Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention...
Transcript of Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention...
Carbapenemase-Producing Enterobacteriaceae
(CPE)
November 28 2018
Madeleine Ashcroft
PublicHealthOntarioca
Warm Up
2
bull How many of you are from LTC
bull How many of you have experience with a CPE colonized resident or patient
bull Are you screening for CPE on admissionre-admission
bull Has anyone had a nosocomial case of CPE
bull Have you conducted point prevalence for CPE
bull Other AROs
bull Do you have PampPs for AROs that include CPE
PublicHealthOntarioca
Objectives
3
bull Define CPE and its importance
bull Note the incidence of CPE provincially
bull Describe CPE guidelines
PublicHealthOntarioca
CPE ndash What is it
4
Carbapenems A class of broad spectrum antibioticsthat are used for treating infection caused by resistant bacteria (eg ertapenem meropenem imipenem doripenem)
Carbapenemase Genes Genes made up of DNA that instruct the bacteria to make protein or enzyme called carbapenemase (genes KPC NDM OXA VIM etc)
Carbapenemase Enzymes that break down most antibiotics including carbapenems
Enterobacteriaceae A large family of bacteria present normally (part of gut flora) or pathogenically in the human intestinal tract (eg Ecoli Enterobacter Klebsiella etc)
PublicHealthOntarioca
Acronyms CPOCPECRECRO
5
C Carbapenems (antibiotics)
R Resistant
P Producing (carbapenemase enzyme)
O Organisms
E Enterobacteriaceae
CPE is most worrisome ndash with ~ 50 mortality with severe infections
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Warm Up
2
bull How many of you are from LTC
bull How many of you have experience with a CPE colonized resident or patient
bull Are you screening for CPE on admissionre-admission
bull Has anyone had a nosocomial case of CPE
bull Have you conducted point prevalence for CPE
bull Other AROs
bull Do you have PampPs for AROs that include CPE
PublicHealthOntarioca
Objectives
3
bull Define CPE and its importance
bull Note the incidence of CPE provincially
bull Describe CPE guidelines
PublicHealthOntarioca
CPE ndash What is it
4
Carbapenems A class of broad spectrum antibioticsthat are used for treating infection caused by resistant bacteria (eg ertapenem meropenem imipenem doripenem)
Carbapenemase Genes Genes made up of DNA that instruct the bacteria to make protein or enzyme called carbapenemase (genes KPC NDM OXA VIM etc)
Carbapenemase Enzymes that break down most antibiotics including carbapenems
Enterobacteriaceae A large family of bacteria present normally (part of gut flora) or pathogenically in the human intestinal tract (eg Ecoli Enterobacter Klebsiella etc)
PublicHealthOntarioca
Acronyms CPOCPECRECRO
5
C Carbapenems (antibiotics)
R Resistant
P Producing (carbapenemase enzyme)
O Organisms
E Enterobacteriaceae
CPE is most worrisome ndash with ~ 50 mortality with severe infections
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Objectives
3
bull Define CPE and its importance
bull Note the incidence of CPE provincially
bull Describe CPE guidelines
PublicHealthOntarioca
CPE ndash What is it
4
Carbapenems A class of broad spectrum antibioticsthat are used for treating infection caused by resistant bacteria (eg ertapenem meropenem imipenem doripenem)
Carbapenemase Genes Genes made up of DNA that instruct the bacteria to make protein or enzyme called carbapenemase (genes KPC NDM OXA VIM etc)
Carbapenemase Enzymes that break down most antibiotics including carbapenems
Enterobacteriaceae A large family of bacteria present normally (part of gut flora) or pathogenically in the human intestinal tract (eg Ecoli Enterobacter Klebsiella etc)
PublicHealthOntarioca
Acronyms CPOCPECRECRO
5
C Carbapenems (antibiotics)
R Resistant
P Producing (carbapenemase enzyme)
O Organisms
E Enterobacteriaceae
CPE is most worrisome ndash with ~ 50 mortality with severe infections
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
CPE ndash What is it
4
Carbapenems A class of broad spectrum antibioticsthat are used for treating infection caused by resistant bacteria (eg ertapenem meropenem imipenem doripenem)
Carbapenemase Genes Genes made up of DNA that instruct the bacteria to make protein or enzyme called carbapenemase (genes KPC NDM OXA VIM etc)
Carbapenemase Enzymes that break down most antibiotics including carbapenems
Enterobacteriaceae A large family of bacteria present normally (part of gut flora) or pathogenically in the human intestinal tract (eg Ecoli Enterobacter Klebsiella etc)
PublicHealthOntarioca
Acronyms CPOCPECRECRO
5
C Carbapenems (antibiotics)
R Resistant
P Producing (carbapenemase enzyme)
O Organisms
E Enterobacteriaceae
