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Containing CRE spread

Jon Otter, PhD FRCPath Scientific Director, Healthcare, Bioquell Research Fellow, King’s College London jonathan.otter@kcl.ac.uk www.micro-blog.info @jonotter. Containing CRE spread. Contents. What ’ s the problem?

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Containing CRE spread

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  1. Jon Otter, PhD FRCPath Scientific Director, Healthcare, Bioquell Research Fellow, King’s College London jonathan.otter@kcl.ac.uk www.micro-blog.info @jonotter Containing CRE spread

  2. Contents • What’s the problem? • A brief overview of CRE including an update on the current spread in the US, UK and elsewhere • Sizing the threat to EU countries and elsewhere • Infection prevention and control challenges and strategies

  3. What’s the problem? Resistance

  4. What’s the problem? Mortality Shorr et al. Crit Care Med 2009;37:1463-1469. Patel et al. Iinfect Control Hosp Epidemiol 2008;29:1099-1106. Falagas et al. Emerg Infect Dis 2014;20:1170-1175.

  5. What’s the problem? Rapid spread

  6. Understanding the enemy • Carbapenem-resistant Enterobacteriaceae.

  7. CRE in the USA NHSN / NNIS data; MMWR 2013;62:165-170.

  8. Invasive carbapenem-resistant K. pneumoniae i.e. CRE (EARS-Net)

  9. Invasive multidrug-resistant K. pneumoniae (EARS-Net)

  10. Emergence of CRE in the UK PHE ARMRL, 24/01/14 Courtosy of Dr Neil Woodford

  11. Available guidelines (not exhaustive list!) UK CRE Toolkit US CRE Toolkit ESCMID Guidelines

  12. Tacconelli et al.Clin Microbiol Infect 2014;20 Suppl 1:1-55

  13. CRE toolkits in the US and UK compared Insert comparison table

  14. Standardise standard precautions. • Avoid an ‘acronym minefield’. • Simple outbreak epidemiology. • Guideline writing dream team. • “Road-test” guidelines. Curran & Otter. J Infect Prevent 2014;15:193-198.

  15. Who do I screen? PHE CPE Toolkit screening triggers: • an inpatient in a hospital abroad, or • an inpatient in a UK hospital which has problems with spread of CPE (if known), or • a ‘previously’ positive case. Also consider screening admissions to high-risk units such as ICU, and patients who live overseas.

  16. You have positive case: now what? ‘Contact precautions’ Single room+glove/gown Consider staff cohort Contact tracing Trigger for screening contacts or whole unit? Flagging Patient notes flagged Receiving unit informed Education Staff Patient / visitor Cleaning / disinfection Use bleach or H2O2vapor at discharge Decolonization? ‘Selective decontamination’ / chlorhexidine bathing?

  17. Single room isolation: Bioquell Pod

  18. Single room isolation: Bioquell Pod • Bioquell Pod • Bespoke, semi-permanent • Infectious patients • Privacy & dignity • Reduce forced transfer • Observation & single room

  19. The challenge of endoscopes • Cluster of 39 cases of NDM-producing CRE linked to contaminated duodenoscopes.1 • No failures in endoscope reprocessing identified, yet outbreak strain cultured from reprocessed endoscope. • Prompted calls for more sterilization rather than high-level disinfection of endoscopes.2 Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it. (FDA Feb 23 2015). Epstein et al. JAMA 2014;312:1447-1455. Rutala & Weber. JAMA 2014;312:1405-1406.

  20. Barriers Carbapenem usage Single rooms ICD staffing Debt ECDC Point Prevalence Survey, 2013.

  21. Cataldo et al. ECCMID 2014. 0125.

  22. What works? Israel * * Physical segregation of CRE carriers; cohorted staff; appointed taskforce. Schwaber et al. Clin Infect Dis 2011;52:848-855.

  23. Conclusions • This is a new an evolving problem • Recognition of patient carriers is vital • Appropriate management of identified carriers is crucial • Information may change in time if we see more cases in the EU / US • Important to try and stay up to date and carry on with safe infection prevention precautions…

  24. Acknowledgements • Pat Cattini for some of the slides • Image credits: • ‘Cotton swabs’ by Jan Gottweiß

  25. Resources • CDC CRE Toolkit • AHRQ CRE Tookit • UK Public Health England CPE Tookit • Bioquell CRE resources • UK ESBL guidelines • ECDC risk assessment on the spread of spreading (CPE) • Canadian guidelines for carbapenem resistant GNB • Australian recommendations for CRE control • ESCMID MDR-GNR control guidelines • Webinar on CRE infection control challenges

  26. Increased risk; prior room occupant +71% +58% +55% +49% +42% +37% +28% Otter et al. Am J Infect Control 2013;41(5 Suppl):S6-11.

  27. CRE – is surface contamination a risk? Error bars represent plus one standard deviation of the mean. Havill et al. Infect Control Hosp Epidemiol 2014;35:445-447.

  28. Conclusion CRE surface contamination • An Israeli hospital investigated CRE environmental contamination in the vicinity of 34 CRE-carriers; mainly K. pneumoniae. • CRE was detected in the surrounding environment of most (88%) of the patients sampled. • Lerner et al. J Clin Microbiol 2013;51:177-1781.

  29. Conclusion K. pneumoniae vs. E. coli • K. pneumoniaeseems to be more environmental than E. coli.1,2 • Surface contamination on five standardized sites surrounding patients infected or colonized with ESBL-producing Klebsiella spp. (n=48) or ESBL-producing E. coli (n=46).1 P<0.001 P<0.001 • Guet-Revilletet al. Am J Infect Control 2012;40:845-848. • Gbaguidi-Haore. Am J Infect Cont 2013 in press.

  30. Enterobacteriaceae “less environmental” Nseiret al. ClinMicrobiol Infect 2011;17:1201-1208. Ajaoet al. Infect Control Hosp Epidemiol 2013;34:453-458.

  31. Terminal decontamination using HPV Patients admitted to rooms decontaminated using HPV were 64% less likely to acquire any MDRO (incidence rate ratio [IRR]=0.36, CI=0.19-0.70, p<0.001) Passaretti et al. Clin Infect Dis 2013;56:27-35.

  32. Control of Gram-negative outbreaks using HPV • Eradication of Serratia from a NICU in Sheffield.1 • Eradication of Acinetobacter and Enterobacter from an ICU in Holland.2 • Terminal disinfection of patient rooms and cohort areas during outbreaks of CRE at Howard County Hospital3 and the NIH hospital.4 Bates & Pearse. J Hosp Infect 2005;61:364-366. Otter et al. Am J Infect Control 2010;38:754-756. Gopinath et al. Infect Control Hosp Epidemiol 2013;34:99-100. Snitkin et al. Sci Transl Med 2012;4:148ra116. Donegan et al. SHEA 2010. Kaiser et al. IDSA 2011.

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