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Carbapenemase-Carbapenemase-Producing Producing Carbapenem-Resistant Carbapenem-Resistant EnterobacteriaceaeEnterobacteriaceae
Nicole Hearon, Nicole Hearon, HAI EpidemiologistHAI Epidemiologist
Surveillance and Investigation DivisionSurveillance and Investigation Division
Indiana State Department of HealthIndiana State Department of Health
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ObjectivesObjectives
• At the end of the presentation attendees should be able to:
– Understand and describe the basic epidemiology of carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE)
– Report cases of CP-CRE via I-NEDSS
– Determine appropriate and efficient interventions that can prevent CP-CRE transmission in healthcare settings
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DefinitionsDefinitions
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• Enterobacteriaceae: a family of bacteria normally found in human intestines; can become carbapenem-resistant; can cause serious infection when spread outside the gut
• Carbapenem: a class of broad-spectrum antibiotics used to treat severe infections; antibiotics of last resort when other antibiotics are not available (e.g., imipenem, meropenem, doripenem, ertapenem)
• Carbapenemase: enzymes that break down (inactivate) carbapenem antibiotics, causing resistance
• CRE: a family of germs that are difficult to treat because they are highly resistant to antibiotics
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CP-CRE DefinitionCP-CRE Definition
• Organisms that are non-susceptible to at least one carbapenem antibiotic with MIC ≥ 2 µg/ml or zone diameter ≤ 22 mm (≤ 21 mm for ertapenem)
AND
• Meet one of the following criteria:(next slide)
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CP-CRE Definition (cont’d)CP-CRE Definition (cont’d)
A. Positive for carbapenemase production by a phenotypic test (e.g., Modified Hodge or Carba NP)
OR
B. Nonsusceptible to at least three (3) carbapenem antibiotics with MIC ≥ 2 µg/ml or zone diameter ≤ 22 mm (≤ 21 mm for ertapenem)
OR
C. Positive for a carbapenemase gene marker
• Examples: Klebsiella pneumoniae carbapenemase (KPC), New Delhi Metallo-beta lactamase (NDM), Verona Integron-Encoded Metallo-beta-lactamase (VIM), Oxacillinase-48 (OXA-48), Imipenemase Metallo-beta-lactamase (IMP)
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Why are CRE Why are CRE epidemiologically epidemiologically
important?important?• Cause infections with high mortality rates (up to 50%)
• Carry genes with high levels of resistance to many antimicrobials, limiting treatment options– Resistance can be transmitted between organisms or between
patients
• Spread rapidly and require the most rigorous infection control measures
• Have spread throughout many areas of the U.S. and can spread more widely
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Carbapenem ResistanceCarbapenem Resistance
• Enterobacteriaceae can become resistant to carbapenems by:
– The transmission of resistance genes from one bacterium to another
– The production of enzymes that inactivate carbapenems (i.e., carbapenemases)
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TransmissionTransmission
• Person to person – via contact with infected or colonized
individuals
– via hands of healthcare personnel
– via contaminated medical equipment
• Contact with stool or wounds
• Contact with contaminated environmental surfaces (e.g., bed rails)
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States with CP-CRE in States with CP-CRE in 20062006
https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinar-presentation-2014-09-25-final.pdf
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10http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html
Current States with CP-Current States with CP-CRECRE
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Global Dissemination of Global Dissemination of CRECRE
Molton J, et al. Clin Infect Dis 2013;56:1310-1318
http://cid.oxfordjournals.org/content/56/9/1310.full?sid=b2bcabcc-cb4d-41ab-ba19-b91734089663
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Risk FactorsRisk Factors
• Exposure to acute care or long-term care facilities
• Exposure to an ICU• Presence of other medical conditions• Compromised immune system• Invasive devices (e.g., ventilators,
central venous catheters, or urinary catheters)
• Invasive procedures (e.g., endoscopic procedures)
• History of extensive antibiotic use
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Types of InfectionsTypes of Infections
• CP-CRE can cause: – Bloodstream infections
– Ventilator-associated pneumonia
– Surgical site infections
– Intra-abdominal abscesses
– Urinary tract infections
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DetectionDetection
• Appropriate specimens:– Stool
– Blood
– Urine
– Wound
• Laboratory tests:– Modified Hodge Test
– Carba NP (Carbapenemase Nordmann-Poirel)
– Polymerase chain reaction (PCR)
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– Sputum– Bile
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• Colonized patients – No antibiotics needed
• Infected patients– Antibiotics are limited
– Other therapies (e.g., draining the infection)
• Strains that have been resistant to all antibiotics have been reported
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TreatmentTreatment
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Infection Control Infection Control MeasuresMeasures
• When CP-CRE are identified:
1. An investigation shall be performed by the local health officer within seventy-two (72) hours and include individuals who have shared a residence with the patient in an acute care or long term care facility.
