On August 25, 2016, the Washoe County Health District in
Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-resistant
Enterobacteriaceae (CRE) that was resistant to all available antimicrobial
drugs. The specific CRE, Klebsiella
pneumoniae, was isolated from a wound specimen collected on August 19,
2016. After CRE was identified, the patient was placed in a single room under
contact precautions. The patient had a history of recent hospitalization
outside the United States. Therefore, based on CDC guidance, the isolate was
sent to CDC for testing to determine the mechanism of antimicrobial resistance,
which confirmed the presence of New Delhi metallo-beta-lactamase (NDM).
The patient was a female Washoe County resident in her
70s who arrived in the United States in early August 2016 after an extended
visit to India. She was admitted to the acute care hospital on August 18 with a
primary diagnosis of systemic inflammatory response syndrome, likely resulting
from an infected right hip seroma. The patient developed septic shock and died
in early September. During the 2 years preceding this U.S. hospitalization, the
patient had multiple hospitalizations in India related to a right femur
fracture and subsequent osteomyelitis of the right femur and hip; the most
recent hospitalization in India had been in June 2016.
Antimicrobial susceptibility testing in the United States
indicated that the isolate was resistant to 26 antibiotics, including all
aminoglycosides and polymyxins tested, and intermediately resistant to
tigecycline (a tetracycline derivative developed in response to emerging
antibiotic resistance). Because of a high minimum inhibitory concentration
(MIC) to colistin, the isolate was tested at CDC for the mcr-1 gene, which confers plasma-mediated
resistance to colistin; the results were negative. The isolate had a relatively
low fosfomycin MIC of 16 μg/mL
by ETEST. However, fosfomycin is approved in the United States only as an oral
treatment of uncomplicated cystitis; an intravenous formulation is available in
other countries.
A point prevalence survey, using rectal swab specimens
and conducted among patients currently admitted to the same unit as the
patient, did not identify additional CRE. Active surveillance for
multidrug-resistant bacilli including CRE has been conducted in Washoe County
since 2010 and is ongoing; no additional NDM CRE have been identified.
The BBC Health described
that the analysis found the superbug was resistant to all 26 available
antibiotics in the US including the "drug of last resort" - colistin.
