Oregon Multi-Drug-Resistant Organism (MDRO) …...Oregon Multi-Drug-Resistant Organism (MDRO)...

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Oregon Multi-Drug-Resistant Organism (MDRO) Surveillance Update 10/9/2018 Maureen Cassidy, MT, MPH Nicole West, MPH Acute and Communicable Disease Prevention

Transcript of Oregon Multi-Drug-Resistant Organism (MDRO) …...Oregon Multi-Drug-Resistant Organism (MDRO)...

Page 1: Oregon Multi-Drug-Resistant Organism (MDRO) …...Oregon Multi-Drug-Resistant Organism (MDRO) Surveillance Update 10/9/2018 Maureen Cassidy, MT, MPH Nicole West, MPH Acute and Communicable

Oregon Multi-Drug-Resistant

Organism (MDRO) Surveillance

Update

10/9/2018

Maureen Cassidy, MT, MPH

Nicole West, MPH

Acute and Communicable Disease Prevention

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MDRO Definitions

• CDC – National Healthcare Safety

Network– Definition varies by organism

• MDR-Acinetobacter: nonsusceptibility ≥ one agent in 3 of 6

antimicrobial classes

• MDR-Pseudomonas: nonsusceptibility ≥ one agent in 3 of 5

antimicrobial classes

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https://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf

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MDRO Definitions

• OHA Interfacility Transfer Notification Rule

broadly categorizes MDROs:– MRSA, VRE, Carbapenem-Resistant

Enterobacteriaceae (CRE), Multidrug-Resistant

Acinetobacter, toxin-producing Clostridiodes difficile

• What’s lab reportable in Oregon?– CRE

– Unusual organisms of public health significance

• pan non-susceptible gram-negatives

Oregon Revised Statute 426.235; Oregon Administrative Rule 333-019 0052

Oregon Revised Statute 433.004; Oregon Administrative Rule 333-018

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Carbapenem-Resistant

Enterobacteriaceae (CRE)

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CRE Terminology Review

• Non-carbapenemase-producing (CRE) – Multiple mechanisms combined for resistance –

AmpC, cell wall changes

– Stable/slight increase incidence over time

• Carbapenemase producing (CP-CRE)– Most concerning!!

– Plasmids directly inactivate carbapenems

• Responsible for rapid global spread!!

– Data suggest higher morbidity/mortality

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Oregon CRE by Subtype and

Specimen Source,

Nov 2010 – June 2018Anatomical Site of culture

Organism Urine Blood Respiratory Wound Other Total

Enterobacter

aerogenes

38 2 4 4 5 53

Enterobacter

cloacae

236 14 22 39 11 322

Escherichia

coli

60 3 2 9 3 77

Klebsiella

pneumoniae

40 4 3 5 3 55

Serratia

marcescens

26 2 9 1 1 39

Other 30 1 1 12 4 48

Total 430 26 41 70 27 5946

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CRE Cases

2010 – June 2018

• 283 (47%) of cases were hospitalized at

time of, or within 30 days after, specimen

collection

• 371 (63%) of cases are women

• 406 (68%) of cases are ≥ 65 yrs

• 56 (9%) listed as deceased

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CP-CRE other CRE

CRE Oregon Residents

Nov 2010 – June 2018

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Carbapenemases

Type of

Carbapenemase

When/where

discovered

Numbers

reported USA

(12/2017)

Numbers

found by

Oregon labs

Klebsiella pneumoniae

carbapenemase (KPC)2001 North

Carolina

Too many to

count

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New Delhi metallo-β-

lactamase (NDM)2009 Sweden

(India)

379 6

Verona integron

encoded metallo-β-

lactamase (VIM)

2004 Turkey 57 1

Imipenemase metallo-β-

lactamase (IMP)1997 Japan 36 0

Oxacillinase–48 (OXA-

48)

2002/2003

Greece,

Korea,Taiwan

146 4

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CP-CRE Identified by Oregon

Labs, by Year, n=22

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CRE in Oregon by

County,

2010 – June 2018

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CP-CRE in Oregon by County,

2010 – June 2018

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CP-CRE identified in Oregon

2010-2018, n=22

• Sex: 13 (59%) males

• Age: 47- 88 years (median: 71)

• Sources: 10 urines, 5 wounds, 1 blood, 3

respiratory, 1 tissue, 1 pleural fluid, 1

ostomy

• 13 (59%) hospitalized at collection

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CP-CRE and Healthcare out of

