Correspondence

posted an urgent inquiry in the Epidemic Intelligence Information System for their Food and Waterborne Diseases and Zoonoses network to assess the current situation in Europe and informed the European Commission, European Food Safety Agency, International Food Safety Authorities Network, and WHO (Regional Office for Europe), which coordinate international exchange of information.

A

B

C

D

We thank the participants in the ECDC Food and Waterborne Diseases and Zoonoses network and the European Union member states that provided data for antimicrobial susceptibility of salmonella infections. We declare that we have no competing interests.

*Therese Westrell, Dominique L Monnet, Céline Gossner, Ole Heuer, Johanna Takkinen [email protected] European Centre for Disease Prevention and Control, Stockholm 171 83, Sweden 1

2

3

4

Le Hello S, Harrois D, Bouchrif B, et al. Highly drug-resistant Salmonella enterica serotype Kentucky ST198-X1: a microbiological study. Lancet Infect Dis 2013; 13: 672–79. Le Hello S, Hendriksen RS, Doublet B, et al. International spread of an epidemic population of Salmonella enterica serotype Kentucky ST198 resistant to ciprofloxacin. J Infect Dis 2011; 204: 675–84. EFSA, ECDC. The European Union summary report on antimicrobial resistance in zoonotic and indicator bacteria from humans, animals and food in 2011. EFSA Journal 2013; 11: 359. WHO. Critically important antimicrobials for human medicine. 3rd revision, 2011. http://apps.who.int/iris/bitstream/10665/ 77376/1/9789241504485_eng.pdf (accessed July 16, 2013).

Clinical epidemiology of Klebsiella pneumoniae carbapenemases The Review by Silvia Munoz-Price and colleagues 1 emphasises the importance of Klebsiella pneumoniae strains that produce K pneumoniae carbapenemases (KPC-KP) that have taught the medical community to fear rapid in-hospital transmission and excess mortality caused by carbapenem resistance.2 Hospitals in www.thelancet.com/infection Vol 14 April 2014

Figure: Positioning pillows as a hidden retreat for long-term persistence of Klebsiella pneumoniae carbapenemases-producing K pneumoniae (A) Positioning pillows in use for the prone position of patients with acute respiratory distress syndrome. (B) Schematic illustration of a complete set of pillows. (C) Inner filling of a pillow contaminated with K pneumoniae carbapenemases-producing K pneumoniae strains. (D) Positive culture of K pneumoniae carbapenemases-producing K pneumoniae strains from a swab of foam paddings (CHROMagar K pneumoniae carbapenemases plate).

Germany that have experienced KPCKP outbreaks in recent years were not mentioned in the Review. From July, 2010, to April, 2013, the Leipzig University Hospital (a 1300-bed referral centre) had the largest outbreak caused by a KPC-2 producing K pneumoniae strain seen in Germany so far.3,4 The outbreak occurred subsequent to the transfer of a patient from a hospital in Rhodes, Greece, where KPC-producing pathogens are endemic.1,2 103 patients became either colonised or infected with KPC-KP, showing a hospital mortality rate of 41%. Successful containment of the outbreak was achieved by implementation of a bundle of infection control measures, including systematic PCRbased screening for carbapenemresistant Enterobacteriaceae (CRE) on admission; repeated screening during stay in hospital; strict cohorting of KPC-positive patients and separation of contacts; refined use of broad-spectrum antibiotics,

especially carbapenems; rigorous barrier precautions; and sustained compliance to hand hygiene.3–5 Prolonged person-to-person transmission was identified as the most probable method of spread, possibly with the contribution of undetected KPC-KP cases before systematic screening was established, causing silent dissemination. Meticulous microbiological investigation of more than 1000 specimens taken from the environment of KPCpositive patients—ie, food trays, miscellaneous surfaces, sinks, disinfectors, ventilators, other medical devices,6 and samples obtained from doctors, nurses, assistant personnel, and cleaning staff—showed no evidence that the outbreak was caused by a point source or that staff members served as an unrecognised reservoir. Whole-genome sequencing used to characterise patchy clonal infection chains in the surgical intensive care unit suggested modes of transmission for individual cases 271

