M-H. Absence of CTX-M enzymes but a high

prevalence of clones, including clone ST131, among the faecal

Escherichia coli isolates of healthy subjects living in the Paris

area. J Clin Microbiol 2008; 46: 3900-3905.

11. Carattoli A. Resistance plasmid families in Enterobacteriaceae.

Antimicrob Agents Chemother 2009; 53: 2227-2238.

12. Aibinu I, Pfeifer Y, Ogunsola F, Odugbemi T, Koenig W, Ghe-

bremedhin B. Emergence of beta-lactamases OXA-10, VEB-1

and CMY in Providencia spp. from Nigeria. J Antimicrob

Chemother 2011; 66: 1931–1932.

13. Ogbolu D. Olusoga, Alli OA Terry, Olanipekun LB, Ojo OI,

Makinde OO. Faecal carriage of extended-spectrum beta-

lactamase (ESBL)-producing commensal Klebsiella pneumoniae

and Escherichia coli from hospital out-patients in southern Nige-

ria. Int J Med Med Sci 2013; 5(3): 97-105.

14. Fortini D, Fashae K, Garcia-Fernandez A, Villa L, Carattoli A.

Plasmid-mediated quinolone resistance and ß-lactamases in Esch-

erichia coli from healthy animals from Nigeria. J Antimicrob

Chemother 2011; 66: 1269-1272.

16 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Ogbolu

sistance determinants. In humans, carriage of ESBL genes in

fecal isolates of commensal E. coli and Klebsiella species in

out-patients revealed carriage of blaCTX-M-15, blaCTX-M-2, blaOXA-

1, blaTEM-1 and bla SHV-1, including non-chromosomal AmpC

enzymes. These blaampC genes were found in isolates carrying

other ESBL genes, as commonly reported in bacterial patho-

gens.13 Similarly, ampicillin-resistant commensal E. coli iso-

lated from healthy chickens and pigs have been found to har-

bour blaTEM and blaCTX-M-15 genes.14 These ESBL-producing

bacteria can enter the human food chain through the consump-

tion of meat or by direct contact, colonizing the human gut.

In conclusion, there is a diversity of beta-lactamases and high-

level resistance to many antimicrobials, including cephalospor-

ins and carbapenems among Enterobacteriaceae in Nigeria.

This has led to increased and widespread use of reserved anti-

biotics such as carbapenems, with consequent ineffectiveness

and escalation to pan-drug resistance. The uncontrolled use of

antibiotics in Nigeria is likely to have contributed largely to

this situation. In an era of frequent global travel, the selection

of highly resistant isolates in countries such as Nigeria, where ß

-lactamases are not routinely identified, may elicit a reservoir

of resistant strains with high mobility for export to other coun-

tries.

References

1. Ogbolu DO, Daini OA, Ogunledun A, Alli AO and Webber MA.

High levels of multidrug resistance in clinical isolates of Gram-

negative pathogens from Nigeria. Int J Antimicrob Agents 2011;

37: 62-66.

2. Livermore D, Canton R, Gniadkowski M et al. CTX-M: changing

the face of ESBLs in Europe. J Antimicrob Chemother 2007; 59:

165–174.

3. Aibinu IE, Ohaegbulam VC, Adenipekun EA, Ogunsola FT,

Odugbemi TO, Mee BJ. Extended-spectrum beta-lactamase en-

zymes in clinical isolates of Enterobacter species from Lagos,

Nigeria. J Clin Microbiol 2003; 41: 2197-2200.

4. Soge OO, Queenan AM, Ojo KK, Adeniyi BA, Roberts MC.

CTX-M-15 extended-spectrum beta-lactamase from Nigerian

Klebsiella pneumoniae. J Antimicrob Chemother 2006; 57: 24-

30.

5. Olowe OA, Grobbel M, Buchter B, Lubke-Becker A, fruth A,

Wieler LU. Detection of bla CTX-M-15 extended-spectrum β-

lactamase genes in Escherichia coli from hospital patients in

Nigeria. Int J Antimicrob Agents 2010; 35: 200–209.

6. Ogbolu DO, Daini OA, Ogunledun A et al. Dissemination of

IncF plasmids carrying beta-lactamase genes in Gram-negative

bacteria from Nigerian hospitals. J Infect Dev Ctries 2013; 7(5):

382-390.

ESBL-producing Enterobacteriaceae

in Bulgaria – a short overview

Rumyana Markovska, APUA-Bulgaria Medical University—Sofia, Bulgaria

Emma Keuleyan, APUA-Bulgaria Medical Institute—Ministry of the Interior

Since the first report of an ESBL-producing microorganism in

Bulgaria in 1992,1 the national data tracking system

(BulSTAR) has recorded increases from 1 - 5.7% for ESBL-

producing Escherichia coli and from 5 - 22.5% for ESBL-

producing Klebsiella pneumoniae (2001-2010).2 These rates

are lower than those for Bulgaria in the European

Antimicrobial Resistance Surveillance System (EARSS) which

reported increases from 7 - 22.9% in E. coli (mostly from

bacteremia resistant to oxyimino-cephalosporins; 2001-2011)

and from 50 - 81% (also invasive isolates; 2005-2011) in K.

