Looming public health catastrophe? Carbapenem-resistant gram-negative bacteraemia in ICU patients at a resource limited tertiary care hospital in the Caribbean - A cause for concern

Introduction: The problem of antibiotic resistance represents a global crisis. Carbapenem resistant Enterobacteriaceae (CRE) including those producing carbapenemases (CPE) have emerged and account for over 8000 drug-resistant infections annually and 600 deaths. To date, there have been no published reports of these organisms in blood stream infections in Jamaica. The study aim was to investigate carbapenemase presence in specific blood-culture pathogens, screen for the blaNDM and blaKPC genes, and to evaluate the ability to treat appropriately from local formularies. Methods: All blood culture samples submitted to the University of the West Indies (UWI) Microbiology Laboratory (accredited by Jamaica National Agency for Accreditation - JANAAC) between September 1, 2021, and March 4, 2022, were evaluated. These were processed in accordance with the laboratory's standard operating procedures and the Clinical Laboratory Standards Institute (CLSI) guidelines. E. coli and Klebsiella spp. that were carbapenem resistant post de-duplication, were further screened using the modified carbapenem inactivation method (mCIM) and underwent PCR for the detection of blaNDM and blaKPC genes. Based on antibiotic susceptibility patterns, local formularies were reviewed to determine options for therapy and their likely efficacy. Results: Of 4287 blood cultures, 1049 were positive and post de-duplication, 125 were Gram negative rods - 7 were carbapenem resistant E. coli and Klebsiella spp. PCR conducted on these isolates detected the blaNDM (N=7) and the blaKPC (N=1) genes; 6 of these were mCIM positive. IDSA (Infectious Diseases Society of America) recommendations for preferred antibiotic treatment was not available on formulary. 43% of the patients with CPE died 30 days post sample collection. Discussion: The detection of carbapenemases including blaKPC notably for the first time in the blood stream in Jamaica is concerning. Additionally, there were no published reports of the KPC gene being detected in Jamaica; in spite of, several studies identifying a relatively high prevalence of KPC producing GNB in other areas of the world. All samples were collected from intensive care unit patients with an associated mortality rate of 43%. Though unfortunate, the high mortality rates seen, reflect the difficulty associated with treating CRE infections. In our setting, the limited treatment options available simply compounded the problem. Such an alarming mortality rate lends support to the WHO placing carbapenem-resistant Enterobacteriaceae in the critical category of its priority pathogen list; thereby, recognizing its potential threat as a serious infection and highlighting the need for ongoing surveillance and enhanced infection prevention and control measures. Conclusions: The detection of CPE in a setting where options for therapy are limited poses a serious threat to health. Novel antibiotic therapy for CPE is needed locally. The need for on-going advocacy, formulary revision, and infection and prevention control measures are critical.