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The following is TODAY'S (Thursday 28 Oct 2010) update from ProMed

Date: Thu, 28 Oct 2010 08:49:57 -0400 (EDT)
From: ProMED-mail <promed@promed.isid.harvard.edu>
Subject: PRO/EDR> Gram negative bacilli, resistant, update (01): NDM-1, KPC

GRAM NEGATIVE BACILLI, RESISTANT,UPDATE (01): NDM-1, KPC 
********************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1] China (Ningxia, Fujian): NDM-1
[2] Israel ex India: NDM-1
[3] Brazil: KPC
[4] USA: KPC

******
[1] China (Ningxia, Fujian): NDM-1
Date: Tue 26 Oct 2010
Source: Xinhua News Agency [edited]
<http://news.xinhuanet.com/english2010/health/2010-10/26/c_13576388.htm>


China's health authorities Tuesday [26 Oct 2010] announced the 
country's 1st 3 cases of NDM-1, a multidrug-resistant "super" 
bacterium. Chinese Center for Disease Control and Prevention (China 
CDC) official Ni Daxin said at a press conference that 2 cases were 
detected from samples submitted by the local CDC in the northwestern 
Ningxia Hui Autonomous Region and one from the southeastern Fujian 
Province.

The samples from Ningxia were drawn from faeces of 2 infants born on 8 
Mar 2010 and 11 Mar 2010. Both were born underweight and showed 
symptoms of diarrhea and respiratory infections 2 days after birth. 
One suffered an oxygen deficiency. One of the babies recovered after 9 
days in hospital and the other after 14 days. They remained healthy, 
said Ni. Although the 2 babies were diagnosed as carrying the NDM-1 
bacteria, there was no link between the bacteria and their illnesses, 
said Ni.

The other sample from Fujian was identified from an 83-year-old, who 
died on 11 Jun 2010. Ni said the primary cause of death was late-term 
lung cancer, and the role of the drug-resistant bacteria in the 
development of the illness was unclear.

The bacteria were identified in laboratories of the China CDC and 
Academy of Military Medical Sciences from among 3500 samples. Ni told 
Xinhua the detection rate was still low. Ni said it was impossible to 
trace the origin of the bacteria, because it had been a long time 
since samples were collected. Ni said there was no cause for panic 
because the bacteria did not spread among people. "It is only 
contagious through medical activities, so hospitals and clinics must 
be on high alert." Ni said China CDC would expand the pool of samples 
for NDM-1 testing.

Xiao Yonghong, director of national drug-resistant bacteria 
surveillance network run by the Ministry of Health, said hospitals 
should step up monitoring and sterilization. Xiao said the network, 
established in 2005, covered 170 top-level hospitals across China.

NDM-1 is most prevalent in South Asia, but has also been found in 
Britain, the Netherlands, Australia, Canada, the United States, and 
Sweden.

[Byline: Zhang Xiang]

- --
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The HealthMap/ProMED-mail interactive map of China is available at
<http://healthmap.org/r/00dj>.
A map showing the provinces can be seen at
<http://www.sacu.org/provmap.html>. Sr.Tech.Ed.MJ]

******
[2] Israel: NDM-1
Date: Wed 27 Oct 2010
Source: Haaretz [edited]
<http://www.haaretz.com/print-edition/news/superbug-diagnosed-in-israeli-woman-1.321340>


For the 1st time, an Israeli patient has been diagnosed with a 
"superbug" -- one that is resistant to antibiotics.

The 50-year-old woman was involved in a traffic accident in India and 
hospitalized in New Delhi for 5 days before being transferred to the 
Sheba Medical Center, Tel Hashomer. There, she was found to have 
intestinal bacteria containing the enzyme New Delhi 
metallo-beta-lactamase-1, better known as NDM-1. The enzyme, which is 
found in a variety of intestinal bacteria, breaks down [beta-lactam] 
antibiotics, thereby rendering the carrier bacteria immune 
[non-susceptible] to them.

The woman was immediately quarantined to prevent her from infecting 
anyone else. Sheba also tested all the staff who had treated her and 
the other patients in the ward, but did not find any who had been 
infected with the bug. The hospital said the woman is due to be 
released in a few days, once it confirms that the bug has left her 
system.