pneumoniae.3, 4 Early studies among different enterobacteria

between 1994 and 1999 at the National Cancer Centre reported

ESBL production at 4.4% and detected enzymes of the SHV

and TEM families.5

The APUA-funded small grants program project on

Antimicrobial Resistance Surveillance (1999–2000) confirmed

an emerging problem.6 Beta-lactamases TEM-3, SHV-5, SHV-

12 were detected among nosocomial strains of K. pneumoniae

isolated in 1999 in Military Medical Academy.7 The wide

investigation of 451 different enterobacteria (K. pneumoniae,

E. coli, Enterobacter spp., Serratia marcescens, Citrobacter

freundii, K. oxytoca, Salmonella enterica serotype Corvallis 1)

conducted between 1997 and 2003 has shown a similar

distribution.8 Until 2000, only SHV- and TEM- ESBLs were

detected, with TEM-139 being reported for the first time

globally. It was limited mainly to one city (Pleven) and one

species (K. pneumoniae).8,9 SHV enzymes detected included

SHV-2, -5, and -12. They were found in all centers through the

entire investigation period.8 The first CTX-M enzyme found in

Bulgaria was CTX-M-15, isolated in 2001 (shortly after its first

report in India).10 CTX-M-3 was also detected for the first time

in Bulgaria in 2002.11 CTX-M frequency subsequently

increased to 65% by the end of the investigation period.8 A

novel CTX-M enzyme, CTX-M-71, was first detected in

Bulgaria in 2003.12

The increased rates of ESBL-producing isolates in Bulgaria are

most probably due to the distribution of a few specific clones

or plasmids. Various studies have found a few primary clones:

K. pneumoniae with SHV-12 or CTX-M-3; E.coli with CTX-M

-15; and S. marcescens with CTX-M-3.13-15 Further

investigation demonstrated country-wide dissemination of a

highly resistant B2 O25b-ST131 CTX-M-1- producing E. coli

clone in Bulgaria, representing 68% of all ESBL-producing E.

coli isolates. Almost all O25b-ST131 E. coli produced CTX-M

-15 (96%).13 The important role of horizontal transfer of

plasmids, carrying blaESBL, predominantly blaCTX-M-3, has been

shown as well.8, 16

In conclusion, the wide spread of ESBLs in Bulgaria is

extremely worrying and suggests a need for more prudent

antibiotic prescription, (e.g. limitation of 3rd generation

cephalosporins) and stricter infection control. It is becoming

obvious that the problem of ESBL-producing

Enterobacteriaceae cannot be resolved without the intervention

of strict government controls and the external assistance of

international societies/communities.

References:

1. Keuleyan E, Kaludova V, Marinova R. Comparative

susceptibility to β-lactams and spectra of β-lactamases in clinical

Enterobacteriaceae strains. 4th Biennial Conference on

Chemotherapy of Infectious Diseases and Malignancies, Prague,

Czechoslovakia. 1992. Program and Abstracts, Abstr 217.

2. Velinov Tz, Todorova B, Kantardjiev T. Surveillance of

antimicrobial resistance in infections of hospitalized patients in

Bulgaria: Bulgarian Surveillance Tracking Antimicrobial

Resistance (BulSTAR) 2010. Nosocomial infections. 2011, 1-2:

50-57 (in Bulgarian)

3. EARSS-Net Annual Reports 2008. ECDC /www.ecdc.europa.eu/

en/activities/surveillance/EARS-et/

Documents/2008_EARSS_Annual_Report.pdf/

APUA Field Report: Bulgaria • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 17

R. Markovska E. Keuleyan

4. EARSS-Net Annual Reports 2009-2011. ECDC (http://

www.ecdc.europa.eu/en/healthtopics/antimicrobial

epidemiological_data/Pages/ears-net_annual_reports.aspx).

5. Sabtcheva S. Phenotypic and genotypic characterization of

extended spectrum beta-lactamases with extended spectrum

among Enterobacteriaceae, isolated from cancer patients. PhD

thesis - Sofia, 2003.

6. Keuleyan E, Sredkova M, Ivanova D, Haydoushka I, Markovska

R, Hadjieva N, Strateva T, Mitov I. ESBLs producing

Enterobacteriaceae from APUA Bulgaria Chapter survey. 11th

ECCMID (European Congress of Clinical Microbiology and

Infectious Diseases), Istanbul, Turkey. Clin Microbiol Infect, 7,

2001.Suppl 1, Astr P1343/ p 286.

7. Jacoby G, Vacheva-Dobrevsky R. Epidemiology of Extended

Spectrum Beta-Lactamases in Sofia, Bulgaria. Eur J Clin

Microbiol Infect Dis 2003; 22: 385-388.

8. Markovska R, Schneider I, Keuleyan E, Sredkova M, Ivanova D,

Markova B, Lazarova G, Dragigeva E, Savov E, Haydouchka I,

Hadjieva N, Setchanova L, Mitov I, Bauernfeind A. Extended-

spectrum beta-lactamase-producing Enterobacteriaceae in

Bulgarian hospitals. Microbiol Drug Resist. 2008. 14, 2: 119-28.

9. Schneider I, Markovska R, Keuleyan E, Sredkova M, Rachkova

K, Mitov I, Bauernfeind A. Dissemination and persistence of a

plasmid-mediated TEM-3-like beta-lactamase, TEM-139, among

Enterobacteriaceae in Bulgaria. Int J Antimicrob Agents. 2007;

29 (6): 710-714.

