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Ryan Hospital Update



Carbapenem-resistant Enterobacteriaceae Frequently Asked Questions

  • What are carbapenem-resistant Enterobacteriaceae (CRE)?

    CRE, which stands for carbapenem-resistant Enterobacteriaceae, are strains of bacteria that are resistant to carbapenem, a class of antibiotic used to treat severe infections, as well as most other antibiotics commonly used today. In some cases, CRE are resistant to all available antibiotics. Klebsiella and Escherichia coli (E. coli), normal bacteria found in the human and animal gastrointestinal tract, are examples of Enterobacteriaceae which can become carbapenem-resistant. 

  • What happened with CRE at Ryan Hospital?

    In July 2018, carbapenem-resistant E. coli was isolated from a cluster of six animals that were housed in the Intensive Care Unit at Ryan Hospital. A second cluster of three cases was identified in September 2018, and an additional six cases have been identified through June 2019.

    Through our Penn Vet Microbiology Laboratory (PVML), infected patients were quickly identified as having a multi-drug resistant (MDR) infection (typically within 48-72 hours of submission of the samples) and the appropriate precautions were put in place. Owners of these patients were also immediately notified of their pet’s MDR infection status.

    The PVML participates with Veterinary Lab Information and Response Network (Vet-LIRN) in a national surveillance project of bacteria isolated from animals. The mechanism of carbapenem-resistance was identified through this passive surveillance program in April 2019. This strain of E. coli has previously been reported from dogs, but never in the United States .

    In May 2019, the PVML learned that all CRE organisms isolated at a healthcare facility in Philadelphia were reportable. In order to contribute to protecting public health and fulfill our responsibilities as a healthcare facility, we immediately reported our cases to Philadelphia Department of Public Health (PDPH) and began our collaboration with them, as well as the Centers for Disease Control and Prevention (CDC).

  • What species does this affect?

    In general, E. coli inhabits the gastrointestinal tract of most mammals, but there is not much information on which species can be affected by CRE. Very little is also known about the likelihood of transmission from one species to another. At Ryan Hospital it has been isolated from dogs and cats .

  • I have a dog that defecates in the yard – do I need to take any precautions? Likewise, do I need to take additional precautions when cleaning my cat’s litter box?

    A variety of bacteria and parasites that can make people sick can be found in the feces of animals. It is important to routinely clean up after your pets and to always use good hygiene when handling fecal material. Hand washing should be part of any routine when interacting with pets or their waste.  For more information, please visit the CDC website on “Healthy Pets, Healthy People.”

  • Do infected pets need to be isolated from people?

    The most likely means of transmission is by inadvertent ingestion of fecal material or other bodily fluids containing the organism. The most effective way of preventing this is proper and thorough hand-washing. As importantly, pet behaviors such as licking of an owner’s face or open wounds are discouraged. For more information on proper hand hygiene, please visit the CDC website on “Handwashing: Clean Hands Save Lives.”

  • How would I know if my pet or I am infected?

    It is important to differentiate between colonization and infection. People or animals who are colonized in the gastrointestinal tract with this bacterium would not have any symptoms of disease or illness. The only way to determine if you or your pets carry this organism would be through a test submitted by your physician or veterinarian, respectively. Infections caused by this bacterium occur when it is transferred to another site of the body such as a wound, the lungs or the urinary tract. A fluid or tissue sample (e.g., urine, wound drainage) from the area of infection would need to be submitted to a laboratory through your physician or veterinarian to determine if this bacterium is the cause.

  • How serious is this? Should I be concerned?

    Infections caused by antibiotic resistant bacteria can be very serious because there are not many antibiotic options to treat these infections. However, most people colonized by CRE do not go on to develop an infection with the organism. Although this has not been studied in animals, we believe it to be true for them as well.

  • Are there any particular cleaning supplies I should be using at home as a precaution?

    In general, most commercial cleaning supplies are effective against E. coli. It is critical that manufacturer instructions are followed explicitly in order for the solutions efficacy to be guaranteed. If you have concerns or need more information about your cleaning agent of choice, you should contact the manufacturer directly.

  • A family member is at high risk for catching infections. Is it safe for me to visit them?

    At Penn Vet, we are experts in animal health – we would defer to our human medical colleagues to make such recommendations. You should speak with your physician if you have any concerns. More information on CRE can be found at the PDPH website.

  • What are you doing to eradicate the bacteria at Ryan Hospital?

    In addition to the routine infection prevention protocols used at Ryan Hospital, we have begun a “terminal cleaning” of the entire facility. This means that every room in our hospital is emptied of supplies and equipment and thoroughly cleaned by a professional team. In addition, we have collaborated with the manufacturer of an ultraviolet disinfection robot to organize further disinfection of our hospital’s patient care areas following the terminal cleaning.