2 months ago, the Health Ministry ordered all hospitals to test any 
patient who had undergone any type of medical treatment in India since 
2008 for NDM-1. The order was issued because the bug has been detected 
in several other Western countries in recent months.

[Byline: Dan Even]

- --
Communicated by:
ProMED-mail Rapporteur Mary Marshall

******
[3] Brazil (Brasilia): KPC
Date: Tue 26 Oct 2010
Source: The New York Times, Associated Press (AP) report [edited]
<http://www.nytimes.com/aponline/2010/10/26/world/americas/AP-LT-Brazil-Deadly-Infection.html?_r=4&ref=world>


An outbreak of deadly antibiotic-resistant bacteria in Brazil has 
killed at least 18 people around Brazil's capital [Brasilia], 
officials said Tuesday [26 Oct 2010], and has prompted hurried 
measures to keep the problem from spreading. The outbreak of 
_Klebsiella pneumoniae_ carbapenemase [KPC] in Brasilia follows others 
in Israel in 2007 and in Puerto Rico in 2008, according to the US 
Centers for Disease Control and Prevention. Brazil's national health 
agency said the known toll so far stands at 18 dead, with 183 people 
hospitalized with the infection in the nation's capital as last 
Thursday [21 Oct 2010]. The figures are updated on a weekly basis.

According to a statement on the website of the Federal District's 
Health Secretariat, from 1 Jan to 1 Oct 2010, the number of known 
cases in Brasilia was 108 people -- meaning there was a spike of 
nearly 70 percent in the last 3 weeks. A spokeswoman for the agency 
said the rise did not necessarily mean the danger of infections was 
growing; it might be due to increasing vigilance and testing for the 
infections.

An official with the CDC in the US said the figures are significant. 
"There is no reason to panic, but there is a need for a call for 
action," said Denise Cardo, director of the division that monitors 
hospital infections at the CDC. "We are seeing an increase in hospital 
infections in recent years and if health professionals don't take 
action now it will be harder and harder to contain them in the future."

_Klebsiella pneumoniae_ carbapenemase -- often just called KPC -- is 
an enzyme produced by bacteria that annuls the effectiveness of modern 
antibiotics and it tends to infect patients who have had surgery or 
other invasive procedures. Most of the cases are seen in intensive 
care unit patients. Cardo said the infections are hard to treat and 
have a fatality rate of about 40 percent.

Brazil's National Agency for Sanitary Vigilance announced on Tuesday 
[26 Oct 2010] it was ordering all hospitals and clinics in the nation 
to require the use of alcohol-based hand cleaners for everyone 
entering any health unit. It called the step "the most important and 
inexpensive" means of controlling infections. Health Minister Jose 
Temporao told the Agencia Brasil news agency last week [week of 18 Oct 
2010] that "citizens can remain calm because this is a situation that 
only happens in hospital environments and with debilitated patients."

KPC was first identified in the late 1990s, according to the CDC, and 
since then nearly 35 American states have reported cases of the 
infection. Chicago and New York both reported outbreaks of KPC 
recently, and cases have also been seen in Colombia, Greece, France, 
and China. Cardo said basic hygiene can help prevent the spread of the 
infection in hospitals, along with proper isolation of infected 
patients and a better control of antibiotic use. "It seems that health 
professionals are not taking these threats seriously," Cardo told The 
Associated Press. "These outbreaks could become more and more common 
and harder to treat if those working in hospitals don't start paying 
more attention to preventive measures, not only when there is an 
outbreak, but all the time."

[Byline: Bradley Brooks]

- --
Communicated by:
ProMED Rapporteur Mary Marshall

[Brasilia can be located on the HealthMap/ProMED-mail interactive map 
of Brazil at
<http://healthmap.org/r/0erE>. - Sr.Tech.Ed.MJ]

******
[4] USA (Chicago): KPC
Date: Fri 22 Oct 2010
Source: Chicago Tribune [edited]
<http://www.chicagotribune.com/health/ct-met-superbug-20101022,0,6867309.story>


A dangerous, often deadly bacterium resistant to the most powerful 
antibiotics known to medicine is spreading in Chicago hospitals and 
nursing homes, prompting an effort to mobilize a region-wide response. 
Known as KPC for short, _Klebsiella pneumoniae_ carbapenemase 
[-producing] bacteria are a drug-resistant form of a common pathogen 
that was first reported 11 years ago in North Carolina.

