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DJ  Shannon, MPH  Antimicrobial Resistance Epidemiologist DJ  Shannon, MPH  Antimicrobial Resistance Epidemiologist

DJ Shannon, MPH Antimicrobial Resistance Epidemiologist - PowerPoint Presentation

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DJ Shannon, MPH Antimicrobial Resistance Epidemiologist - PPT Presentation

Infectious Disease Epidemiology Epidemiology Resource Center Indiana State Department of Health CPCRE and the nonKPCs Overview Definitions Review of antibiotic resistance CRE and CPCRE CPCRE data ID: 752788

resistant 2018 resistance cre 2018 resistant cre resistance district 2016 antibiotic data preliminary cases represents klebsiella indiana common healthcare

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Slide1

DJ Shannon, MPH Antimicrobial Resistance EpidemiologistInfectious Disease EpidemiologyEpidemiology Resource CenterIndiana State Department of Health

CP-CRE and the non-KPCsSlide2

OverviewDefinitionsReview of antibiotic resistanceCRE and CP-CRECP-CRE dataA closer look at the non-KPCsColonization screening overviewSlide3

DefinitionsMultidrug-resistant organism (MDRO): an organism that is resistant to one or more agent in at least three classes of antibiotics – or that exhibits a classification of resistance that is of epidemiological concern (e.g. MRSA, VRE, ESBL, CRE)Extensively drug-resistant organism (XDRO): microorganisms that are resistant to nearly all antimicrobial agents that would be considered for treatmentPandrug-resistant organism (PDRO): microorganisms that are resistant to all antimicrobial agents that would be considered for treatmentSlide4

Mechanisms of Antibiotic ResistanceAntibiotic target changesPorin mutationsEfflux pumpsEnzymatic inhibitionSlide5

Mechanisms of Antibiotic ResistanceSlide6

Antibiotic Target ChangesBacteria can change a site that an antibiotic would normally targetThis can quickly lead to resistance bacterial populationsExample:Penicillin-binding protein modificationSlide7

Porin Mutations

Porins are found in the outer membrane of Gram-negative bacteriaPorins help transport material in and out of the cell

Mutations, often a reduction in

porin

production, can cause resistance to antibioticsSlide8

Efflux PumpsA very efficient mechanism of antibiotic resistanceEfflux pumps actively remove antibiotics from within the cell wallCertain types of efflux pumps can cause multidrug-resistanceExample: Efflux pumps found in Pseudomonas aerugionsaSlide9

Enzymatic InhibitionThe most common mechanism of antibiotic resistanceEnzymes produced by bacteria can inactivate the antibioticß-lactamasesPenicillinasesAmpC cephalosporinasesExtended-spectrum ß-lactamases (ESBL)Carbapenemases Slide10

Mobility of CarbapenemasesSlide11

CarbapenemasesKPC: Klebsiella pneumoniae carbapenemaseMost common in the United StatesNDM: New Delhi Metallo-ß-lactamaseMost common in IndiaIMP: ImipenemaseMost common in JapanVIM: Verona Integron-mediated Metallo-ß- lactamase

Most common in western EuropeOXA-48: Oxacillinase-48 Most common in Mediterranean countriesSlide12

CRE: A Public Health ThreatCRE in the United States are an urgent threatCRE infections are associated with high mortality ratesCRE confer high levels of resistanceCP-CRE have very mobile resistance genes that can easily be shared with other organisms (CPOs)Slide13

Carbapenem-Resistant EnterobacteriaceaeDefinition: Any Enterobacteriaceae that are not susceptible (i.e. intermediate or resistant) to a carbapenem antibioticCurrent Breakpoint (CLSI M100-S27) MIC µg/mlAntibiotic

SusceptibleIntermediateResistant

Doripenem

≤ 1

2

≥ 4

Ertapenem

≤ 0.5

1

≥ 2

Imipenem

≤ 1

2

≥ 4

Meropenem

≤ 1

2

≥ 4Slide14

Carbapenem-Resistant EnterobacteriaceaeEnterobacteriaceae can be resistant to carbapenems through several resistance mechanismsCarbapenemase production is currently the most concerningSlide15

Carbapenemase-Producing Carbapenem-Resistant EnterobacteriaceaeEnterobacteriaceae isolates that demonstrate carbapenemase production via one of the following:Positive for carbapenemase production by a phenotypic test (e.g., Carba NP, mCIM)Positive for a carbapenemase gene markerSlide16

CRE vs. CP-CRECP-CRE !!!

