Carbapenem -Resistant Enterobacteriaceae - PowerPoint Presentation

1. Carbapenem-Resistant Enterobacteriaceae: Detect and ProtectVDH Healthcare-Associated Infections Program TeamApril 2013

2. Background Carbapenem antibiotics (ertapenem, imipenem, meropenem, and doripenem) are often used as the last line of treatment for infections caused by resistant Gram-negative bacilli Over the past decade, members of the Enterobacteriaceae family of bacteria have begun to develop resistant to carbapenems and these resistant bacteria have spread throughout the U.S.Klebsiella spp., especially K. pneumoniaeE. coliEnterobacter spp.CRE refers to carbapenem-resistant Enterobacteriaceae

3. Resistance Mechanisms and Risk FactorsCarbapenemase enzymes confer resistance to carbapenems. Most prevalent carbapenemase in the U.S. is Klebsiella pneumoniae carbapenemase (KPC)Yet CDC suggests US distribution likely heterogeneousPersons at risk are those receiving serious medical care: Invasive medical devicesOpen woundsLong courses of antibiotic therapy“Unusual” resistance mechanisms (NDM-1, VIM, OXA-48)Risk factor: recent (within last 6 months) exposure to hospitalization in a country outside the US

4. EpidemiologyJan-June 2012:4% of U.S. hospitals reported at least one patient18% of long-term acute care hospitals reported at least one patientLast 10 years:One type of CRE infection reported in medical facilities in 42 statesMore common in NortheastCRE with unusual resistance mechanismsAs of mid-Feb 2013, 37 reports in U.S. – 15 since July 2012Since then, at least 2 more cases in VA alone (both NDM-1)First two cases of OXA-48 identified in US were from Virginia (2012)http://www.cdc.gov/vitalsigns/hai/cre/Mathers et al. First Clinical Cases of OXA-48-Producing Carbapenem-Resistant Klebsiella pneumoniae in the United States: the “Menace” Arrives in the New World. Journal of Clinical Microbiology 2013;51(2): 680-683.

5. CRE: Just Another Type of MDRO?What makes CRE special…No decolonization strategy Few treatment options availableHigh mortality rate (50% or greater in some studies)Resistance can hop between many Enterobacteriaceae (there are over 70 bacteria in the Enterobacteriaceae family)High speed/rate of resistance transfer

6. CRE in Long-Term Care SettingsCRE not just in acute care hospitalsSince 2004, reports of CRE cases from long-term acute care hospitals (LTACHs) and long-term care facilitiesCRE prevalence as high as 50%, even with few infectionsPotential for large reservoir of patients with CREMultiple comorbiditiesConcentrated in one location for extended time period

7. CRE ConcernsIn addition to spreading among people, CRE easily spread their antibiotic resistance to other kinds of germsMaking those potentially untreatableInfections could begin appearing in otherwise healthy people

8. Inter-Facility Transmission of MDROs (Including CRE)Munoz-Price SL. Clin Infect Dis 2009;49:438-43.Facilities with known CRE: complete inter-facility transfer form when transferring patients (include CRE status, presence of open wounds/devices, antimicrobial use and length of therapy)

9. Critical Opportunity for CRE Control: “Detect and Protect”

10. Current CDC Guidance for CRE ControlCoordinated efforts from all stakeholdersAcute and long-term care facilitiesKey principles:Recognizing epidemiologic importance of CREUnderstand prevalence of CRE within a given regionIdentify colonized and infected patients in facilitiesImplement regional and facility-based interventions to halt transmission

11. 2012 CDC CRE ToolkitFacility-level recommendationsAcute careLong-term careHealth department involvementVaries depending on regional prevalenceFocused emphasis on preventing further transmission and widespread emergence of CREhttp://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

12. Know Your BaselineQuantify clinical evidence of these organismsReview archived lab resultsNumber and/or proportion of Enterobacteriaceae that meet CRE definitionMay elect to focus on E. coli and Klebsiella spp.Specified time period (6-12 months)How soon after admission into facility are CRE identified?Evidence of inter-facility transmission?Intra-facility transmission?Which units/wards most affected?Consider collecting basic epidemiology of patients colonized or infected with CREPatient demographics, dates of admission, outcomes, medications, common exposures

