A recently published report from Eurosurveillance (Nov. 12) about carbapenemase producing enterobacteriaceae (CPE) in Europe states: Cases of this germs are showing a sharp rise. About details concerning this study we asked Dr. Thomas Hauer, medical director of the German consulting centre for hygiene in Freiburg.
Mr. Hauer, what does carbapenemase producing mean exactly, and are this bacteria as dangerous as for example MRSA or Clostridium difficile?
Carbapenemases are bacterial enzymes, which enable microorganisms belonging to Gram-negative bacteria (enterobactericeae) to inactivate even broad spectrum antibiotics like Imipenem or Meropenem. These antibiotics are commonly used as a reserve for serious or life threatening infections. Gram-negative bacteria can, similar to Staphylococci or Clostridium difficile cause various nosocomial infections. Increasing resistance through carbapenemases compromises treatment options for Gram-negative bacteria with carbapenemase production (CPE) and leads therefore to a serious threat to patient safety in Europe and even human health globally.
In the introduction of the report states, that „over the last two years, the epidemiological situation of CPE worsened“. In which countries a rise is recorded, and what has to be therefore considered?
Since the launch of the “European survey of carbapenemase-producing Enterobacteriaceae (EuSCAPE)” by the European Centre for Disease Control and Prevention (ECDC) in 2012 more or less all European countries experienced increasing therapeutic problems with CPE between 2013 and 2015. A rise is one thing and the level to which the rise goes another. For example, Greece, Hungary haven no rise recorded but are already on a worrying stage 4 or higher. This means, there is not only regional spread but also interregional spread. In other countries like e.g. Poland, Romania, Slovakia and Spain a rise to this stage has now occurred. In Germany and Austria the situation has not changed dramatically, Austria being stable on stage 2b (CPE only in connection with special outbreak problems) and Germany on stage 3 (the former plus regional spread).
But one should not over-interpret marginal differences in the classification of countries which can fluctuate over time. Furthermore all countries have to treat patients from other countries with possibly higher risk profile. Important is: All European countries have to face the situation of a loss of effectivity of such an important therapeutic principle that is antibiotics.
A majority of countries reacted by establishing national CPE surveillances systems and issuing guidance on control measures for health professionals. Which are the 14 countries where there is still a lack of specific national guidelines for prevention and control of CPE?
The implementation of guidelines on the control of CPE is only one necessary step. In principle those guidelines are already available and if a small country does not issue proprietary guidelines they can adopt and translate international guidelines. But even the best CPE guideline thoroughly implemented will not be enough. The basic problems are lying much deeper and are interconnected:
We need a much more rational use of the precious resource “antibiotic” and need therefore “antibiotic stewardship” in every hospital and also for the ambulatory sector. Infectious disease specialists should be recruited and asked in difficult cases.
Simple tools of microbiologic diagnostic before starting an antibiotic are often underused, for example blood cultures and other microbiologic samples. Not establishing a diagnosis urges clinicians into over-using (and wasting) broad spectrum antibiotics like the carbapenems. As if all this would not be difficult enough Germany for example experiences right now a shortage of smaller spectrum antibiotics like Ampicillin/Sulbactam according to concentration of the production in only a few sites abroad with the accompanying dependence. Unfortunately there are no obligations for manufacturers in Germany to guaranty a certain provisioning with health care-essential drugs. As a result, doctors are even more pressurized into over-using our antibiotic reserves.
What about infection control measures using “search and destroy” like advocated by some for MRSA? This is not feasible with Gram-negative bacteria including CPE. First, our screening methods are fare from sensitive and can lead to dangerous complacency through false negative results. Second, working methods of decolonization are currently not available.
On the contrary, we need a better horizontal approach: In every patient we have to consider multi-drug resistant bugs in general. Our basic infection control measures for all patients have to get much better to prevent further spread of pathogens.
It is also striking that we should not put farm animals with their bacterial flora under general antibiotic “pressure”.
All this will cost money and manpower but doing not enough will be much more costly in economic and humanitarian terms.