Reportable

+ ESBLSlide17

Indiana CP-CRE Cases, 2016-2018MonthCasesAverage:

28

Total: 355

2017

2016

Total: 294

2018

Total:

230

*Preliminary 2018 data represents 1/1/2018 –

7/31/2018Slide18

Indiana CP-CRE Cases by District, 2016-2018

State:

879

District 1:

380

District 2:

30

District 3:

70

District 4:

19

District 5:

200

District 6:

90

District 7:

51

District 8:

17

District 9:

17

District 10:

5

*Preliminary 2018 data represents 1/1/2018 –

7/31/2018Slide19

Organisms664 Klebsiella pneumoniae70 Serratia marcescens53 Escherichia coli42 Enterobacter cloacae

complex19

Citrobacter

freundii

complex

15

Klebsiella

oxytoca

6

Citrobacter koseri

4

Proteus mirabilis

2

Klebsiella aerogenes

2

Providencia

rettgeri

1

Klebsiella ozaenae

1

Klebsiella

variicola

1

Leclercia adecarboxylata

1

Morganella

morganii

Mechanisms

804

KPC

22 NDM

18 VIM

9 OXA-48-like

2 IMP

24

unknown

Indiana CP-CRE

Cases, 2016-2018

879 CP-CRE cases

*Preliminary 2018 data represents 1/1/2018 –

7/31/2018Slide20

A Closer Look at the non-KPCsNDM: New Delhi Metallo-ß-lactamaseIMP: ImipenemaseVIM: Verona Integron-mediated Metallo-ß-lactamase

Most clinically threatening

More

resistant

More mobile

Fewer antibioticsSlide21

*Preliminary 2018 data represents 1/1/2018 – 7/31/2018Indiana NDM cases

by healthcare facility,

2016-2018Slide22

*Preliminary 2018 data represents 1/1/2018 – 7/31/2018

Indiana VIM

c

ases

by

healthcare facility

,

2016-2018Slide23

*Preliminary 2018 data represents 1/1/2018 – 7/31/2018

Indiana IMP

cases

by

healthcare facility

,

2016-2018Slide24

A Closer Look at the non-KPCsOXA-48: Oxacillinase-48

Less resistant*

Difficult to detect

*Unless other mechanism presentSlide25

*Preliminary 2018 data represents 1/1/2018 – 7/31/2018

Indiana OXA

cases

by healthcare facility

,

2016-2018Slide26

AST Profile Cheat SheetDrugESBLAmpC1st –gen cephR

R2nd –gen ceph

S

R

3

rd

–gen

ceph

R

R

4

th

–gen

ceph

R

S

Pip-

tazo

S

R

Carbapenems

S

Erta

R, others S

CP-CRE bonus: If Aztreonam is resistant,

t

hink KPC – not NDM/VIM/IMPSlide27

Infection Prevention ImplicationsHealthcare Personnel EducationIdentificationLaboratory notificationInter-facility communicationScreening contacts of CRE patientsActive surveillance for CRE colonizationPreventionCareful use of invasive medical devicesAntibiotic Stewardship

ContainmentHand hygieneContact precautions

Cohorting

of residents and staff

Environmental cleaning

Chlorhexidine bathingSlide28

Antibiotic Resistance Laboratory NetworkSlide29

Tier 1: Novel resistance, rare resistant organisms or pandrug-resistant organismsExample: Candida aurisTier 2: Known, yet uncommon, resistance mechanismsExample: VIM-producing EnterobacteriaceaeTier 3: Targeted, non-endemic resistance mechanismExample: KPC-producing Enterobacteriaceae

Response TiersSlide30

Photo Source: CDC

Response TiersSlide31

What happens after colonization screening?Contact precautions useIndefinite use for CP-CRESee SHEA Guidelines RetestingWhen a negative isn’t really a negative…Patient and staff cohorting as neededSharing isn’t caring

To treat or not to treat?Slide32

ResourcesFacility Guidance for Control of CRESlide33

ResourcesManagement of Multidrug-Resistant Organisms In Healthcare Settings, 2006 Slide34

ResourcesSHEA Expert Guidance for the Duration of Contact Precautions for Acute-Care Settings Slide35

Contact InformationDJ Shannon, MPHAntimicrobial Resistance EpidemiologistInfectious Disease EpidemiologyEpidemiology Resource CenterIndiana State Department of Health

Work: 317-233-1306Email: dshannon1@isdh.in.gov