Inside this issue:

Sentinel Sites 2

Isolates of Interest 2

In Today’s Research 3

HP Printer 3

Regional Lab Tests 4

Fungal Awareness

Week

5

Meet the Staff 6

Recipes, Word Search 7-8

F a l l 2 0 1 8

V O L U M E 1 , I S S U E 1

Welcome to the first issue of the Southeast Regional Antibiotic Resistance Lab Network Newsletter.

This newsletter will be distributed on a quarterly basis to all SE AR Lab Network sentinel sites, public

health epidemiologists and labs. Articles will include regional updates, lab protocols, surveillance

updates, and staff introductions. Please email ARLN.Health@TN.gov if you are interested in

submitting an article for the next newsletter. We are excited to use this newsletter as a means for the

SE region to stay updated and connected!

Southeast Regional Newsletter

More than 23,000 Americans die each year due to infections from germs

that are resistant to antibiotics. In 2017, the Centers for Disease Control

and Prevention identified 221 instances of unusual resistance genes in

‘nightmare bacteria’. These germs are urgent threats, and new resources

along with aggressive responses can prevent them from spreading.

Established by the CDC in 2016, the Antibiotic Resistance Lab Network

consists of 56 state and jurisdictional laboratories and seven regional

laboratories. The Tennessee Department of Health Division of Laboratory

Services is the Southeastern Regional lab funded to perform reference

characterization of isolates in the region with new or unusual resistance.

The network’s strong investment to combat resistance allows health care

facilities access to free shipment and testing of organisms with unusual

resistance.

What is the AR Lab Network?

W h y B e a n A R L a b N e t w o r k S e n t i n e l S i t e ?

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S E A RL N N e w s l e t t e r

Benefits of Being an ARLN Sentinel Laboratory

Be on the front lines of detection of novel resistance types

Provide data essential to better understanding emerging or changing antimicrobial resistance

threats

Obtain reports of data from additional characterization of submitted isolates

Data from isolates can be compared to the data from the Southeast region

Candida spp.

Submit all Candida species other than C. albicans from any specimen source, especially invasive sites AND yeast isolates from any specimen source when unable to identify species after identification was attempted.

Submit all confirmed or suspected Candida auris isolates from any specimen source.

Carbapenem resistant Acinetobacter spp.

Submit all Acinetobacter spp. isolates resistant to imipenem, doripenem or meropenem by standard

AST methods.

Extended-spectrum beta-lactamase producing Klebsiella spp. and E. coli

Submit a sampling (e.g. 20 isolates per month) of isolates of Klebsiella spp. and E.coli that are

susceptible to all carbapenems and resistant to at least one third-generation cephalosporin, by

standard susceptibility testing methods.

I s o l a t e s o f I n t e r e s t

A Nosocomial Foodborne Outbreak of a VIM Carbapenemase-Expressing Citrobacter freundii1

In 2016, an outbreak of VIM carbapenemase-producing C. freundii was identified in a German hospital.

C. freundii is a gram-negative opportunistic pathogen that can colonize the gastrointestinal tract and

cause nosocomial infections. Prior to 2016, CP-C was rare and had not been implicated in any

foodborne outbreaks. The outbreak was initially identified through routine weekly screening. During

this outbreak, which lasted from February 8, 2016 to June 31, 2016, investigators identified 76

colonized patients. Crude clonal analyses using MALDI-TOF revealed marked similarities among the

isolates tested, which led to the assumption that the outbreak was of nosocomial origin. The outbreak

strain of CP-C was then isolated from both salad dressing and pudding that was served at the hospital.

Both food items were prepared in the same mixing machine, from which an isolate was recovered that

carried the VIM. This same machine had also been used to mix pre-sliced carrots for salads.

Shipments of the pre-sliced carrots were subsequently found to be highly contaminated with C.

freundii, although without VIM. Additional laboratory testing showed that the bacteria multiplied much

more rapidly in the pudding than in the Mueller-Hinton broth. This investigation highlighted the need

to think outside traditional health care exposures in the setting of patients infected or colonized with

novel carbapenemase producers.

