CRE Surveillance and Prevention - PowerPoint Presentation

Slide1

CRE Surveillance and Prevention

Cody Loveland, MPH

Surveillance Epidemiologist

Wyoming Department of Health

Slide2

Learning Objectives

Upon completion of this presentation, attendees will be able to:

1

.

    

Understand the clinical significance of CRE and its modes of

transmission

2

.

    

Identify and describe the WDH CRE definition

3

.

    

Describe 12 facility-level CRE prevention strategies

4

.

    

Evaluate your facility’s readiness for detecting, reporting, and

containing CRE

Slide3

CRE Basics

Slide4

CRE =

C

arbapenem

-

R

esistant

Enterobacteriaceae

Family of bacteria -

Enterobacteriaceae

Normal part of human gut flora

Carbapenems are broad spectrum antibacterial drugs

Imipenem,

meropenem

,

doripenem

,

ertapenem

Often treatment of last choice for gram-negative bacteria

CRE are bacteria that have developed resistance to carbapenems

Either through susceptibility testing or through the production of carbapenemase

Slide5

Family of

Enterobacteriaceae

Medically Important CRE

Klebsiella

pneumoniae

Enterobacter

species

Escherichia coli

Klebsiella

oxytoca

Salmonella

entericaSerratia marcescensCitrobacter freundii

https://www.livingoceansfoundation.org/education/portal/course/classification/

Slide6

Why are CRE Important?

Slide7

Mortality in CRE Bacteremia

p

<0.001

Patel et al. Infect Control

Hosp

Epidemiol

2008;29:1099-1106

Slide8

Not just a hospital problem

Matters for whole healthcare system

Shared healthcare providers

Patient and resident transfers

Mode of transmission

Person-to-person

Especially contact with wounds or stool

Contaminated medical equipment

Slide9

Mechanisms of Resistance

Carbapenemase Producing (CP-CRE)

enzyme that breaks down Carbapenems

KPC (most common)

NDM

OXA-48

VIM

IMP

Others??

These are an infection control emergency!

Non-Carbapenemase Producing, but resistant (Non-CP-CRE)

Slide10

WDH CRE Definition

The Wyoming Department of Health defines CRE as any

Enterobacteriaceae

that:

A

re

resistant to at least one carbapenem (including imipenem

1

, meropenem, doripenem, or ertapenem) using the current M100-S25 CLSI

breakpoints

2

; OR

Test positive for carbapenemase production by the Carba NP test; ORTest positive for a known carbapenemase gene by nucleic acid amplification testing.

1, 2

See WDH CRE Toolkit p. 3.

Available at https://health.wyo.gov/publichealth/infectious-disease-epidemiology-unit/disease/cre/

Slide11

Sample CRE Lab Result

Susceptibility Results (WDH Def. part 1)

Whether sample produces carbapenemase (WDH Def. Part 2)

Results of NAAT Testing (WDH Def. Part 3)

Genus and species

This is a non-CP-CRE

Slide12

Other

Carbapenem

-Resistant Organisms

Pseudomonas aeruginosa

and

Acinetobacter

baumannii

species

are not part of the

Enterobacteriaceae

family and therefore are not technically considered CRE.HOWEVER, still medically important and drug resistant!Often contain same carbapenemase genes as CRESend CR-PA and CR-AB samples to WPHL for confirmation testing! Only send non-mucoid CR-PA samples Follow same prevention principles as CRE, but also consult with WDH

Slide13

Colonization vs. Infection

Colonization

– The presence of bacteria on a body surface (like on the skin, mouth, intestines or airway) without causing disease in the person

.

CRE colonization can be prolonged (>6 months)

Can lead to unidentified transmission

Infection

– The presence of bacteria on the body that is associated with an immune response.