10. Markovska, R., Schneider, I., Keuleyan, E., and Bauernfeind, A.

Extended spectrum beta-lactamase( ESBL) CTX-M-15 producing

E. coli and K. pneumoniae in Sofia, Bulgaria , Clinical

Microbiolody Infection. 2004. 8, 752- 755.

11. Markovska R, Keuleyan E, Schneider I, Markova B, Rachkova

K, Sredkova M, and Bauernfeind A. CTX-M-3 Extended

Spectrum Beta-Lactamase producing K. pneumoniae and

dissemination of the plasmidic blaCTX-M-3 in Bulgaria. Eur. J. Clin.

Microbiol. Infect. Dis. 2006. 25; 123-125.

12. Schneider I, Qeenan AM, Markovska R, Markova B, Keuleyan

E, Bauernfeind A. New Variant of CTX-M-Type Extended-

Spectrum β-Lactamases, CTX-M-71, with Gly238Cys

Substitution in a Klebsiella pneumoniae Isolate from Bulgaria.

Antimicrob Agents Chemother. 2009, 53,10:4518-4521.

13. Markovska R, I Schneider, D Ivanova, E Keuleyan, T Stoeva, M

Sredkova, B Markova, K Bojkova, R Gergova, A Bauernfeind, I

Mitov. High prevalence of CTX-M-15-producing O25b-ST131

Escherichia coli clone in Bulgarian hospitals. Microb Drug

Resist; 2012. 18 (4):390-5.

14. Ivanova D, Markovska R, Hadjieva N, Schneider I, Mitov I ,

Bauernfeind A.Extended-spectrum b-lactamase-producing

Serratia marcescens outbreak in a Bulgarian hospital. J Hosp.

Infect. 2008; 70: 60-65.

15. Ivanova D., R. Markovska, B. Markova, M. Leseva, N. Hadjieva,

E. Zamfirova, Y. Marteva-Proevska, I. Mitov . Complex

molecular epidemiology of ESBL-producing Klebsiella

pneumoniae: long-term persistence and spread of epidemic

clones among Bulgarian hospitals. 22th European Congress of

Clinical Microbiology and Infectious Diseases London UK.

31.03 – 3.04.2012. P 1872.

16. Sabtcheva S, Saga T, Kantardjiev T, Ivanova M, Ishii Y, Kaku

M. Nosocomial spread of armA-mediated high-level

aminoglycoside resistance in Enterobacteriaceae isolates

producing CTX-M-3 beta-lactamase in a cancer hospital in

Bulgaria. J Chemother. 2008. 20 (5):593-9.

18 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Markovska & Keuleyan

September 10-13, 2013: Interscience Conf. on

Antimicrobial Agents and Chemotherapy (ICAAC

2013), Denver, CO, USA.

September 28, 2013: MRSA Survivors' Network

hosts (5th Annual World MRSA Day Kickoff Event and

the Global MRSA & C. diff Summit), Chjcago, IL, USA.

October 2-6, 2013: Infectious Diseases Society of

America (IDSA), the Society for Healthcare Epi-

demiology of America (SHEA), the HIV Medicine

Association (HIVMA), and the Pediatric Infectious

Diseases Society (PIDS)'s IDWeek 2013, San Francisco,

CA.

November 18-24, 2013: CDC Hosts Get Smart

About Antibiotics Week, Online.

November 19-22, 2013: International Conference on

Infectious Disease Dynamics (EPIDEMICS 2013),

Amsterdam, Netherlands.

December 9-13: RIPAQS-INPIQS hosts its 1st

International Congress.

APUA will host a Learning Lab on Thursday, October 3rd

from 12:15pm to 1pm at ID Week, entitled, “Antibiotic

stewardship and the role of diagnostics: barriers and

opportunities.”

Upcoming Events

For instance, a surgical site infection study in one of the local

district hospitals was successfully completed recently.

Interventions done through continuous medical education on

rational use of antibiotics for surgical prophylaxis showed a

decrease in antibiotic consumption and eventual rational use of

antibiotics through the development of an antibiotic use policy

within the hospital. Currently, this study is being replicated in

two other hospitals by members of the working group, with the

aim of rationalizing antibiotic use in surgical procedures. In

addition, the working group is in the process of developing an

exciting 5-day training course on AMR and rational antibiotic

use targeting both human and veterinary medicine practitioners

from different regions in the country who will then serve as

“AMR champions” countrywide.

In the course of its activities, the working group has learned a

number of lessons, including the following:

Global problems are best tackled through national action

Both underuse and overuse of antibiotics co-exist.

Underuse of antibiotics leads to childhood deaths from

common infectious diseases, while overuse is propagated

mostly by hospitals and through self-treatment.

The need for antibiotics can be reduced through coverage

by childhood immunization programs (e.g. Hib and the

newly introduced pneumococcal vaccines) and improved

hospital infection control.

Inappropriate antibiotic use can be reduced through the

following three ways: reducing provider and self-

prescribing for coughs and colds; reducing use for watery

diarrhea; and reducing use in food animals.

