Carbapenemase-Carbapenemase-Producing Producing Carbapenem-Resistant Carbapenem-Resistant EnterobacteriaceaeEnterobacteriaceae

Nicole Hearon, Nicole Hearon, HAI EpidemiologistHAI Epidemiologist

Surveillance and Investigation DivisionSurveillance and Investigation Division

Indiana State Department of HealthIndiana State Department of Health

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ObjectivesObjectives

• At the end of the presentation attendees should be able to:

– Understand and describe the basic epidemiology of carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE)

– Report cases of CP-CRE via I-NEDSS

– Determine appropriate and efficient interventions that can prevent CP-CRE transmission in healthcare settings

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DefinitionsDefinitions

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• Enterobacteriaceae: a family of bacteria normally found in human intestines; can become carbapenem-resistant; can cause serious infection when spread outside the gut

• Carbapenem: a class of broad-spectrum antibiotics used to treat severe infections; antibiotics of last resort when other antibiotics are not available (e.g., imipenem, meropenem, doripenem, ertapenem)

• Carbapenemase: enzymes that break down (inactivate) carbapenem antibiotics, causing resistance

• CRE: a family of germs that are difficult to treat because they are highly resistant to antibiotics

CP-CRE DefinitionCP-CRE Definition

• Organisms that are non-susceptible to at least one carbapenem antibiotic with MIC ≥ 2 µg/ml or zone diameter ≤ 22 mm (≤ 21 mm for ertapenem)

AND

• Meet one of the following criteria:(next slide)

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CP-CRE Definition (cont’d)CP-CRE Definition (cont’d)

A. Positive for carbapenemase production by a phenotypic test (e.g., Modified Hodge or Carba NP)

OR

B. Nonsusceptible to at least three (3) carbapenem antibiotics with MIC ≥ 2 µg/ml or zone diameter ≤ 22 mm (≤ 21 mm for ertapenem)

OR

C. Positive for a carbapenemase gene marker

• Examples: Klebsiella pneumoniae carbapenemase (KPC), New Delhi Metallo-beta lactamase (NDM), Verona Integron-Encoded Metallo-beta-lactamase (VIM), Oxacillinase-48 (OXA-48), Imipenemase Metallo-beta-lactamase (IMP)

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Why are CRE Why are CRE epidemiologically epidemiologically

important?important?• Cause infections with high mortality rates (up to 50%)

• Carry genes with high levels of resistance to many antimicrobials, limiting treatment options– Resistance can be transmitted between organisms or between

patients

• Spread rapidly and require the most rigorous infection control measures

• Have spread throughout many areas of the U.S. and can spread more widely

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Carbapenem ResistanceCarbapenem Resistance

• Enterobacteriaceae can become resistant to carbapenems by:

– The transmission of resistance genes from one bacterium to another

– The production of enzymes that inactivate carbapenems (i.e., carbapenemases)

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TransmissionTransmission

• Person to person – via contact with infected or colonized

individuals

– via hands of healthcare personnel

– via contaminated medical equipment

• Contact with stool or wounds

• Contact with contaminated environmental surfaces (e.g., bed rails)

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States with CP-CRE in States with CP-CRE in 20062006

https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinar-presentation-2014-09-25-final.pdf

10http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html

Current States with CP-Current States with CP-CRECRE

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Global Dissemination of Global Dissemination of CRECRE

Molton J, et al. Clin Infect Dis 2013;56:1310-1318

http://cid.oxfordjournals.org/content/56/9/1310.full?sid=b2bcabcc-cb4d-41ab-ba19-b91734089663

Risk FactorsRisk Factors

• Exposure to acute care or long-term care facilities

• Exposure to an ICU• Presence of other medical conditions• Compromised immune system• Invasive devices (e.g., ventilators,

central venous catheters, or urinary catheters)

• Invasive procedures (e.g., endoscopic procedures)

• History of extensive antibiotic use

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Types of InfectionsTypes of Infections

• CP-CRE can cause: – Bloodstream infections

– Ventilator-associated pneumonia

– Surgical site infections

– Intra-abdominal abscesses

– Urinary tract infections

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DetectionDetection

• Appropriate specimens:– Stool

– Blood

– Urine

– Wound

• Laboratory tests:– Modified Hodge Test

– Carba NP (Carbapenemase Nordmann-Poirel)

– Polymerase chain reaction (PCR)

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– Sputum– Bile

• Colonized patients – No antibiotics needed

• Infected patients– Antibiotics are limited

– Other therapies (e.g., draining the infection)

• Strains that have been resistant to all antibiotics have been reported

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TreatmentTreatment

Infection Control Infection Control MeasuresMeasures

• When CP-CRE are identified:

1. An investigation shall be performed by the local health officer within seventy-two (72) hours and include individuals who have shared a residence with the patient in an acute care or long term care facility.

