Maryn McKenna

Journalist and Author

Resistant 'Nightmare Bacteria' Increase Fivefold in Southeastern U.S.

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Klebsiella, Janice Carr, CDC

Klebsiella, Janice Carr, CDC

There’s worrisome news here in the southeastern U.S., buried in a journal that is favorite reading only for superbug geeks like me. The rate at which hospitals are recognizing cases of CRE — the form of antibiotic resistance that is so serious the CDC dubbed it a “nightmare” — rose five times over between 2008 and 2012.

Within that bad news, there are two especially troubling points. First, the hospitals where this resistance factor was identified were what is called “community” hospitals, that is, not academic referral centers. That’s an important distinction, because academic medical centers tend to be where the most cutting-edge care is performed, and where the sickest people are. As a result, they are where last-resort antibiotics are used the most, and therefore where resistance is most likely to emerge. That CRE was found so widely not in academic centers, but rather in community hospitals, is a signal that it is probably moving through what medicine calls “the community,” which is to say, anywhere outside healthcare. Or, you know, everyday life.

A second concern is that the authors of the study, which is in Infection Control and Hospital Epidemiology, assume that their finding is an underestimate of the actual problem.
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World Health Organization: Antibiotic Resistance Grave Global Problem

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NathanReading-staph

Image: Nathan Reading (CC), Flickr

The World Health Organization has released a significant report marking what I think must be the first attempt to quantify antibiotic resistance globally. It’s a very sobering read — not just for what the data says about the advance of resistance worldwide, but also because of what the organization could not say, because the data doesn’t exist.

The numbers themselves are unsettling. Dr. Keiji Fukuda, the WHO’s assistant director general, told the press: “It’s clear that rates are very high of resistance among bacteria causing many of the most common serious infections – the ones that we see both occurring in the community as well as in hospitals … In all regions of the world, we now see that hospitals are reporting untreatable, or nearly untreatable, infections.”

But the gaps in the numbers are too: There are 194 member countries in the WHO, but only 114 had the data-gathering resources to contribute something to the report, and only 22 were able to send in data on the most important occurrences of resistance in very common bacteria. Thus it’s possible that the report could be an under-estimate, or an over-estimate. But I can’t think of a scenario in which it could be considered substantially inaccurate. Its portrait of a world in which antibiotic resistance is advancing to grave proportions ought to be taken seriously.

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NDM: "A Great Challenge for the Future of Healthcare"

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Jason Scragz (CC), Flickr

Jason Scragz (CC), Flickr

A paper published this week reminded me to take a fresh look at NDM, the “Indian superbug” — actually a gene and enzyme — that got so much attention, including from me, in 2011. (Most of the posts are here.) Quick reminder: NDM surfaced in 2008 in Sweden, then was found in the United Kingdom, then in the United States and then elsewhere in the world. It had several distinctive qualities. It appeared in gut bacteria such as Klebsiella and E. coli, and caused infections when those bacteria escaped the gut and got elsewhere in the body. It rendered those bacteria not-vulnerable to almost all antibiotics, leaving so few drugs to use against it that medical personnel found it truly alarming. And it had strong links to South Asia: The first known patient was an Indian man living in Sweden who had gone home for a visit and been hospitalized; victims found later either had family links to India and Pakistan or had gotten medical care there, as medical tourists or because they were injured while traveling.

NDM (which stands for New Delhi metallo-beta-lactamase; it was originally NDM-1, but there are now at least seven variants) generated a lot of alarm at the time, with good reason. Its unusual resistance pattern made useless the last category of broad-spectrum, last-resort antibiotics, called carbapenems, that were still working reliably. Physicians treating patients who had infections involving NDM had to hunt among just a few remaining drugs that were still on the shelf because they were toxic or did not work reliably. Plus, because bacteria carrying the NDM resistance factor colonize the gut, the infection could be transported across borders and into hospitals without anyone noticing. With no symptoms showing, few hospitals would bother to check a patient (or a family member), especially since testing for gut bacteria is more complicated and intimate than, for instance, testing someone’s nostrils for MRSA.

