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Page 1: CPE- The challenges facing healthcare organisations

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CPE – The Challenges facing Healthcare ProvidersLauren GouldInfection Prevention and Control Support NurseWirral University Teaching HospitalSeptember 2014

Page 2: CPE- The challenges facing healthcare organisations

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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 strategy

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ESBL’S, THE FIRST “NEW” PROBLEM WITH GRAM NEGATIVES

• Gram negative Enterobacteriaceae (E.coli, Klebsiella etc) are usually found in the gut, and have the ability to produce enzymes capable of destroying certain antibiotics e.g. penicillin.

• Some of these Gram negative Enterobacteriaceae also have the ability to produce Beta-lactamases (ESBL) which have resistance to cephalosporins (eg Ceftriaxone, Cephotaxime)

• Many bacteria that produce ESBL’s, also have genes coding for resistance to fluoroquinolones (e.g. Ciprofloxacin), AND/OR genes coding for resistance to aminoglycosides (eg Gentamycin)

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ESBL treatment• Hospital cases of ESBLs from Ventilator Associated Pneumonia

and UTI’s: many sensitive to tazocin or gentamycin

• For those ESBLs which are also resistant to Tazocin , Cipro and Gent, Meropenem is used

• Meropenem, imipenem, and ertapenem, are carbapenem antibiotics, activity against most Gram negative bacteria

• We have to regard carbapenems as one of the last frontiers in treatment of Gram negatives

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Carbapenamase - producing Enterobacteriaceae

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NDM Widespread in Enterobacteriaceae (especially K. pneumoniae and E.Coli in India and Pakistan)

VIM Scattered globally, endemic in Greece; mostly K. pneumonia. Sometimes imported to UK via patients previously hospitalised in Greece

IMP Scattered worldwide; no clear associations

KPC USA since 1999. Prevalent also Israel, and Greece; outbreaks elsewhere in Europe. Some UK cases imported via patient transfers, but local spread in NW England

OXA-48 Widespread K. pneumoniae in Turkey, Mid-East and N.Africa. Some import to UK and an outbreak in one London renal unit 2008-9

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Getting ahead of the curve??

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CPE – the challenges

• 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

possible treatment options are Tigecycline, Colistin, Fosfomycin, all have significant side effects or contra indications

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In 2013 Public Health England (PHE) published the ‘Acute trust toolkit for the early detection,

management and control of carbapenemase-producing Enterobacteriaceae’ which advises 4 weeks of contact screening after identifying a case.

A broader approach had already been implemented at WUTH following our first outbreaks in 2011 and 2013

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WUTH CPE outbreaks• September 2011 – VIM outbreak• April 2013 – OXA 48 outbreak

Issues identified:• The unknown carrier is the risk• WUTH readmission screening to be considered• Readmissions who have previously been exposed –

alert as high risk contacts• Risks of transmission increased when Periods of

Increased Incidence of diarrhoea e.g. norovirus

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WUTH CPE strategy

Screening • Inter-hospital transfers from other countries • Inter-hospital transfer from any hospital in the UK• All patients on any ward with positive case are

screened weekly. Once the positive patient has vacated the ward full ward screening continues for a further four weeks and a reduced screening programme is then introduced.

• All patients in haematology and critical care are screened weekly

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Infection Prevention and Control measures

Isolation

• A case of CPE must be isolated in a side room preferably with en suite facilities on admission and until discharge from hospital.

• Contact precautions are instigated (gloves and apron). Long sleeved disposable gowns must be worn where any part of staff uniform, not protected by an ordinary apron, is expected to come into contact with the patient - for e.g. when assisting movement for a dependent patient

• Equipment should be single patient use/dedicated equipment

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CPE outbreak 2014• Between November 2013 – May 2014 no new cases of CPE

associated with WUTH identified• May 2014 – new case identified on a surgical ward, linked with

2013 outbreak• Prevalence screening on a care of the elderly ward identified 3

new cases• This in turn affected a rehabilitation ward where patients were

transferred prior to identification of the positive result• CPE also identified during prevalence screening on a second care

of the elderly ward (although not of the same type as the other wards, therefore not epidemiologically linked)

• Second surgical ward also affected due to the transfer of a positive patient

• July 2014 – CPE bacteraemia• Trust-wide CPE outbreak declared

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CPE bacteraemia July 2014

• Patient was transferred to 5 different wards during admission inc. the dialysis unit

• Patient was nursed in a main bay prior to identification of result

• Documentation relating to wounds (likely source) was inconsistent

• IV access poor – alternative access not considered until after patient had developed a bacteraemia

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Outbreak management• Establishment of a CPE OXA 48 cohort ward – split

with positive patients nursed in one area, and exposed patients nursed in another

• Separate nursing staff for each area – identified by different coloured scrubs

• Predominantly en-suite side rooms in each area• Separate sluices and clinic rooms• VIM positive patients nursed in side rooms on

original wards – to prevent transmission between types

• Transfers from all affected wards based upon clinical need only

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Cumulative cases of CPE (Pre and Post)

7

19

35

1005

10152025303540

Apr

il

May

June

July

Aug

ust

Sep

t

Oct

Nov

Dec Ja

n

Feb

Mar

ch

No of cases of CPE2011/12

No of cases of CPE2012/13

No of cases ofconfirmed CPE2013/14

No of cases ofconfirmed CPE2014/15

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PHE review 2014 recommendations• Staff education, engagement and leadership for HCAI and CPE• IPC everybody’s business• An update of facilities within the Trust to include hand

washing facilities, ventilation, macerators and a ward refurbishment programme to be re-established

• A dedicated isolation unit for CPE• Antimicrobial stewardship• Domestic services to be reviewed to include domestic

cleaning hours and the Trust’s current cleaning products• Microbiology lab support • Collaborative working across the whole health economy

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Conclusion• CPE is a growing concern for all Trusts• There will also be an increasing reservoir within

community settings such as nursing homes• Need an increasing awareness and engagement

from all healthcare personnel• Back to basics approach – hand hygiene and

environmental decontamination essential

Prevention is better than cure