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DROP-CRE Network IP Survey and Oregon CRE Toolkit Review

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  1. DROP-CRE Network IP Survey andOregon CRE Toolkit Review Christopher D. Pfeiffer, MD, MHS OSWAPIC Chapter Meeting April 9, 2013

  2. Learning Objectives • Learn about the newly established DROP-CRE Network. • Review results of the DROP-CRE Infection Prevention Survey on MDRO practices. • Review the updated Oregon CRE Toolkit with a focus on understanding the Oregon CRE definition and Infection Preventionists’ role in CRE prevention and control.

  3. Drug-Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network CRE Statewide network to detect, control, and prevent multidrug-resistant organisms (MDROs) Initiated September 2012

  4. DROP-CRE Network Personnel • ZintarsBeldavs, MS (OHA) • Genevieve Buser, MD (OHA) • Margaret Cunningham, MPH (OHA) • Tasha Poissant, MPH (OHA) • Ann Thomas, MD, MPH (OHA) • Jon Furuno, PhD (OSU College of Pharmacy) • Chris Pfeiffer, MD, MHS (PVAMC, OHSU) • John Townes, MD (OHSU)

  5. Advisory Committee Members • Dianna Appelgate, MS, MPH, CIC (Sacred Heart, Springfield) • AvanthiDoppalapudi, MD (Providence, Medford) • Ronald Dworkin, MD (Providence, Portland) • Kendra Gohl, RN, BSN, CIC (Columbia, Astoria) • Alex Kallen, MD, MPH (CDC, Atlanta GA) • Margret Oethinger, MD, PhD (Providence, Portland) • Robert Pelz, MD, PhD (PeaceHealth, Springfield) • Kathy Phipps, RN, BSN, CPUR (Acumentra, Portland) • Mary Post, RN, MS, CNS, CIC (OPSC, Portland) • Pat Preston, MS (McMinnville) • Sheryl Ritz, RN, BSN (Vibra, Portland) • Susan Sharpe, PhD, DABMM, FAAM (Kaiser, Portland) • Sarah Slaughter, MD (Providence, Portland) • Cathy Stone, MT, CIC (Good Sam, Corvallis)

  6. DROP-CRE Network: 2012-13 Goals • Assess statewide needs and capabilities for MDRO/CRE response. • Coordinate statewide CRE education. • Develop capacity for rapid carbapenemase identification. • Offer real-time epidemiologic outbreak assistance to Oregon facilities with CRE. • Track CRE regionally between facilities.

  7. Part 1: IP Needs Assessment Survey Results

  8. IP Needs Assessment Survey:Facility characteristics • 45/62 (72%) responded • Response rate by bed size • 5-49 beds: 21/29 (72%) • 50-99 beds:4/6 (66%) • 100-149 beds: 9/10 (90%) • >150 beds: 8/13 (61%)

  9. Facility-specific definitions for MDR-Enterobacteriaciae Are β-lactams and cephalosporins considered to be in the “same class”? Yes 9%; Unsure 21%, No 70%

  10. Infection Prevention Activities • Patients placed in contact precautions: • CRE: 85% • ESBL: 73% • MDR-Pseudomonas spp. : 69% • MDR-Acinetobacter spp. : 76% • MRSA/VRE: 97% • C. diff: 100% • Activities monitored: • Hand hygiene: 91% • Isolation precautions: 79% • Environmental cleaning: 85% • Most UV fluorescence marker or ATP monitor • None: 3%

  11. Interfacility Transfer Awareness • 58% stronglyagree or agree that their facility is aware of patients’ MDRO status upon admission • 82% a stronglyagree or agree that a receiving facility is made aware of patients’ MDRO status upon discharge

  12. CRE awareness/surveillance • 15% listed CRE amongst top 3 MDRO priorities • 97% MRSA and Cdiff; 61% VRE; 42% ESBL • 94% aware of CDC CRE Toolkit • 79% used the OHA CRE definition stated on the survey (21% were unsure) • 18/33 (55%) had not reviewed microbiology records to detect unrecognized CRE cases • Of those who had reviewed, 20% (3/15) identified CRE. • No facility had conducted a CRE point prevalence survey

  13. MDRO Educational Preferences • Extremely valuable: • Teleconference with experienced epi team during CRE outbreak/exposure 67% • APIC presentation 55% • Site visit with experienced epi team during CRE outbreak/exposure 55% • Webinar 49% • Educational handouts/algorithms 44% • Grand Rounds at your hospital 16% • Moderately or Not Valuable 68%

  14. Summary of the Survey • Definitions of MDRO-GNR vary widely • IPs are often not confident whether MDRO status of patients is communicated in transfer • ~50% of facilities have reviewed microbiology records for CRE • Facilities are frequently monitoring adherence to contact precautions (79%), hand hygiene (91%), and environmental cleaning (85%). • Thanks again to all survey participants!

