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Public Health Support for Antimicrobial Stewardship

Maureen Tierney, MD MSc.HAI/AR Director

Caitlin Pedati, MD,MScHAI Medical Epidemiologist

Nebraska DHHS

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Who We Are

DHHS

DPH Dr. Tom Williams

Epi & Informatics

Qu MIng

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Dr. Tom Safranek State Epidemiologist

HAI Office @ DHHS Lincoln

ICAP-MR, KT, SA, TF

ASAP-SA, TVS, KT

MD Stewardship-RV,JH

NPHL-Pete and CM

Safe Injection Program-Peg Gilbert

Who We Are

4

Maureen Tierney, MD. MSc.-HAI/AR Lead

Caitlin Pedati, MD. MPH-HAI Outbreak Lead, Medical Epidemiologist

Margaret Drake, MT, CIC-HAI Infection Preventionist

Supported by:

EIS Officer: Dr. Rebecca Free

Informatics Group

HAI/AR Team Nebraska DHHS

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Monitor and Reduce HAIs

Support Stewardship and IP assessment and improvement #1

Education for Public-website #2

Educational Resources for HCWs #3

Coordination of IP improvement and AMS Efforts and Resources #4

Detect Outbreaks and Resistance #5

Manage/Contain Resistance and Outbreaks

Goals of DHHS HAI Team

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Support for Stewardship

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ELC Grant-funding to NE DHHS, Epidemiology Unit, HAI program

Work with partners to put together a top-notch proposal

Look for other funding sources

AHQR

CMS

IDSA

CSTE

CDC-other programs

Funding

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Public

• Informatics-ELR, Registry, other Epis-hepatitis

• LHDs

Public Private-Education, Mentoring

• ASAP

• MDStewardship

• NPHL-NM Lab

Public Public-Dr. Ali Khan and Dr. Deborah Levy

• COPH

Partnership Support

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NHSN AU/AR Enrollment

Recommendations for CDI Testing

Transfer Form

Examples of Coordination

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INTRODUCTION

The Centers for Disease Control and Prevention (CDC) estimates that with appropriate awareness and intervention, healthcare-associated infections (HAIs) can be reduced by more than 70%, saving tens of thousands of lives annually. The Nebraska Department of Health and Human Services (NDHHS) developed a tool to communicate the need for personal protective equipment (PPE) and specific infection control measures at the time of inter-facility transfer. METHODS

Three versions of transfer forms were reviewed by the Nebraska HAI Advisory Council including:

• CDC

• Utah Department of Health

• Chicago Department of Public Health

These templates were used to inform a collaborative review with nurses, physicians, public health personnel, and infection prevention specialists from a variety of patient care settings.

RESULTS

The Development of a Simplified Inter-Facility Transfer Form for Infection

Control

BACK

FRONT

All stakeholders emphasized the following areas of importance:

1. Simplicity and ease of use

2. Readily understood, intuitive images

3. Minimal time to complete at discharge

4. Ease of incorporation into patient chart

5. Preservation of confidentiality

CONCLUSIONS

NDHSS engaged key partner organizations to develop a simplified tool

for effective communication during patient transfer. Information about the

presence of organisms requiring precautions upon patient arrival to a

new facility is critical in the preventions of HAIs. Plans for an evaluation

of the use of this form are currently underway.

Madison Sullivan1; Margaret Drake, MT, ASCP, CIC1; Renuga Vivekanandan, MD2; Kate Tyner, BSN, RN3; Caitlin Pedati, MD, MPH2; Maureen Tierney, MD, MSc2

1Nebraska Department of Health and Human Services 2CHI Health Creighton University Medical Center,3 Nebraska Medicine

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Antibiotic Awareness Week

Press Release and Educational Display at Capitol

Next Year- Middle Schools

Website-Stewardship and Resistance

http://dhhs.ne.gov/publichealth/hai/pages/home.aspx

Public Education and Awareness

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HAI Web Site

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Who is Doing What

HAI Advisory Committee

Stakeholder Collaboration

QIN/QIO

NHA-HIN

Office of Rural Health

NMA/ NDA

Links on Website (Repository)

Coordination of Stewardship Efforts

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Individual cases of highly resistant organisms

Clusters of resistance

Higher CDI Rates

Where to Focus Stewardship

Reportable Diseases

Reportable Diseases-LAB Chart-Lab Relationship is Crucial!

