Thursday, August 28, 2014

Carbapenem-Resistant Enterobacter cloacae Isolates Producing KPC-3 in North Dakota, USA.

A recent letter in the Emerging Infectious Diseases journal discussed the emerging threat of Carbapenem-Resistant Enterobacter cloacae (CRE) in the "far-flung" land of North Dakota (ND).

CRE infections are usually mediated by acquisition of Klebsiella pneumoniae carbapenemase (KPC) expressed by Klebsiella spp.

Klebsiella pneumoniae on a MacConkey Agar Plate
After reporting of CRE infections became mandatory in ND in 2011, 20 CRE cases were noted in 12 of 53 counties. Most cases occurred in Cass County, where ND's largest city (Fargo) is located.

Sanford Health is a 538-bed, acute-care facility that represents roughly 70% of acute-care beds in Fargo. Sanford Health is currently in the process of attempting to bring a quality healthcare product to rural areas of ND, SD and MN. Sanford has been slowly working its way west, buying out healthcare facilities and attempting to revamp healthcare in rural areas.

According to the letter, during the period between December 2011 and December 2012, all isolates of Enterobacteriacea (a large family of Gram-negative bacteria that include normal gut microbiota, pathogens, and normal gut microbiota that can become pathogens in certain circumstances) with reduced susceptibility to ertapenem (MIC > 1 ug/mL) identified at the hospital's clinical microbiology laboratory were screened for carbapenemase production using the modified Hodge tests (mHT)

Ertapenem is a carbapenem antibiotic (broad-spectrum beta-lactam) marketed by Merck as Invanz. Ertapenem has been designed to be effective against both Gram-negative and Gram-positive bacteria. It is not active against Methycillin-resistant Staphylococcus aureus (MRSA), ampicillin-resistant enterococci, Pseudomonas aeruginosa, or Acinetobacter species.

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Identification and sensitivity testing were done with the MicroScan system and MICs of carbapenems were done with Etest.

MicroScan System

Etest - Biomerieux










The 20 patients from whom KPC-producing CRE isolates were obtained had been hospitalized at Sanford Health during the three months before CRE isolation; of the 20, 13 were admitted to intensive care. 13 was also the number of patients that had been admitted to the long-term care facility during the year before CRE isolation. Co-colonization with multi-drug resistant bacteria was documented in 16 patients, including extended-spectrum beta-lactamase producing and carbapenem-resistant organisms in four and two patients respectively. Seven of the documented patients died with three of those deaths being attributed to the CRE infection.

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The authors end with...

"This outbreak of KPC-producing E. cloacae infections in a health care system in North Dakota highlights the infection control challenges of long-term care facilities and the potential role they play in CRE dissemination."

CRE's have been identified in almost every state in the U.S. and with rising rates, figure to be an important factor for every infectious disease practitioner.

  • Lance D. Presser has a PhD in microbiology and immunology and is a clinical/public health laboratorian.
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Saturday, August 9, 2014

New Smallpox Relative Discovered in Georgia (the country).

Smallpox Virus - False colored to demonstrate structure
Smallpox. It has been in the news a lot lately due to the recent discovery of viable virus tucked away in storage at a government facility in Maryland.

Smallpox killed an estimated 300 to 500 million people in the 1900's until it was eradicated in the late 1970's by an aggressive worldwide vaccination campaign.

Smallpox relatives are also particularly virulent. Other members of the orthopoxvirus family include cowpox, monkeypox, vaccinia, etc.

Recently, the CDC has announced a new orthopoxvirus that was discovered in three people from the nation of Georgia in Western Asia. Two of which were herdsmen who had daily contact with cows and other livestock.

Both men had painful blisters covering their body, swollen lymph nodes, and high fevers. 

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It is believed that the new poxvirus spread to the two men from cattle. Most of the orthopoxviruses typically infect animals, then jump to humans who have close contact with animals carrying viruses. The new poxvirus is as yet unnamed since little is known about it, however thus far, no human to human spread has been documented.

The CDC interviewed 55 people who had contact with the herdsmen or their cattle. It was found that of nine interviewees (who were not previously vaccinated for smallpox) five had orthopoxvirus antibodies. It was also discovered that some of the herdsmen's cows had previously been exposed, more than likely by the rodents that live in the area.
Johann Friedrich Voltz - Herdsman and cows, in the distance a village
Issues like these continue to pop up. Nature can be difficult to predict. Not to be reactionary, but what if an "as virulent" relative of smallpox emerged? People are notorious for being terrible at risk-assessment and while I understand why people overreact to Ebola or Influenza, I don't understand why those overreactions don't translate to proper scientific research. 

I encourage everyone to use the comments section below!
  • Lance D. Presser has a PhD in microbiology and immunology and is a public health laboratorian.
  • Hire Lance for any of your microbiology, virology, teaching, editing, grant writing, or public health consulting needs.
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Friday, August 8, 2014

Hantavirus in North Dakota

Earlier this summer, it was reported by the North Dakota State Health Department that a case of Hantavirus Pulmonary Disease resulted in the death of an infected adult.
Hantavirus disease transmission cycle
It is the first case of the disease since 2009 and only 12 cases have been reported to the state health department since 1993. There have been seven total recorded deaths in North Dakota including the most current this year.

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I am honestly surprised that the number of reported cases and mortality is as low as it is in the state of ND and the rest of the upper Midwest. When Hantavirus was first reported, I thought it would have a much larger impact on the state. 

ND is an extremely rural, large farming industry state, with a relatively large percentage of older farmers. The deer mouse is extremely prevalent in the state and I contacted them numerous times growing up on a farm when I was young. 

Another aspect is exposure; activities such as shoveling and sweeping grain bins, train cars, storage sheds, barns, etc. are all extremely common.

I think it is important to remember that the best way to avoid exposure (look at the diagram above) is to avoid dust or cleaning buildings with large populations of deer mice.  


I encourage everyone to use the comments section below!
  • Lance D. Presser has a PhD in microbiology and immunology and is a public health laboratorian.
  • Hire Lance for any of your microbiology, virology, teaching, editing, grant writing, or public health consulting needs.
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Sunday, August 3, 2014

Heartland Virus

The Oklahoma State Health Department recently confirmed the state's first case, and death of Heartland virus.
Lone Start Tick - Centers for Disease Control - Division of Vector Borne Infectious Diseases
A resident of Delaware County (North East corner of the state) was the victim of complications of the virus.

The Heartland virus is spread via the bite of a Lone Star tick (Amblyomma americanum), which has established it self primarily in the United States South East.
Lone Star Tick distribution in the U.S.A. - Centers for Disease Control
Heartland virus was first identified in 2009 with cases in Missouri. This case in Oklahoma is the 10th person confirmed with the virus and the 2nd person to die from Heartland. Other cases have been documented in Missouri and Tennessee.

Symptoms of Heartland virus can include fever, fatigue, headaches, muscle aches, loss of appetite, nausea, bruising easily, and diarrhea. There is no routine
testing available for Heartland virus. However, protocols are in place
for investigational diagnostic testing.

As this is an emerging pathogen, there is currently no vaccine or drug to prevent or treat the disease. Preventing bites from ticks and mosquitoes is the best way to limit your chances of infection of Heartland, and multiple other infections.

I encourage everyone to use the comments section below!
  • Lance D. Presser has a PhD in microbiology and immunology and is a public health laboratorian.
  • Hire Lance for any of your microbiology, virology, teaching, editing, grant writing, or public health consulting needs.
  • Follow Lance @ldpsci