APUA-Kenya’s antimicrobial

stewardship program

Sam Kariuki, PhD, APUA-Kenya Chapter Leader Kenya Medical Research Institute, Nairobi, Kenya

Kenya is challenged with increasing rates of antimicrobial

resistance (AMR), which can be attributed to a multiplicity of

factors, including a high infectious disease burden. Acute

respiratory infections, diarrheal diseases and HIV/AIDS are

among the leading causes of mortality. HIV/AIDS has

predisposed infected individuals to an undue increase in the

utilization of antibiotics in order to prevent and treat

opportunistic infections—raising concerns over the looming

emergence and spread of resistance to commonly available

antibiotics. Other factors include inadequate diagnostic capacity

and a large rural dwelling population (70%) with limited access

to formal healthcare services. The latter is demonstrated by the

prevalence of self-medication and inadequate knowledge of

appropriate antibiotic use in both healthcare providers and the

general population.

A recent situation analysis cites 2002, 2008 and 2009 reports

that most pharmacies dispensed antibiotics without

prescriptions. It also documents that most doctors and other

healthcare professionals wrote prescriptions for antibiotics

inappropriately—for common coughs, colds and diarrhea.

Many, perhaps most, of those who self-prescribe would have

been prescribed antibiotics officially if they had visited a

doctor or clinic. There is good evidence that many patients

simply have no option but self-medication as they may have no

access to healthcare for financial reasons or because an

appropriate health facility is physically inaccessible, or

antibiotic supplies are depleted. Another challenge for Kenya

is posed by the widespread use of antibiotics in animals for

prophylaxis and treatment, especially in poultry farming in the

neighborhoods of big cities.

It is a complex situation, but the Antimicrobial Resistance

Working Group established in 2011—with a membership of 20

and with representation from different stakeholders in the

Ministry of Health, non-governmental organizations, and

private sector healthcare providers—is volunteering its time to

mobilize resources to fight AMR. One of its objectives is to fill

information gaps with regard to the rational use of antibiotics.

APUA Field report: Kenya • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 19

susceptibility (98.57%), followed by imipenem (85.94%).

PFGE and Quantitative Antibiotic Testing both revealed the

presence of 2 clusters. Phenotypic tests for MBL and AmpC

production were negative. The 4 strains of A. baumannii (2

each from 2011 and 2012) selected for SDS-PAGE analysis

revealed no difference in the OMP profile. An efflux pump for

imipenem was not detected in any isolate (all CCCP negative);

however, all 8 strains isolated in 2011 and 2012 revealed

positive results for the oxacillinase phenotype test. The PCR

performed for blaOXA-23-like and blaOXA-24-like genes gave

negative results, while all 8 strains gave positive results for

blaOXA-51 and blaOXA-58 genes.

Conclusion

Determining the mechanism of resistance to imipenem in A.

baumannii and the number of circulating epidemic strains helps

to understand how the resistance is spreading and emphasizes

the need for having infection control and antimicrobial

stewardship programs in hospitals.

Objective

This study aimed to determine the relatedness of Acinetobacter

baumannii strains collected from the north of Lebanon and to

identify their mechanism(s) of resistance to imipenem.

Acinetobacter baumannii causes opportunistic nosocomial

infections, mainly in intensive care units. In addition to its

natural resistance, acquired resistance to many antibiotics can

occur. As a result, carbapenems have become the drug of

choice in treating such resistant strains. Unfortunately,

resistance to imipenem has been reported in several countries

since 1990.

Methods

A total of 149 non-duplicate strains of A. baumannii (identified

by API 20NE) were isolated and analyzed between 2006 and

2012 from different types of infections in hospitalized patients.

Their profile of resistance was determined using the Kirby-

Bauer disk diffusion method, in which the diameters of

inhibition were measured and used for Quantitative

Antibiogram Typing. Typing was also performed using ST

typing by multiplex PCR and PFGE.

For the detection of the mechanisms

of resistance, phenotypic methods

were used: DDST IMP-EDTA for

MBL detection, 200mM NaCl for

OXA detection, 200mg/l cloxacillin

and PBA for AmpC detection, and

noital carbonyl-cyanide m-chloro

phenylhydrazone as efflux inhibitor.

In addition, PCR was used to detect

the genes of resistance and SDS-

PAGE was performed to study the

protein profiles of resistant versus

susceptible strains.

Results

Forty-five percent of the isolates

were collected from the Intensive

Care Unit and 58% of the specimens

were from the sputum. Colistin was

associated with the highest

20 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • APUA Field report: Lebanon

Acinetobacter baumannii epidemiology

and resistance in north Lebanon Ziad Daoud, PhD, APUA-Lebanon Chapter Leader University of Balamand; CHN Hospital, Deir El-Balamand, Al-Kurah, North Lebanon

State and national responses to CRE & ESBL alarms

U.S. CDC to publish comprehensive report

on antibiotic-resistant bacteria

The U.S. CDC is releasing a full scientific report on antibiotic

resistant organisms on September 16th, 2013. The report is the

first of its kind, covering 18 specific organisms and the

problems they each pose as they increasingly become resistant

to available antibiotics.

CDC Vital Signs: Making health care safe—

“Stop infections from lethal CRE germs

now”

The CDC recently published a Vital Signs article on the

increasing prevalence of difficult-to-treat carbapenem-resistant

Enterobacteriaceae (CRE) infections among patients in

medical facilities. The fact sheet is geared towards health

providers and the public, and it describes in detail the growing

problem of CRE infections, which are resistant to all or most

antibiotics. Infections with CRE are increasing, and have now

been reported in hospitals in 42 US states. The incidence of

CREs can be reduced using comprehensive prevention

programs, and the US CDC provides guidelines that hospitals

can follow.

