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To Infinity and Beyond! No Distance is too Far for the Spread of Multi-Drug Resistant Organisms

Posted by Holly Montejano, MS, CIC, CPHQ on Jan 25, 2019 1:21:00 PM

To Infinity and Beyond! No Distance is too Far for the Spread of Multi-Drug Resistant Organisms

We all know they’re out there.  So small that you can’t see them, yet able to pack a nasty punch with colonization or infection.  Lurking on surfaces and hands WORLDWIDE, and now according to research, in outer space.  These bugs aren’t just causing alarm for physicians, public health practitioners and infection preventionists. International (and interplanetary!) travelers (and astronauts!) need to take heed.  These multi-drug resistant organisms (MDROs) are mobile – and whether our travel is for leisure, medical tourism or expanding our scientific frontiers in space – these pesky organisms are ubiquitous and can put even the otherwise healthy traveler (or astronaut) at risk. 

Multi-drug resistant Salmonella Typhi in South Asia:

Travelers beware!  A recent Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly (MMWR) discusses the concern of exposure to extensively drug resistant (XDR) Salmonella enterica serotype Typhi in travelers to or from South Asia, particularly Pakistan and India1.  Due to an uptick in cases reported in Pakistan, the United States (US) responded with enhanced surveillance, specifically among travelers to and from this area during 2016-2018 diagnosed with typhoid fever.  They identified 29 typhoid fever patients who had traveled during this period, five of which had the XDR Typhi1

Per the CDC, Typhoid fever is a systemic febrile illness requiring prompt antibiotic treatment.  Approximately 12-27 million cases of typhoid fever occur yearly worldwide; in the US about 350 culture-confirmed cases are reported to the CDC yearly with most cases having international travel within the 30 days prior to illness1.  Local public health departments forward all Typhi isolates to CDC’s National Antimicrobial Resistance Monitoring System (NARMS) for susceptibility testing.  Unfortunately, susceptibility patterns of Typhi has changed over the past several decades and providers should not use fluoroquinolones as empiric therapy for travelers returning from South Asia1.  The MMWR states that most typhoid fever infections in the US are fluoroquinolone-resistant (non-susceptible) and XDR Typhi strain associated with travel to Pakistan is only susceptible to azithromycin and carbapenems1.  Azithromycin is preferred to treat patients with suspected uncomplicated typhoid fever (who have traveled to or from Pakistan).  Treatment with carbapenems may be required in patients with suspected severe or complicated typhoid fever (who have traveled to or from Pakistan)1.  As is always so important with antibiotic stewardship practice, treatment regimens can be adjusted based on the results of culture and sensitivity testing1.

Vaccination and safe food and water practices are the best way to prevent infection with this bug.  Frequent hand washing is imperative in this endeavor! Travelers who become ill while abroad or after returning home should see their provider to ensure appropriate testing and treatment to reduce morbidity and mortality from potential Typhi infection. In the US, providers and public health are partnering to quickly identify emerging resistance patterns and appropriately treat patients effected by this increasingly difficult to treat infection1.

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Carbapenem-resistant Pseudomonas aeruginosa (CRPA) in Mexico:

MDROs continue their trek across the continent. The CDC has issued a level 2 alert regarding patients who have gone to Tijuana, Baja California, Mexico for medical procedures (a majority had weight-loss surgery) and have returned to the US with multi-drug resistant Pseudomonas aeruginosa infections2.  Many patients who have returned with this type of infection had their procedure performed at the Grand View Hospital,which the Mexican government has closed until further notice2.  This strain is very difficult to treat given its resistance to carbapenems (CRPA)2.  When these infections are identified in patients who travel to Mexico for surgical procedures, it is important to test for antibiotic susceptibility and to notify the local or state health department. The CDC offers testing for carbapenem-resistant bacteria free of charge at the Antibiotic Resistance Laboratory Network2.

