CPE- The challenges facing healthcare organisations

download CPE- The challenges facing healthcare organisations

of 19

  • date post

  • Category


  • view

  • download


Embed Size (px)


CPE is a growing concern for all healthcare trusts. This presentation looks at some of the challenges...

Transcript of CPE- The challenges facing healthcare organisations

  • 1. CPE The Challenges facingHealthcare ProvidersLauren GouldInfection Prevention and Control SupportNurseWirral University Teaching HospitalSeptember 2014wuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU

2. IntroductionCPE growing concern for all Healthcare Trusts WUTH identified first case in 2011 Increase in cases year on year Dedicated strategy for managing cases with PHE support Outbreak strategywuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 3. ESBLS, THE FIRST NEW PROBLEM WITH GRAMwuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOUNEGATIVES Gram negative Enterobacteriaceae (E.coli, Klebsiella etc)are usually found in the gut, and have the ability to produceenzymes capable of destroying certain antibiotics e.g.penicillin. Some of these Gram negative Enterobacteriaceae also havethe ability to produce Beta-lactamases (ESBL) which haveresistance to cephalosporins (eg Ceftriaxone, Cephotaxime) Many bacteria that produce ESBLs, also have genes codingfor resistance to fluoroquinolones (e.g. Ciprofloxacin),AND/OR genes coding for resistance to aminoglycosides (egGentamycin) 4. wuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOUESBL treatment Hospital cases of ESBLs from Ventilator Associated Pneumoniaand UTIs: many sensitive to tazocin or gentamycin For those ESBLs which are also resistant to Tazocin , Cipro andGent, Meropenem is used Meropenem, imipenem, and ertapenem, are carbapenemantibiotics, activity against most Gram negative bacteria We have to regard carbapenems as one of the last frontiers intreatment of Gram negatives 5. Carbapenamase - producingwuth.nhs.uk@wuthnhs #proudEnterobacteriaceae#PROUD TO CARE FOR YOU 6. NDM Widespread in Enterobacteriaceae (especially K. pneumoniae andVIM Scattered globally, endemic in Greece; mostly K. pneumonia.Sometimes imported to UK via patients previously hospitalised inGreeceKPC USA since 1999. Prevalent also Israel, and Greece; outbreakselsewhere in Europe. Some UK cases imported via patient transfers,but local spread in NW EnglandOXA-48 Widespread K. pneumoniae in Turkey, Mid-East and N.Africa. Someimport to UK and an outbreak in one London renal unit 2008-9wuth.nhs.uk@wuthnhs #proudE.Coli in India and Pakistan)IMP Scattered worldwide; no clear associations#PROUD TO CARE FOR YOU 7. wuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 8. Getting ahead of the curve??wuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 9. Gut colonisation no signs or symptoms Transmitted via faecal-oral route Increasing bio-burden in environment and on equipment Limited antibiotic therapies available -the only possibletreatment options are Tigecycline, Colistin, Fosfomycin,all have significant side effects or contra indicationswuth.nhs.uk@wuthnhs #proudCPE the challenges#PROUD TO CARE FOR YOU 10. In 2013 Public Health England (PHE) published theAcute trust toolkit for the early detection, management andcontrol of carbapenemase-producingEnterobacteriaceae which advises 4 weeks of contactscreening after identifying a case.A broader approach had already been implemented atWUTH following our first outbreaks in 2011 and 2013wuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 11. Issues identified: The unknown carrier is the risk WUTH readmission screening to be considered Readmissions who have previously been exposed alert ashigh risk contacts Risks of transmission increased when Periods of IncreasedIncidence of diarrhoea e.g. noroviruswuth.nhs.uk@wuthnhs #proudWUTH CPE outbreaks September 2011 VIM outbreak April 2013 OXA 48 outbreak#PROUD TO CARE FOR YOU 12. WUTH CPE strategyScreening Inter-hospital transfers from other countries Inter-hospital transfer from any hospital in the UK All patients on any ward with positive case arescreened weekly. Once the positive patient hasvacated the ward full ward screening continues for afurther four weeks and a reduced screeningprogramme is then introduced. All patients in haematology and critical care arescreened weeklywuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 13. Infection Prevention and Control measuresIsolation A case of CPE must be isolated in a side room preferablywith en suite facilities on admission and until discharge fromhospital. Contact precautions are instigated (gloves and apron). Longsleeved disposable gowns must be worn where any part ofstaff uniform, not protected by an ordinary apron, is expectedto come into contact with the patient - for e.g. when assistingmovement for a dependent patient Equipment should be single patient use/dedicated equipmentwuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 14. CPE outbreak 2014 Between November 2013 May 2014 no new cases of CPE associated with May 2014 new case identified on a surgical ward, linked with 2013 Prevalence screening on a care of the elderly ward identified 3 new cases This in turn affected a rehabilitation ward where patients were transferred CPE also identified during prevalence screening on a second care of theelderly ward (although not of the same type as the other wards, thereforenot epidemiologically linked) Second surgical ward also affected due to the transfer of a positive patient July 2014 CPE bacteraemia Trust-wide CPE outbreak declaredwuth.nhs.uk@wuthnhs #proudWUTH identifiedoutbreakprior to identification of the positive result#PROUD TO CARE FOR YOU 15. Patient was transferred to 5 different wards duringadmission inc. the dialysis unit Patient was nursed in a main bay prior to identification ofresult Documentation relating to wounds (likely source) wasinconsistent IV access poor alternative access not considered untilafter patient had developed a bacteraemiawuth.nhs.uk@wuthnhs #proudCPE bacteraemia July 2014#PROUD TO CARE FOR YOU 16. Outbreak management Establishment of a CPE OXA 48 cohort ward split withpositive patients nursed in one area, and exposedpatients nursed in another Separate nursing staff for each area identified bydifferent coloured scrubs Predominantly en-suite side rooms in each area Separate sluices and clinic rooms VIM positive patients nursed in side rooms on originalwards to prevent transmission between types Transfers from all affected wards based upon clinicalneed onlywuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 17. wuth.nhs.uk@wuthnhs #proudCumulative cases of CPE (Pre and Post)71940353025201510#PROUD TO CARE FOR YOU350 10 5AprilMayJuneJulyAugustSeptOctNovDecJanFebMarchNo of cases of CPE2011/12No of cases of CPE2012/13No of cases ofconfirmed CPE2013/14No of cases ofconfirmed CPE2014/15 18. PHE review 2014 recommendations Staff education, engagement and leadership for HCAI and CPE IPC everybodys business An update of facilities within the Trust to include handwashing facilities, ventilation, macerators and a wardrefurbishment programme to be re-established A dedicated isolation unit for CPE Antimicrobial stewardship Domestic services to be reviewed to include domesticcleaning hours and the Trusts current cleaning products Microbiology lab support Collaborative working across the whole health economywuth.nhs.uk@wuthnhs #proud#PROUD TO CARE FOR YOU 19. Conclusion CPE is a growing concern for all Trusts There will also be an increasing reservoir withincommunity settings such as nursing homes Need an increasing awareness and engagement from allhealthcare personnel Back to basics approach hand hygiene andenvironmental decontamination essentialwuth.nhs.uk@wuthnhs #proudPrevention is better than cure#PROUD TO CARE FOR YOU