Health Advisory: Drug-Resistant Infections Imported from Mexico, April 15, 2019

Situation Overview

The Texas Department of State Health Services (DSHS) along with the Centers for Disease Control and Prevention (CDC) is investigating an outbreak of Verona integron-encoded metallo-beta-lactamase-producing Pseudomonas aeruginosa (VIM-CRPA) infections in patients who underwent surgery at Grand View Hospital in Tijuana, Mexico beginning in August 2018. Infections caused by VIM-CRPA are rare in the United States and difficult to treat. Nationwide, the CDC has identified 12 patients with VIM-CRPA who reported undergoing surgery at Grand View Hospital in 2018. There were an additional three patients who underwent surgery there and had CRPA, but further testing was not done to determine if these isolates had the VIM resistance mechanism. Of the 15 patients with infections who had surgery at Grand View Hospital, 10 (67 percent) reported booking their surgery through Weight Loss Agents, which is a weight loss travel agency.

Per CDC, approximately 100 residents of Texas were referred to Grand View Hospital by Weight Loss Agents. It is not currently known how many of them actually had surgery there. Texas has identified one case from this group. Additional cases may be identified as the CDC continues to receive reports of infections in patients who had surgery at Grand View Hospital.

As part of this investigation, Mexican health officials identified poor infection control practices at the hospital, including failure to follow recommended practices for assuring the quality of sterilization of medical devices and instruments. These failures put patients at risk of contracting blood-borne infections.

The CDC requested that Weight Loss Agents send written communication to their clients advising them to seek immediate medical care should they have any signs of an infection and to talk to their healthcare provider about being tested for blood-borne pathogens.

Guidance for Healthcare Professionals

• For those patients who had surgery at Grand View Hospital on or after August 1, 2018, consider testing for blood-borne pathogens, including hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV).
• When caring for patients who have a recent history of having undergone invasive medical procedures in Mexico, obtain cultures, perform susceptibility testing to guide treatment, and test any carbapenem-resistant bacteria for Verona integron as well as other plasmid-mediated carbapenemases.
  • Mechanism testing for carbapenem-resistant bacteria and rectal screening for carbapenemases is available free of charge via the Antibiotic Resistance Laboratory Network, which can be accessed by contacting your local health department.
  •  Report any CRPA-positive cultures in patients who had invasive medical procedures in Mexico to your local health department.
• CRPA infections are drug-resistant and difficult to treat, requiring protracted and complex intravenous antibacterial drug combinations and courses of treatment. Consider consulting an infectious disease specialist for treatment recommendations.

Infection Control Precautions

• When admitting patients who have a history of overnight stays in healthcare facilities outside the United States, consider performing rectal screening for carbapenemase-producing organisms. This recommendation applies to patients hospitalized outside the United States at any time during the 6 months before their U.S.-based hospital admission.
• While awaiting screening results, consider implementing contact precautions for any patient presenting with a history of undergoing invasive procedures in Mexico.
• Any patient with open, draining wounds should be placed on contact precautions. Standard precautions should be employed for all patients.
• Facilities should ensure that all healthcare personnel perform hand hygiene by using alcohol-based hand rub or by washing their hands with soap and water before and after contact with patients and their environment.

If you have questions regarding VIM-CRPA or would like to report a suspected VIM-CRPA case, please contact your local health department or SHS regional office (contact information for each local health department and DSHS regional office is available.

View additional information about screening and isolation recommendations from the CDC.