Earlier this year [2010], 37 health facilities in Chicago reported an 
average of 10 KPC cases each, up from an average of 4 cases in 2009 in 
26 facilities, according to a new study presented Friday [22 Oct 2010] 
at the annual meeting of the Infectious Diseases Society of America. 
The resistant bacterium was first identified in Chicago in December 
2007.

"Although the number of infections is small, the fact that so many 
places are seeing KPCs is very concerning," said Dr Robert Weinstein, 
interim chairman of the department of medicine at Stroger Hospital and 
chief operating officer of the Ruth M Rothstein CORE Center for 
HIV/AIDS at the Cook County Health System. "This is a considerable 
threat that requires a coordinated response," he said.

While it is unclear how many people have died in Chicago from KPC, 
studies suggest that the germ kills about 40 percent of people who 
become infected, according to Dr Arjun Srinivasan, a medical 
epidemiologist with the US Centers for Disease Control and Prevention 
(CDC). Typically, these are older, frail patients with multiple 
medical problems and compromised immune systems.

_Klebsiella_ bacteria live in the gut and can sicken people when they 
enter the body through other avenues -- often [via] catheters inserted 
in the urinary tract or blood vessels of seriously ill patients. 
They're part of a class of organisms known as Gram negative bacteria, 
whose best-known member is _Escherichia coli_, or _E. coli_.

Over the last decade, Gram negative bacteria have begun to evolve 
resistance to drugs once commonly used to fight them as well as to the 
drugs called carbapenems -- medications of last resort that are used 
to treat infections that don't respond to other interventions. "These 
[carbapenems] are the most potent antibiotics available," said Dr Mary 
Hayden, director of clinical microbiology at Rush University Medical 
Center and an author of the new study.

Another drug-resistant Gram negative bacterium originating in India 
made headlines around the world in September [2010] when disease 
trackers noted its emergence in Europe and the US. That organism 
carries a carbapenem-disabling gene known as NDM-1, which experts 
worry might be transferred to other pathogens and hasten drug 
resistance.

Today, 8 percent of all _Klebsiella_ infections in the US involve 
drug-resistant forms of the bacterium, and cases have been discovered 
in 35 states. "This is a growing problem" not only in the US, but 
across the world, said Srinivasan of the CDC. An outbreak of KPC in 
Rio de Janeiro this year [2010] claimed 18 lives. The epicenter for 
infections in the US is New York.

In Chicago, researchers found that 75 percent of patients who tested 
positive for KPC came from nursing homes or other facilities serving 
people with long-term, chronic illnesses. "We think long-term care 
settings may be a significant reservoir of this organism," Hayden said.

KPC bacteria are transmitted through physical contact with unclean 
surfaces or equipment or with health care workers who have not washed 
their hands, experts said. For many people who become infected, the 
only therapy is an old antibiotic, colistin, that can be highly toxic 
to the kidneys. "If there is an abscess, we'll drain it, or if a 
central line is infected, we'll remove it," Hayden said. "But 
treatment is very difficult."

All infections have been confined to medical institutions, and healthy 
people do not need to worry about picking up the bacterium in the 
community, Srinivasan said.

For Chicago hospitals and nursing homes, the challenge is to contain 
the spread of KPC bacteria. That involves identifying patients who may 
be harboring the organism in their bodies, isolating them from other 
patients, and making sure doctors and nurses wear gowns and gloves 
when they enter their rooms, Hayden said.

It also means making sure that when patients carrying KPC bacteria are 
transferred from one medical institution to another -- say from a 
nursing home to a hospital -- their status is clearly communicated so 
precautionary measures can be taken, she said. "We need more 
infection-control resources to fight these bacteria," said Dr Susan 
Gerber, associate medical director of the Cook County Department of 
Public Health. She said her department has begun working with Chicago 
and state public health officials to educate medical providers about 
the threat posed by drug-resistant Gram negative organisms, noting 
that "we all recognize that we're in this together."