For a more comprehensive discussion of the Vital Signs

publication, see our feature article, “Sounding the alarm on

nightmare bacteria,” by CDC expert Dr. Arjun Srinivasan.

Colorado initiates statewide CRE surveillance

In 2011, the Colorado Department of Public Health and

Environment (CDPHE) began a major effort to better

understand the extent of carbapenem-resistant

Enterobacteriaceae (CRE) in Colorado. They began by

administering an online survey to laboratories to gather data on

CRE detection methods and statewide prevalence. CDPHE

then formed a working group of infection control experts,

physicians, pharmacists, and public health officials to

determine the next best steps and to facilitate the process of

making CRE a reportable condition in the state.

After managing a CRE outbreak in August of 2012, the state of

Colorado successfully made CRE infection a reportable

condition by November of the same year. This has led to major

improvements in CRE surveillance and outbreak detection,

which, in addition to educational support for health care

providers, now enables outbreaks to be rapidly detected and

contained.

Oregon’s statewide network to contain CRE

After conducting a needs assessment survey of acute-care

hospitals, laboratories, and long-term care facilities in Oregon,

the Oregon Health Authority (OHA) decided to develop a

comprehensive approach to combat the rising threat of CRE.

OHA created the Drug-Resistant Organism Prevention and

Coordinated Regional Epidemiology (DROP-CRE) Network to

establish statewide approaches for the prevention and control

of multi-drug resistant organisms, including CRE. The DROP-

CRE Network is currently: developing a statewide database for

resistant organisms; conducting rapid identification of CRE;

promoting CRE education; tracking CRE across the spectrum

of care; and providing real-time outbreak assistance to Oregon

facilities reporting cases of CRE. The success of these initial

goals has led to a focus on active CRE response methods and

network expansion to other states.

New UK study to assess impact of ESBL-

positive E. coli

The UK government announced last month that it is launching

a new study on in-

creasingly prevalent

extended-spectrum

beta-lactamase

(ESBL)-positive E.

coli. E. coli is the

most common bac-

terial pathogen in

the world, and it is

estimated that as

many as 80% of

urinary tract infections are caused by E. coli. Certain strains of

E. coli can produce ESBL enzymes that destroy commonly

used β-lactam antibiotics. The study will establish the most

significant reservoirs of ESBL E. coli by looking at sewage,

raw meat, and farm slurry to assess the potential risks they pose

to human health.

CRE & ESBL-related news • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 21

E. coli; Source: Wikimedia Commons.

APUA headquarters in action

APUA 2013 Leadership and Chapter Award

Recipients

APUA is pleased to award Dr. Keith

Klugman, Director for Pneumonia at the

Gates Foundation, the 2013 Leadership

Award. Keith has served on numerous

committees as an expert in antimicrobial

resistance, including those for the World

Health Organization (WHO) and the

Centers for Disease Control and Prevention

(CDC). He has published more than 450

scientific papers on the subjects of

pneumonia, meningitis, antimicrobial resistance, and vaccines

for bacterial pathogens.

The annual APUA Leadership Award recognizes an individual or

organization demonstrating extraordinary leadership in promoting the

prudent use of antibiotics in order to contain antibiotic resistance.

APUA is also pleased to announce APUA-Cuba as the winner

of the 2013 Chapter Award. APUA-Cuba has over 1,000

members in 60 different

medical specialties. Chapter

leader Dr. Moisés Morejón

(Manual Fajardo Hospital)

and his colleagues have held

multiple symposia on

antimicrobial resistance and

the need for new antibiotics.

The annual APUA Chapter Award recognizes one of 66 international

chapters affiliated with the organization for its members’ dedication

to the APUA mission of ensuring access to effective treatment and

promoting appropriate antibiotic use to contain drug resistance.

The 2013 winners will be celebrated a special event at ID

Week, October 2—6 in San Francisco, CA.

Directorship Transition at APUA

Effective October 15, Ms. Kathleen Young will be

transitioning from her position as APUA Executive Director to

a role as program consultant. According to Dr. Stuart B. Levy,

APUA President, “Through Kathy’s commitment and

initiative, APUA has played a major role in driving the drug

resistance issue to the top of the national and international

health agenda.” During her 15 year tenure, APUA expanded its

affiliated international chapter network to over 66 countries

and extended its mission to increase access to effective

antibiotics in resource-poor countries.

Ms. Young introduced important research projects to document

antibiotic resistance problems and then forged public and

private partnerships to build consensus on interventions.

Among the projects she initiated were:

the first international antibiotic resistance surveillance

meeting involving over fifteen major surveillance systems

(1997)

the first peer-reviewed study providing evidence and

detailed recommendations to limit antibiotics in food

animal production (FAAIR report 2002)

the first multi-university network investigating resistance

in commensal organisms for early warning signs for

resistance in pathogens (2002-2007)

the first report to document global antimicrobial resistance

trends in the major pathogens (GAARD report 2005)

the first detailed African country situation analysis of

antibiotic use and resistance (2008), and

an updated peer-reviewed estimate of the U.S. cost of

antibiotic resistance in over ten years, now widely cited in

policy debates (2009)

Ms. Young notes: “Fortunately, we are now seeing active

investments in antibiotic stewardship and infection control and

new treatment and diagnostics coming online. With the

continued commitment of APUA’s board and advisors and

dedicated staff in place, APUA will continue to play a

leadership role in ensuring access to effective antimicrobials

for generations to come.” With a background in biochemistry

and corporate organizational development, Dr. Barbara

Lapinskas, PhD (Barbara.lapinskas@tufts.edu), will continue

as APUA’s Administrative Director. Jane Kramer, JD, is

serving as APUA’s Program Development Director with

experience as Director of Communications for several global

pharmaceutical companies supporting programs to increase

access to medicines.

