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Notes from the Field: Verona Integron-Encoded Metallo-Beta-Lactamase–Producing Carbapenem-Resistant Enterobacteriaceae in a Neonatal and Adult Intensive Care Unit — Kentucky, 2015

Weekly / February 26, 2016 / 65(7);190


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Anna Q. Yaffee, MD1,2; Lynn Roser, MSN2; Kimberly Daniels2; Kraig Humbaugh, MD2; Robert Brawley, MD2; Douglas Thoroughman, PhD2,3; Andrea Flinchum, MPH2 (View author affiliations)

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During August 4–September 1, 2015, eight cases of Verona integron-encoded metallo-beta-lactamase (VIM)–producing Carbapenem-resistant Enterobacteriaceae (CRE) colonization were identified in six patients, using weekly active surveillance perirectal cultures in a Kentucky tertiary care hospital. No cases of clinical infection or complications attributable to colonization were reported. Four of the eight isolates were identified as Enterobacter cloacae; other organisms included Raoultella species (one), Escherichia coli (one), and Klebsiella pneumoniae (two). Six isolates were reported in a neonatal intensive care unit (ICU), and two isolates in an adult trauma and surgical ICU. Patient ages at isolate culture date ranged from 21 days to 68 years. Fifty percent of the patients were male. Previously, only one VIM-producing CRE-colonized patient (an adult, in 2013) had been reported by the same hospital. The six cases are the largest occurrence of VIM-producing CRE colonization reported in the United States and the only recognized cluster of VIM-producing CRE colonization in the United States reported to include a neonatal population. Despite environmental sampling over the same period, surveying patients for exposure to health care outside the United States, surveying health care providers for risk factors, and surveillance culturing of health care provider nares and axillae, a source of VIM-producing CRE has not been identified for this cluster. Prevention measures throughout the ICUs have been enhanced in response to this cluster, as detailed in CDC’s 2015 CRE toolkit update (1).

CRE are defined as any Enterobacteriaceae species resistant to any carbapenem or possessing a documented carbapenemase (2). Outbreaks of VIM-producing CRE have been described previously, including outbreaks in pediatric and neonatal populations in Spain (3) and Hungary (4). However, both of these outbreaks involved a single CRE species (E. cloacae). The first VIM to be identified in the United States was in an adult patient with K. pneumoniae in 2006 (5).

Clinical infections with CRE have been reported, with mortality rates of up to 50% (6). Enterobacteriaceae species are a common cause of infection in both health care–associated and community-associated infections, and the potential exists for carbapenem-resistant strains to add to this burden of infections. VIM-producing CRE are a substantial threat to public health, with more complicated patient outcomes, including higher relapse rate and a prolonged duration of antimicrobial therapy (7). The carbapenemases can be transferred easily from organism to organism through plasmid exchange, facilitating spread of resistance (2).

Risk factors for CRE acquisition in the United States primarily include exposure to health care settings and antimicrobial agents (2). Travel to countries with higher prevalence also is a risk factor for acquisition, particularly of novel carbapenemases like VIM (8). Transmission is believed to be person-to-person, either via contaminated hands of health care providers or through shared equipment. Control measures focus on optimizing infection control practices. Health care facilities should follow prevention strategies outlined in CDC’s 2015 CRE toolkit update (1).

Corresponding author: Anna Q. Yaffee, vmv7@cdc.gov, 502-564-3418, ext. 4316.

1Epidemic Intelligence Service, CDC; 2Kentucky Department for Public Health; 3Career Epidemiology Field Officer, CDC.

References

  1. CDC. Facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE)—November 2015 update CRE toolkit. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. http://www.cdc.gov/hai/organisms/cre/cre-toolkit
  2. CDC. Carbapenem-resistant Enterobacteriaceae in healthcare settings. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. http://www.cdc.gov/HAI/organisms/cre/index.html
  3. Oteo J, Hernández-Almaraz JL, Gil-Antón J, et al. Outbreak of vim-1-carbapenemase-producing Enterobacter cloacae in a pediatric intensive care unit. Pediatr Infect Dis J 2010;29:1144–6. CrossRef PubMed
  4. Juhász E, Jánvári L, Tóth A, Damjanova I, Nobilis A, Kristóf K. Emergence of VIM-4- and SHV-12-producing Enterobacter cloacae in a neonatal intensive care unit. Int J Med Microbiol 2012;302:257–60. CrossRef PubMed
  5. Moland ES, Hong SG, Cleary T, Morris MI, Hanson ND, Thomson KSUS. Isolate of Klebsiella pneumoniae (KP) producing VIM metallo-beta-lactamase (MBL) and SHV-5-like ESBL. In: proceedings of the 46th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco, CA: September 27–30, 2006.
  6. Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008;29:1099–106. CrossRef PubMed
  7. Falcone M, Mezzatesta ML, Perilli M, et al. Infections with VIM-1 metallo-beta-lactamase-producing enterobacter cloacae and their correlation with clinical outcome. J Clin Microbiol 2009;47:3514–9. CrossRef PubMed
  8. Ruppé E, Armand-Lefèvre L, Estellat C, et al. High rate of actionquisi but short duration of carriage of multidrug-resistant Enterobacteriaceae after travel to the tropics. Clin Infect Dis 2015;61:593–600. CrossRef PubMed

Suggested citation for this article: Yaffee AQ, Roser L, Daniels K, et al. Notes from the Field: Verona Integron-Encoded Metallo-Beta-Lactamase–Producing Carbapenem-Resistant Enterobacteriaceae in a Neonatal and Adult Intensive Care Unit — Kentucky, 2015. MMWR Morb Mortal Wkly Rep 2016;65:190. DOI: http://dx.doi.org/10.15585/mmwr.mm6507a5.

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