Identifying and Responding to Newly Resistant Infections

August 28, 2019

Notes from the field detailing a case of a patient with a Klebsiella pneumoniae isolate with 3 carbapenem resistance genes can help guide practices against antibiotic resistance.

In the world of growing antimicrobial resistance, the identification of patients with highly resistant (or newly resistant) infections is critical. Because this is an emerging challenge, national and international surveillance efforts are still being strengthened to tackle all the avenues that contribute to antimicrobial resistance. The frontline identification of these newly resistant infections is critical though and surveillance is not only the first step in identifying and understanding the problem, but it also allows us to properly isolate the patient to avoid further transmission.

Bacteria like Klebsiella pneumoniae are increasingly developing resistance to antimicrobials and can easily be spread through health care facilities. Klebsiella bacteria are also showing a relatively new resistance to the carbapenem class of antibiotics. Typically, these bacteria cause infections like pneumonia, bloodstream infections, wound or surgical site infections, and even urinary tract. A recent publication in the US Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR) described experiences surrounding the identification of a Klebsiella pneumoniae isolate that had 3 carbapenem-resistant genes (CR-Kp) and was related to urinary procedures.

This case was first identified in late 2018 in King County, Washington, when public health officials were notified by the Antibiotic Resistance Laboratory Network that a urine culture from a 65-year-old man had some concerning findings. “It tested positive for carbapenemase activity by the modified carbapenem inactivation method and positive for genes encoding the carbapenemases New Delhi metallo-beta-lactamase, Verona integron-encoded metallo-beta-lactamase, and OXA-48—type beta-lactamase, by polymerase chain reaction.” When antimicrobial susceptibility testing was performed, they found that that the bacteria was resistant to 15 antibiotics but had low minimum inhibitory concentrations to colistin as well. Following this observation, researchers and public health officials worked to identify where this emerging resistance could have come from.

The patient had been receiving treatment from a local outpatient urology clinic in King County, Washington, since September 2017. Treatments for this individual included cystoscopy, urinary catheter placement, and a computed tomography scan of the urinary tract. On November 1, 2018, the patient underwent outpatient urodynamic studies at a hospital in Punjab, India, which included urinary and rectal catheter placement. It was when the patient returned to the United States that persisting urinary tract infection symptoms began. A urinalysis was conducted, revealing an elevated white blood cell count. From there, a urinary culture was conducted and the highly resistant organism was identified.

Following the identification of CR-Kp, the patient and his family were provided education about preventing the spread of the organism at home. The family was also instructed to share this information with all future health care providers during medical visits. The outpatient urology clinic he visited was repeatedly inspected by 2 different public health agencies to ensure that proper infection control measures were in place. It was recommended that the patient be placed under contact isolation precautions going forward.

The authors of this report emphasized that not only is antimicrobial resistance globally prolific, but that public health departments should consider standardized assessments for these clinics and high-risk environments to ensure infection control measures are being used appropriately. Lastly, they highlighted the importance of asking patients about recent medical care or hospitalizations in foreign countries, as this can be a high-risk factor for antimicrobial resistant infections.