Introduction• First strain of Klebsiella pneumoniaeresistant to Carbapenems (KPC) 2001in North Carolina.• Now spread to Russia, Central Europe• KPC resistance has mostly beenreported from tertiary care centers.• Lack of data– On prevalence from community hospitals– Clinical outcomes
Evolution of Drug Resistance in KlebsiellaKlebsiellaCephalosporins[1990’s]ESBL KlebsiellaCarbapenemsCarbapenemase +[2000’s] KlebsiellaTigecyclinePolymixinKlebsiellaresistant toeverything?
Introduction• Method of testing antibioticssensitivity- Disk Diffusion method.• Gold standard to diagnose Klebsiellapneumoniae resistant to Carbapenem1) Modified Hodge test2) PCR for the blaKPC gene
Klebsiella pneumoniae Blood Isolateby Automated SusceptibilityPatient A persistent fever bacteremia being treated withImipenem
When to Test for Carbapenemase Gene
Aim of the study• Primary Objective –To identify the prevalence of Klebsiellapneumoniae resistant to carbapenemsover a period of two years.• Secondary Objective –To identify the clinical implication oftreating KPC strain as recommend bydisk diffusion method.
Method1) Hospital IRB approval.2) Duration of study – 2 years (Oct 1, 2007-Sept 30, 2009).3) All specimens were identified as Klebsiellapneumoniae (KP).4) All KP were tested for KPC by ModifiedHodge test .5) Chart review was conducted on KPC +veinfected patients for clinical outcomes..
Method• What is Modified Hodge test
Method• The prevalence of KPC gene among KlebsiellapneumoniaeTotal number of Hodge test positive= -------------------------------------------------------------Number of Klebsiella Pneumonia samples
Method• Mortality due to improper treatment ofinfection as patient dying due secondary tosepsis or bacteremia .• Death due to other causes such as MI, PEwere excluded.• Clinical outcomes –• a) recovered clinically• b) Death
40,309 – C & S7836 32473Klebsiella pneumoniaeModified Hodge testResults+ -+ -106 7730+ -KPC + 8KPC - 98
ResultsKPC + - 8Chart ReviewClinical Infection – 7 Contaminant – 1Disk diffusion ResultsExcludedResistant to Carbapenem= 3(True Positive)Sensitive to Carbapenem = 4(False Positive)
ResultsResistant to Carbapenem= 3(True Positive)Sensitive to Carbapenem = 4(False Positive)Antibiotic changed toTigecycline andPolymyxinCarbapenem ContinuedClinical ImprovementPoor Outcome
ResultsPoor Outcome1 patient – had tohave surgery toremove theinfected site2 patients – loss oflimb due to worseninginfection1 patient -death
• Gender M – 2F - 8•Results• Length of stay in the hospital -16.5±21 days.–Antibiotics prior to isolation -Piperacillin/Tazobactam and Vancomycin• Prevalence of KPC = 7.5%.• Clinical outcome – 100% morbiditymortality if continued carbapenem
Discussion• This is the first study showing theprevalence and clinical outcome ofKPC in a community hospital.• KPC – Emerging pathogen – present atSaint Peter’s Hospital.• KPC infection is associated withincreased length of stay.
Discussion• The prevalence of KPC strain is 7.5%.• Modified Hodge test should be used toidentify KPC since the disk diffusionmethod is not sensitive in detectingKPC.• Clinical outcomes are poor in patientswith KPC strain infection if appropriatechanged to the antibiotics are notmade.
Conclusion• Prevalence KPC is 7.5% at SaintPeter’s Hospital.• As a result of this study all Klebsiellapneumoniae samples at Saint Peter’shospital are tested for KPC gene usingModified Hodge test.