The Rise of Carbapenem Resistant Organisms RUSI/STFC workshop on Antimicrobial Resistance 6th February 2013 Professor Mike Sharland Professor of Paediatric Infectious Diseases St George’s, University of London Chair of the DH advisory committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI)

Carbapenem Resistant Organisms (CRO’s) Extremely Resistant Gram Negative Bacteria Complex names – KPC, NDM, VIM, OXA – enzymes and bacteria Rapid global Spread Resistant to last decent antibiotic class – carbapenems (meropenem) With inadequate treatment can become pan-resistant

CRO – Serious Adverse Outcomes Mortality 20-40% - associated with: Extended Hospital Stay Esp ICU Exposure to Invasive Devices E.g. Ventilators, Central Venous Catheters Comorbidities assoc with Advanced Age E.g. immunosupression, cardiac disease, chronic airway disease – also premature

Worldwide Distribution of Klebsiella pneumoniae carbapenemase producers Kumarasamy et al., Lancet Infect Dis 2010 10:597-602

Spread of NDM-Mediated Carbapenem Resistance Johnson and Woodford J Med Micro 2013; doi: 10.1099/jmm.0.052555-0

Klebsiella pneumoniae: percentage of invasive isolates with resistance to carbapenems. 2010 2011

KPC-producing K. pneumoniae - Italian experience early 2011 late 2012 late 2008 The first reported cases of KPC-Kp (ST258) ST258, ST512 (CC258) ST512 ST258 Fontana et al – BMC Res Notes 2010 Marchese et al – J Chemother 2010 Ambretti et al – New Microb 2010 Gaibani et al – Eurosurv 2011 Mezzatesta et al – CMI 2011 Agodi et al – JCM 2011 Richter et al – JCM 2011 Di Carlo et al – BMC Gastroenterol 2011 Rossolini GM – unpublished ST101 ST15 ST147-like AMCLI – CoSA CRE network Frasson et al – JCM 2012 ARISS-CoSA study – unpublished Giani et al – JCM 2009 Rossolini GM – unpublished

Carbapenen-resistant K. pneumoniae AMCLI-CoSA – Italian National CRE Surveillance 2011

AMCLI-CoSA – Italian National CRE Surveillance 2011

Israel’s KPC Outbreak and Intensive IPC Intervention

Antimicrobial Resistance spread into and within the UK CRO colonized residents or visitors Hospital treatment or travel overseas Non-human reservoirs: foodstuffs (domestic or imported) Medical Tourism Elective & cosmetic Non-human reservoirs: animals and environment Military and civilian casualties from conflict zones Community Carriage? Inter-hospital transfers (UK)