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Extended spectrum B-lactamase producing E.coli in the community and in hospital. Dr Graham Harvey Consultant Microbiologist Director of Infection Prevention & Control Shrewsbury & Telford Hospitals NHS Trust, Shropshire,UK. PENICILLIN. BETA LACTAM RING.

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extended spectrum b lactamase producing e coli in the community and in hospital

Extended spectrum B-lactamase producing E.coli in the community and in hospital

Dr Graham Harvey

Consultant Microbiologist

Director of Infection Prevention & Control

Shrewsbury & Telford Hospitals NHS Trust, Shropshire,UK

slide2

PENICILLIN

BETA LACTAM RING

BETA LACTAMASES enzymes that inactivate the beta-lactam ring

CEPHALOSPORIN

BETA LACTAM RING

slide3
Some beta-lactamases only inactivate a small number of antibiotics e.g. penicillin
  • Others have extendedspectrum to all the penicillins and cephalosporins e.g. cefuroxime, ceftriaxone (ESBLs)
  • In addition may also carry resistance to other antibiotics e.g. ciprofloxacin.
esbl evolution
ESBL Evolution
  • Mid 1980s
  • Variants of TEM and SHV
  • Breakdown 3rd generation cephalosporins
  • Mainly in hospital Klebsiella
  • Spread world wide
control of a hospital outbreak of esbl producing klebsiella peumoniae
Control of a hospital outbreak of ESBL producing Klebsiella peumoniae
  • Aberdeen, Scotland, 1992-4
  • ITU associated
  • SHV-2 ESBL
  • Increased use of third generation cephalosporins
  • Only sensitive to amikacin & imipenem
  • Environmental contamination (sinks)
  • Improved plumbing !
  • Multi-disciplinary team approach
the rise of ctx m in europe livermore et al jac 2007 59 165 174
The rise of CTX-M in EuropeLivermore et al JAC (2007) 59 165-174
  • Increasing problem since 2000.
  • Mainly in E coli
  • Now over 50 types described
  • 1998 Poland CTX-M 3 & 15
  • 2000 Spain CTX-M 9
  • 2001 France CTX-M 15
  • 2003 Italy CTX-M 1& 15
spread of ctx m in the uk
Spread of CTX-M in the UK
  • 2000-1 – First UK isolates (Klebsiella)
  • 2003 onwards – widespread across UK
  • E coli
  • Especially CTX-M-15
  • Five major clones A-E
  • Also diverse unrelated strains
health protection agency report september 2005
Health Protection Agency report September 2005
  • Recommendations
    • Laboratory detection of ESBL producers
    • Urine samples in Rx failures
    • Treatment guidelines
    • Better surveillance
    • Investigation of animal carriage
health protection agency report september 200510
Health Protection Agency report September 2005
  • Infection Control of CTX-M
    • Need for hospital and community guidelines
    • ? Interventions needed
    • ? Endemic in hospitals
    • Limited data as only recently emerged as a problem
shropshire hospital setting
Shropshire hospital setting
  • 540,000 population.
  • 2 main hospital sites 300 & 520 beds 30 Km apart
    • 7 intermediate care hospitals : 3 in Wales
    • 230 bed spinal injury & orthopaedic hospital
    • 12% single rooms
    • Minimal neutropenia / transplantation.
start of the shropshire outbreak
Start of the Shropshire outbreak
  • Multi-resistant E coli UTIs from May 2003
  • Mainly community patients
  • Two E.coli strains
    • Both resistant to quinolones, cephalexin and trimethoprim.
    • Both sensitive to nitrofurantoin & carbapenems
    • One strain (strain A) gentamicin resistant.
e s b l producing e coli in shropshire
E.S.B.L producing E coliin Shropshire
  • 1 Jan 03 to 30 Sep 04 – 364 cases
    • 68% female
    • mean age 74 years
    • 49% community samples
    • Diabetes, dementia and malignancy
early findings
Early Findings
  • Gentamicin sensitive strain initially apparent as a community problem.
    • samples from GPs and few from psychiatric hospital.
    • Only 1 nursing home resident.
    • No apparent serious cases.
  • Gentamicin resistant strain mainly in hospital patients.
the evolution of the outbreak clinical and epidemiology 1
The evolution of the outbreak – Clinical and epidemiology 1.
  • In-patient cases initially in Telford Hospital
  • Later spread to Shrewsbury Hospital
  • No obvious ward focus (21wards)
  • 90% Hospital contact in past 3 years
  • But in 10% cases no local acute hospital contact.
response to the outbreak 1
Response to the outbreak .1
  • Community/Hospital outbreak team (Aug 03)
  • Letter to consultants/GPs Sept 03
  • Restrictive antibiotic reporting
  • Increased use of carbapenems
  • Cases isolated in side rooms
response to the outbreak 2
Response to the outbreak 2
  • March 2004 new hospital antibiotic guidelines introduced and strongly promoted
antibiotic policy changes
Antibiotic Policy changes
  • Nitrofurantoin substituted for quinolones in UTIs
  • Imipenem substituted for quinolones in serious sepsis
  • Ertapenem introduced for ESBL sepsis
  • Gentamicin substituted for cephalosporins in surgical prophylaxis
  • Return to amoxycillin in respiratory tract infections
response to the outbreak 3
Response to the outbreak .3
  • Increased use of hand gel
    • Hand gel by each bedside
  • Marking of patient’s electronic records
  • Daily computer search for re-admissions
  • Patient screening (stool & urine)
  • “ESBL management unit”
    • Cohort ward
    • Opened May to June 04
    • Closed July and August 04
    • Re-opened September 04
shropshire esbl outbreak aug02 dec04
Shropshire ESBL outbreakAug02-Dec04

Antibiotic policy

Isolation ward

do the sick no harm
“Do the sick no harm”
  • The ones that got away
    • If you do not look you will not find
  • Antibiotic disc problems
  • Gentamicin assays
  • Asymptomatic carriage in the community
  • You are what you eat
quinolone r cephalexin s urinary e coli
Quinolone R Cephalexin S Urinary E coli
  • Jan 2003 to March 2004
  • 562 ESBL isolates in 370 patients
  • 98 patients had CiproR TriR NitS “LexS” strains
  • ESBL found in 27 of them

68 pats

laboratory testing issues
Laboratory testing issues
  • Cefotaxime and ceftazidime
  • or Cefpodoxime +/- clavulanate
  • Manufacture (Oxoid) MHRA
  • Batch to batch variation +/- 40%
    • 10 ug could be 6-14 ug
  • Mixing batches
    • Test like with like
  • Storage esp clavulanate
slide33

Shrewsbury and Telford NHS Trust

New hospital cases of ESBL from May 2003 to March 2007

Ward opened May – June 04

Ward re-opened Sept 04 to Dec 05

2007

2003

Total 20

2004

Total 147

2005

Total 80

2006

Total 53

conclusion
Conclusion
  • ESBL vs MRSA
    • Epidemic strains
    • Multiple antibiotic resistance
    • Laboratory tests
      • Detection
      • Chromogenic agar
    • Silent carriage
      • Screening
    • Hospital spread
      • Isolation
      • Hand hygiene
    • Community reservoir
and finally

MRSA- 4002

ESBL- 662

3572

466

134

36

26

260

780

C DIFF - 1104

And finally…

Jan 2003 to Dec 2006

5274 patients with ESBL, MRSA and/or C DIFF

ESBL 662 cases

9.3% C DIFF +ve

25.6% MRSA +ve