13. Interim CRE Surveillance Case DefinitionNonsusceptible to one of the following carbapenems: doripenem, meropenem, or imipenem ANDResistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidime.(Note: All three of these antimicrobials are recommended as part of the primary or secondary susceptibility panels for Enterobacteriaceae)Klebsiella species and Escherichia coli that meet the CRE definition are a priority for detection and containment in all settings; however, other Enterobacteriaceae (e.g., Enterobacter species) might also be important in some regions.For bacteria that have intrinsic imipenem nonsusceptibility (i.e., Morganella morganii, Proteus spp., Providencia spp.), requiring nonsusceptibility to carbapenems other than imipenem as part of the definition might increase specificity.

14. Facility-Level Prevention StrategiesAcute and Long-Term CareCore MeasuresHand HygieneContact PrecautionsHealthcare Provider (HCP) EducationMinimize Device UsePatient and Staff CohortingLaboratory NotificationAntimicrobial StewardshipCRE Screening

15. Hand HygieneEducate staffOrientation and periodicallyMonitor hand hygiene adherence and provide feedbackEnsure access to hand hygieneInstall alcohol-based hand gel dispensers in patient rooms

16. Contact Precautions (CP) – Acute CarePatients colonized or infected with CREConsider pre-emptive CP for patients transferred from high-risk settingSystem to identify patients at admissionCDC Health Advisory: History of recent inpatient stay in hospital outside US?Ensure proper PPE by HCPHand hygiene before gown and glovesGown and gloves before entering patient’s roomRemove gown and gloves, hand hygiene before exitingMonitor adherence and provide feedbackNot enough information for firm recommendation re: discontinuation

17. Contact Precautions – Long-Term CareModify by risk Use Contact Precautions:Dependent on HCP for activities of daily livingVentilator-dependentIncontinent of stoolWounds with drainage that is difficult to controlConsider relaxing Contact Precautions:Continent of stool, less dependent, w/o draining woundsALWAYS observe Standard Precautions

18. HCP EducationWhat is CRE?Basic education about MDRO preventionHand hygieneContact precautionsAppropriate handling of invasive devices, removal of devices when no longer needed

19. Device UseMinimize use of invasive devicesEnsure implementation of HICPAC recommendationsUrinary cathetersCentral linesVentilators

20. Patient and Staff CohortingPlace CRE patients in single-patient roomsIf not available, cohort patients in the same roomPreference for single rooms given to patients at highest transmission risk (stool incontinent, medical devices, open wounds)To the extent possible, cohort CRE patients to specific areas and staffCohort patients with CRE infection or colonization to specific units/wards or a specific area within the unit/wardDedicate staff to CRE patients or minimize the number of staff caring for CRE patients

21. Laboratory NotificationPerform appropriate screening for CRE Use up-to-date lab standardsProtocols in place for notificationNotify clinical staffNotify infection preventionApplies to both on and off-site laboratories

22. Promote Antimicrobial StewardshipEnsure antimicrobials are used for appropriate indications and durationUse narrowest spectrum appropriate antimicrobial

23. CRE ScreeningPurpose: to identify unrecognized CRE colonization among high risk patients Point prevalenceRapid evaluation of CRE prevalence in particular unit(s)/affected area(s)One time if few or no additional CRE patients identifiedConduct serially if colonization more widespread and/or to follow effect of interventionEpi-linked (e.g., roommate)Screening indicated for patients with history of recent inpatient stay in hospital outside USStool, rectal, or peri-rectal cultureshttp://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdfFor surveillance cultures, may also consider cultures of wounds or urine (if urinary catheter present)

