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The following is TODAY'S (Thursday 28 Oct 2010) update
Date: Thu, 28 Oct 2010
08:49:57 -0400 (EDT)
From: ProMED-mail <firstname.lastname@example.org>
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
ProMED-mail is a program of the
International Society for Infectious Diseases
In this update:
 China (Ningxia, Fujian): NDM-1
 Israel ex India: NDM-1
 Brazil: KPC
 USA: KPC
 China (Ningxia, Fujian): NDM-1
Date: Tue 26 Oct 2010
Source: Xinhua News Agency [edited]
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
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,
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
[Byline: Zhang Xiang]
ProMED-mail Rapporteur Mary Marshall
[The HealthMap/ProMED-mail interactive map of China is available at
A map showing the provinces can be seen at
 Israel: NDM-1
Date: Wed 27 Oct 2010
Source: Haaretz [edited]
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
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]
ProMED-mail Rapporteur Mary Marshall
 Brazil (Brasilia): KPC
Date: Tue 26 Oct 2010
Source: The New York Times, Associated Press (AP) report [edited]
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
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]
ProMED Rapporteur Mary Marshall
[Brasilia can be located on the HealthMap/ProMED-mail interactive map
of Brazil at
 USA (Chicago): KPC
Date: Fri 22 Oct 2010
Source: Chicago Tribune [edited]
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 , 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
"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  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
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  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]
Thomas James Allen
[Chicago, in the state of Illinois, can be located on the
HealthMap/ProMED-mail interactive map at
[_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
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
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
NDM-1 carrying Enterobacteriaceae (02): worldwide ex India, Pakistan
NDM-1 carrying Enterobacteriaceae: N America, UK ex India 20100815.2812]