Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention...

26
Carbapenemase-Producing Enterobacteriaceae (CPE) November 28, 2018 Madeleine Ashcroft

Transcript of Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention...

Page 1: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 2: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 3: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 4: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 5: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 6: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 7: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 8: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 9: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 10: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 11: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 12: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 13: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 14: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 15: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

Page 16: Carbapenemase-Producing Enterobacteriaceae (CPE) · Enterobacteriaceae (CRE) control and prevention toolkit. (Prepared by Boston University School of Public Health and Montefiore

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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26