By last year, NDM had mostly dropped out of the headlines, even though it was still moving across the globe (this 2013 paper details countries where it has been identified), and had also begun causing hospital outbreaks (for instance, this one in Denver in 2012). So the new paper I mentioned, written by staff from Public Health England and analyzing the first 250 patients with NDM in the UK, is a useful reminder of how formidable a microbiologic foe this can be.

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CDC Threat Report: 'We Will Soon Be in a Post-Antibiotic Era'

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Image: CDC

The U.S. Centers for Disease Control and Prevention has just published a first-of-its-kind assessment of the threat the country faces from antibiotic-resistant organisms, ranking them by the number of illnesses and deaths they cause each year and outlining urgent steps that need to be taken to roll back the trend.

The agency’s overall — and, it stressed, conservative — assessment of the problem:

  • Each year, in the U.S., 2,049,442 illnesses caused by bacteria and fungi that are resistant to at least some classes of antibiotics;
  • Each year, out of those illnesses, 23,000 deaths;
  • Because of those illnesses and deaths, $20 billion each year in additional healthcare spending;
  • And beyond the direct healthcare costs, an additional $35 billion lost to society in foregone productivity.

“If we are not careful, we will soon be in a post-antibiotic era,” Dr. Tom Frieden, the CDC’s director, said in a media briefing. “And for some patients and for some microbes, we are already there.”

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'Nightmare Bacteria' Attack an ICU and Close a Burn Unit

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Flickr: Denis Bocquet, CC

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.

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More on 'Nightmare Bacteria': Maybe Even Worse Than We Thought?

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Flickr: CelesteH, CC

In my last post I talked about the under-appreciated emergence of “nightmare bacteria” (those are the Centers for Disease Control and Prevention’s words, not mine) that are widely distributed in hospitals and nursing homes around the world and do not respond to a last-ditch small family of antibiotics called carbapenems. That seemed dire enough, but new research suggests the problem, bad as it looks, has been understated.

There’s an ahead-of-print article in Antimicrobial Agents and Chemotherapy whose authors include David Shlaes, a physician-researcher and former pharmaceutical executive, now consultant, and Brad Spellberg, an infectious disease physician on the UCLA medical faculty and author among other books of Rising Plague, about antibiotic resistance. In a commentary examining the Food and Drug Administration’s promised “reboot” of antibiotic development rules, they analyze privately gathered data on resistance in the United States and conclude the incidence of highly resistant bacteria is greater than the CDC has estimated.

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Where 'Nightmare Bacteria' Came From, And How Our Inattention Helped Them Emerge

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Zebbie (CC), Flickr

Cast your minds back a few months ago, to when the director of the US Centers for Disease Control and Prevention announced, “We have a very serious problem” with “nightmare bacteria,” and the chief medical officer of the United Kingdom backed him up a few days later, describing a “ticking time bomb” that threatens national security as seriously as terrorism.
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'We Have a Limited Window of Opportunity': CDC Warns of Resistance 'Nightmare'

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It’s not often that you get to hear a top federal health official deliberately deploy a headline-grabbing word such as “nightmare,” or warn: “We have a very serious problem, and we need to sound an alarm.”

Dr. Thomas Frieden, director of the US Centers for Disease Control and Prevention, said both Tuesday, during a press conference announcing new CDC statistics on the advance of the highly drug-resistant bacteria known as CRE. His language — plus the fact that he conducted the entire press conference himself, instead of just making a brief opening statement — seem to me a clear signal that the CDC is taking this resistance problem seriously, and hoping we do too.

And we should. Here’s what the CDC announced Tuesday:

  • Healthcare institutions in 42 states have now identified at least one case of CRE.
  • The occurrence of this resistance in the overall family of bacteria has risen at least four-fold over 10 years.
  • In the CDC’s surveillance networks, 4.6 percent of hospitals and 17.8 percent of long-term care facilities diagnosed this bug in the first half of 2012.

Those are dire reports.

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