1Pletz, M. W., Wollny, A., Dobermann, U., Rödel, J., Neubauer, S., Stein, C., . . . Maschmann, J. (2018). A Nosocomial Foodborne Outbreak of a VIM Carbapenemase-Expressing Citrobacter freundii. Clinical Infectious Diseases, 67(1), 58-64. doi:10.1093/cid/ciy034

I n t o d a y ’ s r e s e a r c h

In May, the Tennessee Department of Health Division of Laboratory Services acquired the HP D300e

digital dispensing platform. Through the use of HP inkjet printing technology, the HP digital dispenser

can rapidly titrate microdilutions of different antimicrobial agents for susceptibility testing. This allows

us to custom build broth microdilution panels without the need for manual, time-consuming

preparations. The digital dispenser provides AR Lab Network the capacity to support the CDC’s new

strategy to screen novel drugs and drug combinations against multi-drug or pan-resistant isolates.

Since effective treatment for these types of highly resistant isolates can be limited, incorporating this

remarkable technology into the AR testing strategy may provide significant insight into new therapeutic

options.

Victoria Stone, Ph.D. Tracy McLemore—Manager, ARLN/Enterics

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H P P r i n t e r

Pictured above is the HP D300e digital dispensing platform. Dilutions of different antimicrobial agents can be

titrated into 96-well microtiter plates for susceptibility testing.

S E R e g i o n a l L a b T e s t i n g T i m e F r a m e s

C a n d i d a A c t i v i t i e s

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V O L U M E 1 , I S S U E 1

Summary of the Candida auris Colonization Timeline Typically negative colonization results are reported within 14 days after receipt of swabs.

Summary of Candida species Identification and Antimicrobial Susceptibility Testing

The typical turnaround time from identification to completion of AST is approximately seven days

from receipt of isolate.

Isolates are identified within one to three days of receipt and AST results are completed within three

to five days of isolate identification.

C R E C o l o n i z a t i o n

Here we address estimated timelines for CRE Colonization and Candida activities so you know when

you should see results. Times may vary due to a variety of lab factors (i.e. mixed cultures, incorrect

swab collection, missing requisition data).

Fungal Disease Awareness Week was October 1-5, 2018

Bacteria are likely to come to mind when people think of antimicrobial resistance. However, drug-

resistant fungi have become a significant world-wide problem. Antifungal resistance is particularly

concerning in species of Candida that cause invasive infections, such as Candida glabrata. Out of all the

Candida bloodstream isolates sent to the CDC, most of which were Candida glabrata, about seven

percent showed resistance to the first-line defense antifungal, fluconazole. Echinocandin resistance in

Candida glabrata doubled from four percent in 2008 to eight percent in 2014.

Multidrug-resistant Candida auris is a major concern. While there are currently no breakpoints for

Candida auris in the Clinical and Laboratory Standards Institute document M60 – Performance

Standards for Antifungal Susceptibility Testing of Yeasts, some isolates have shown resistance to all

three classes of antifungals. Candida auris represents a paradigm shift in how we view Candida spp.

because it can easily spread among patients and can persist in the environment for long periods of

time. It is frequently misidentified as other species, which hinders containment efforts. The table

below, which summarizes common misidentifications by method of identification, can also be found

here along with other identification resources.

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V O L U M E 1 , I S S U E 1

Identification Method Misidentified Organism

VITEK® 2 YST Candida haemulonii, Candida duobushaemulonii

API® 20C Rhodotorula glutinis (characteristic red color not

present), Candida sake

BD Phoenix™ yeast identification system Candida haemulonii, Candida catenulata

Microscan® Candida famata, Candida guilliermondii,

Candida lusitaniae, Candida parapsilosis

RapID™ Yeast Plus Candida parapsilosis

Allison Chan is the AR Lab Network Epidemiologist in the Healthcare Associated

Infections and Antimicrobial Resistance Program at the Tennessee Department of

Health. She assumed this role in May 2018 but has worked in the department as the

CRE epidemiologist since July 2016. Allison moved to Nashville after graduating from

the University of Michigan School of Public Health with a concentration in Hospital &

Molecular Epidemiology. She is a Michigan native and an avid sports fan of her college

alma mater, the Michigan State University Spartans. Go Green! She enjoys playing

soccer, running and picked up rock climbing since moving to Tennessee. She’s

attempting to learn how to knit.

M e e t t h e s t a f f

P l a t e A r t

Carolyn Stover is an epidemiologist in the Healthcare Associated

Infections and Antimicrobial Resistance Program at the Tennessee

Department of Health. She has been in this position since June 2018,

when she moved to Nashville from New York. Carolyn works primarily on

Candida surveillance data and CRE investigations. She graduated from

the University at Albany School of Public Health in May 2018 with an MPH

in epidemiology and a focus on infectious diseases, surveillance and

preparedness. She enjoys reading, rock climbing and traveling.

