Carbapenem -Resistant Enterobacteriaceae : Detect and Protect

1. Carbapenem-Resistant Enterobacteriaceae: Detect and Protect VDH Healthcare-Associated Infections Program Team April 2013

2. Background • Carbapenem antibiotics (ertapenem, imipenem, meropenem, and doripenem) are often used as the last line of treatment for infections caused by resistant Gram-negative bacilli • Over the past decade, members of the Enterobacteriaceae family of bacteria have begun to develop resistant to carbapenems and these resistant bacteria have spread throughout the U.S. • Klebsiella spp., especially K. pneumoniae • E. coli • Enterobacter spp. • CRErefers to carbapenem-resistant Enterobacteriaceae

3. Resistance Mechanisms and Risk Factors • Carbapenemase enzymes confer resistance to carbapenems. Most prevalent carbapenemase in the U.S. is Klebsiellapneumoniaecarbapenemase(KPC) • Yet CDC suggests US distribution likely heterogeneous • Persons at risk are those receiving serious medical care: • Invasive medical devices • Open wounds • Long courses of antibiotic therapy • “Unusual” resistance mechanisms (NDM-1, VIM, OXA-48) • Risk factor: recent (within last 6 months) exposure to hospitalization in a country outside the US

4. Epidemiology • Jan-June 2012: • 4% of U.S. hospitals reported at least one patient • 18% of long-term acute care hospitals reported at least one patient • Last 10 years: • One type of CRE infection reported in medical facilities in 42 states • More common in Northeast • CRE with unusual resistance mechanisms • As of mid-Feb 2013, 37 reports in U.S. – 15 since July 2012 • Since then, at least 2 more cases in VA alone (both NDM-1) • First two cases of OXA-48 identified in US were from Virginia (2012) http://www.cdc.gov/vitalsigns/hai/cre/ Mathers et al. First Clinical Cases of OXA-48-Producing Carbapenem-Resistant Klebsiellapneumoniae in the United States: the “Menace” Arrives in the New World. Journal of Clinical Microbiology2013;51(2): 680-683.

5. CRE: Just Another Type of MDRO? What makes CRE special… • No decolonization strategy • Few treatment options available • High mortality rate (50% or greater in some studies) • Resistance can hop between many Enterobacteriaceae (there are over 70 bacteria in the Enterobacteriaceae family) • High speed/rate of resistance transfer

6. CRE in Long-Term Care Settings • CRE not just in acute care hospitals • Since 2004, reports of CRE cases from long-term acute care hospitals (LTACHs) and long-term care facilities • CRE prevalence as high as 50%, even with few infections • Potential for large reservoir of patients with CRE • Multiple comorbidities • Concentrated in one location for extended time period

7. CRE Concerns • In addition to spreading among people, CRE easily spread their antibiotic resistance to other kinds of germs • Making those potentially untreatable • Infections could begin appearing in otherwise healthy people

8. Inter-Facility Transmission of MDROs (Including CRE) Munoz-Price SL. Clin Infect Dis 2009;49:438-43. Facilities with known CRE: complete inter-facility transfer form when transferring patients (include CRE status, presence of open wounds/devices, antimicrobial use and length of therapy)

9. Critical Opportunity for CRE Control: “Detect and Protect”

10. Current CDC Guidance for CRE Control • Coordinated efforts from all stakeholders • Acute and long-term care facilities • Key principles: • Recognizing epidemiologic importance of CRE • Understand prevalence of CRE within a given region • Identify colonized and infected patients in facilities • Implement regional and facility-based interventions to halt transmission

11. 2012 CDC CRE Toolkit • Facility-level recommendations • Acute care • Long-term care • Health department involvement • Varies depending on regional prevalence • Focused emphasis on preventing further transmission and widespread emergence of CRE http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

12. Know Your Baseline • Quantify clinical evidence of these organisms • Review archived lab results • Number and/or proportion of Enterobacteriaceae that meet CRE definition • May elect to focus on E. coli and Klebsiella spp. • Specified time period (6-12 months) • How soon after admission into facility are CRE identified? • Evidence of inter-facility transmission? • Intra-facility transmission? • Which units/wards most affected? • Consider collecting basic epidemiology of patients colonized or infected with CRE • Patient demographics, dates of admission, outcomes, medications, common exposures

