Jamieson D, et al. What obstetrician-gynecologists should know about Ebola: A perspective from the Centers for Disease Control and Prevention. Obstet Gyn 2014;124 (5):1005-1010.
Hospital infection control policies for the management of suspect or documented Ebola Virus disease (EVD) should give consideration to appropriate triage procedures for their labor and delivery units. Only 4 cases of EVD have thus far been diagnosed within the United States, 2 of which were imported, and 2 of which were health care worker (HCW)-acquired. The chances of a pregnant woman with EVD presenting for care are relatively small. If it does occur, it is unlikely the patient would coincidentally presenting in term labor. It is more likely that a pregnant woman with EVD would present with vaginal and uterine bleeding or hemorrhage, spontaneous miscarriage, or fetal distress.
No data on pregnancy outcomes are available for the current outbreak ongoing in Liberia, Guinea, and Sierra Leone, which has, by conservative estimates, affected 17,527 people, resulting in 6,187 deaths. Limited data from earlier and much smaller outbreaks indicate that pregnant woman may be at increased risk for pregnancy complications and death. And neonates born to mothers with EVD have not survived.
For example, during an outbreak in Kikwit, Democratic Republic of Congo, in 1996, which affected 105 women, 14 of 15 pregnancies ended in maternal death within 10 days (93%). In contrast, 70% of non-pregnant persons requiring hospitalization died. All 10 first- and second-trimester pregnancies ended in spontaneous miscarriage, and all 5 term deliveries ended in fetal or neonatal death. Young pregnant women were disproportionately affected in one of the original outbreaks in Zaire in 1976, perhaps because young women more frequently act as caregivers. Of 177 women infected with EVD, 82 (44%) were pregnant and their mortality was high (89%). Nearly one-fourth had spontaneous abortions during their first or second trimester, and all 11 neonates born to mothers with EVD died.
With this in mind, procedures should be developed for screening patients presenting to labor and delivery for recent travel and signs and symptoms of EVD. Emergency department triage protocols should include questions about pregnancy. In addition, Ob-Gyns should be counseled about potential complications of pregnancy in EVD, as well as the likelihood of other travel-related diseases, including influenza, malaria, and typhoid fever. The medical care of a pregnant woman with EVD is similar to that for non-pregnant persons, with an emphasis on aggressive treatment of coagulopathy and hemorrhage. EVD precautions should automatically extend to any live or dead infants born to affected women.
There’s an ESBL in My Soup!
Seiffert SN, et al. High prevalence of extended-spectrum beta-lactamase, plasmid-mediated AmpC, and Carbapenemase genes in pet food. Antimicrob Agents Chemother 2014;58(10);6320-6323.
Investigations into resistance factors present in human foodstuffs prompted these authors to turn their attention to the presence of similar genetic footprints in pet food. Thirty different cat and dog food products (both wet and dry) were purchased from 3 stores in Bern, Switzerland. All of the products were manufactured in the European Union, and nearly three-fourths provided a list of ingredients on the packaging, including the presence of meat products (duck, chicken, turkey) in proportions ranging from 4% to 18%. The rest of the ingredients were listed as various grains, organic products, fruits and vegetables, and fish byproducts.
The different samples were diluted in an enriched media plus ampicillin and held overnight at 37°F. DNA was extracted, looking for various beta-lactamases, including ESBL (CFT-M and VEB), plasmid-mediated AmpC (pCMY), and carbapenemases (KPC, OXA-48-like, and NDM).
Sixteen of the samples (53%) were positive for blaESBL genes. Fourteen (47%) of these were positive for blaCTX-M-1 group DNA, one was positive for blaCTX-M-1 and blaVEB DNA, and one had blaVEB DNA alone. Six samples (14%) were positive for blaCMY-4 genes and two (6.7%) had blaVEB genes. Most concerning, OXA-48-like genes were found in 4 of the specimens (13%) — which could result in potential transmission of these extra-drug resistance genes to pets.
Because of the food processing and sterilization procedures, which cause denaturation and fragmentation of the larger pieces of DNA, it was not possible to determine the genetic source for the genes. In other words, whether certain bacteria harboring resistance genes were present in the food could not be determined. But the lack of other specific bacterial genes suggested that the resistance genes identified were unlikely to be due to bacterial flora in the animals — but rather to extrinsic contamination from environmental or even human sources.
Indian Neonatal Deaths from MDR Bacteria
Pro-MED-mail post. Antimicrobial resistance — India. December 3, 2014. promedmail.org.
The increase in ESBL- and NDM1 (New Delhi metallo-beta-lactamase 1)-containing bacteria in India has triggered an unexpected national health crisis. Just as in-roads were being made in decreasing the neonatal death rate in India, multidrug-resistant bacterial infections are claiming the lives of thousands of infants. In just 5 years, an unprecedented increase in neonatal deaths from NDM and other multi-drug resistant bacteria has been occurring. Last year (2013), it is estimated that 58,000 neonates (7.3% of all infant deaths) died from multidrug-resistant infection. Pediatricians and neonatal intensive wards struggle to provide care to these infants, many of whom have infections that are untreatable.
Many of these infections are due to NDM1-containing Klebsiella or multi-drug resistant Acinetobacter, which are commonly found in untreated sewage and waste water. While indiscriminate antibacterial use for decades may have triggered the problem, the spread of these multidrug-resistant organisms (MDRO) has been magnified by the lack of adequate sewage treatment, contaminated water supplies, and crowded living conditions.
This means that otherwise healthy Asian Indians have become colonized with these organisms as part of their normal fecal flora — which has implications for the management of these individuals when they present for care in other parts of the world. Rectal swab screening for CRE/NDM is recommended for high-risk persons recently hospitalized in India or Pakistan. However, even apparently young healthy people may be affected by these organisms. At our medical facilities in Mountain View, CA, which services the large Indian population in Silicon Valley, many first-time UTIs in young healthy Indian women are ESBL-E. coli, presumably from intestinal and perineal colonization with these organisms. One neonate born to a young Indian mother quickly succumbed to sepsis and meningitis from ESBL-E. coli within hours of birth, presumably from vaginal and skin colonization from intestinal flora.
Correction
In the December 2014 issue of IDA (page 26, left column) an error occurred in a sentence explaining how VAP was confirmed. Superscripted numbers 6 and 4 were inadvertently published in normal size. The sentence should have read:
"VAP was confirmed by quantitative bacterial culture of > 106 CFU/mL from an endotracheal specimen of > 104 CFU/mL from bronchoalveolar lavage fluid.”
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