Oregon

• Oregon is still a low prevalence state

• 18/594 (3%) of Oregon cases are CP-CRE

• 14/18 (77%) CP-CRE – documentation of

healthcare out of state

• Compare to Illinois – 331 CP-CRE cases

reported in 2015

http://dph.illinois.gov/sites/default/files/publications/publicationsoppscre-surveillance-report-2015.pdf

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Carbapenem-Resistant

Acinetobacter baumannii

(CRAB)

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Other Surveillance for Multi-Drug-

Resistant Organisms (ARLN)

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ARLN and CRAB Surveillance

• Sentinel lab reported 2 highly resistant CRAB

isolates among residents of the same SNF

• 3 weeks later 3 more isolates reported; 2 from

another SNF, 1 no SNF exposure

• 1 more 2 months later– Residence in both SNFs

• All 6 cases had been to same hospital within 4

months of each other

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2

1

SNF A

CRAB transmission

HCF A

SNF B

2

Resident

screening

(n=4)

Environmental

screening (n=24)

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CRAB screening

• Hospital environmental cultures– Outbreak strain found in 1 sink

• Resident screening – all negative

• Extensive environmental cleaning

recommended for all facilities

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MICs for Outbreak CRAB cases

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Case Study

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Page 21: Oregon Multi-Drug-Resistant Organism (MDRO) …...Oregon Multi-Drug-Resistant Organism (MDRO) Surveillance Update 10/9/2018 Maureen Cassidy, MT, MPH Nicole West, MPH Acute and Communicable

Case Study

• Middle-aged male presented to acute care

hospital

• Draining, post-surgical wound after

procedure in middle east

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Case Study

• Wound grew multiple organisms

• Klebsiella pneumoniae

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Case Study

Also had

• Carbapenem-resistant Acinetobacter

baumannii (CRAB)

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Case Study

Carbapenemase Testing

• Klebsiella pneumoniae tested at public

health lab– Carba NP: Positive

– PCR: NDM

• Acinetobacter tested at ARLN– modified carbapenem inactivation method (mCIM):

Positive

– PCR: NDM

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Carbapenem-Resistant

Pseudomonas aeruginosa

(CRPA)

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CRPA Surveillance

• Multnomah, Clackamas, & Washington counties

• August 2016 – July 2018Time & Place

• Incident case: 1st CRPA culture from a single patient in a 30 day period

• Resistant to >1 carbapenem (imipenem, meropenem, or doripenem; MIC > 8 or zone diameter <15)

Cultures

• Chart reviews for incident cases

• Isolates submitted for carbapenemase testing

Study Elements

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CRPA Surveillance

Case Counts Number (N=258)

CRPA Incident Cases 258

Year 1 137 (53%)

Year 2 121 (47%)

Eligible for Chart Reviews 228 (88%)

Year 1 137 (100%)

Year 2 91 (75%)

CRPA from Sterile Sites 21 (8%)

Year 1 6 (29%)

Year 2 15 (71%)

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Specimen Sources & InfectionsSpecimen Source

& Type of Infection

Number (Percent)

N=220

Respiratory Specimens 103 (59%)

Pneumonia 28 (27%)

CF Exacerbation 27 (26%)

Colonization 34 (33%)

Urine 94 (43%)

UTI 69 (26%)

Colonization 20 (33%)

Wound 14 (6%)

Sterile 11 (5%)

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Numbers based on completed chart reviews

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Risk FactorsAverage number of comorbid conditions3.7

• Range: 0-10

• Top: diabetes (34%), pulmonary disease (31%), neurological conditions (30%

Average number of indwelling devices0.5• Range: 0-4

• Top: urinary catheter (31%), CVC (23%), trach (12%)

Antibiotic use in previous 2 weeks56%• For case cultures collected in hospital/ED, LTCF, or LTACH

• Range: 1-8 medications among users (avg=1)

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Carbapenemases - CRPA

Statewide

• 7 pan-nonsusceptible at clinical lab

– 4 carbapenamase positive• 1 VIM

• 2 with beta-lactamase combination GES-19, GES-26, and

OXA-2

• 1 positive (mCIM) but carbapenemase unknown

• 3 carbapenemase negative

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Carbapenemases - CRPA

Statewide

• 3 XDR CRPA at clinical lab

– 3 carbapenemase positive

• 1 VIM

• 2 positive (mCIM) but carbapenemase unknown

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Questions?

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