APUA cautions against use of antibiotics to

treat malnutrition

On June 20, a letter crafted by the APUA Nutrition Group was

22 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • APUA headquarters

Keith Klugman,

MD, PhD

APUA invites its chapter organizations and any

interested readers to submit commentary on their

opinions and observations regarding the use of

antibiotics to treat malnourished children in their

countries.

APUA headquarters in action

APUA headquarters • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 23

APUA’s ID Week Learning Lab Antibiotic Stewardship and the Role of Diagnostics: Barriers and Opportunities

Thursday, October 3, 2013; 12:15 pm – 1:00 pm; Booth 1501

Agenda (12:15-12:45pm)

1. The mandate for stewardship: antibiotic resistance trends and costs

2. Benefits of hospital antibiotic resistance susceptibility testing in targeting therapy

3. Diagnostics and their role in antibiotic stewardship

Group Discussion: (12:45-1:00pm)

What are the barriers to greater use of susceptibility testing?

What would increase the value of diagnostics for clinicians? (sensitivity? specificity?)

What incentives would promote use of diagnostics and stewardship programs?

Presenters:

Stuart B. Levy, M.D. Co-founder and President of the Alliance for the Prudent Use of Antibiotics (APUA). Distinguished Professor of Molecular

Biology and Microbiology, and of Medicine, Director of the Center for Adaptation Genetics and Drug Resistance, Tufts

University School of Medicine; Staff Physician, Tufts Medical Center, Boston, MA

Kavita K. Trivedi, M.D. Public Health Medical Officer of Healthcare Associated Infections Program at the Center for Health Care Quality, California

Department of Public Health. Dr. Trivedi leads the California Antimicrobial Stewardship Initiative and is a former Epidemic

Intelligence Service Officer with the CDC.

Learning Lab Summary:

Antibiotic stewardship experts, Levy and Trivedi will review and lead an open discussion on current drug resistance trends, antibiotic

stewardship practices, and new resources available to control antibiotic resistance. APUA is an international public health organization

conducting research and education in conjunction with affiliated chapters in 66 countries (www.apua.org).

published in the New England Journal of Medicine. The letter,

which cautioned against the use of antibiotics to treat

malnutrition in resource-limited settings, was a response to an

earlier article by researchers at the University of Washington in

St. Louis who tested antibiotic treatment of severely

malnourished Malawi children in a clinical trial. The authors

claim that recovery rates were higher and mortality rates were

lower among children who received antibiotics than among

those who received placebo as part of their outpatient treatment

with ready-to-use therapeutic foods (RUTFs).

APUA compiled expert opinion from its Scientific Advisory

Board, including co-authors Iruka Okeke, Jose Ramiro Cruz,

and Gerald Keusch, in order to formulate an editorial in

response to the suggested implementation of routine antibiotics

for severe malnutrition. APUA supports further research

because the potential broad-scale expansion of antibiotic use

could prompt widespread antibiotic misuse and resistance in

the community. Instead, researchers should focus on immediate

expansion of validated interventions, including breast-feeding,

the use of probiotics, and increased access to traditional RUTFs

and clean water. These strategies will be more effective in

reducing malnutrition in the long run.

APUA collaborates with Alere to produce

webinar

As part of an ongoing partnership, APUA and Alere

Diagnostics held the first of three live webinars on July 2nd.

Dr. Philip Carling, Professor of Clinical Medicine at Boston

University School of Medicine, hosted the webinar on the

impact of antimicrobial stewardship in healthcare settings.

With over 500 attendees, the webinar discussed the elements of

successful antimicrobial stewardship, how to analyze and

measure antibacterial use in hospitals, and the importance of

rapid diagnostics to ensure appropriate antimicrobial use.

The full webinar recording and slides can be accessed here.

German parliament proposes strict

measures to cut antibiotic use

Germany’s Parliament, The Bundestag, has made major

revisions to its policies on the use of medications for livestock.

The Ministry for Food, Agriculture and Consumer Protection

announced in March that the use of antibiotics in food animal

production needs to be significantly reduced, and ideally,

strictly limited to therapeutic purposes. The policy will give

regional authorities greater power over the exchange of

information between regions thanks to a new national database

of antibiotic use on farms. Authorities, as well as farmers, will

be able to compare the frequency of antibiotic therapy between

farms across the country. Farmers and veterinarians will bear

the responsibility of monitoring the frequency of medication

and enacting measures to reduce antibiotic use if appropriate.