24. Supplemental Measures for Facilities with Ongoing CRE TransmissionActive surveillance culturesCulturing patients not epi-linked to known CRE patients but meet certain criteria (e.g., admitted from LTCF, admitted to ICU)Chlorhexidine bathingDiluted liquid (2%) or 2% chlorhexidine-impregnated wipesDaily in high risk (e.g., ICU)Less frequent in LTCFApplied to all patients in affected unit(s), not just those with CRE infection/colonization

25. In Your Facility…Is the laboratory able to identify CRE? How is a CRE defined?Are there any barriers to implementing the recommended prevention strategies?Your Infection Control Committee may be able to help brainstorm solutions to address some of the challenges regarding surveillance and prevention of CRE

26. Inter-facility CommunicationIn “detect and protect”, communication is key!When transferring patients with CRE infection/colonization from your facility, indicate:CRE status of patientPresence of open wounds/devicesAntimicrobial use and length of therapyIf CRE present on admission to facility (within 2 days), communicate information to originating facility

27. Role of Public Health in CREAssess CRE incidence/prevalenceProvide situational awareness to facilitiesServe as resource to facilities re: prevention and controlAssist with coordination of laboratory testing when indicated, especially in situations with outbreaks and when “unusual” type of CRE suspected or confirmedPhone a Friend!

28. Priorities for Testing/ScreeningFor patients admitted to healthcare facility in the U.S. after recent hospitalization (within 6 months) in countries outside the U.S., consider:Rectal screening cultures to detect CRE colonization.Place patients on Contact Precautions while awaiting the results of these screening cultures.When a CRE is identified in a patient (infection or colonization), send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism; at a minimum, this should include evaluation for Klebsiella pneumoniae carbapenemase (KPC) and NDM carbapenemase.

29. Please Report to Local Health DepartmentSuspected or confirmed outbreaks of CRE CRE infection or colonizationAny patient suspected or confirmed to be infected or colonized with one of the unusual forms of CRE (e.g., NDM or VIM carbapenemases). The local health district will work with you and DCLS to assist with appropriate laboratory evaluation for these new forms of CRE.

30. Regions with Few CRE Identified: Infection PreventionFacility w/o CRE but located in Region where CRE present:Engage facility administrators to prioritize CRE preventionEnsure CRE control plan is in placeReinforce core prevention measuresGuide implementation of active surveillance testing and preemptive Contact Precautions for:Patients admitted from facilities with ongoing CRE transmissionPatients admitted from LTACHs/LTCFs or with CRE risk factors (open wounds, indwelling devices, high antimicrobial use)

31. Regions with Few CRE Identified: Infection PreventionFacility with CRE present:Engage facility administrators to prioritize CRE preventionReview infection prevention practices to ensure core prevention measures are in placeProvide in-service training (as needed)Ensure CRE screening in place and guide implementation of supplemental measuresIf CRE rates do not decrease, consult health department and/or regional experts for additional guidance

32. Regions with Few CRE Identified: Education of all Healthcare FacilitiesExplain importance of CRE and provide updates on regional prevalence and epidemiologyReview recommended surveillance and prevention measuresIncrease vigilance for CRE detectionOverview of CRE surveillance and prevention strategies for acute care and long-term care facilities (developed by VDH)1-page “Cliff Notes” version of CDC CRE toolkitPlans for additional education for healthcare facilities and health department staff

33. ResourcesCDC CRE Toolkit (2012): http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.htmlCDC Health Advisory (Feb 2013): http://emergency.cdc.gov/HAN/han00341.aspCRE Vital Signs (Mar 2013): http://www.cdc.gov/vitalsigns/hai/cre/CDC CRE website: http://www.cdc.gov/HAI/organisms/cre/index.htmlCDC CRE lab protocol: http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdfVDH MDRO website: http://www.vdh.virginia.gov/epidemiology/surveillance/hai/MRSAandMDRO.htm

34. Questions?VDH HAI Team: 804-864-8141April Achter – HAI/Influenza EpiAndrea Alvarez – Program CoordinatorCarol Jamerson – Nurse EpiAngela West – Central Region EpiAngela.West@vdh.virginia.gov804-864-8232