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Published Date: 2011-11-26 10:02:20
Subject: PRO/EDR> Antibiotic resistance, E. coli - UK: (Wales) ESBL
Archive Number: 20111126.3454

ANTIBIOTIC RESISTANCE, E. COLI - UK: (WALES) ESBL
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Date: Tue 22 Nov 2011
Source: The Telegraph [edited]
http://www.telegraph.co.uk/health/healthnews/8907472/Two-babies-dead-and-three-people-ill-after-E.coli-outbreak.html

Health officials confirmed today that 2 babies have died of an
_Escherichia coli_ infection. Both cases are under investigation at
Singleton Hospital, Swansea, South Wales. One of the babies was "very
premature" and died in hospital. The 2nd case involved a baby who died
in the community but whose mother is suspected of contracting the
infection at the hospital.

Abertawe Bro Morgannwg (ABM) University Health Board runs Singleton
Hospital. It is investigating both cases of ESBL [extended spectrum
beta-lactamase] _E. coli_ cross-infection in the hospital's
maternity/neonatal unit, supported by Public Health Wales. Health
chiefs at the hospital stressed today that ESBL _E.coli_ is not the
same as _E.coli_ O157, which causes food poisoning. In most people
ESBL _E.coli_ does not cause harm but in vulnerable individuals it can
cause serious infections. Action has been taken by hospital chiefs to
restrict use of the unit to full-term babies.

Dr Bruce Ferguson, medical director of ABM University Health Board,
said: "Tests have confirmed that in one of these cases the ESBL
_E.coli_ infection was contracted in the hospital. "Sadly, this was a
very premature baby who, despite the best efforts of staff, later
died. The cause of death of this baby is currently being investigated
by the coroner. Everyone involved with the unit and in the care of
this baby deeply regret this tragic loss. The 2nd case involved a
mother who tested positive for ESBL E. coli but who has not shown any
symptoms and has not required treatment. We suspect she also
contracted ESBL _E. coli_ within the hospital, but this can only be
confirmed in test results which we expect later this week." He added:
"These appear to be isolated incidents which have been contained, and
there is no evidence of the infection spreading further. Checks have
been taken of patients, equipment and areas in the maternity/neonatal
unit and no evidence of ESBL _E. coli_ has been found."

He said the unit has "an excellent record for hand-hygiene and general
infection control adherence." Reported infection levels have also been
below the national average in recent years. But extra precautions have
been taken which include carrying out a "deep clean" at the obstetric
theatres and increasing cleaning in the neonatal and labour wards. He
said: "As a precaution, we have temporarily restricted the neonatal
unit to admissions for babies of 36-weeks and over gestation. This is
under constant review and we anticipate lifting this restriction
shortly. All routine full-term births are continuing at the Singleton
maternity unit as normal."

ESBL (extended-spectrum beta-lactamase) producing _E. coli_ are
strains of _E. coli_ that are resistant to antibiotics, making them
difficult to treat. In many cases, only 2 types of antibiotic taken by
mouth and a "very limited" group of intravenous antibiotics are
effective, according to information from the Health Protection Agency
(HPA). _E. coli_ can lead to serious infections such as blood
poisoning, which can be life threatening.

Dr Ferguson added: "We would like to reassure expectant mothers due to
give birth in Singleton Hospital that the maternity unit is open as
usual for full-term births. However, any mothers-to-be who have
concerns or questions should speak to their community midwife in the
1st place. In addition, a helpline has also been set up: 0774 761
5627. The 2 cases of ESBL _E. coli_ transmissions currently under
investigation are linked to three other confirmed cases of ESBL _E.
coli_ where the infection was contracted outside hospital. Sadly, one
of these cases, also a very young baby, has died. Everyone associated
with the unit also regrets the tragic loss of this baby. It is
important to note that ESBL _E. coli_ is not the same as _E. coli_
O157, which causes food poisoning. In most people ESBL _E. coli_ does
not cause harm but in vulnerable individuals it can cause serious
infections. This is a very complex ongoing investigation and we are
unable to give any further details at this stage to safeguard patient
confidentiality. We will, however, be providing appropriate updates as
soon as possible."

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[ESBLs (i.e., extended spectrum beta-lactamases) are beta-lactamases
that hydrolyze penicillins and cephalosporins, including the
extended-spectrum cephalosporins with an oxyimino side chain
(cefotaxime, ceftriaxone, ceftazidime, and cefepime), as well as the
oxyimino-monobactam aztreonam. Most ESBLs are inhibited by
beta-lactamase inhibitors such as clavulanate, sulbactam, or
tazobactam in vitro; but the clinical effectiveness of
beta-lactam/beta-lactamase inhibitor combinations cannot be relied on
consistently for therapy (Stratton C. Extended-Spectrum
Beta-Lactamases: An Unappreciated Global Problem. Medscape. Available
at: http://www.medscape.org/viewarticle/442307 membership
required).

Because the genes that encode ESBLs are located on plasmids, the
ESBL-encoding genes are easily transferable to other bacteria of the
same or even different species. These plasmids also carry genes
conferring resistance to several non-beta-lactam antibiotics.
Consequently, ESBL-producing isolates are commonly resistant to many
classes of antibiotics, most frequently aminoglycosides,
fluoroquinolones, tetracyclines, chloramphenicol, and
sulfamethoxazole-trimethoprim. Infections caused by these multiple
drug-resistant organisms are most reliably treated with a carbapenem
antibiotic, such as ertapenem, imipenem, meropenem and doripenem.

ESBL resistance can arise in the community, as well as the hospital.
There are multiple types of ESBLs, e.g., TEM, SHV, CTX-M, OXA, each
with multiple subtypes. More than 80 CTX-M enzymes are currently
known. CTX-M-15 were unrecorded in the UK prior to 2000; they have
spread rapidly since 2003
(http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1274090495083).
CTX-M-15 is currently the most widespread type in E. coli the UK and
is widely prevalent in the community (N. Woodford N, Ward ME, Kaufmann
ME, et al. Community and hospital spread of Escherichia coli producing
CTX-M extended-spectrum b-lactamases in the UK. J Antimicrob Chemother
2004; 54: 735-743. Available at:
http://jac.oxfordjournals.org/content/54/4/735.full.pdf+html.)
However, the type of ESBL involved in the Swansea outbreak is not
stated in the above news report.

Swansea is a coastal city and county in South West Wales. For a map
that locates Swansea, see
http://en.wikipedia.org/wiki/File:Swansea_UK_location_map.svg. A
HealthMap/ProMED-mail interactive map of the UK can be seen at
http://healthmap.org/r/1rMk. - Mod.ML.]

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