[Byline: Judith Graham]

- --
Communicated by:
Thomas James Allen
<tjallen@pipeline.com>

[Chicago, in the state of Illinois, can be located on the 
HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/0erG>. - Sr.Tech.Ed.MJ]

[_Enterobacteriaceae_ that produce New Delhi metallo-beta-lactamase-1 
(NDM-1) have been reported from the UK, the US, Canada, Australia, 
Japan, Sweden, Belgium, the Netherlands, Taiwan, and now China and 
Israel. Many patients either infected or colonized with bacteria that 
produce NDM-1 had initially gone abroad to India and Pakistan for 
treatments such as cosmetic surgery, and carried these organisms back 
to their home countries. Once these patients were hospitalized in 
their home countries, NDM-1-producing bacteria could then spread 
locally to other hospitalized patients.

NDM-1 is an enzyme produced by some _Enterobacteriaceae_ that confers 
resistance to carbapenems, a class of beta-lactam antibiotics that 
includes imipenem and meropenem. In addition, NDM-1 confers resistance 
to all other beta-lactam antibiotics, except aztreonam (a monobactam). 
Nevertheless, isolates that produce NDM-1 are commonly resistant to 
aztreonam, presumably by a different mechanism. NDM-1 also can 
co-exist with resistance to other classes of antibiotics, including 
the fluoroquinolones and aminoglycosides. Colistin and tigecycline may 
retain activity against NDM-1 producing bacteria, but these 
antibiotics either have significant side effects, are potentially 
inferior to more conventional therapies, and can be costly.

Carbapenem-resistance in _Enterobacteriaceae_ is not uniquely due to 
NDM-1. Other mechanisms of carbapenem-resistance are the Verona 
integron-encoded metallo-beta-lactamase (VIM) carbapenemases and the 
_Klebsiella pneumoniae_ carbapenemases (KPC). These carbapenemases 
compromise the critical role that carbapenems have played historically 
as antibiotics of last resort for therapy of many infections due to 
multidrug-resistant Gram negative bacilli.

Like NDM-1, KPC and VIM inactivate other beta-lactam antibiotics, such 
as penicillins and cephalosporins, in addition to the carbapenems. 
Unfortunately, bacteria producing KPC or VIM are typically also 
resistant to many other classes of antibiotics, thereby making these 
pathogens multidrug-resistant. Although KPC are usually produced by 
_Enterobacteriaceae_ such as _K. pneumoniae_ and _Escherichia coli_, 
they may also be produced by other Gram negative bacilli such as 
_Pseudomonas aeruginosa_ and _Acinetobacter_; and although initially 
cloned from a _P. aeruginosa_ strain, the VIM-1 gene is also found in 
_Enterobacteriaceae_.

The genes encoding NDM-1, KPC, and VIM are located on mobile genetic 
elements, which facilitates their spread between bacteria of the same 
or even different species and which plays a major role in the spread 
of antimicrobial resistance among Gram negative bacilli. Infection 
control interventions aimed at preventing transmission of 
carbapenemase-producing isolates include recognition of 
carbapenem-resistant _Enterobacteriaceae_ when cultured from clinical 
specimens, placement of patients colonized or infected with these 
isolates on contact precautions, and in some circumstances, conducting 
point prevalence surveys or active-surveillance testing among 
high-risk patients (CDC: Guidance for control of infections with 
carbapenem-resistant or carbapenemase-producing _Enterobacteriaceae_ 
in acute care facilities. MMWR 2009; 58: 256-60. Available at 
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm>). - Mod.ML]

[see also:
NDM-1 carrying Enterobacteriaceae (04): Taiwan ex India 20101005.3604
VIM carrying Enterobacteriaceae - USA ex Greece: 1st rep. 20100922.3422
NDM-1 carrying Enterobacteriaceae (03): worldwide ex India, Pakistan 
20100914.3325
NDM-1 carrying Enterobacteriaceae (02): worldwide ex India, Pakistan 
20100817.2853
NDM-1 carrying Enterobacteriaceae: N America, UK ex India 20100815.2812]
...................................ml/mj/dk