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From the Centers for Disease Control and Prevention
November 17, 2010

Update: Detection of a Verona Integron-Encoded Metallo-Beta- Lactamase in Klebsiella pneumoniae—United States, 2010

JAMA. 2010;304(19):2122. doi:

MMWR. 2010;59:1212

On September 21, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).

In July 2010, CDC was notified of a patient with a carbapenem-resistant Klebsiella pneumoniae strain that produced a Verona integron-encoded metallo-beta-lactamase (VIM) carbapenemase1 not reported previously among Enterobacteriaceae in the United States. The patient was a woman from the United States who became ill with diarrhea during a Mediterranean cruise and was hospitalized in Greece, where she received a diagnosis of sepsis and Clostridium difficile infection. After 12 days in two hospitals in Greece, she was transferred to a hospital in the United States for continued management of sepsis and acute renal failure. On admission, blood was drawn for culture through a central venous catheter that had been placed while the patient was hospitalized in Greece. The blood subsequently grew carbapenemase-producing Klebsiella pneumoniae exhibiting the VIM resistance mechanism, which has been described previously in Greece but not in the United States. Further testing showed the isolate to be nonsusceptible to all antimicrobials usually used to treat Klebsiella. Despite the resistance of the Klebsiella strain, the patient recovered sufficiently to be discharged after 26 days in the U.S. hospital. A search for other patients colonized with the same isolate was conducted by screening 22 patients whose U.S. hospital stays overlapped with this patient; no carbapenem-resistant Enterobacteriaceae (CRE) were detected.

This report of a VIM-producing CRE follows a June 2010 report of three cases of New Delhi metallo-beta-lactamase (NDM-1)–producing Enterobacteriaceae.2 However, the most common mechanism of carbapenem resistance among Enterobacteriaceae in the United States remains the production of the Klebsiella pneumoniae carbapenemase (KPC). KPC-producing Enterobacteriaceae are widespread in the United States and other countries.3 Cases of CRE are a significant, emerging public health problem regardless of the mechanism of carbapenem resistance, and procedures to rapidly recognize and report CRE cases to infection prevention personnel should be in place in all acute and long-term—care facilities. Facilities that have not identified cases of CRE should undertake periodic laboratory reviews to identify cases. Patients with CRE should be managed using contact precautions, and patients exposed to CRE patients (e.g., roommates) should be screened with surveillance cultures.3 State and local health departments should promote adoption of current prevention guidance and monitoring of the prevalence of these organisms in their jurisdictions.3 Public health officials and health-care facility staff can consult with the Division of Healthcare Quality Promotion at CDC on the best practices for identifying and preventing transmission of these organisms (e-mail: hip@cdc.gov).

References
1.
Vatopoulos A. High rates of metallo-beta-lactamase-producing Klebsiella pneumoniae in Greece—a review of the current evidence.  Euro Surveill. 2008;13:1-6
2.
Centers for Disease Control and Prevention (CDC).  Detection of Enterobacteriaceae isolates carrying metallo-beta-lactamase - United States, 2010.  MMWR Morb Mortal Wkly Rep. 2010;59(24):750PubMed
3.
Centers for Disease Control and Prevention (CDC).  Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities.  MMWR Morb Mortal Wkly Rep. 2009;58(10):256-260PubMed
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