Both statuses have different implications in the healthcare setting and impact your response

Created

by Uwe

Kils

(iceberg) and User:Wiska Bodo (sky). [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons

ColonizedPatients

Infected Patients

Slide14

Measure

CP-CRE Infection

CP-CRE Colonization

Non-CP-CRE Infection

Non-CP-CRE Colonization

††

Notify Receiving facility

Yes

Yes

Yes

Yes

Notify WDH upon transfer or death

Yes

Yes

No

No

Standard Precautions

Yes

Yes

Yes

Yes

Contact Precautions

†

Gown/gloves

for in-room resident care

Yes

Yes

Yes

For residents at higher risk of CRE transmission

Door Signage

Yes

Yes

Yes

For residents at higher risk of CRE transmission

Private Room

Yes (strongly encouraged)

Yes (strongly encouraged)

Yes

No

Restricted to room

Yes

No**

No**

No**

Enhanced Environmental Cleaning

Yes

Yes

Yes

No

Designated or disposable equipment

Yes

Yes

Yes

No

If >1 case, cohort staff if feasible

Yes

Yes

Optional

Optional

If >1 case, cohort residents if feasible

Yes

Yes

Optional

Optional

Consult with WDH regarding screening cultures

Yes

Yes

No

No

Visitor recommendations

:

Perform hand hygiene often, particularly after leaving the resident’s room

.

Gown/gloves if contact with body fluids is anticipated

.

Gown/gloves if no contact with body fluids is anticipated.

 

 

Yes

  

 

Yes

 

 

No

 

 

Yes

 

 

Yes

 

 

No

 

 

Yes

  

 

Yes

 

 

No

 

 

Yes

 

 

Yes

 

 

No

Slide15

Facility-Level Prevention Strategies

Slide16

Facility-Level Prevention Strategies

1.

Hand Hygiene

Single most important aspect of preventing CRE transmission!

Reminders, education, audits

http://www.glasbergen.com/diet-health-fitness-medical/hand-washing-hygiene/

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Facility-Level Prevention Strategies

2. Contact Precautions

In acute care and ventilator units of skilled nursing facilities:

Perform hand hygiene

Donning gown and gloves before entering

patient’s

room

Removing the gown and gloves and performing hand hygiene

before

exiting the affected patient’s room

Lower-acuity post-acute setting:

Depends on procedures and perceived

riskhttps://www.compliancesigns.com/NHE-18543.shtml

Slide18

Facility-Level Prevention Strategies

3. Education

Need to educate HCP about preventing transmission of CRE

At minimum, education should include reviews of proper use of contact precautions and proper donning and doffing of PPE so HCP don’t expose

themselves

Consider giving in-service to staff on CRE and other gram-negative

MDRO

MDR-

Klebsiella pneumoniae

Photo credit:

David

Dorward

; Ph.D.; National Institute of Allergy and Infectious Diseases (NIAID)

Slide19

Facility-Level Prevention

Strategies

4. Use of Devices

Device use has been associated with CRE

Minimizing device use should be part of effort to prevent all MDROs

Regularly review device use to ensure it’s still required and promptly discontinue use when no longer needed

5. Laboratory Notification

Need protocol in place to notify proper clinical and IP staff in a timely manner (i.e. within 4 to 6 hours)

True for facilities with both on-site and off-site laboratories

Slide20

Facility-Level Prevention

Strategies

6. Inter-facility Communication

CRE infection/colonization shouldn’t preclude transfers

Facilities transferring patients colonized or infected with CRE

must

notify the receiving facility of the patient’s CRE status

Notify about invasive devices the patient has and the duration of any ongoing antimicrobial therapy

Identification of CRE Patients at

admission

Need a mechanism to identify patients colonized or infected with CRE at re-admission so the appropriate infection control precautions can be initiated

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Facility-Level Prevention

Strategies

7. Antimicrobial stewardship

Multiple antimicrobial classes have been shown to be a risk for CRE colonization and/or infection

Active antimicrobial stewardship program

8. Environmental Cleaning

Once CRE patients are discharged, terminal cleaning of CRE patient rooms should be performed.