FY14 Global Health Appropriations

In the last week of July, the House Appropriations Committee

approved its FY 2014 State/Foreign Operations spending bill,

allocating $40.6 billion in discretionary funding—a 19%

decrease from FY 2013. While eliminating spending for certain

international organizations, the House bill does provide

generous funding to various key global health programs,

including $6 billion to the President’s Emergency Plan For

AIDS Relief, and hundreds of millions of dollars each to

tuberculosis, malaria, maternal and child health, and nutrition

programs. Meanwhile, the Senate Appropriations Committee

passed its FY 2014 bill which sets overall spending at $50.5

billion and provides much more for foreign assistance than the

House. It appears most likely that committee staff on both

sides of the Capitol will have to work to bridge the major gaps

between the two bills.

India poised for National Antibiotics Policy

The Union Health Ministry of India is considering a new

National Antibiotics Policy to restrain the overuse of

antibiotics and reduce an already alarming rate of resistance. A

policy was drawn up in 2011 following the release of Timothy

Walsh’s article in The Lancet which detailed the emergence of

a new enzyme—named New Delhi Metallo-1 (NDM-1) after

the city it was discovered in—that made bacteria resistant to all

antibiotics. The policy was ultimately scrapped, but as

antibiotic resistance has only increased, policy makers are re-

examining options to limit antibiotic use. The Chennai

Declaration, an August 2012 event that convened specialists to

form a plan for tackling antimicrobial resistance in India, is

believed to have reignited Indian stakeholders’ calls for

change.

FDA requires veterinary oversight for

livestock antibiotics

The U.S. Food and Drug Administration (FDA) is

implementing a new strategy to encourage more appropriate

and prudent use of antibiotics in food animal production. The

strategy intends to curb antibiotic overuse and misuse by

identifying certain antibiotics that will now require veterinary

oversight via the Veterinary Feed Directive (VFD). The FDA

will also help drug companies voluntarily re-label antibiotic

products to remove feed efficiency and growth promotion

claims. Labels will instead emphasize antibiotic use for the

prevention, control, and treatment of bacterial diseases.

Michelle Arnold, a veterinarian from the University of

Kentucky College of Agriculture, Food, and Environment,

approved of the FDA’s program, stating that “veterinarians are

uniquely qualified to determine which specific disease-causing

organisms are likely to be present and to determine

appropriately timed administration of medication relative to the

disease.”

In July, APUA, along with multiple other national health

organizations, signed a letter submitted to the FDA and the US

Department of Agriculture (USDA) commenting on their

proposed changes to the VFD. While the changes would keep

certain over-the-counter drugs under closer supervision by

veterinarians, they would alter the definition of the veterinary

client patient relationship (VCPR) in a way that allows a

veterinarian’s practice to issue a VFD without requiring a visit

to each facility. The letter states support for the FDA and

USDA to retain the current, stricter VCPR definition. The letter

also recommends that language be included to define a limit of

21 days for the duration of use of an antibiotic in a herd, pen or

barn.

Policy updates

24 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Policy updates

Triclosan alters stream bacteria—leads to

resistance

Evidence continues to mount regarding the toxic nature of

triclosan, an antibacterial incorporated into a host of

commercial products, including soap, toothpaste, fabrics,

deodorants, cosmetics, toys, and plastics. Antibacterial

chemicals such as triclosan enter waterways mostly via

household wastewater and combined sewer overflows.

Triclosan has been accumulating in the environment, causing

growing concern over potential ecologic effects. In a recent

study of both field surveys and artificial stream experiments,

researchers noted marked declines in diversity among sediment

bacteria, shifts in community

composition (notably, increases in

cyanobacteria), and a marked die-off

of algae. In artificial stream

experiments, the proportion of

triclosan-resistant bacteria reached a

maximum of 14% over the course of

the 5-week study. This is the first

report of evidence for a link between

triclosan exposure and bacterial

resistance in environmentally

relevant field conditions.

Ocean mud yields new

antibiotic effective against

anthrax

Researchers from the University of

California, San Diego along with biopharmaceutical company

Trius Therapeutics, recently discovered a novel antibiotic

compound that exists in the mud along the coast of Santa

Barbara, CA. The new antibacterial, derived from a species of

Streptomyces and named “anthracimycin,” has been successful

at destroying anthrax and bears potential for treatment of other

gram-positive pathogens such as Staphylococcus aureus

(MRSA), enterococci and streptococci. A chlorinated

derivative also demonstrates activity against some gram-

negative bacteria.

CDDEP showcases new ResistanceMap The Center for Disease Dynamics, Economics & Policy

(CDDEP) has created a fascinating and useful array of

interactive tools called ResistanceMap that explore antibiotic

use and bacterial resistance in North America and Europe (Fig.

1). The maps allow comparison of antibiotic use and resistance

across different geographic areas over time.

Synthetic stool will enable treatment of

stubborn C. difficile infections

Researchers are now creating synthetic feces using “Robogut,”

a mechanical device that mimics the conditions of the human

colon. The synthetic stool, which consists of 33 different types

of bacteria, will be used to treat patients infected with

Clostridium difficile, the bacterium that causes serious bouts of

diarrhea and is increasingly resistant to antibiotic treatment. A

recent report in Microbiome found that the synthetic stool

successfully cured the infections in two study patients, who

had previously failed standard antibiotic therapy.