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S E A RL N N e w s l e t t e r

ChromAGAR art by Natasha Lindahl, Supervisor Special Microbiology, TDH

Q u a r t e r l y R e c i p e S h a r e

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V O L U M E 1 , I S S U E 1

C a r a m e l i z e d O n i o n , A p p l e a n d S a u s a g e S t u f f e d A c o r n S q u a s h

Ingredients

2 small/medium acorn squash, cut in half lengthwise

and seeds/strings scooped out

1 lb pork sausage, casings removed if necessary

1 large onion or 2 small, cut in half and sliced thin

3 Tbsp cooking fat (for caramelizing the onions) + 2

tsp (for sautéing the garlic)

2 cloves garlic ,minced

1 medium-large apple ,cored and diced

2 cups fresh spinach, roughly chopped

1 Tbsp fresh rosemary, chopped

2 tsp fresh thyme, chopped

sea salt and black pepper to taste

1. Preheat your oven to 400 degrees and line a baking sheet with parchment paper.

2. Place the acorn squash halves (seeds removed) open-side down on the baking sheet and roast

in the preheated oven for about 20-30 minutes, or until the top of your squash feels tender when

gently pressed. You can always check them and continue to roast a few more minutes if they

aren't tender enough. Set aside after removing from oven.

3. While the squash roasts, make the filling. Begin by caramelizing the onions (this process takes

a good 20-25 minutes to really bring the flavor out!)

4. In a medium skillet, heat the cooking fat over low heat and add all the onions, stirring to coat.

Sprinkle with a bit of salt and cook over low heat, stirring every 5 minutes ago to prevent burning.

Once onions have been cooking for about 25 minutes and are deep golden brown, remove from

heat and set aside.

5. While the squash roasts and the onions cook, heat a large saucepan over medium low heat

and add the remaining 2 tsp cooking fat to melt. Add the garlic and cook until just tender, then

add all the sausage and increase the heat to medium.

6. Cook the sausage and stir to break up lumps, about 5-8 minutes until just browned. Add the

apples and herbs and continue to cook, stirring until the apples soften. Add the spinach and a

pinch of salt and pepper and cook, stirring, until the spinach wilts.

7. Add the caramelized onions to the sausage mixture, leaving excess cooking fat in the pan.

Preheat your broiler, then fill all 4 halves of the squash with the stuffing mixture (you may have

leftover depending on how big your squash was)

8. Arrange the squash on the baking sheet, stuffing side up, and put under the broiler for 5-10

minutes until the tops get nice and toasty, checking often to prevent burning. Once nice and

browned, remove from oven, allow to cool a bit and then serve warm. Enjoy!

TN Laboratory Services

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F i n d t h e f o l l o w i n g w o r d s :

A G A R

B E T A L A C T A M A S E

B I O H A Z A R D

C A R B A P E N E M

C O L I S T I N

E N T E R O B A C T E R I A C E A E

I S O L A T E

M U E L L E R H I N T O N

M Y C O L O G Y

R E S I S T A N T

S L A N T

S U S C E P T I B L E

Ingredients: 1 package (18.25 ounces refrigerated chocolate chip cookie dough or your favorite cookie recipe) 1/2 cup prepared vanilla frosting, tinted red 1 3/4 cups miniature marshmallows 48 slivered almonds Instructions: Prepare cookies as directed on package or according to your

favorite recipe. Let cookies cool. Cut each cookie in half for a total of 48 halves.

Frost the bottoms of all cookie halves with frosting. Place 6 marshmallow teeth around curved perimeter of 24 halves. For additional support, an additional marshmallow can be placed behind the teeth. Top with remaining 24 halves just slightly behind the marshmallows so that they show. Insert two almond slivers in between teeth for fangs. If fangs do not adhere, dip tips into frosting.

DRACULA’S DENTURES FOR HALLOWEEN

Contact:

TN HAI Phone: (615) 741-7247

Regional Lab Phone: (615) 262-6300

Regional Lab Fax: (615) 741-3857

E-mail: ARLN.Health@TN.gov

Tennessee Department of Health Authorization Number 343200.

Electronic only publication Produced at no cost. October 2018.