Carbapenem-resistant K. pneumoniae surfaces in LA County facilities

DALLAS — More cases of carbapenem-resistant Klebsiella pneumoniae, previously thought to have been contained to eastern US facilities and communities, have been reported in Los Angeles County, particularly in long-term acute care hospitals, according to results presented by Dawn Terashita, MD, MPH.

“We do not know if the presence of [carbapenem-resistant K. pneumonia] in these long-term acute care settings is the result of improper care or has more to do with the population they serve,” Terashita, of the LA County Department of Public Health, said during a telebriefing in advance of the Society for Healthcare Epidemiology of America 2011 Annual Scientific Meeting. “We were especially surprised to discover the higher rate of [carbapenem-resistant K. pneumonia] among patients in long-term acute care hospitals compared to general acute care hospitals across the country.”

After carbapenem-resistant K. pneumonia was declared a laboratory-reportable disease in LA County in June, officials requested for all 102 acute care hospitals and five reference laboratories in the county to submit results on susceptibility testing among those who tested positive for carbapenem-resistant K. pneumonia.

The researchers monitored disease existence and assessed patient characteristics among cases reported between June and December. A total of 356 cases of carbapenem-resistant K. pneumoniae were identified in 52 of the acute care hospitals and in one regional laboratory. Specifically, 41% were reported from all eight long-term acute care hospitals in the county; only 6% were reported in skilled nursing facilities.

Terashita said there is currently no explanation for these high rates, given that these patients are already at a greater risk for heath care-acquired infections based on several contributing factors.

“These patients tend to be elderly, they are commonly on ventilators, and they often stay at the facility for an extended period of time,” she said. “They tend to have many health problems and are often placed on antibiotics, which may or may not be appropriate.”

Heightened awareness is necessary because patients tend to travel frequently between skilled nursing facilities and long-term acute care hospitals, according to Terashita. New guidelines are recommended on proper infection control, hand hygiene and appropriate use of antibiotics to control multidrug-resistant pathogens.

“Our next steps will be to continue surveillance and gather risk-specific data for targeted intervention. There is a need for public health to monitor the development of [carbapenem-resistant K. pneumonia] and other emerging pathogens more closely in health care facilities, including [long-term acute care hospital settings],” Terashita said. – by Ashley DeNyse

For more information:

• Terashita D. #359. Presented ahead of: the SHEA 2011 Annual Scientific Meeting; April 1-4, 2011; Dallas.

Disclosure: Dr. Terashita reports no relevant financial disclosures.

This report from LA doesn't surprise me.Carbapenem-resistant Klebsiella do not know geography — they can go anywhere. However, surveillance studies to determine the extent highly resistant potential pathogens have penetrated a region or single health care facility is very useful. Hopefully, preventive efforts can diminish the further spread of multiantibiotic class resistant Klebsiella that produce the poorly named KPC( Klebsiella Pneumoniae Carbapenemase) which has also been found in non-Klebsiella Enterobacteraciae. No bacterial disease has been eliminated by vaccine, quarantine, or treatment, so money spent controlling spread guided by surveillance data is a good use of our limited resources.

– George A. Pankey, MD
Infectious Disease News Editorial Board member

Disclosure: Dr. Pankey reports no relevant financial disclosures.

I think this is an important study because it's the first time that we've had a geographic area that sought out and attained detailed information on the state of affairs, if you will, with these organisms in their entire area. And that is critically important when we talk about these drug-resistant bacteria that clearly don't respect the borders of different health care facilities. Knowing what is going on in all of the facilities in any given area is very important. So I think the study is incredibly important and I think it establishes a model for how we need to work across all of the different health care facilities in a given city, county, and state to really understand what's going on with these drug-resistant bacteria in those areas. From this, we can determine how best to prevent the spread.

– Arjun Srinivasan, MD, FSHEA, CDR USPHS
Medical director, Get Smart for Healthcare, CDC

Disclosure: Dr. Srinivasan reports no relevant financial disclosures.

Carbapenem-producing Enterobacteriaceae, usually Klebsiella pneumoniae, have been the cause of nosocomial outbreaks of infection along the East coast and in Chicago with smaller outbreaks in other parts of the country. In fact, isolates have been reported in over two-thirds of the states in the US, and that is probably just the tip of the iceberg. It is not surprising that they are also established in Los Angeles. As the saying goes 'seek and ye shall find'. Without knowing the indication for the cultures or the denominator of how many patients or cultures were available in each setting, hospital, long term acute care facility (LTAC) and skilled nursing facility (SNF), it is impossible to make valid prevalence or attack rate comparisons. For example, were there surveillance cultures as well as cultures of active infection? From personal experience, cultures are much less likely to be obtained in SNFs than more acute facilities. The carrier rate of resistant organisms is likely to be high in SNFs, but actual culturable infections are less common than generally thought in well run SNFs. If indwelling catheters are restricted and asymptomatic bacteria is not cultured (as it shouldn't be), there are not large numbers of urinary cultures. Sputum cultures are very difficult to obtain in the SNF situation. Similarly there should be few decubiti to culture in well run SNFs. Therefore comparing acute care settings with SNFs in terms of isolates is very difficult without much more information.

– Donald Kaye, MD
Infectious Disease News Editorial Board member

Disclosure: Dr. Kaye reports no relevant financial disclosures.

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