BMJ 2017;356:j254 doi: 10.1136/bmj.
j254 (Published 16 January 2017)
News
Woman dies after infection with bacteria resistant to
all antibiotics available in US
Michael McCarthy
Seattle
A woman in the US died of septic shock last year after becoming
infected with carbapenem resistant Enterobacteriaceae (CRE)
that were resistant to all antimicrobial drugs available in the
US.
The bacterium, a Klebsiella pneumoniae, was found to be
resistant to 26 antibiotics, including all aminoglycosides and
polymyxins tested, and intermediately resistant to tigecycline.
The case was described in the 13 January issue of the US Centers
for Disease Control and Prevention’s (CDC) Morbidity and
Mortality Weekly Report.1 It involved a woman in her 70s living
in Washoe County, Nevada, who had lived in India for an
extended period. In the previous two years she had been
repeatedly admitted to hospital in India after fracturing her right
femur and subsequently developing osteomyelitis of the right
femur and hip. Her last admission in India was in June 2016.
She returned to the US in early August and was admitted to
hospital on 19 August with a diagnosis of systemic inflammatory
response syndrome thought to be due to an infected right hip
seroma. She developed septic shock and died in early September.
After CRE had been detected an isolate was sent to the CDC,
where the presence of New Delhi metallo-β-lactamase (NDM)
was confirmed. NDM is an enzyme that confers resistance to a
broad range of β-lactam antibiotics, including those of the
carbapenem family. The strain was first identified in 2009 in a
Swedish patient of Indian origin who had developed a urinary
tract infection while travelling in New Delhi, India.2
Because the isolate in the Nevada case had a high minimum
inhibitory concentration (MIC) to colistin, the isolate was also
tested for the mcr-1 gene, which confers plasma mediated
resistance to colistin, but the results were negative.
The report’s authors noted that CRE isolates tested by CDC are
rarely resistant to all antimicrobials: “Among >250 CRE isolate
reports collected as part of the Emerging Infections Program,
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approximately 80% remained susceptible to at least one
aminoglycoside and nearly 90% were susceptible to tigecycline,”
they wrote.
In this case the isolate had a relatively low fosfomycin MIC of
16 micrograms/mL, but, although intravenous fosfomycin is
available in some other countries including the UK, it is
approved in the US only as an oral treatment for uncomplicated
cystitis.
After CRE infection was identified the patient was placed in a
single room under contact precautions. Testing of patients
currently admitted to the same unit where she was treated has
not detected additional CRE; nor has ongoing surveillance in
Washoe County, which was initiated in 2010.
Paul Hoskisson, of the University of Strathclyde in Glasgow,
Scotland, said that the case report highlighted the importance
of infection control measures, such as testing drug susceptibility,
isolation of infected patients, and knowledge of a patient’s
medical history. “Drug resistant infections are a global problem,
and the movement of people around the world can lead to the
dissemination of drug resistant bacteria,” he said.
bmj.com Clinical Review: Antibiotic resistance in Enterobacteriaceae:
mechanisms and clinical implications (BMJ 2016;352:h6420, doi:10.
1136/bmj.h6420)
1 Chen L, Todd R, Kiehlbauch J, Walters M, Kallen A. Notes from the field: pan-resistant
New Delhi metallo-beta-lactamase-producing Klebsiella pneumoniae—Washoe County,
Nevada, 2016. MMWR Morb Mortal Wkly Rep 2017;66:33.
doi:10.15585/mmwr.mm6601a7.28081065
2 Yong D, Toleman MA, Giske CG. Characterization of a new metallo-beta-lactamase gene,
bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure
in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother
2009;53:5046-54. doi:10.1128/AAC.00774-09.19770275
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Figure

[Image: Branden Camp/PA]

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