CPE is most worrisome ndash with ~ 50 mortality with severe infections
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Acronyms CPOCPECRECRO
5
C Carbapenems (antibiotics)
R Resistant
P Producing (carbapenemase enzyme)
O Organisms
E Enterobacteriaceae
CPE is most worrisome ndash with ~ 50 mortality with severe infections
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
How is CPE Spread
6
bull Most with CPE are colonized in the lower GI tract
bull Direct contact Unwashed hands
bull Indirect Contact Contaminated equipment and surfaces including sinks shower drains and endoscopes
bull Infection Enters at specific site and causes symptoms eg pneumonia and UTI
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Incidence of CPE in Ontario
7
2016 Report2017 Report
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
CPE is now reportable
8
Effective May 1 2018
bull CPE colonization and infection are now included in the regulations for reporting diseases of public health significance (DOPHS) and reportable to the local public health unit
bull First isolate only
bull All confirmed cases of CPE require investigation to determine if nosocomial transmission of CPE has occurred and to identify the source of transmission
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Preliminary Reports ndash Caveats
9
bull New system ndash voluntary to mandatory public reporting
bull Date entry challenges
bull Data reflects previous positives
bull New cases may come to light
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Ontario Reports May 1 ndash Aug31 2018
10
bull 106 cases reported in 101 patients
bull 53 male
bull 58 age 65+
bull 72 identified on hospital admission
bull 16 associated with reporting facility
bull Most (38) NDM Ecoli
bull 60 colonization
bull 51 rectal swab 36 urine
bull NO first isolates from Complex Continuing Care Rehab or LTCHs
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Risk Factors for Reported CPE CasesMay 2018 to Aug 2018 Ontario
11
Risk Factor Percent
Chronic illness 88
Hospitalization in Canada in last 12 months 69
Travel outside Canada in last 12 months 58
Other medical risk factors 50
Previous CPE colonization 40
Hospitalization outside of Canada in last 12 months 37
ICU admission in Canada in last 12 months 32
Medicalsurgical procedure outside of Canada in last 12 months 27
Endoscopic procedure in Canada in last 12 months 20
Other behavioural risk factors 14
Known contact with confirmed case in last 12 months 3
Medicalsurgical procedure in Canada in last 12 months ndash excluding endoscopic 0
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Proportion of Reported CPE cases by Diagnosing Health Unit - May 2018 to August 2018
12
bull Data is preliminary and for discussion purposes onlybull Source Ontario Ministry of Health and Long-Term Care integrated Public Health Information System (iPHIS) database extracted by Public Health Ontario [20180906]
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Recommended Screening for CPE
13
bull Previously colonized or infected with CPE
bull In the past 12 months been in receipt of health care
bull On the US eastern seaboard region (eg New York City)
bull Greece
bull Israel
bull Indian subcontinent
bull Travel to the Indian subcontinent in the past 12 months (even without exposure to health care ndash Peel Region)
bull Receipt of care in any hospital that has reported transmission of CPE
bull Contact of a known case of CPE
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Screening Specimens
14
bull Rectal swab or Stool
AND if indicated
bull Urine
bull Wounds
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca 15
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
1 Prevent the Spread
16
bull Private room
bull Dedicate toileting - this is essential
bull Private washroom or commode
bull Contact precautions
bull Gloves and gowns for entering room in hospitaldirect resident care in LTC
bull Ensure adherence to hand hygiene
bull Dedicate equipment
bull Hand hygiene sinks for hand washing only
bull Body fluids and bath water should not be disposed in these sinks
bull Consider chlorhexidine for bathing
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Prevent the Spread Accommodation
17
bull A private room is always preferred
bull Patientsresidents with the same gene of CPE (eg KPC) may share a room
bull Example someone with a Klebsiella spp KPC colonization may share their room with a resident who has E coli KPC colonization
bull PIDAC Hospital Contact precautions for entire stay
bull LTC Resident can leave hisher room and go to dining room and participate in community activities Residents should always be remindedhelped to clean their hands prior to leaving their room before meals or before community activities
