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EDITORIAL
Year : 2013  |  Volume : 7  |  Issue : 1  |  Page : 1-2

Carbapenemase-producing Gram-negative bacteria: An emerging threat to health care in Africa


Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria

Date of Web Publication18-Oct-2013

Correspondence Address:
Shamsudin Aliyu
Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.119978

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How to cite this article:
Aliyu S. Carbapenemase-producing Gram-negative bacteria: An emerging threat to health care in Africa. Ann Nigerian Med 2013;7:1-2

How to cite this URL:
Aliyu S. Carbapenemase-producing Gram-negative bacteria: An emerging threat to health care in Africa. Ann Nigerian Med [serial online] 2013 [cited 2020 Jun 5];7:1-2. Available from: http://www.anmjournal.com/text.asp?2013/7/1/1/119978

Antimicrobial resistance has become an important public health problem. The rapid spread of carbapenemase-producing Gram-negatives (CPGNs) has raised serious concerns in the international medical and scientific community. Gram-negative bacteria that produce extended-spectrum β-lactamases capable of hydrolyzing most cephalosporins have been reported worldwide. [1] The Carbapenems namely imipenem, meropenem, ertapenem, and doripenem became the antimicrobials of last resort used in treating infections due to these highly drug resistant bacteria. These antimicrobial agents became crucial in the management of life-threatening healthcare-associated and community acquired infections. The consequence of this widespread use of carbapenems was the emergence of the first carbapenemase-producing Enterobacteriaceae in 1993. [2] Subsequently, CPGNs have been isolated from all over the world. [3],[4],[5]

Gram-negative bacteria that produce carbapenemase show generalized resistance to carbapenems, penicillins, and cephalosporins. These strains also usually exhibit resistance to aminiglycosides and quinolones. These enzymes are encoded by genes on chromosomes and mobile genetic elements such as plasmids; and belong to three classes of β-lactamases: the Ambler class A, B, and D β-lactamases. [6] Examples include Klebsiella pneumoniae carbapenemases (KPCs) and Guiana-extended-spectrum β-lactamases (GESs) belonging to class A; the metallo-β-lactamases (MBLs), such as the Verona integron-encoded MBLs (VIMs) and the recently described New Delhi metallo-β-lactamases (NDM-1) belonging to class B; and the oxacillinase-type carbapenemases such as OXA-48 and its derivates, which belong to class D. These enzymes have been found in Klebsiella pneumoniae,  Escherichia More Details coli, Klebsiella oxytoca,  Salmonella More Details enterica, Citrobacter freundii, Enterobacter species, Proteus mirabilis, Serratia marcescens. They been also been identified in non-fermenting gram-negative bacilli like Pseudomonas aeruginosa, Pseudomonas putida, and Acinetobacter species. [3],[7]

The emergence of resistance to carbapenems in gram-negative bacteria is an important and growing threat to public health in Africa. Burden of infectious diseases is high in Africa, and gram-negative bacteria cause most of the common clinical infections such as urinary tract infection, septicemia, pneumonia, meningitis, and peritonitis. Decades of poor medical antibiotic prescribing and non implementation of infection prevention and control (IPC) policies in African hospitals have put patients at-risk of acquiring these difficult to treat bacterial infections. The scourge of fake and substandard drug has only made the problem worse. Medical tourism has now resulted in patients acquiring these resistant bacteria in countries outside the continent and bringing them back to African hospitals.

CPGN bacteria have been reported in many African countries. Earliest documentation were the reports of NDM-1 producing K. pneumoniae from Kenya and Morocco. [8],[9] Bacteria carrying the highly mobile NDM-1 gene have also been documented in South Africa. [10] The NDM-1 has been associated with rapid spread of carbapenem-resistant Enterobacteriaceae (CRE). [3] In 2012, Brink et al., [11] reported the emergence of KPCs in clinical isolates of K. pneumoniae. This was the first time this enzyme had been detected in South Africa or anywhere in Africa for that matter. Recently in Nigeria, multidrug-resistant Acinetobacter baumannii producing OXA-23 carbapenemase has emerged. [12] These reports paint a grim picture. It means that CPGN bacteria have been isolated in North, South, East, and West Africa.