  15. Part 2: Oregon CRE Toolkit Photos from CDC CRE Toolkit 2012

  16. Oregon CRE Toolkit • Overview of the Toolkit • Definition • Infection Prevention/Control in Acute Care Facilities • Infection Prevention/Control in Long Term Care Facilities • Infection Prevention/Control in Ambulatory Care Settings • Microbiology Laboratories: Detection and Reporting • References • Appendices(CRE Interfacility transfer form, CDC environmental cleaning monitoring tool, Screening culture laboratory protocol and sample letter for staff and patients, Basic and Advanced CRE FAQ, Patient Safety Tips)

  17. Oregon CRE Definition

  18. CRE Assessment Tiers

  19. Challenges with defining CRE • Understanding Enterobacteriaceae. • CRE: “non-susceptible” or “resistant”? • Low adoption rate of new CLSI breakpoints of Enterobacteriaceae to carbapenems. • Inability to rapidly identify the resistance mechanism (carbapenemase vs. other). • And, does resistance mechanism matter for infection control?

  20. CRE “Reference Guide”

  21. Enterobacteriaceae • Gram negative bacilli (rods) mostly found in the gastrointestinal tract • Laboratory basics: all ferment glucose, mostly oxidase negative • Examples: • Main: E. coli, Klebsiella spp., Enterobacter spp. • Other: Proteus spp., Providencia spp., Morganella spp., Citrobacter spp., Serratia spp., Salmonella spp. • Pseudomonas spp.and Acinetobacter spp. are NOT Enterobacteriaceae.

  22. CLSI Breakpoint ChangesEnterobacteriaceae to carbapenems

  23. Categories of CRE Resistance • Carbapenemase (Tier 1) • Non-Carbapenemase (Tiers 2 & 3) Routine susceptibility testing in the microbiology laboratory does not reliably differentiate the resistance mechanism.

  24. Tier 1: Carbapenemase-producing (CP) CRE • Carbapenemases directly inactivate carbapenems • CP CRE are primarily responsible for rapid worldwide spread of CRE. • “plasmid mediated” transmission • Klebsiella spp. most common • Carbapenemases to know: • Klebsiella pneumoniae carbapenemase (KPC) • New Delhi metallo-β-lactamase (NDM) • Verona integron encoded metallo-β-lactamase (VIM) • Imipenemase metallo-β-lactamase (IMP) • Oxacillinase-48 (OXA-48).

  25. Tier 2: Acquired carbapenem resistance not due to carbapenemase production • Resistance mechanism is typically: • extended spectrum β-lactamase (ESBL) or extended spectrum cephalosporinase (e.g. AmpC) plus • decreased permeability of the cell wall (e.g. porin mutation). • Epidemiology: • stable over time • Most often seen in Enterobacter spp. • Local (i.e. unit- or facility-wide) rather than global impact.

  26. Tier 3: Naturally imipenem- resistant Enterobacteriaceae • Using “new” CLSI breakpoints, it is common to encounter imipenem non-susceptible organisms (MICs 2–4 µg/mL) that were considered susceptible by the “old” CLSI breakpoints. • Proteus spp., Providencia spp., and Morganella spp. • PVAMC Antibiogram: Morganella morganii 2009 100% imi-S 2010 100% imi-S 2011 20% imi-S 2012 34% imi-S • Non-susceptibility to any other carbapenem is unusual and reason for concern.

  27. Global Epidemiology: KPC Gupta et al. Clin Infect Dis 2011;53:60-67

  28. Global Epidemiology: NDM Gupta et al. Clin Infect Dis 2011;53:60-67

  29. Global Epidemiology: VIM/IMP Nordmann et al. Emerg Infect Dis 2011;17:1791-98

  30. Global Epidemiology: OXA-48 Nordmann et al. Emerg Infect Dis 2011;17:1791-98

  31. Slide from Alex Kallen,MD, MPH) Carbapenemase-producing CRE in the United States DC KPC KPC, NDM KPC, NDM, OXA KPC, NDM, VIM KPC, NDM, VIM, IMP HI PR AK Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR MMWRMorb Mortal Wkly Rep. 2010 Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212. CDC, unpublished data

  32. Oregon CRE Epidemiology • 45 CRE • 3 KPC • No NDM • No other known carbapenemases

  33. CRE in Oregon

  34. Ertapenem • Different than the other carbapenems • No activity against Pseudomonas aeruginosa • Slightly weaker activity against Enterobacteriaciae • Lowest barrier to resistance via ESBL/AmpC + porin change • Typical use in practice: outpatient antibiotic therapy • In the lab: the most sensitive but least specific carbapenem used to screen for CRE. • For labs using the “Old” CLSI breakpoints: ertapenem non-susceptibility may be the only indicator of CP CRE.