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All Potential CREs (Enterobacter, E.coli, Klebsiella, Citrobacter)

CP-CRE

CR-Pseudomonas

Colistin resistance, Pan resistance

VISA, VRSA

Candida auris

Emerging Resistant Organisms

HAI Pathogens

In accordance with Nebraska Title 173 the following must be reported immediately:

Carbapenem resistant Enterobacteriaceae (suspected or confirmed)

Staphylococcus aureus, vancomycin-intermediate/resistant suspected or confirmed

Soon to add suspected or conformed C.auris, colistin resistant or pan-resistant organisms

HAI Pathogens

And the following must be reported within seven days of detection or diagnosis:

Acinetobacter spp., Citrobacter spp., Enterobacter spp., Enterococcus spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumonia (applies only to laboratories performing electronic lab reporting as described in 173 NAC 1-005.02C) soon to add Serratia, Providencia and Morganella

Clostridium difficile (antibiotic-associated colitis and pseudomembranous colitis)

Mycobacterium spp. (including M. tuberculosis complex organisms [for genotyping] and all “atypical” species, to include culture, nucleic acid tests, or positive histological evidence indicative of tuberculosis infection or disease)

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Carbapenem Resistant Enterobacteriaceae (CRE) – resistant to one or more of the carbapenems through the presence of a carbapenemase or due to the presence of other resistance mechanisms

Carbapenemase Producing Organism (CPO) – an organism that encodes a carbapenemase

Carbapenem Resistance

* Slide from Dr. Caitlin Murphy, Nebraska Public Health Laboratory

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Amp-C or ESBL + loss of porins

Carbapenemases- movable genetic components

Klebsiella pneumoniae Carbapenemase (KPC)

New Delhi Metallo-B-lactamase (NDM)

Verona Integron-encoded metallo-B-lactamase (VIM)

Oxacilinases-48-type carbapenemase (OXA-48)

Imipenem metallo-B-lactamase (IMP)

Carbapenem Resistance

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Phenotypic Testing

• Carba NP

• mCIM

Molecular Testing

• Real Time PCR

• Cepheid Xpert Carba-R

Lab Detection NPHL and Alegent Core Lab

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CRE and CRPA at ARLN 2017

CRE N-6891

No.(%)*

*>100%-some isolates more

than 1 CP)

CRPA N=3699

No. (%)

Carbapenemase Producing 2311(34) 98 (3)

KPC 2056 (89) 11 (11)

NDM 185 (9) 3 (3)

OXA-48-type 77 4 (0) 0

VIM 24 (1) 52 (53)

IMP 24 (1) 8 (8)

Courtesy of Sarah Malik, CDC

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Total

Potential CP EnterobacteriaceaeInvestigated

0 0 3 2 5 2 6 10 5 3 5 3 44

CP Enterobacteriaceae Confirmed 0 0 0 1 0 1 2 0 1 1 0 1 7

0

5

10

15

20

25

30

35

40

45

50

Carbapenemase-producing (CP) Enterobacteriaceae Investigated and Confirmed by Month,

January 1, 2017 to December 31, 2017

Potential CP Enterobacteriaceae Investigated CP Enterobacteriaceae Confirmed

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Number of Isolates by State at Central ARLN

CP-CRE CRPA

NE 6 0

Iowa 28 0

Kansas 23 4

ND 8 0

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Types of CarbapenemasesNational vs Central Region

National 6891 (CP%) Central Region 654 (CP%)

KPC 2056 (30%) 97 (15%)

NDM 185 (3%) 15 (2%)

