Carbapenem Resistance: It Keeps Spreading (and Why Medical Tourism Is a Really Bad Idea)

Two recent articles in Emerging Infectious Diseases (what? Isn’t that your favorite bedtime reading?) describe the further spread of carbapenem resistant organisms. Before we get to the articles, just to bring everyone up to speed, carbapenem resistance confers resistance to all antibiotics derived from penicillins–any drug that starts with “cef-” or “ceph-” or ends with “-penem” or “-cillin.” These genes are usually linked with resistance to other classes of antibiotics. As a result, these organisms are resistant to just about all antibiotics, and in some cases, we simply do not have any antibiotics that work.

The first article describes two patients from Bangladesh admitted to separate hospitals in Singapore who had carbapenem-resistant Klebsiella pneumoniae infections (K. pneumoniae is a relative of E. coli and lives in both the external environment as well as many human guts). The mechanism of resistance was a gene known as OXA-181 (OXA class genes are widespread in Acinetobacter) and which is relatively infrequent in carbapenem-resistant Klebsiella sp. This gene was first seen in India but cases associated with India (e.g., travel, etc.) have since been described in Oman, the Netherlands, and New Zealand. And now Singapore.

The second article is as disturbing in a different way. The authors examined twenty “seepage water samples” from rivers, lakes and water pools in streets in Hanoi, Vietnam. Two of the twenty samples yielded carbapenem-resistant K. pneumoniae (the resistance gene was a common one, NDM-1).

What we have is a region of the world, Southeast Asia, that seems to have significant carbapenem-resistance, to the extent that it’s relatively to find in the environment outside of the clinic. It’s safe to say that, in those countries, prevention has failed completely, and containment is failing.

Anyone who thinks that medical tourism is a good idea is kidding themselves (the Singapore isolates were associated with foreign patients). Although at this point, if carbapenem resistance is becoming established in commensal populations–that is, being carried in healthy people and animals–in Southeast Asia, we’re probably screwed in the U.S. It’s a matter of time, unless we adopt rigorous infection control–which is not cheap. The only good news is that a rapid testing method to identify these organisms has been developed.

Anyone think that any government led by neo-liberals (which includes the U.S.) will be able to muster the political will to spend the money to fight this problem?

Yeah, me neither.

Cited articles: Koh TH, Cao DYH, Chan KS, Wijaya L, Low SBG, Lam MS, et al. blaOXA-181–positive Klebsiella pneumoniae, Singapore [letter]. Emerg Infect Dis [serial on the Internet]. 2012 Sep [date cited].

Rie Isozumi, Kumiko Yoshimatsu, Tetsu Yamashiro, Futoshi Hasebe, Binh Minh Nguyen, Tuan Cuong Ngo, Shumpei P. Yasuda, Takaaki Koma, Kenta Shimizu, and Jiro Arikawa. Emerg Infect Dis [serial on the Internet]. August 2012 blaNDM-1–positive Klebsiella pneumoniae from Environment, Vietnam. DOI: 10.3201/eid1808.111816

Nordmann P, Poirel L, Dortet L. Rapid detection of carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis [serial on the Internet]. 2012 Sep [date cited].

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