    Ryan Hospital has had an active infection prevention program for many years and we constantly strive to improve it. We have collaborated with the PDPH to review all of our infection control policies and are making several positive changes to prevent the spread of this organism, including enhancement of our cleaning protocols and increasing our hospital-wide infection prevention education.

    To honor our educational mission, Penn Vet’s Ryan Hospital is also committed to raising awareness of CRE infections to the general public and veterinary community. Preventing the spread of CRE and other antibiotic resistant infections begins with practicing good hand hygiene and using antibiotics only when necessary.

  • Contact Us

    If you have any further questions, please contact the Ryan Hospital CRE Team at ryanhospitalcre@vet.upenn.edu.

Penn Vet’s Ryan Hospital Identifies Carbapenem-resistant E. coli in Fifteen Animal Patients

[July 9, 2019 – Philadelphia, PA] The Microbiology Laboratory at the University of Pennsylvania’s School of Veterinary Medicine (Penn Vet), in collaboration with the U.S. Food and Drug Administration’s Veterinary Laboratory Information and Response Network (FDA Vet-LIRN), confirmed the precise identification of a carbapenem-resistant E. coli from 14 dogs and one cat that were treated at Penn Vet’s Ryan Hospital over the course of one year. Carbapenem-resistant Enterobacteriaceae, or CRE, are a family of bacteria that can cause difficult-to-treat infections because they have high levels of resistance to antibiotics. CRE are extremely rare in dogs and cats, but they have been reported in animals from the United States.

The Microbiology Laboratory reported the CRE cases to the Philadelphia Department of Public Health (PDPH) in May 2019 when they became aware that CRE infection or colonization in healthcare facilities was reportable to the PDPH. As one of the largest veterinary teaching hospitals in the United States, Ryan Hospital adheres to the same standards as human healthcare facilities. The FDA’s Vet-LIRN test results identified a New Delhi metallo-beta-lactamase gene, called NDM-5. This is the first report of an NDM-5 gene in E. coli from companion animals in Philadelphia, and in the United States. The NDM-5 gene has previously been identified in E. coli from animals in Europe and in China.

Ryan Hospital has been working closely with PDPH and the Centers for Disease Control and Prevention (CDC) to determine the source of the bacteria and to contain it. The E. coli have been submitted to the CDC for additional testing. Control measures recommended by the PDPH have, and will continue to be, implemented to protect patients. “All hospitals, both human and veterinary, periodically manage the presence of drug-resistant bacteria,” said Dr. Michael Mison, Ryan Hospital’s Chief Medical Officer. “Since it is not possible to completely eliminate the risk, we continually monitor our infection control procedures and isolation protocols. Once the Microbiology Laboratory made us aware CRE are reportable within the city of Philadelphia, we did so immediately. Our goal is to ensure the safety of our animal patients, and humans.”

Ryan Hospital has a long-standing and active infection prevention program and works closely with Penn Vet’s Microbiology Laboratory as part of their national partnership with the FDA. “Not only are we a high-volume veterinary hospital, but we are a top-tier research institution,” said Mison. “Penn Vet’s microbiologist, Dr. Shelley Rankin, is recognized for her work on antibiotic resistant bacterial infections in companion animals, particularly with Salmonella and E. coli. The Microbiology Laboratory saved CRE isolates from all of the animal cases to perform additional testing. Initially, two of the isolates were submitted to the FDA’s Vet-LIRN as part of a passive surveillance initiative to detect antibiotic resistance in bacteria from animals. The FDA’s Vet-LIRN performed whole genome sequence analysis on these isolates and subsequently on all other isolates.”

The E. coli strains were analyzed from the 15 companion animals who were treated at Ryan Hospital between June 2018 and June 2019. E. coli is regularly isolated from animal infections during diagnostic testing. In consultation with Penn Vet’s veterinary clinical microbiologist, Dr. Stephen Cole, all of the animal patients that had a carbapenem resistant E. coli were managed under the care of Ryan Hospital veterinary specialists. In total, 13 of the 15 patients were discharged from the hospital. The owners of the remaining two patients elected humane euthanasia following post-surgical complications that were not related to the infection. The owners of the animals are currently being informed.

Additional information and FAQs about CRE can be found on Penn Vet’s website. The CDC also has an informative website called Healthy Pets, Healthy People, and the PDPH offers a brief CRE fact sheet on their website.

Media Contacts

Martin Hackett
Director of Communications and Marketing
mhackett@vet.upenn.edu
215-898-1475

Hannah Kleckner Hall
Associate Director of Communications
hkleck@vet.upenn.edu
610-925-6241

John Donges
Communications Coordinator
jdonges@vet.upenn.edu
215-898-4234