Advertisement

Nosocomial outbreaks in Brazil: can they be controlled?

  • M.C.B. Tognim
    Correspondence
    Corresponding author. Address: Laboratório de Microbiologia, Departamento de Ciências Básica da Saúde, Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil. Tel.: +55 44 3011 4952; fax: +55 44 3011 4860.
    Affiliations
    Departamento de Ciências Básica da Saúde, Centro de Ciências da Saúde, Universidade Estadual de Maringá, PR, Brazil
    Search for articles by this author
  • C.L. Cardoso
    Affiliations
    Departamento de Ciências Básica da Saúde, Centro de Ciências da Saúde, Universidade Estadual de Maringá, PR, Brazil
    Search for articles by this author
Published:October 06, 2016DOI:https://doi.org/10.1016/j.jhin.2016.10.002
      Healthcare-associated infections caused by multidrug-resistant micro-organisms remain an important health problem worldwide, due to the limited treatment options. These infections increase morbidity and mortality, necessitate the use of additional resources, and prolong hospital stays.
      • Lautenbach E.
      • Perencevich E.M.
      Addressing the emergence and impact of multidrug-resistant Gram-negative organisms: a critical focus for the next decade.
      In most Brazilian hospitals, the presence of resistant bacteria, especially Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae producing SPM-1, OXA-23 or KPC-2 carbapenemases, has required a high use of polymyxins, mainly in intensive care units (ICUs).
      • Rossi F.
      The challenges of antimicrobial resistance in Brazil.
      A study conducted from January 2011 to December 2015 at 10 private tertiary care hospitals in São Paulo, including 3085 K. pneumoniae isolates, showed an alarming yearly increase in the rate of polymyxin-B resistance among carbapenem-resistant K. pneumoniae isolates (0% to 27.1%), mostly K. pneumoniae carbapenemase type 2 (KPC-2)-producing strains. The occurrence of inter- and intra-hospital dissemination of carbapenem- and polymyxin-resistant K. pneumoniae from clonal complex 258 was observed.
      • Bartolleti F.
      • Seco B.M.S.
      • dos Santos C.C.
      • et al.
      Polymyxin B resistance in carbapenem-resistant Klebsiella pneumoniae, São Paulo, Brazil.
      This issue of the Journal includes an interesting study by Gonçalves et al. describing two outbreaks of KPC-producing K. pneumoniae in a Brazilian adult ICU.
      • Rossi Gonçalves I.
      • Ferreira M.L.
      • Araujo B.F.
      • et al.
      Outbreaks of colistin-resistant and colistin-susceptible KPC-producing Klebsiella pneumoniae in a Brazilian intensive care unit.
      The outbreaks were associated with previous consumption of carbapenems and, to a lesser extent, colistin. Mortality rates were 42.9% and 44.4% for colistin-susceptible KPC-producing strains and colistin-resistant KPC-producing strains from infected patients, respectively. Traditional control measures were inadequate to halt the outbreaks. The results of this study demonstrate the risk presented by these organisms in a healthcare institution. The authors propose that selective pressure from antibiotic overuse and transmission via the hands of healthcare workers were likely the major factors in the transmission of KPC-producing K. pneumoniae. A similar problem with A. baumannii has also been encountered in our institution.
      • Viana G.F.
      • Zago M.C.B.
      • Menegucci T.C.
      • et al.
      Change in the dissemination mode of multidrug-resistant Acinetobacter baumannii isolates after implementation of control measures.
      In Brazil the acquisition of antibiotics from pharmacies by the general community has been restricted since 2011; however, in-hospital use is not restricted, a situation that may facilitate the development of resistance.

      Agencia Nacional de Vigilância Sanitária (Brasil). RDC no 20, 5 de Maio de 2011. Dispõe sobre o controle de medicamentos à base de substâncias classificadas como antimicrobianos, de uso sob prescrição, isoladas ou em associação. Diário Oficial da União no 87, 9 de maio de 2011. Seção 1, páginas 39 a 41. Available at: http://portal.anvisa.gov.br/ [in Portuguese; last accessed October 2016].

      Braun et al. have recently reported that different mechanisms of resistance to polymyxin-B may be related to genes that might emerge after polymyxin therapy.
      • Braun G.
      • Cayô R.
      • Barbosa A.C.N.
      • Gales A.C.
      In vivo emergence of polymyxin B-resistant Klebsiella pneumoniae in patients with bloodstream infections.
      This understanding was possible due to the analysis of seven pairs of KPC-2-producing K. pneumoniae composed of a polymyxin-B-susceptible and polymyxin-B-resistant isolate, before and during/after polymyxin therapy.
      • Braun G.
      • Cayô R.
      • Barbosa A.C.N.
      • Gales A.C.
      In vivo emergence of polymyxin B-resistant Klebsiella pneumoniae in patients with bloodstream infections.
      In Brazil, the National Network of Microbial Resistance Monitoring in Health Services created by the Brazilian National Health Surveillance Agency determines the obligation to send samples of resistant bacteria to reference laboratories of the State for epidemiological monitoring studies. Yet, there is no ongoing education for healthcare workers related to the investigation or notification of outbreaks of multidrug-resistant bacteria.