Study quantifies antibiotic resistance on

Chinese swine farms

Recent research published in the Proceedings of the National

Academy of Sciences quantifies for the first time the amount of

bacterial resistance on swine farms in China. The study found

149 unique resistance genes at just three large swine farms in

China. Quantified, scientific evidence of such high resistance

levels increases cause for alarm over the growing international

issue of antibiotic resistance. China uses four times more

antibiotics for veterinary purposes than the United States.

News and publications of note

News and publications • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 25

Figure 1. Sample data from ResistanceMap: Carbapenem-

resistant A. baumannii*

* % resistant by US region

Source: http://www.cddep.org/map

News and publications of note

Within the scope of the natural environment is antibiotic

resistance, an area the Institute refers to as the “invisible”

environment and believes is of critical importance to human

interaction and health. To inform Harmony residents of the

impending crisis of antibiotic resistance and the overuse of

antibacterial products, the Institute included language in the

Residential Properties document and regularly educates

residents through science advisories in its quarterly newsletter.

The Institute also presents a youth education program entitled

“Good Germ, Bad Germ” in an effort to instill in children the

reality that bacteria are alive and the vast majority of them are

their friends.

A major Florida university has recently committed to pursuing

longitudinal studies within the town of Harmony and the

Institute is proposing that antibacterial resistance be one of two

initiating studies.

Updates in C. difficile management

In a recent Medscape article, Dr. John G. Bartlett discussed

five important developments on the topic of preventing and

treating C. difficile infections (CDI):

1. A new U.S. CDC study found that 75% of patients

admitted to a hospital or nursing home were already

colonized with C. difficile at the time of admission. This

knowledge has important ramifications for infection

control practices.

2. Fidaxomicin is now the second drug approved by the U.S.

FDA for the treatment of CDI. While relatively costly, it

has global cure rates superior to those of vancomycin.

3. Doctors in the Netherlands have trained a beagle to detect

CDI based on the odor of p-cresol, the phenolic compound

that is thought to be associated with C. difficile. The

beagle’s performance in the trial was near perfect.

4. Surgeons at the University of Pittsburgh have reported a

new surgical approach, called “diverting loop ileostomy

with colonic vancomycin lavage,” which has lower

mortality rates than the standard colectomy procedure.

5. Stool transplants for patients with multiple relapses of CDI

are becoming more widely accepted, thanks to more

research and relaxed FDA requirements.

A novel community addresses antibiotic

resistance

Martha E. Lentz

Founder and President of The Harmony Institute

In 1996 the Harmony Institute was created with a unique

mission that proposes that people who have routine interactions

with animals and the natural environment experience the

benefits of a healthier lifestyle. Based upon existing science

that demonstrates the health benefits of human-animal-nature

interactions, and with the knowledge of the concept and

capacity of longitudinal studies to affect human health choices

and community environments such as the Framingham Heart

Study, the Institute believed a similar study might drive better

health and smarter, more sustainable, living.

The Institute formed a science advisory board of renowned

researchers in disciplines including environmental psychology,

human-animal relations, public health, energy, education,

urban design, veterinary medicine and wildlife management to

work with the community development team in designing the

community of Harmony, Florida to specifically accommodate,

encourage and maximize these interactions and to serve as a

living laboratory for longitudinal study. To direct the

education and management of the community, the Institute’s

advisory board authored the document “Harmony Residential

Properties Restrictions, Guidelines and Goals Concerning

Companion Animals, Habitat and Wildlife©.”

26 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • The Harmony Institute

was founded in 1996

with the mission of

promoting “human

health and well-being through the interaction

of people, animals and the environment.” The

vision and goals of the Institute led to the

formation of Birchwood Acres L.L.L.P., the

purchase of an 11,000+ acre property in

1998, and the development of the Town of

Harmony. Harmony, Florida is a town

specially formed with the Institute’s mission

in mind, and it serves as a “living laboratory”

for the study of green living.

About us

Antibiotics are humanity's key defense against disease-causing microbes. The growing prevalence of antibiotic resistance

threatens a future where these drugs can no longer cure infections and killer epidemics run rampant. The Alliance for

the Prudent Use of Antibiotics (APUA) has been the leading global non-governmental organization fighting to preserve

the effectiveness of antimicrobial drugs since 1981. With affiliated chapters in more than 66 countries, including 33 in

the developing world, we conduct research, education and advocacy programs to control antibiotic resistance and en-

sure access to effective antibiotics for current and future generations.

Our global network of infectious disease experts supports country-based activities to control and monitor antibiotic

resistance tailored to local needs and customs. The APUA network facilitates the exchange of objective, up-to-date

scientific and clinical information among scientists, health care providers, consumers and policy makers worldwide.

The APUA Clinical Newsletter has been published continuously three times per year since 1983.

Tel: 617-636-0966 • Email: apua@tufts.edu • Web: www.apua.org

APUA global chapter network

of local resources & expertise

200 Harrison Ave, Posner Building (Business) Level 3, Boston, MA 02111

Phone: 617-636-0966 | Fax: 617-636-0458 | E-mail: apua@tufts.org

www.apua.org

“Preserving the Power of Antibiotics”®

About us • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • 27

28 • The APUA Newsletter Vol. 31. No. 2 • © 2013 APUA • Upcoming events

“Preserving the Power of Antibiotics”®

200 Harrison Ave, Posner Building

(Business) Level 3, Boston, MA 02111

Phone: 617-636-0966 | Fax: 617-636-0458 |

E-mail: apua@tufts.org

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