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I thought I was done for the time being with “nightmare bacteria” (the US CDC’s characterization of disease organisms resistant to the last-ditch antibiotics called carbapenems), but there are two stories today that deserve to be called out as examples of how rapidly and dangerously these pathogens are spreading.
In today’s edition of EuroSurveillance, the weekly journal of the European Center for Disease Prevention and Control, there’s a report of an outbreak of the common ICU infection Acinetobacter, which was multi-drug resistant, including to carbapenems, because it carried the resistance factor NDM-1. You might remember NDM, the “Indian supergene,” from a few years ago; it has since spread around the world, in several species of bacteria, but this is the first outbreak in Europe of Acinetobacter carrying NDM.
It’s quite a complex outbreak, and it illustrates both that patients can import resistant organisms into a hospital, and also how difficult it can be to prevent those organisms spreading. Here is how it unspooled:
The first patient, a woman in her 80s with cirrhosis of the liver, was born in Algeria but lived mostly in France. She was staying in Algeria last December, developed kidney failure, and was admitted to a hospital there for dialysis. Her liver began to fail, and in January she was transferred to a hospital outside Paris, the University Hospital Henri Mondor in Créteil. France has been very alert to the problem of highly resistant organisms, and requires patients going into ICUs to be checked for them; so this woman was checked, and was found to be carrying Acinetobacter with the gene and enzyme NDM-1. She was intubated, but died on Jan. 28, 10 days after she was admitted.
On Jan. 25, Jan. 27, and Feb. 2, NDM Acinetobacter was found in three other patients in that ICU. None of them had harbored the organism when they were admitted. Two of them — a man in his 60s with cirrhosis and a woman in her 40s recovering from a liver transplant — survived. The third patient, a man in his 60s who had also received a liver transplant, died.
Just after the first Algerian patient died, another woman in her 80s — suffering from a stroke, this time — was brought to the French hospital’s emergency room. She came from the same province in Algeria as the first woman, but had been treated at a different hospital than the first woman had.
Then in mid-March, a woman in liver failure was admitted to the French hospital; she was sent to the same ICU on April 6 in preparation for a liver transplant. She was not carrying NDM Acinetobacter when she was admitted; but by April 15, ICU personnel found she was infected with the resistant bacterium. The last patient in the outbreak, a man in his 50s, came into the ICU on April 3, was checked and found clear of any resistant organisms, and yet was carrying NDM Acinetobacter on May 5.
Here’s the timeline, from EuroSurveillance:
It’s pretty clear, once you look at the timeline, that the patients could not all have infected each other; there’s not enough overlap. So: a contaminated piece of equipment? A colonized health care worker? Bacteria surviving on a surface — a counter, a bed rail — and then carried unknowingly into another room? The difficult thing in this story is that the hospital would have been aware of all those risks, as they had dealt with multi-drug resistant Acinetobacter — though not carrying NDM — before:
Intensive-care units are particularly susceptible to outbreaks associated with MDR-AB: it is sometimes difficult for them to adhere strictly to infection control measures when patients require a high and persistent care-load. Four years ago, the same hospital faced a hospital-wide outbreak of MDR-AB colonisations and infections due to the importation of an index case from Tahiti. Despite this experience and the implementation in 2010 at the national and local level of strict measures on hospital admission to detect, screen and place under contact-isolation precautions repatriated patients, another outbreak linked to the admission of a patient previously hospitalised abroad again occurred (in 2010).
It’s really striking that a hospital this aware and well-prepared would nevertheless have this much difficulty forestalling an outbreak, and speaks to how very hard it is to corral these highly resistant organisms. But it’s not the only one.
As reported on ProMED and by the Gainesville Sun, the University of Florida’s Shands Hospital had to close its burn unit after 8 patients were infected with carbapenem-resistant Acinetobacter, beginning in March; one of those patients is still in isolation, presumably still infected. In the press conference that triggered the newspaper story, the hospital declined to say whether any of the patients died, but there is a hint in a quote from one leading expert — J. Glenn Morris, director of the university’s Emerging Pathogens Institute — that things did not go well:
Once detected, it is very hard to treat, since it resists all but one known antibiotic on the market, and that drug, known as colistin, has serious side effects, namely complications to the kidney, said Dr. Glenn Morris, the director of the Emerging Pathogens Institute at UF and the interim epidemiologist at Shands Hospital.
“In this case we did use it (colistin) where we had to,” Morris said. “We weren’t able to successfully treat patients with colistin.”
Cite: Decousser JW, Jansen C, Nordmann P, et al. Outbreak of NDM-1-producing Acinetobacter baumannii in France, January to May 2013 . Euro Surveill. 2013;18(31):pii=20547.
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