13. Interim CRE Surveillance Case Definition • Nonsusceptible to one of the following carbapenems: doripenem, meropenem, or imipenemAND • Resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidime.(Note: All three of these antimicrobials are recommended as part of the primary or secondary susceptibility panels for Enterobacteriaceae) • Klebsiella species and Escherichia coli that meet the CRE definition are a priority for detection and containment in all settings; however, other Enterobacteriaceae (e.g., Enterobacter species) might also be important in some regions. • For bacteria that have intrinsic imipenemnonsusceptibility (i.e., Morganellamorganii, Proteus spp., Providencia spp.), requiring nonsusceptibility to carbapenems other than imipenem as part of the definition might increase specificity.

14. Facility-Level Prevention StrategiesAcute and Long-Term Care • Core Measures • Hand Hygiene • Contact Precautions • Healthcare Provider (HCP) Education • Minimize Device Use • Patient and Staff Cohorting • Laboratory Notification • Antimicrobial Stewardship • CRE Screening

15. Hand Hygiene • Educate staff • Orientation and periodically • Monitor hand hygiene adherence and provide feedback • Ensure access to hand hygiene • Install alcohol-based hand gel dispensers in patient rooms

16. Contact Precautions (CP) – Acute Care • Patients colonized or infected with CRE • Consider pre-emptive CP for patients transferred from high-risk setting • System to identify patients at admission • CDC Health Advisory: History of recent inpatient stay in hospital outside US? • Ensure proper PPE by HCP • Hand hygiene before gown and gloves • Gown and gloves before entering patient’s room • Remove gown and gloves, hand hygiene before exiting • Monitor adherence and provide feedback • Not enough information for firm recommendation re: discontinuation

17. Contact Precautions – Long-Term Care • Modify by risk • Use Contact Precautions: • Dependent on HCP for activities of daily living • Ventilator-dependent • Incontinent of stool • Wounds with drainage that is difficult to control • Consider relaxing Contact Precautions: • Continent of stool, less dependent, w/o draining wounds • ALWAYS observe Standard Precautions

18. HCP Education • What is CRE? • Basic education about MDRO prevention • Hand hygiene • Contact precautions • Appropriate handling of invasive devices, removal of devices when no longer needed

19. Device Use • Minimize use of invasive devices • Ensure implementation of HICPAC recommendations • Urinary catheters • Central lines • Ventilators

20. Patient and Staff Cohorting • Place CRE patients in single-patient rooms • If not available, cohort patients in the same room • Preference for single rooms given to patients at highest transmission risk (stool incontinent, medical devices, open wounds) • To the extent possible, cohort CRE patients to specific areas and staff • Cohort patients with CRE infection or colonization to specific units/wards or a specific area within the unit/ward • Dedicate staff to CRE patients or minimize the number of staff caring for CRE patients

21. Laboratory Notification • Perform appropriate screening for CRE • Use up-to-date lab standards • Protocols in place for notification • Notify clinical staff • Notify infection prevention • Applies to both on and off-site laboratories

22. Promote Antimicrobial Stewardship • Ensure antimicrobials are used for appropriate indications and duration • Use narrowest spectrum appropriate antimicrobial

23. CRE Screening • Purpose: to identify unrecognized CRE colonization among high risk patients • Point prevalence • Rapid evaluation of CRE prevalence in particular unit(s)/affected area(s) • One time if few or no additional CRE patients identified • Conduct serially if colonization more widespread and/or to follow effect of intervention • Epi-linked (e.g., roommate) • Screening indicated for patients with history of recent inpatient stay in hospital outside US • Stool, rectal, or peri-rectal cultures • http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf • For surveillance cultures, may also consider cultures of wounds or urine (if urinary catheter present)

