Inquiry about resistant bacteria strains overseas

[Jack-of-all-trades]

This is part of a CME thing from Web MD. I just copied the pertinent stuff about overseas care. The KPCs are Klebsiella pneumoniae bacteria and the NDM-1 is a type of Enterobacter from New Delhi. More reasons to not take antibiotics for common colds which are viruses.

Dr. Kallen: Yes, there's an article in Clinical Infectious Diseases that came out in 2009 that described 2 pan-resistant KPCs found in New York City.[3] So, they do appear sporadically already with the KPCs and other forms of carbapenem resistance. We haven't seen it in NDM-1 yet but of course we've only seen 3 isolates.

Medscape: What's the approach when an infection is totally resistant to antibiotics? Is it just supportive?

Dr. Kallen: It varies and depends on the type of infection. Sometimes infections can get better if the source is drained, or, if there's a device involved, it can be removed. However, again, this type of resistance obviously makes infections much more difficult to treat.

Medscape: Is there any indication that medical tourism will be a significant factor in spreading these resistant bacteria, and how would a doctor counsel a patient who wants to go abroad for medical or surgical treatment?

Dr. Kallen: The first thing I want to point out is that of the 3 isolates that we had in the United States so far, none were results of medical tourism, so at least in this country we haven't recognized that as a problem. Certainly, we acknowledge that it's a potential problem, and your readers can get more information from the CDC's Yellow Book, which has a section about medical tourism. One thing to keep in mind of course is that when people go for medical care in the United States, many organizations, including the CDC, the Department of Health and Human Services, and others try to ensure that patient care meets certain standards for quality and safety. When people travel outside the United States for medical care, we no longer have control over these aspects. It is important then for patients to be cognizant of that fact and to do the best they can to obtain good information on levels of quality either from the medical centers where they're going or from the people who are sending them there.

Medscape: What other precautions should be taken to prevent the spread of resistant bacteria? Of course, we know overprescribing antibiotics is a big problem, but are there any other precautions that clinicians can take or patients can take to help reduce the risk either when traveling abroad or here in the United States?

Dr. Kallen: Speaking specifically to the carbapenem-resistant strains, in 2009 the CDC published recommendations for acute care facilities on how to control these isolates.[4] This isn't just for NDM-1; it's for all carbapenem-resistant strains. We need to do a better job promoting those kinds of recommendations, which include making sure that these isolates are recognized. Carbapenem-resistant strains are very common in some parts of the United States, but some places haven't seen many of them yet and still have the potential to intervene and to prevent these strains from becoming endemic.

Dr. Limbago: I want to add that the 2009 MMWR report that Dr. Kallen referred to talks about detection and infection control to prevent the spread of carbapenem-resistant Enterobacteriaceae. There's also a brief MMWR report this year describing the detection of the NDM.[5]

In that second report, we ask that clinicians who identify a patient with carbapenem-resistant Enterobacteriaceae, especially in a nonendemic area, inquire specifically about whether that patient has been to India or Pakistan and whether he or she received medical care there. Then, the clinicians should forward on to their state labs and CDC any isolates associated with travel and medical care in those countries.

Medscape: Thanks so much for taking the time to talk to us.

[Katie]

Thank you for posting this.

The risk of infection was one of my biggest worries going into surgery. Every other time I have been in hospital, especially for surgery, I have come home with a very tenacious infection.

In fact, the cleanliness of the Brazilian hospital was one of the things I liked most about having my surgery there. I have no doubt that I would have had another infection if I had stayed here in Canada for the procedure. The hospital in Sao Paulo was spotless, and didn't even have the typical hospital odour. The ratio of staff to patient was very high, and the rooms were cleaned thoroughly every day. And this is in a very old building, albeit the wing we were in was newly renovated.

I was in surgery for over seven hours, which gave plenty of time for those nasty bugs to slip in, but no, there was no resulting infection.

It was also the reason I had originally hoped to go to Germany for surgery. Several of my in-laws have lived there for a number of years, and often said that their garages were cleaner than our hospitals. So I think that the risk to patients can more often come from home than abroad. A big reason for this is because of the budget cuts that prevent the proper maintenance required.

[Justin]

This is part of a CME thing from Web MD. I just copied the pertinent stuff about overseas care. The KPCs are Klebsiella pneumoniae bacteria and the NDM-1 is a type of Enterobacter from New Delhi. More reasons to not take antibiotics for common colds which are viruses.

This is very true JOAT. It's unfortunate that patients demand antibiotics for common "colds" that are most likely viral in nature.

[KBear]

This is very true JOAT. It's unfortunate that patients demand antibiotics for common "colds" that are most likely viral in nature.

I know this is a huge problem with pediatrics, as many parents demand antibiotics and there are studies showing that most pediatricians will prescribe an antibiotic if the parent asks/insists. When we interviewed our pediatric office they flat out told us, we will not give you an antibiotic because you ask and only when we feel it will help the situation. They are a conservative practice when it comes to medication and referring out for surgery, which I like.

My older daughter has maybe had antibiotics twice in her life. My younger was sickly and had tons of ear infections, that would not clear up, would go on an antibiotic, still not clear up, go on another antibiotic and sometimes clear up or would have to get a shot. At 11 months she had tubes put in.... they didn't help and she kept getting ear infections. Finally at 15 months she had new tubes put in and her adenoids removed and that did the trick. I hate that she was on antibiotics for so long, but she had to be. I believe she had 18 ear infections in 14 months (she got her first at 1 month old and was hospitalized because she just wouldn't eat.) It's such a fine balance between jumping the gun and doing surgery that is unnecessary and keeping putting them on medication.