OXA-48-like 77 77 (1%) 11(2%)

VIM 26 (<1%) 4 (<1%)

IMP 24 (<1%) 11 (2%)

Total 2368 (34%) 138 (21%)

Sarah Malik, CDC

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1 IMP (novel IMI mutation) in E. cloacae

1 IMP in Providencia

4 KPCs in Citrobacter, K. pneumoniae, and 2 E. coli

2 NDM in E. coli and E. cloacae

1 NDM and OXA in a Klebsiella

Carbapemenases in NE

#1-Citrobacter-mostly KPC

#2-Providencia-mostly IMP

#3-Proteus

#4-Serratia

Non KPC carbapenemases-33% from Non Big 3

• 53% of Acinetobacter R to carbapenem

• 106 CRAB from 15 states, 2013-2015 –

• 77 isolates from 8 sentinel surveillance sites –

• 29 isolates from reference testing

• 80 (75%) harbored acquired OXA-variants

• 53 (50%) produced OXA-23 –

• 33 (62%) were ST-2

• Courtesy of Alex Kallen, CDC

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Containment Strategy

Systematic approach to slow spread of novel or

rare multidrug-resistant organisms or

mechanisms through aggressive response to

≥1 case of targeted organisms:

-Pan-resistant organisms

-Carbapenemase-producing organisms

-mcr-1

-Candida auris

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Define outbreaks and investigation protocols

Coordinate with local health departments and

ARLN

Provide education to facilities

Provide guidance on screening for colonization

when needed

Outbreak Detection and Management

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Management Guidelines

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Detection of any single carbapenemase-producing organism in Nebraska will be considered an outbreak that requires investigation –CALL US!

Epidemiologic information collected for any submitted CRE:

Patient demographics (name, date of birth, location)

Local health department jurisdiction

Ordering and reporting facility

Inpatient/facility status

Additional information collected for carbapenemase-producing organisms:

History of prior contact with healthcare facilities, especially outside the United States within the past 6 months

Antibiotic treatment course and duration as well as repeat testing

Procedures with reusable devices

Travel history

Occupation

Public Health Management

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Confirm appropriate hand hygiene practices are being followed

Confirm use of contact precautions (gowns and gloves available and used correctly)

Private room if at all possible, cohorting if not possible

Minimize device utilization where possible (indwelling lines, endotracheal tubes, urinary catheters, etc)

Facility should examine need for special precautions if patient has a procedure with a reusable device

Ensure appropriate antimicrobials are being used (stewardship)

Infection Control Recommendations

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Cohort affected patients with minimal shared staff when possible

Establish clear communication methods if inter-facility transfer is needed (Nebraska InterfacilityTransfer Form can be used if there is not a current method in place)

Ensure appropriate environmental cleaning is performed2

Perform screening/surveillance cultures if needed

Identify a primary care provider to coordinate follow-up with test of cure culture 10 to 14 days after completion of antibiotics

Infection Control Recommendations

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Ring approach, using epidemiologic and clinical characteristics to identify those at risk

Screening to identify unrecognized colonization (rectal swab)

Identify transmission

Social network/shared facility analysis

Screening and Surveillance Cultures

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Discuss with IP at facility the level of state epidemiology support they would like

Facility can run internal screening program with notification to state if carrier found

Facility can run internal screening program with guidance from state

Identify appropriate epidemiologic contacts for screening

Consider facility layout, timing of contact precautions and antibiotics for risk determination

Roommates

Patient on the same hallway for 3 or more days of shared admission with index patient

Pursue outpatient screening only for highest risk patients (particularly roommates)

Can perform screening for at-risk contacts every other week while case is admitted in facility

Obtain appropriate swabs to be sent directly to facility (from NPHL or ARLN)

NPHL screening performed by rectal swab for routine stool culture

ARLN screening performed by rectal swab with Cepheid-specific swab

Screening and Surveillance Cultures

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Swabs will be sent to either NPHL or ARLN for testing (facilitated by NDHHS)