Pseudomonas aeruginosa is an environmental bug which really enjoys water and infections typically happen in hospitalized patients or those with a compromised immune system3.  Infection in the blood, lungs, or following surgery can cause serious illness and even death. Pseudomonas can be spread via the contaminated hands of healthcare workers or by equipment that is not cleaned appropriately3.  In the hospital setting, where people are particularly susceptible to this type of bug, it is important to follow infection prevention practices such as hand hygiene and environmental cleaning3.

CDC’s alert mentions vacation-related risks after surgery in Mexico, including sunbathing, drinking alcohol, swimming, taking long tours and strenuous exercise2.  It should be noted that outside of the hospital setting, Pseudomonas enjoys hot tubs and pools3.  Patients with fresh surgical wounds should avoid exposing themselves to these leisurely activities.

Antibiotic Resistance Concerns in Space:

As space missions become longer, due to our increasing curiosity, astronauts are spending extended periods of time in space.   Not only are their concerns about their health on these extended trips, there are concerns about the organisms which could make them sick, as well as their response to a space environment.  Research has shown that bacteria, particularly Escherichia coli and Staphylococcus aureus, developed enhanced resistance to antibiotics in a microgravity environment versus those isolates on the ground4,5. This is concerning as astronaut’s immune systems are often compromised “…due to the microgravity environment, sleep deprivation, isolation or microbial contamination”5 and he/she can be in space for long missions leaving them at risk for opportunistic infections.  For these reasons, use of antibiotics to prevent infection (prophylactically while in space) is not without risk of resistance developing.  These resistant organisms could certainly then travel back to earth with the astronauts once their mission is complete.  While more research is needed in this area of study, these results are a sobering reminder that bacteria are resilient and savvy in all environments they encounter.

Antibiotic Stewardship: 

You’ll notice a running theme with these bugs.  Not only are they mobile BUT they’re also RESISTANT, making them very difficult to treat. While the microbial concerns above stem from international and space travel, the CDC has made recommendations for antibiotic use in US healthcare facilities to help address the issue nationally.  Within the US, the CDC estimates that two million people are infected with antibiotic-resistant organisms and this results in approximately 23,000 deaths annually6.  Antibiotics are a critical component of modern medicine and have saved many lives since their introduction.  Antibiotic Stewardship Programs (ASPs) have been implemented within the acute care setting to address the fact that 20 -50% of all antibiotics prescribed are either unnecessary or inappropriate6.  Placing a patient on unnecessary antibiotics puts them at increased risk for complications with no clinical benefit while also contributing to the growing issue of resistance.  As we know, growing antibiotic resistance also puts the health of the entire community at risk.   ASPs aim “...to improve the quality of patient care, and improve patient safety through increased cure rates, reduced treatment failures, and increased frequency of correct prescribing for therapy and prophylaxis”6.

Antibiotic resistance is a growing and continual concern for providers, communities, sick patients and the healthy. Prudent adherence to international travel recommendations, appropriate antibiotic therapies, enhanced surveillance efforts and infection prevention practices, such as hand hygiene and environmental disinfection, can help stop these bugs in their travel tracks- and keep all of our fellow travelers safe and healthy on their wanderlust journeys.

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References:

  1. Chatham-Stephens, K. (2019). Emergence of Extensively Drug-Resistant Salmonella Typhi Infections Among Travelers to or from Pakistan—United States, 2016–2018.  Morbidity and mortality weekly report68.
  2. https://wwwnc.cdc.gov/travel/notices/alert/drug-resistant-infections-mexico. Accessed January 24, 2019.
  3. https://www.cdc.gov/hai/organisms/pseudomonas.html Accessed Jan 24, 2019.
  4. Tirumalai, M. R., Karouia, F., Tran, Q., Stepanov, V. G., Bruce, R. J., Ott, C. M., ... & Fox, G. E. (2019). Evaluation of Acquired Antibiotic Resistance in Escherichia coli Exposed to Long-Term Low-Shear Modeled Microgravity and Background Antibiotic Exposure. mBio10(1), e02637-18.
  5. https://www.beckershospitalreview.com/quality/antibiotics-used-in-space-could-rapidly-cause-drug-resistance-researchers-warn.html Accessed January 24, 2019.
  6. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html Accessed January 24, 2019.