Antimicrobial resistance has become a threat to global health security. The emergence of carbapenemases in Africa poses a significant challenge to clinical microbiologists, infection control and prevention practitioners, and treating clinicians. Resistant infections increase mortality, treatment costs, disease spread, and duration of illness. [13] Colistin, tigecycline, and intravenous fosfomycin are often the only treatment options, [14],[15] and these antimicrobials are not available in most African countries. As the prevalence of these multidrug-resistant bacteria is still low in Africa, policies that delay their spread are key to control and prevention. This emerging epidemic in Africa will not stop spontaneously. Priority areas that must be urgently addressed include rational drug use and regulation, surveillance, research and development, infection prevention, clean animal husbandry, aquaculture and agriculture. [16] The era of untreatable bacterial infections is upon us. The time to act is now.

 
   References Top

1.Pitout JD, Laupland KB. Extended-spectrum β-lactamase-producing Enterobacteriaceae: An emerging public-health concern. Lancet Infect Dis 2008;8:159-66.  Back to cited text no. 1
    
2.Naas T, Nordmann P. Analysis of a carbapenem-hydrolyzing class A β-lactamase from Enterobacter cloacae and of its LysR-type regulatory protein. Proc Natl Acad Sci U S A 1994;91:7693-7.  Back to cited text no. 2
    
3.Nordmann P, Naas T, Poirel L. Global spread of carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis 2011;17:1791-8.  Back to cited text no. 3
    
4.Cantón R, Akóva M, Carmeli Y, Giske CG, Glupczynski Y, Gniadkowski M, et al. Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe. Clin Microbiol Infect 2012;18:413-31.  Back to cited text no. 4
    
5.Villegas MV, Lolans K, Correa A, Suarez CJ, Lopez JA, Vallejo M, et al. Colombian Nosocomial Resistance Study Group. First detection of the plasmid-mediated class A carbapenemase KPC-2 in clinical isolates of Klebsiella pneumoniae from South America. Antimicrob Agents Chemother 2006;50:2880-2.  Back to cited text no. 5
    
6.Queenan AM, Bush K. Carbapenemases: The versatile beta-lactamases. Clin Microbiol Rev 2007;20:440-58.  Back to cited text no. 6
    
7.Hirsch EB, Tam VH. Detection and treatment options for Klebsiella pneumoniae carbapenemases (KPCs): An emerging cause of multidrug-resistant infection. J Antimicrob Chemother 2010;65:1119-25.  Back to cited text no. 7
    
8.Poirel L, Revathi G, Bernabeu S, Nordmann P. Detection of NDM-1-producing Klebsiella pneumoniae in Kenya. Antimicrob Agents Chemother 2011;55:934-6.  Back to cited text no. 8
    
9.Poirel L, Benouda A, Hays C, Nordmann P. Emergence of NDM-1-producing Klebsiella pneumoniae in Morocco. J Antimicrob Chemother 2011;66:2781-3.  Back to cited text no. 9
    
10.Communicable Diseases Communique. Outbreak of newly emerged, highly antibiotic resistant bacteria in hospitalized patients in Gauteng Province: New Delhi metallo-beta-lactamase (NDM-1). NICD Communique (Wash DC) 2011;10:2-3.  Back to cited text no. 10
    
11.Brink AJ, Coetzee J, Clay CG, Sithole S, Richards GA, Poirel L, et al. Emergence of New Delhi metallo-beta-lactamase (NDM-1) and Klebsiella pneumoniae carbapenemase (KPC-2) in South Africa. J Clin Microbiol 2012;50:525-7.  Back to cited text no. 11
    
12.Olaitan AO, Berrazeg M, Fagade OE, Adelowo OO, Alli JA, Rolain JM. Emergence of multidrug-resistant Acinetobacter baumannii producing OXA-23 carbapenemase, Nigeria. Int J Infect Dis 2013;17:e469-70.  Back to cited text no. 12
    
13.Laxminarayan R, ed. Battling resistance to antibiotics and pesticides: An economic approach.Washington D.C.: RFF Press, 2003.  Back to cited text no. 13
    
14.Carmeli Y, Akova M, Cornaglia G, Daikos GL, Garau J, Harbarth S, et al. Controlling thespread of carbapenemase-producing Gram-negatives: Therapeutic approach and infection control. Clin Microbiol Infect 2010;16:102-11.  Back to cited text no. 14
    
15.Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: Extended-spectrum ß-lactamase producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multi-drug resistant Pseudomonas aeruginosa. Mayo Clin Proc 2011;86:250-9.  Back to cited text no. 15
    
16.Heymann DL. Antimicrobial Resistance: An Urgent Threat to Global Health Security. Available from: http://www.chathamhouse.org/media/comment/view/163773 [Last accessed 2013 June 20].  Back to cited text no. 16
    




 

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