The CDC reported the first death from carbapenem-resistant Enterobacteriaceae (CRE) that was resistant to all antibiotics available in the United States (MMWR Morb Mortal Wkly Rep 2017;66:3).
The Nevada woman, who was in her 70s, died from septic shock last September, but the CDC just reported the case, emphasizing that continued surveillance showed that it was an isolated case from a person who spent time outside the country.
According to the report, the woman had suffered osteomyelitis as the result of a femur fracture, and was hospitalized multiple times in India over the course of two years—the last time in June 2016. She was admitted to an acute care hospital in Reno, Nev., on Aug. 18, 2016, with an infected right hip seroma. The diagnosis was systemic inflammatory response syndrome. A sample was collected from the wound on Aug. 19, and the specific CRE identified was Klebsiella pneumoniae.
“The isolation of a completely drug-resistant K. pneumoniae from a fatal infection occurring in Nevada is further evidence of the steady march of antimicrobial resistance,” said Amesh Adalja, MD, FACP, a spokesman for the Infectious Diseases Society of America.
Once the CRE was identified, she was placed in isolation, and the sample was sent to the CDC to determine the mechanism of resistance. The CDC confirmed the presence of the New Delhi metallo-beta-lactamase (NDM), but did not find the mcr-1 gene. The isolate was resistant to 26 antibiotics, including all aminoglycosides and polymyxins. It was intermediately resistant to tigecycline. The CDC said isolates that are resistant to all antimicrobials are uncommon; “approximately 80% remained susceptible to at least one aminoglycoside and nearly 90% were susceptible to tigecycline,” the CDC wrote in its report.
The isolate had a relatively low fosfomycin minimum inhibitory concentration, but the oral version of that antibiotic is only indicated in the United States for uncomplicated cystitis and the IV formulation is not approved here.
Dr. Adalja, an infectious disease physician at the UPMC (University of Pittsburgh Medical Center) Center for Health Security and an affiliated scholar at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, said this case just emphasizes the importance of good stewardship and antimicrobial practices.
“This latest incident is a premonition of what the world will look like if the spread of antibiotic resistance is not reversed. This case also illustrates the importance of global travel networks, as hospitalization in India, where the NDM-1 resistance mechanism this isolate harbored is highly prevalent, was a factor in the case,” Dr. Adalja said.
The CDC also noted that hospitalization in India was an important factor in this case and suggested that health care facilities ask about medical care obtained outside their regions upon admission, and “consider screening for CRE when patients report recent exposure outside the United States or in regions of the United States known to have a higher incidence of CRE.”
Samples taken from patients hospitalized at the same time as the woman were negative for this resistant strain, and no other NDM CRE have been identified in the area, according to the CDC.
“That this isolate did not have any secondary spread in the involved health facility was fortunate,” Dr. Adalja said. “However, it is only a matter of time before microbes with these types of resistance patterns become more common and place more patients at risk. These facts highlight the importance of robust infection control and antibiotic stewardship programs.
“Antibiotic resistance is arguably the most daunting public health challenge the world faces and, if not solved, will compromise much of modern medicine and relegate the world to the pre-penicillin era in which routine surgery, let alone organ transplantation or chemotherapy, was a highly risky proposition,” Dr. Adalja said.