  35. Oregon Microbiology Laboratory Practices (from survey) • 39/48 (81%) labs responded • CRE screening methods (n=37) • 25 labs: automated testing only (Microscanor Vitek) • 7/25 use new CLSI breakpoints • 3 labs: both automated and manual testing • 9 labs: manual testing only • 3/9 use new CLSI breakpoints • Confirmatory carbapenemase testing • 7/37 use Modified Hodge Test • 5/7 use new CLSI breakpoints • We are encouraging labs to either A) Switch over to new breakpoints; or B) Perform Modified Hodge Testing. If not possible, send isolates meeting screening criteria (carbapenem MIC ≥2 and resistance to any 3rd generation cephalosporin) to OSPHL for MHT

  36. Why 3rd Gen Cephalosporins? • Carbapenemases not only directly hydrolyze carbapenems but also penicillins and cephalosporins • Addition of 3rd generation (IV) cephalosporins to the definition • Improves specificity • Does not sacrifice (much) sensitivity • Increases complexity • Cefepime: 4th gen cephalosporin; NOT included in the CRE definition

  37. Detection of CP CRE: Modified Hodge Test (MHT) • Indirect phenotypic test of carbapenemase production. • Accuracy: • Great: KPC detection in E. coli and Klebsiella spp., • BAD: KPC detection in Enterobacter spp. • >50% of Enterobacter spp. CRE in Oregon are MHT+ (all are PCR neg) • Variable/Uncertain: non-KPC carbapenemases

  38. Detection of CP CRE: PCR • Carbapenemase PCR (or other genotypic method) is the most accurate way to detect CP CRE. • Carbapenemase PCR testing is currently not widely available. • No private labs performing the test in Oregon • We anticipate PCR to be online at OSHPL in May

  39. Oregon CRE Definition (again)

  40. CRE Reporting in Oregon • 1st mandated Dec, 2011 • Laboratories and clinicians required to report • Report all CRE using the revised CRE case definition • Labs are asked to submit a subset of isolates for further testing at OHA and CDC • OSPHL will perform in real-time: MHT (available now) and PCR for KPC and NDM (available soon)

  41. CRE Reporting and Isolate Submission(Appendix F)

  42. Oregon CRE Toolkit • Overview of the Toolkit • Definition • Infection Prevention/Control in Acute Care Facilities • Infection Prevention/Control in Long Term Care Facilities • Infection Prevention/Control in Ambulatory Care Settings • Microbiology Laboratories: Detection and Reporting • References • Appendices(CRE Interfacility transfer form, CDC environmental cleaning monitoring tool, Screening culture laboratory protocol and sample letter for staff and patients, Basic and Advanced CRE FAQ, Patient Safety Tips)

  43. General Measures for CRE Prevention in Acute Care • Educate staff (CRE and other MDR-GNRs) • Communicate with your microbiology lab • Use the OHA CRE definition • Ensure IPC is notified when CRE is detected • Know which CLSIbreakpoints are used at your facility • Review past 12 months of lab records for previously unrecognized CRE • Consider active surveillance cultures for CRE colonization in select patients on admission

  44. Specific Recommendations for IPC when CRE recognized at your facility • Notify Local Health Dept. • Assess “Tier” of CRE; act accordingly • Follow the “NICE” Toolkit Recommendations

  45. Think “NICE” for CRE • Notify: • Local health department, clinician groups (ID, ICU, etc.), antibiotic stewardship program • For CP-CRE: Notify hospital administration • Intervene • Emphasize core strategies: hand hygiene, Contact Precautions, private rooms, environmental cleaning • Reduce unnecessary antibiotics • Reduce use of invasive devices • For CP CRE:screen patient contacts; cohort staff/patients • CommunicateCRE status to any receiving facility • Educatepatients, staff, and visitors about CRE

  46. Oregon CRE Toolkit • Overview of the Toolkit • Definition • Infection Prevention/Control in Acute Care Facilities • Infection Prevention/Control in Long Term Care Facilities • Infection Prevention/Control in Ambulatory Care Settings • Microbiology Laboratories: Detection and Reporting • References • Appendices(CRE Interfacility transfer form, CDC environmental cleaning monitoring tool, Screening culture laboratory protocol and sample letter for staff and patients, Basic and Advanced CRE FAQ, Patient Safety Tips)

  47. Toolkit Educational Material • 2 CRE FAQs • CDC Vital Signs • OSTLTS PHPSF • General Patient Safety Tips