Stewardship / Resistance Scan for Dec 18, 2019

Resistant Campylobacter and puppies
CRE outbreak in Lithuania
Extra-intestinal E coli carriage

Contact with puppies tied to MDR Campylobacter in 13 states

Puppies from Petland pet stores are again implicated in a multistate outbreak of multidrug-resistant (MDR) Campylobacter infections, this time affecting at least 30 people in 13 states, the Centers for Disease Control and Prevention (CDC) said yesterday in an update.

Four people have been hospitalized in this outbreak, caused by Campylobacter jejuni, but none have died. "Epidemiologic and laboratory evidence indicate that contact with puppies, especially those at pet stores, is the likely source of this outbreak," the CDC said. The agency added, "Laboratory evidence indicates that bacteria from ill people in this outbreak are closely related genetically to bacteria from ill people in the 2016–2018 outbreak of multidrug-resistant Campylobacter infections linked to pet store puppies."

In both the current and earlier outbreaks, the CDC named Petland stores as a likely source of the contaminated puppies. Of 15 people in the current outbreak who reported contact with a puppy from a pet store, 12 (80%) were linked to Petland, including 5 employees.

The 2016-18 MDR Campylobacter outbreak involved 113 cases and 23 hospitalizations in 17 states. The CDC posted its final outbreak notice on that event on Jan 30, 2018.

Illnesses in this year's outbreak began from Jan 6 to Nov 10, with patients ranging from 8 months to 70 years. Whole-genome sequencing of 26 isolates from patients predicted antibiotic resistance to tetracycline (26 isolates), ciprofloxacin (25), nalidixic acid (25), azithromycin (23), erythromycin (23), clindamycin (23), telithromycin (23), and gentamicin (18).
Dec 17 CDC statement
Jan 30, 2018, CDC final notice on previous outbreak


ECDC details CRE outbreak in Lithuanian hospitals

The European Centre for Disease Prevention and Control (ECDC) today issued a report on an outbreak of Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacteriaceae (KPC-CRE) in Lithuania.

According to the ECDC's rapid risk assessment, 199 KPC-CRE cases were detected from Feb 1 through Nov 26, with 186 cases (93%) occurring in a single hospital (hospital 1). The cases include infections as well as carriage, and most of the isolates were Klebsiella pneumoniae (186 cases, 93%), followed by Escherichia coli (16 cases, 8%), Citrobacter freundii (2 cases), and Enterobacter aerogenese (1 case). In all isolates, carbapenem resistance was mediated by the KPC enzyme. Additional resistance to colistin was detected in 26 of 52 isolates tested.

The outbreak was first identified in April 2019, with the first case detected in a patient with a surgical-site infection admitted to the intensive care unit of hospital 1, and was still ongoing as of Dec 11.

"The risk of further spread of CRE in the most-affected hospital is high, as a large number of cases have been identified from multiple wards and new cases continue to be detected at the time of this risk assessment," the report says. "While enhanced infection control measures have been implemented, the outbreak appears not yet to have been controlled."

Six additional hospitals have also reported KPC-CRE cases, and the ECDC says the risk of further spread in the Lithuanian health system is high, since screening for CRE carriage was not in place in Lithuanian hospitals before December 2019. Lithuania reported only 5 and 12 cases of CRE in 2017 and 2018, respectively.

The ECDC says screening of patients at high risk for digestive tract carriage of CRE due to healthcare contact in the preceding 12 month, along with pre-emptive contact precautions and isolation, should be considered. Further epidemiologic investigations are ongoing.
Dec 18 ECDC rapid risk assessment


Resistant E coli intestinal carriage found in VA patients, housemates

Veterans Affairs (VA) patients and members of their household commonly carry and share a strain of multidrug-resistant E coli that's emerged as a common source of extra-intestinal infections in hospitals, researchers from the University of Minnesota and the Minneapolis VA Medical Center reported today in the Journal of Infectious Diseases.

For the study, the researchers screened fecal samples from 741 volunteers (383 VA patients and 358 household members, including pets) for fluoroquinolone-resistant E coli (FQREC) and E coli sequence type (ST) 131. They were specifically interested in the H30 subclone within ST131, and its fluoroquinolone-resistant H30R subset, both of which have expanded rapidly in recent years. Because these extra-intestinal pathogenic E coli strains usually originate in patients' gut microbiota before causing extra-intestinal infections, it's been theorized that widespread gut colonization could underlie epidemic clonal emergence.

The results showed that colonization prevalence was 5.1% for H30R, 8% for ST131 (67% FQREC), and 10% for FQREC (52% ST131). Among the 425 strains that underwent virulence genotyping, ST131 isolates exhibited more virulence genes than non-ST131 isolates. Strain sharing appeared in 27% of the 100 assessed multi-subject households and 18% of corresponding subjects, and was associated with the elderly, FQREC, H30R, H30Rx, E coli ST73, and specific virulence genes. Comparison of fecal ST131 and FQREC isolates with a collection of clinical E coli isolates from Minneapolis VA patients found similarities in virulence gene content, resistance profiles, and other traits, a finding that supports the idea that the clinical strains emerge from the gut reservoir.

"In conclusion, as an intestinal colonizer of uninfected veterans and their human household members, H30R was much more prevalent than any other FQREC strain, largely independent of the studied host characteristics," the authors of the study write.

"Comparative prevalence values suggested that, relative to other FQREC, H30R is likely both a better gut colonizer and more capable of causing infections in colonized hosts, phenotypes possibly promoted by H30R's extensive repertoire of virulence factors, which may also represent colonization factors. Thus, colonization fitness, virulence, and within-household strain sharing may all underlie H30R's epidemic success, and could be targets for preventive interventions."
Dec 18 J Infect Dis abstract

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