Perspective

Nevada woman dies of pan-resistant CRE infection

A Nevada woman died recently from an infection that was resistant to every antibiotic available to treat it, health officials said.

The woman, a Washoe County resident in her 70s, was hospitalized in Reno last Aug. 18 for systematic inflammatory response syndrome after returning from an extended stay in India, where she had a history of hospitalizations over the prior 2 years related to a right femur fracture, most recently in June.

The next day, doctors isolated carbapenem-resistant Enterobacteriaceae (CRE) — specifically, Klebsiella pneumoniae — from a right hip seroma and the woman was isolated in a single room under contact precautions.

The infection was resistant to all 14 available antibiotics at the hospital, according to Lei Chen, PhD, epidemiology program manager for the Washoe County Health District. CDC testing later showed that the infection was resistant to all 26 antibiotics that could be used to treat it.

The woman died in September. Her death certificate listed three causes of death: cardiac arrest, respiratory failure and septic shock, Chen said.

“It’s scary to everyone because we’re out of treatment options,” Chen told Infectious Disease News. “Truly, it’s scary.”

Thomas Frieden
Thomas R. Frieden

CDC Director Thomas R. Frieden, MD, MPH, has called CRE “nightmare bacteria” and has urged the health care community to work together to stop the infections from spreading. In the Nevada case, the health department worked with the hospital to screen every patient in the same unit and no further cases of CRE were identified. Luckily, Chen said, the patient did not have a roommate while she was hospitalized.

The type of CRE was identified by the CDC as New Delhi metallo-beta-lactamase (NDM) — the first time it has been reported in Nevada, according to Chen and Randall Todd, DrPH, director of epidemiology and public health preparedness at the Washoe County Health District.

Randall Todd, DrPH
Randall Todd

Todd said the woman likely acquired the infection in India, which has a high prevalence of CRE.

“We live in an ever-shrinking world because of international travel, so being alert to the possibility that a patient who presents with a drug-resistant infection may have been in another part of the world is important,” Todd told Infectious Disease News. “Somebody can come into your hospital who has traveled in other parts of the world and acquired infections there that can turn your whole system upside-down, so it’s important to be open to those possibilities and to inquire about them so that appropriate isolation and treatment options can be implemented quickly. We feel the hospital here did that.”

CDC testing showed that the woman’s infection did not carry the colistin-resistant mcr-1 gene. The testing showed the infection was mildly susceptible to fosfomycin, an antibiotic approved in the United States only for uncomplicated urinary tract infections. However, Todd said there was no way to know after the fact if the drug would have worked on her infection.

“It would have needed to be administered intravenously, which would not be an on-label use of that drug,” Todd said. “Sometimes doctors will go ahead and use a drug off-label, although by the time they got to that point, there wasn’t time to do that.”

Chen and Todd both stressed the need for active surveillance and quick response in the battle against drug resistance. Washoe County has been testing for CRE since 2010.

“It’s scary, but we are not panicked because we are prepared. We expect it,” Chen said. – by Gerard Gallagher

Disclosure: The researchers report no relevant financial disclosures.

A Nevada woman died recently from an infection that was resistant to every antibiotic available to treat it, health officials said.

The woman, a Washoe County resident in her 70s, was hospitalized in Reno last Aug. 18 for systematic inflammatory response syndrome after returning from an extended stay in India, where she had a history of hospitalizations over the prior 2 years related to a right femur fracture, most recently in June.

The next day, doctors isolated carbapenem-resistant Enterobacteriaceae (CRE) — specifically, Klebsiella pneumoniae — from a right hip seroma and the woman was isolated in a single room under contact precautions.

The infection was resistant to all 14 available antibiotics at the hospital, according to Lei Chen, PhD, epidemiology program manager for the Washoe County Health District. CDC testing later showed that the infection was resistant to all 26 antibiotics that could be used to treat it.

The woman died in September. Her death certificate listed three causes of death: cardiac arrest, respiratory failure and septic shock, Chen said.

“It’s scary to everyone because we’re out of treatment options,” Chen told Infectious Disease News. “Truly, it’s scary.”

Thomas Frieden
Thomas R. Frieden

CDC Director Thomas R. Frieden, MD, MPH, has called CRE “nightmare bacteria” and has urged the health care community to work together to stop the infections from spreading. In the Nevada case, the health department worked with the hospital to screen every patient in the same unit and no further cases of CRE were identified. Luckily, Chen said, the patient did not have a roommate while she was hospitalized.

The type of CRE was identified by the CDC as New Delhi metallo-beta-lactamase (NDM) — the first time it has been reported in Nevada, according to Chen and Randall Todd, DrPH, director of epidemiology and public health preparedness at the Washoe County Health District.

Randall Todd, DrPH
Randall Todd

Todd said the woman likely acquired the infection in India, which has a high prevalence of CRE.

“We live in an ever-shrinking world because of international travel, so being alert to the possibility that a patient who presents with a drug-resistant infection may have been in another part of the world is important,” Todd told Infectious Disease News. “Somebody can come into your hospital who has traveled in other parts of the world and acquired infections there that can turn your whole system upside-down, so it’s important to be open to those possibilities and to inquire about them so that appropriate isolation and treatment options can be implemented quickly. We feel the hospital here did that.”

CDC testing showed that the woman’s infection did not carry the colistin-resistant mcr-1 gene. The testing showed the infection was mildly susceptible to fosfomycin, an antibiotic approved in the United States only for uncomplicated urinary tract infections. However, Todd said there was no way to know after the fact if the drug would have worked on her infection.

“It would have needed to be administered intravenously, which would not be an on-label use of that drug,” Todd said. “Sometimes doctors will go ahead and use a drug off-label, although by the time they got to that point, there wasn’t time to do that.”

Chen and Todd both stressed the need for active surveillance and quick response in the battle against drug resistance. Washoe County has been testing for CRE since 2010.

“It’s scary, but we are not panicked because we are prepared. We expect it,” Chen said. – by Gerard Gallagher

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Amesh Adalja

    Amesh A. Adalja

    The report of the isolation of a totally drug-resistant Klebsiella pneumoniae from a fatal infection in Nevada is extremely alarming. This virtually impervious bacteria exhibited resistance to the entire armamentarium of antibiotics available in the U.S. and is a harbinger of what is in store for the human race if the spread of antibiotic resistance is not taken seriously. The specifics of this case included hospitalization in India, where the NDM-1 resistance mechanism that this bacterium possessed is prevalent, highlighting the capacity of infectious diseases to exploit travel networks to reach distant continents and emphasizing the global nature of this problem.

    Thankfully, no secondary spread of this infection occurred at the health facility, but it is only a matter of time, if existing trends are not reversed and antibiotic stewardship and infection control not given the stature required by hospital administrators, before microbes with these types of resistance patterns become more common and place more patients at risk. Antibiotic resistance is arguably the most pressing public health challenge the world faces and, if not solved, threatens to destroy much of modern medicine and drag humans back to the pre-penicillin era in which routine surgery, let alone organ transplantation or chemotherapy, was a highly risky proposition.

    • Amesh A. Adalja, MD, FACP
    • Infectious disease physician at the University of Pittsburgh

    Disclosures: Adalja reports no relevant financial disclosures.