Slide22

Facility-Level Prevention

Strategies

9. Patient and Staff

Cohorting

Patients colonized

or

infected with CP-CRE should be housed in single patient rooms.

If insufficient numbers of rooms, give preference to patients at highest risk of transmission (incontinent, uncontrolled draining wounds, medical devices

)

Consider a dedicated staff that provide the bulk of patient’s care. The specific staff that are dedicated may vary depending on the healthcare setting.

Not generally recommended for single patients, but in high prevalence areas and during outbreaks

.

CRE

Patient w/o CRE

Slide23

Facility-Level Prevention

Strategies

10. Screening Contacts of CRE Patients

Screening process for CRE is rectal or

peri

-rectal swabs

Screen

patient with epidemiologic links to unrecognized

CP-CRE

colonized or infected patients

Should be done even if patient has been discharged – consult with WDH!

Slide24

Facility-Level Prevention

Strategies

11. Active Surveillance Testing

Clinical cultures identify only a minority of patients colonized with CRE and unrecognized colonized patients who are not on contact precautions may be a source of CRE transmission.

Screen

high-risk patients at admission or at admission and periodically during their facility stay for

CRE (during outbreaks)

Consider surveillance cultures for patients admitted overnight to healthcare setting in foreign country within last 6-12 months, or within the US in an area with high CP-CRE prevalence.

Slide25

Facility-Level

Prevention Strategies

12. Chlorhexidine Bathing

Used successfully to prevent certain types of HAIs and to decrease MDRO colonization in ICUs.

Bathe patients daily with 2% liquid chlorhexidine or 2% chlorhexidine wipes

Usually high risk settings (ICUs)

Do not use above the jaw line or on open wounds

In LTC, may be used on targeted high-risk residents or high-risk settings (i.e. ventilator unit).

Slide26

Facility CRE Readiness Evaluation

Slide27

CRE Readiness Questions to Ask in Your Facility

Does your lab and/or reference lab test for CRE?

What CLSI standards are they using

?

Can they test for Carbapenemase production?

What

indicators prompt them to suspect a CRE? Positive ESBL? Ceftazidime or Ceftriaxone resistance

?

If my lab cannot perform carbapenemase testing, what will be the infection control response protocol while we wait for confirmatory results?

Slide28

CRE Readiness Questions to Ask in Your Facility

What is the timeframe in which you want to be notified for a CRE?

How will the lab notify the IP staff and clinicians of a positive?

Will they notify you if they

suspect

a positive before it’s identified?

Make sure they still notify you and report to public health if the sample is Carbapenem resistant, but susceptible to a more first-line drug!

Are

our

notification systems and protocol

set up in a way that everything can be implemented properly (i.e. initiating precautions,

communicating

CRE status at transfers) if you (the IP) are gone?

Slide29

CRE Readiness Questions to Ask in Your Facility

Do we have a system in place to flag patients with CRE at re-admission?

Is

this something our EMR can handle?

D

o

I need to talk to IT staff about setting this up?

Will our administration support this as a priority? Who can be a champion to help administration understand this should be a priority

?

Do we have a procedure upon intake to identify potentially infectious people (especially nursing homes

)?

If the patient is transferred, how will you notify the receiving facility?

Do NOT assume that just because it is in the chart, they have read it.Who will be responsible for making sure this notification is clear?Don’t forget to notify medical transport

Slide30

CRE Readiness Questions to Ask in Your Facility

What is my system for tracking CRE in my facility?

Line list? EMR? MS Access Database? NHSN?

Is my system capable of tracking patient risk factors?

Can I come back and review former cases to identify trends?

Slide31

Resources

https://health.wyo.gov/publichealth/infectious-disease-epidemiology-unit/disease/

cre

/

https

://

www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

Slide32

Questions?

cody.Loveland@wyo.gov

307-777-8634