NPHL or ARLN will notify the facility and NDHHS HAI program with results

Establish method for communication CRE status upon transfer of patients to other facilities

NDHHS HAI program and NPHL will work with CDC/ARLN as needed for notification/support

If transmission is identified, perform follow-up point prevalence surveys until two sequential surveys are negative (no additional cases identified)

Consider performing active surveillance cultures upon admission to a unit if transmission is identified

Consider use of daily 2% chlorhexidine bathing for patients in high-risk settings/units

Screening and Surveillance Cultures

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January February March April May June July August September October November December

Isolates 3189 4109 4869 5659 6247 6412 6747 7007 6669 7076 6694 6241

Facilities 16 16 17 18 19 20 23 21 23 24 27 28

0

5

10

15

20

25

30

0

1000

2000

3000

4000

5000

6000

7000

8000

Number of Reported Isolates and Reporting Facilities by Month,

January 1, 2017 to December 31, 2017

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Descriptive Epidemiology

70,919 isolates from 28 facilities among all 20 local health departments and 8 out-of-state jurisdictions

Approximately 6000 reports per month

62,265 isolates when restricted to 1 isolate per patient

101 different antimicrobials

Over 50 species reported

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Reported Species

Achromobacter spp

Acinetobacter spp

Aerococcus spp

Aeromonas spp

Alcaligenes spp

Burkolderia cepaceia

Campylobacter spp

Citrobacter spp

Clostridium spp

Coagulase-negative

staphylococcus

Corynebacterium spp

Diphtheroids spp

Elizabethkingia spp

Enterobacter aerogenes

Enterobacter cloacae

Enterobacter spp

Enterococcus spp

Escherichia coli

Escherichia spp

Haemophilus influenzae

Haemophilus

parahaemolyticus

Kingella spp

Klebsiella oxytoca

Klebsiella pneumoniae

Klebsiella spp

Kluyvera ascorbata

Leclercia spp

Morganella spp

Mycobacterium spp

Mycobacterium spp (TB)

Pantoea spp

Pasturella spp

Plesiomonas spp

Proteus spp

Providencia spp

Pseudomonas aeruginosa

Pseudomonas spp

Raoultella spp

Salmonella spp

Serratia marcescens

Serratia spp

Shigella spp

Staphylococcus aureus

Staphylococcus spp

Stenotrophomonas

maltophilia

Stenotrophomonas spp

Streptococcus pneumoniae

Streptococcus spp

Yersinia spp

Vibrio alginolyticus

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Approximately 1,300 reports per week

Approximately 40 species

25 antimicrobials

34 facilities reporting

Antibiotic Susceptibility Data Registry

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Creation of a database containing susceptibility patterns for all reportable organisms

Requires appropriate receipt of HL7 formatted messages from hospital to secure servers

End result is a line list

Screen for resistant organisms (CRE, VISA/VRSA, etc)

Detect clusters of MDROs

Follow development of resistance over time

Antibiotic Susceptibility Data Registry

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Previous 365 days of reports from all specimen sources

Based on report of interpretation (S, I, R) from laboratory

One isolate per patient per analysis period

Only susceptibilities for which >/=30 isolates were tested

Populates nightly

5 gram positive organisms

14 gram negative organisms

Antibiogram

Gram Positives

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Gram Negatives

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Surveillance system for detection of CREs

Staph and influenza: able to provide information on resistant patterns state-wide

Screening of data for unusual resistance patterns in outbreak settings

Applications

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Further develop antibiograms to make available regionally

Development of surveillance and response protocol for multi-drug resistant organisms

Continue to explore collaborations throughout the state and facilitate access to relevant resources as needed

Future Directions

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•Back to Apollo 13

Closing Remarks M. Tierney

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Apollo 13

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• Failure is not an option:

• “..When bad things happened, we just calmly laid out all the options, and failure was not one of them. We never panicked, and we never gave up on finding a solution."

• Team Approach-Dr. Ashraf

Closing Remarks M. Tierney