2. The facility should initiate Contact Precautions; additional precautions should be added if any other transmissible condition is present.

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http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

Infection Control Infection Control Measures (cont’d)Measures (cont’d)

3. Supplemental measures for a healthcare facility with CP-CRE transmission include the following:

A. Refer to the most recent CRE Toolkit from CDC at http://www.cdc.gov/HAI/organisms/cre/

B. Consider screening patients to determine if they are epidemiologically linked

C. Consider chlorhexidine gluconate bathing

4. Case definition is established by the department.

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ReportingReporting

• CP-CRE must be reported to the health department within 72 hours

• IP can create a communicable disease report (CDR)– Select “Carbapenemase producing – Carbapenem resistant

Enterobacteriaceae (CP-CRE)” from the drop down list

• ISDH HAI Epidemiologist will assign CDR to the LHD

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Reporting (cont’d)Reporting (cont’d)

• Electronic lab reports (ELRs) are also be submitted to ISDH via I-NEDSS by laboratories

• ISDH HAI Epidemiologist will assign ELR to LHD

• Laboratories must submit isolates within 3 business days of isolation– Only submit one isolate per patient

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WHAT’S NEXT?WHAT’S NEXT?

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InvestigationInvestigation• LHD contacts facility IP within 72 hours of notification

– Ensure facility places patient on Contact Precautions

– Determine if patient has shared a room or staff with other patients

– Determine if there is a potential for transmission within facility

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• Local health departments should also:

– Promote antimicrobial stewardship

– Ensure facility communicates patient’s infection/colonization status to receiving facility (e.g., LTC facility) if patient will be transferred

• Inter-facility transfer form with laboratory reports

– Complete case investigation in I-NEDSS

Investigation (cont’d)Investigation (cont’d)

Inter-facility TransferInter-facility Transfer

• If a CP-CRE patient will be transferred to a different facility:– Infection Preventionist or designee should notify the accepting

facility AND send an “inter-facility infection control transfer form” which should include:

– Patient name, date of birth, medical record number– Sending facility contact information– Type of isolation precautions for patient– Infection, colonization, or history of positive culture of a multidrug-

resistant organism– Symptoms – Antibiotic use, vaccines– Contact information for person completing transfer form

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http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf

Prevention Prevention RecommendationsRecommendations

• Healthcare personnel should:– Practice hand hygiene

– Clean & disinfect patient rooms and medical equipment

– Don PPE before entering patient room

– Doff PPE and wash hands before exiting patient room

– Keep colonized or infected patient in a single room on Contact Precautions

– Dedicate equipment and staff

– Only prescribe antibiotics when necessary

– Remove temporary medical devices

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Patient ScreeningPatient Screening

• Point prevalence surveys:– Used to quickly evaluate the prevalence of CP-CRE in specific

wards/units

– Screen all patients in a specific high-risk ward/unit

– Could be conducted once or multiple times (e.g., if colonization is more widespread or during an intervention)

• Screening of epidemiologically linked patients:– Screen contacts of patients to identify transmission

– Contacts: • Roommates of CP-CRE patients or patients who may have been cared

for by the same healthcare personnel

26http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

ReferencesReferences• http://www.cdc.gov/hai/organisms/cre/index.html

• http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html

• http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

• http://phil.cdc.gov/phil/home.asp

• http://ce.nurse.com/RVignette.aspx?TopicId=8822

• http://www.cdc.gov/vitalsigns/hai/cre/infographic.html

• https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinar-presentation-2014-09-25-final.pdf

• https://www.youtube.com/watch?v=-FfMCv8FUXI&feature=youtu.be

• https://www.youtube.com/watch?v=vnAtuG9ULB4

• http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf

• http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=53

• http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm

• http://www.mayoclinic.org/ercp-procedure/IMG-20007655

• http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11

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Questions or Remarks?Questions or Remarks?

Email: nhearon@isdh.in.gov

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