Treating KPCs? - Eat Yogurt? NOT

CNN's advice for KPCs? - Eat Yogurt

In a recent piece on CNN, Elizabeth Cohen discusses the recent KPC outbreak in SoCal.  She offers some advice to patients and families as to how they can help prevent these 'superbug' infections under the heading "sorting fact from fiction."  Let's go through this: 1) Wash hands - check  2) Remove unnecessary catheters - check  and ....3) Eat Yogurt.?!?  What the?  To be fair, when she was challenged by the other news person, she backed off and said yogurt prevented some infections and not specifically KPCs, but why include it in the graphic?  Was yogurt the fiction to the hand hygiene fact?  Is the data even suggestive that yogurt "prevents" C. diff? Maybe this is a case of powerpoint making us stupid because she felt the need to have at least three bullet points per slide?

A study in Altern Ther Health Med from 2005 found no benefit of a non-dairy probiotic on the gut microflora including Klebsiella. The CNN article quotes my long lost co-fellow Mitch Schwaber, who was the author of the Israeli KPC outbreak that we highlighted last week. Hopefully Mitch will be in Dallas and I can ask him about the yogurt...

Blaming the health care worker: KPCs in Ireland

Mike posted yesterday about KPCs in LA, and now there is a report of a KPC outbreak in Ireland. I have read several reports of the outbreak, which involved 5-7 patients (two infected, three colonized) at the Mid-Western Regional Hospital in Limerick, and there is one consistent aspect to what is reported:  It's the health care workers fault. See the article "Hospital Staff Warned" in the Irish Times.

The articles state that "steps had been taken to improve hand hygiene standards among hospital staff but warned that a zero-tolerance approach was being enforced in respect of anyone who failed to comply with these standards" and that "This will include disciplinary action and or notification to relevant professional registration bodies if warranted in any particular case." 

Mike has written before about the dangers of this adversarial approach to infection prevention, so I won't belabor the point.  However, when the authorities state that they are already doing everything right since MRSA and C. diff prevention efforts are all you need to control KPC, I get a bit worried.  There is no evidence that this one-size-fits-all approach works for infection prevention.  Yes, compliance with infection prevention is important, but there must be other approaches besides punishing the health care worker that will protect our patients. 

The larger problem is that little to no research funding is available to study the epidemiology and optimal prevention methods for Gram-negative (or Gram-positive) bacteria.  Before we blame the health care worker, perhaps we could ask why there is almost no funding for infection prevention research and implementation and why there are no new antibiotic classes in the pipeline.  You do get what you pay for...

KPCs in LA

In the previous post, we learned from Eli that MRSA is going away. But there's no rest for hospital epidemiologists. The LA Times reports today that in the last 6-months of 2010 there were more than 350 cases of carbapenemase-producing Klebsiella pneumoniae infections reported from healthcare facilities in LA County. The epicenter appears to be long-term care facilities. Given the lack of treatment options for these pathogens, this is a very disturbing development.

Regional Control of a large KPC outbreak: The Israeli Experience

The oubreak DID NOT occur here.
However, it IS St. Patrick's Day.

Hello everybody.  I hope you're all having a great St. Patrick's Day and a great Match Day.  Not sure those two days should be combined, at least for the safety of the future of the medical profession, but for some reason, that decision is not left up to me...

There is a report out electronically in CID (scheduled for April 1) by Mitch Schwaber et al. that describes the containment of a country-wide, carbepenem-resistant Klebsiella pneumoniae outbreak in Israel.  The outbreak of a highly-resistant strain, typically susceptible only to gentamicin and colistin, began in 2006 in multiple Israeli hospitals. The resistance was mediated by KPC-3 and local efforts to control the outbreak were largely unsuccessful. By March 31, 2007 there had been 1275 patients in 27 hospitals affected (13,040 beds).

In March 2007, the Israel Ministry of Health implemented a 3 component intervention: 1) Mandatory reporting of every patient with a carbepenem-resistant Enterobacteriaceae (CRE); 2) mandatory contact isolation of all known CRE carriers within self-contained nursing units in single rooms or cohorts with dedicated equipment AND dedicated nursing; and 3) creation of a nationwide task-force with statutory authority to intervene as necessary to control the outbreak.

Did it all work?  Well, they probably wouldn't have published this if it didn't work. They'd still be working too hard trying to stop the problem!  From the peak of 185 cases (56 cases/100,000) in March 2007 (92% of CREs were Klebsiella) infections fell to a low of 45 (12 cases/100,000) in May 2008, a 79% decline. I have pasted the incidence curve below. So it worked, but there are still too many CREs. If they let their guard down, the outbreak could easily reoccur.

As far as the study design, the usual caveats apply.  Despite great statistical control, they did not include a non-equivalent control group, etc, so perhaps these findings could be partially explained by regression to the mean or other biases, such as non-recorded interventions. Do I think that is what is going on here?  No.  I think the nationwide effort probably worked and their analysis and interpretation are correct.  This overwhelming response might be needed more often in the future given the lack of new antimicrobials, poor overall support for infection control (everywhere, not just in Israel) and continued overuse of the antimicrobials we do have.

Reference: Schwaber MJ et al. CID April 2011

Note: Dan posted on the CDC Guidance for Carbapenem-Resistant Enterobacteriaceae a couple years ago.

Ctrl+F

…will bring up the “Find and Replace” tool in Microsoft Word. Illinois legislators, you may want to use this tool today, so you can get yourselves a shiny new law to deal with the latest emerging antimicrobial resistance threat.

Hint: you’ll want to find “MRSA”, and replace with “KPC”. Make sure to go to “search options” and click on “Match Case”, or you’ll mess it all up.

That should do it.

Links:
Illinois screening legislation
IDSA abstract on emergence of KPC-producers in Illinois
Chicago Tribune story