bull Ask Can we work towards this at our LTC home
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
18
Prevent the Spread Duration of Precautions
bull Follow up screening (rectal swabs) of 97137 CRE patients post-discharge
bull Time to clear ndash mean 387 days (95 CI 312-463)
bull Infected and colonized patients remain in contact precautions for entire hospital stay (PIDAC)
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Quebec Recommendations for CPE in LTC
19
httpswwwinspqqccasitesdefaultfilespublications2426_interim_measures_carbapenemase_other_multidrug_resistant_gram_negativepdf
Contact precautions for at least 6 months
bull Screen after 3 months
bull If negative screen again monthly x 3
bull Follow up screening every 3 months or as IPAC team specifies
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
2 Report to Public Health and Investigate
20
bull Case Definition Laboratory confirmation of CPE (colonization or infection) by an Ontario microbiology laboratory
bull All confirmed cases of CPE require investigation
bull Overall you want to identify if there is evidence to suggest that the case is associated with your facility
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
Resources
21
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Key References
22
bull Public Health Ontario Carbapenemase-producing Enterobacteriaceae (CPE) Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPagesIDLandingPagescarbapenamase-producing-enterobacteriaceaeaspx
bull Provincial Infectious Diseases Advisory Committee Routine practices and additional precautions Available from httpswwwpublichealthontariocaenBrowseByTopicInfectiousDiseasesPIDACPagesRoutine_Practices_Additional_Precautionsaspx
bull Public Health Ontario Frequently asked questions CPE Available from httpswwwpublichealthontariocaeneRepositoryfaq-cpepdf
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Key References
23
bull Ontario Ministry of Health and Long-Term Care Infectious disease protocol Appendix A Disease-specific chapter Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonization May 2018 Available from httpwwwhealthgovoncaenproprogramspublichealthoph_standardsdocsCPE_chapterpdf
bull Pubic Health Agency of Canada Guidance Infection prevention and control measures for healthcare workers in all healthcare settings Carbapenem-resistant gram-negative bacilli 2010 Available from httpwwwphac-aspcgccanois-sinpguideipcm-mpcipdfguide-engpdf
bull Centers for Disease Control Facility guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE) November 2015 Update CRE Toolkit Available from httpwwwcdcgovhaipdfscreCRE-guidance-508pdf
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Additional Resources
24
bull Public Health England Acute trust toolkit for the early detection management and control of Carbapenemase-producing Enterobacteriaceae 2013 Available from httpwwwhpaorgukwebcHPAwebFileHPAweb_C1317140378646
bull Australian Commission on Safety and Quality in Health Care Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE) A guide for acute care health facilities May 2017 Available from httpswwwsafetyandqualitygovauwp-contentuploads201705Recommendations-for-the-control-of-Carbapenemase-producing-Enterobacteriaceaepdf
bull Health Protection Surveillance Centre (Ireland) Guidance relating to Carbapenemase Producing Enterobacterales1 (CPE) for long-term care facilities for older people July 2018 Available from httpwwwhpsciea-zmicrobiologyantimicrobialresistancestrategyforthecontrolofantimicrobialresistanceinirelandsaricarbapenemresistantenterobacteriaceaecreguidanceandpublicationsGuidance20relating20to20CPE20for20long20term20care20facilities_final_14Jun18_signedoffamendedpdf
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
PublicHealthOntarioca
Additional References
25
bull World Health Organization Global action plan on antimicrobial resistance 2015 Available from httpappswhointirisbitstream1066519373619789241509763_engpdfua=1
bull Mariappan S Sekar U Kamalanathan A Carbapenemase-producing Enterobacteriaceae Risk factors for infection and impact of resistance on outcomes Int J Appl Basic Med Res 2017 Jan-Mar 7(1) 32ndash39 Available from httpswwwncbinlmnihgovpmcarticlesPMC5327604
bull Parker VA Logan CK Currie B Carbapenem-Resistant Enterobacteriaceae (CRE) control and prevention toolkit (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No 290-2006-0012-l) AHRQ Publication No 14-0028 Rockville MD Agency for Healthcare Research and Quality April 2014 Available from httpwwwahrqgovsitesdefaultfilespublicationsfilescretoolkitpdf
26
26