24. Supplemental Measures for Facilities with Ongoing CRE Transmission • Active surveillance cultures • Culturing patients not epi-linked to known CRE patients but meet certain criteria (e.g., admitted from LTCF, admitted to ICU) • Chlorhexidine bathing • Diluted liquid (2%) or 2% chlorhexidine-impregnated wipes • Daily in high risk (e.g., ICU) • Less frequent in LTCF • Applied to all patients in affected unit(s), not just those with CRE infection/colonization

25. In Your Facility… • Is the laboratory able to identify CRE? • How is a CRE defined? • Are there any barriers to implementing the recommended prevention strategies? Your Infection Control Committee may be able to help brainstorm solutions to address some of the challenges regarding surveillance and prevention of CRE

26. Inter-facility Communication • In “detect and protect”, communication is key! • When transferring patients with CRE infection/colonization from your facility, indicate: • CRE status of patient • Presence of open wounds/devices • Antimicrobial use and length of therapy • If CRE present on admission to facility (within 2 days), communicate information to originating facility

27. Role of Public Health in CRE • Assess CRE incidence/prevalence • Provide situational awareness to facilities • Serve as resource to facilities re: prevention and control • Assist with coordination of laboratory testing when indicated, especially in situations with outbreaks and when “unusual” type of CRE suspected or confirmed Phone a Friend!

28. Priorities for Testing/Screening • For patients admitted to healthcare facility in the U.S. after recent hospitalization (within 6 months) in countries outside the U.S., consider: • Rectal screening cultures to detect CRE colonization. • Place patients on Contact Precautions while awaiting the results of these screening cultures. • When a CRE is identified in a patient (infection or colonization), send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism; at a minimum, this should include evaluation for Klebsiellapneumoniaecarbapenemase (KPC) and NDM carbapenemase.

29. Please Report to Local Health Department • Suspected or confirmed outbreaks of CRE • CRE infection or colonization • Any patient suspected or confirmed to be infected or colonized with one of the unusual forms of CRE (e.g., NDM or VIM carbapenemases). • The local health district will work with you and DCLS to assist with appropriate laboratory evaluation for these new forms of CRE.

30. Regions with Few CRE Identified: Infection Prevention Facility w/o CRE but located in Region where CRE present: • Engage facility administrators to prioritize CRE prevention • Ensure CRE control plan is in place • Reinforce core prevention measures • Guide implementation of active surveillance testing and preemptive Contact Precautions for: • Patients admitted from facilities with ongoing CRE transmission • Patients admitted from LTACHs/LTCFs or with CRE risk factors (open wounds, indwelling devices, high antimicrobial use)

31. Regions with Few CRE Identified: Infection Prevention Facility with CRE present: • Engage facility administrators to prioritize CRE prevention • Review infection prevention practices to ensure core prevention measures are in place • Provide in-service training (as needed) • Ensure CRE screening in place and guide implementation of supplemental measures • If CRE rates do not decrease, consult health department and/or regional experts for additional guidance

32. Regions with Few CRE Identified: Education of all Healthcare Facilities • Explain importance of CRE and provide updates on regional prevalence and epidemiology • Review recommended surveillance and prevention measures • Increase vigilance for CRE detection • Overview of CRE surveillance and prevention strategies for acute care and long-term care facilities (developed by VDH) • 1-page “Cliff Notes” version of CDC CRE toolkit • Plans for additional education for healthcare facilities and health department staff

33. Resources • CDC CRE Toolkit (2012): http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html • CDC Health Advisory (Feb 2013): http://emergency.cdc.gov/HAN/han00341.asp • CRE Vital Signs (Mar 2013): http://www.cdc.gov/vitalsigns/hai/cre/ • CDC CRE website: http://www.cdc.gov/HAI/organisms/cre/index.html • CDC CRE lab protocol: http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf • VDH MDRO website: http://www.vdh.virginia.gov/epidemiology/surveillance/hai/MRSAandMDRO.htm

34. Questions? VDH HAI Team: 804-864-8141 • April Achter – HAI/Influenza Epi • Andrea Alvarez – Program Coordinator • Carol Jamerson – Nurse Epi Angela West – Central Region Epi Angela.West@vdh.virginia.gov 804-864-8232