2. The facility should initiate Contact Precautions; additional precautions should be added if any other transmissible condition is present.
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http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
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Infection Control Infection Control Measures (cont’d)Measures (cont’d)
3. Supplemental measures for a healthcare facility with CP-CRE transmission include the following:
A. Refer to the most recent CRE Toolkit from CDC at http://www.cdc.gov/HAI/organisms/cre/
B. Consider screening patients to determine if they are epidemiologically linked
C. Consider chlorhexidine gluconate bathing
4. Case definition is established by the department.
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ReportingReporting
• CP-CRE must be reported to the health department within 72 hours
• IP can create a communicable disease report (CDR)– Select “Carbapenemase producing – Carbapenem resistant
Enterobacteriaceae (CP-CRE)” from the drop down list
• ISDH HAI Epidemiologist will assign CDR to the LHD
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Reporting (cont’d)Reporting (cont’d)
• Electronic lab reports (ELRs) are also be submitted to ISDH via I-NEDSS by laboratories
• ISDH HAI Epidemiologist will assign ELR to LHD
• Laboratories must submit isolates within 3 business days of isolation– Only submit one isolate per patient
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WHAT’S NEXT?WHAT’S NEXT?
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InvestigationInvestigation• LHD contacts facility IP within 72 hours of notification
– Ensure facility places patient on Contact Precautions
– Determine if patient has shared a room or staff with other patients
– Determine if there is a potential for transmission within facility
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• Local health departments should also:
– Promote antimicrobial stewardship
– Ensure facility communicates patient’s infection/colonization status to receiving facility (e.g., LTC facility) if patient will be transferred
• Inter-facility transfer form with laboratory reports
– Complete case investigation in I-NEDSS
Investigation (cont’d)Investigation (cont’d)
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Inter-facility TransferInter-facility Transfer
• If a CP-CRE patient will be transferred to a different facility:– Infection Preventionist or designee should notify the accepting
facility AND send an “inter-facility infection control transfer form” which should include:
– Patient name, date of birth, medical record number– Sending facility contact information– Type of isolation precautions for patient– Infection, colonization, or history of positive culture of a multidrug-
resistant organism– Symptoms – Antibiotic use, vaccines– Contact information for person completing transfer form
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http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf
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Prevention Prevention RecommendationsRecommendations
• Healthcare personnel should:– Practice hand hygiene
– Clean & disinfect patient rooms and medical equipment
– Don PPE before entering patient room
– Doff PPE and wash hands before exiting patient room
– Keep colonized or infected patient in a single room on Contact Precautions
– Dedicate equipment and staff
– Only prescribe antibiotics when necessary
– Remove temporary medical devices
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Patient ScreeningPatient Screening
• Point prevalence surveys:– Used to quickly evaluate the prevalence of CP-CRE in specific
wards/units
– Screen all patients in a specific high-risk ward/unit
– Could be conducted once or multiple times (e.g., if colonization is more widespread or during an intervention)
• Screening of epidemiologically linked patients:– Screen contacts of patients to identify transmission
– Contacts: • Roommates of CP-CRE patients or patients who may have been cared
for by the same healthcare personnel
26http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
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ReferencesReferences• http://www.cdc.gov/hai/organisms/cre/index.html
• http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html
• http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
• http://phil.cdc.gov/phil/home.asp
• http://ce.nurse.com/RVignette.aspx?TopicId=8822
• http://www.cdc.gov/vitalsigns/hai/cre/infographic.html
• https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinar-presentation-2014-09-25-final.pdf
• https://www.youtube.com/watch?v=-FfMCv8FUXI&feature=youtu.be
• https://www.youtube.com/watch?v=vnAtuG9ULB4
• http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf
• http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=53
• http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm
• http://www.mayoclinic.org/ercp-procedure/IMG-20007655
• http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11
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