      Agência Nacional de Vigilância Sanitária − ANVISA (Brasil). Boletim de Segurança do Paciente e Qualidade em Serviços de Saúde no 12. Rede Nacional de Monitoramento da Resistência Microbiana em Serviços de Saúde − Rede RM. Brasília, 31 de dezembro de 2015. Available at: http://portal.anvisa.gov.br/ [in Portuguese].

      This important subject is covered in this issue by Maciel et al.
      • Maciel A.L.P.
      • de Carvalho B.A.
      • Timmons S.
      • Padoveze M.C.
      Barriers to investigating and reporting nosocomial outbreaks to health authorities in São Paulo, Brazil: a mixed methods approach.
      The authors describe barriers to investigating and reporting nosocomial outbreaks to health authorities in São Paulo, Brazil. In the area studied, the obstacles include difficulty in translating the knowledge gained from investigating the outbreak into practice, weaknesses in planning in the outbreak investigation process, and the organizational culture. In the reporting context, the barriers included lack of both awareness and autonomy in reporting outbreaks to public health authorities.
      • Maciel A.L.P.
      • de Carvalho B.A.
      • Timmons S.
      • Padoveze M.C.
      Barriers to investigating and reporting nosocomial outbreaks to health authorities in São Paulo, Brazil: a mixed methods approach.
      A multi-centre antimicrobial resistance surveillance study investigated colistin resistance between 2000 and 2016 in Brazil. A total of 4620 Enterobacteriaceae isolates were collected, and it was determined that the mcr-1 gene-harbouring strain of Escherichia coli has been occurring in food-producing animals since 2012, including colistin-susceptible isolates. None of the isolates from humans was carrying the mcr-1 gene, although the majority of them (9/16) carried CTX-M genes, further facilitating its dissemination.
      • Fernandes M.R.
      • Moura Q.
      • Sartori L.
      • et al.
      Silent dissemination of colistin-resistant Escherichia coli in South America could contribute to the global spread of the mcr-1 gene.
      It is clear from the approaches taken by the two articles in this issue that the control of outbreaks of multidrug-resistant organisms in Brazilian hospitals is hampered by several factors related to the lack of human resources and inadequate infrastructure. Furthermore, antibiotic selection pressure due to their high use in hospitals is a crucial factor in the emergence and dissemination of multidrug-resistant bacteria. The present nightmare situation of colistin resistance in KPC-producing isolates shows that the problem is nearly beyond control. Effective governmental programmes should be established in order to improve the healthcare situation, from ongoing education of health professionals to the politics of health management. Otherwise, within a few years the country will have entered the post-antibiotic era.

      References

        • Lautenbach E.
        • Perencevich E.M.
        Addressing the emergence and impact of multidrug-resistant Gram-negative organisms: a critical focus for the next decade.
        Infect Control Hosp Epidemiol. 2014; 35: 333-335
        • Rossi F.
        The challenges of antimicrobial resistance in Brazil.
        Clin Infect Dis. 2011; 52: 1138-1143
        • Bartolleti F.
        • Seco B.M.S.
        • dos Santos C.C.
        • et al.
        Polymyxin B resistance in carbapenem-resistant Klebsiella pneumoniae, São Paulo, Brazil.
        Emerg Infect Dis. 2014; 22: 1849-1851
        • Rossi Gonçalves I.
        • Ferreira M.L.
        • Araujo B.F.
        • et al.
        Outbreaks of colistin-resistant and colistin-susceptible KPC-producing Klebsiella pneumoniae in a Brazilian intensive care unit.
        J Hosp Infect. 2016; 94: 322-329
        • Viana G.F.
        • Zago M.C.B.
        • Menegucci T.C.
        • et al.
        Change in the dissemination mode of multidrug-resistant Acinetobacter baumannii isolates after implementation of control measures.
        J Hosp Infect. 2016; 93: 217-220
      1. Agencia Nacional de Vigilância Sanitária (Brasil). RDC no 20, 5 de Maio de 2011. Dispõe sobre o controle de medicamentos à base de substâncias classificadas como antimicrobianos, de uso sob prescrição, isoladas ou em associação. Diário Oficial da União no 87, 9 de maio de 2011. Seção 1, páginas 39 a 41. Available at: http://portal.anvisa.gov.br/ [in Portuguese; last accessed October 2016].

        • Braun G.
        • Cayô R.
        • Barbosa A.C.N.
        • Gales A.C.
        In vivo emergence of polymyxin B-resistant Klebsiella pneumoniae in patients with bloodstream infections.
        J Hosp Infect. 2016; 94: 338-340
      2. Agência Nacional de Vigilância Sanitária − ANVISA (Brasil). Boletim de Segurança do Paciente e Qualidade em Serviços de Saúde no 12. Rede Nacional de Monitoramento da Resistência Microbiana em Serviços de Saúde − Rede RM. Brasília, 31 de dezembro de 2015. Available at: http://portal.anvisa.gov.br/ [in Portuguese].

        • Maciel A.L.P.
        • de Carvalho B.A.
        • Timmons S.
        • Padoveze M.C.
        Barriers to investigating and reporting nosocomial outbreaks to health authorities in São Paulo, Brazil: a mixed methods approach.
        J Hosp Infect. 2016; 94: 330-337
        • Fernandes M.R.
        • Moura Q.
        • Sartori L.
        • et al.
        Silent dissemination of colistin-resistant Escherichia coli in South America could contribute to the global spread of the mcr-1 gene.
        Euro Surveill. 2016; 21 (pii=30214)