Correspondence

other than contaminated hands of medical staff. Nevertheless, environmental sources were continuously screened for CRE even after the outbreak had ended. Surprisingly, after removal of plastic coatings, systematic microbiological exploration of the inner foam padding of positioning pillows (designed for the prone position of patients with acute respiratory distress syndrome, figure), which had last come into contact with KPCpositive patients in the intensive care unit more than 6 months ago, showed a hidden retreat for longterm persistence of KPC-KP since cultures on chromogenic media (CHROMagar KPC) were positive and isolates were identified as KPC-2-KP by molecular methods. By contrast, all regular pillows and mattresses used in the intensive care unit were tested negative, although in many publications contamination of mattresses with different pathogens have been described.7 The negative results are possibly explainable by the regular steam sterilisation of mattresses done in our hospital. Our findings show that the search for environmental sources of outbreak strains has to be all-embracing.6 When tackling outbreaks of multidrugresistant organisms such as KPC-KP clinicians have to take into account that a new generation of Gramnegative bacteria is perfectly adapted to hospital and intensive care unit settings because of their tremendous environmental resistance.8 NL and CL contributed equally. We declare that we have no competing interests. We thank Sylvia Köppen (Leipzig University Hospital, Germany) for her mindful clinical observance and Reinier Mutters (Marburg University Hospital, Germany) for his valuable support.

Norman Lippmann, *Christoph Lübbert, Thorsten Kaiser, Udo X Kaisers, Arne C Rodloff [email protected] Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Leipzig, Germany (NL, ACR); Hospital Hygiene Staff

272

Unit, Leipzig University Hospital, Leipzig, Germany (NL, ACR); Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr 20, D-04103 Leipzig, Germany (CL); Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, Leipzig University Hospital, Leipzig, Germany (TK); and Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany (UXK) 1

2

3

4

5

6

7

8

Munoz-Price LS, Poirel L, Bonomo RA, et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis 2013; 13: 785–96. Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis 2009; 9: 228–36. Lübbert C, Faucheux S, Becker-Rux D, et al. Rapid emergence of secondary resistance to gentamicin and colistin following selective digestive decontamination in patients with KPC-2-producing Klebsiella pneumoniae: a singlecentre experience. Int J Antimicrob Agents 2013; 42: 565–70. Lübbert C, Lippmann N, Busch T, et al. Longterm carriage of Klebsiella pneumoniae carbapenemase-2-producing K. pneumoniae after a large single-center outbreak in Germany. Am J Infect Control 2014; 42: 376–80. US Centers for Disease Control and Prevention. 2012 CRE toolkit—guidance for control of carbapenem-resistant enterobacteriaceae. http://www.cdc.gov/hai/organisms/cre/cretoolkit/ (accessed March 7, 2014). Lerner A, Adler A, Abu-Hanna J, Meitus I, Navon-Venezia S, Carmeli Y. Environmental Contamination by Carbapenem-Resistant Enterobacteriaceae. J Clin Microbiol 2013; 51: 177–81. Creamer E, Humphreys H. The contribution of beds to healthcare-associated infection: the importance of adequate decontamination. J Hosp Infect 2008; 69: 8–23. Sandora TJ, Goldmann DA. Preventing lethal hospital outbreaks of antibiotic-resistant bacteria. N Engl J Med 2012; 367: 2168–70.

Colorectal neoplasia associated with Streptococcus gallolyticus subspecies pasteurianus The association of colorectal neoplasia with bacteraemia caused by Streptococcus bovis is well known. Findings from a systematic review1 showed that 69% of patients infected with S bovis had concomitant colorectal neoplasia, but there were differences among the S bovis subspecies and their association

with underlying colorectal neoplasia; patients with S gallolyticus subspecies gallolyticus (biotype I) had a higher risk of colorectal neoplasia than did patients infected by other S bovis subspecies. We read with interest the Personal View by Annemarie Boleij and Harold Tjalsma (August, p 719), 2 in which they affirm that a major drawback of most studies is the lack of discrimination between S bovis biotype II subspecies. S gallolyticus gallolyticus bacteraemia is an indication to search for colorectal neoplasia,3 but more detailed analysis of the other subspecies is needed to rule out or confirm their association with colorectal neoplasia. Facklan4 suggested that S gallolyticus gallolyticus and S gallolyticus subspecies pasteurianus (formerly known as S bovis biotype II/2) are isolated from haemocultures of patients with colorectal neoplasia more often than is S infantarius (biotype II/1). We have noted significant differences between S gallolyticus gallolyticus and S infantarius in their association with colorectal neoplasia, both in the percentage (63·3% vs 10·3%, p

Clinical epidemiology of Klebsiella pneumoniae carbapenemases.

Clinical epidemiology of Klebsiella pneumoniae carbapenemases. - PDF Download Free
716KB Sizes 4 Downloads 3 Views