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Public Health and Long Term Care: A Cautionary Tale

Public Health and Long Term Care: A Cautionary Tale. Susan I. Gerber, MD Associate Medical Director Cook County Department of Public Health. Healthcare 1970-1980: Hospital is Center of Universe. Jarvis WR Emerg Infect Dis 2001;7: 170-3. Healthcare Surveillance Needed Now.

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Public Health and Long Term Care: A Cautionary Tale

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  1. Public Health and Long Term Care: A Cautionary Tale Susan I. Gerber, MD Associate Medical Director Cook County Department of Public Health

  2. Healthcare 1970-1980:Hospital is Center of Universe Jarvis WR Emerg Infect Dis 2001;7: 170-3

  3. Healthcare Surveillance Needed Now Jarvis WR Emerg Infect Dis 2001;7: 170-3

  4. Healthcare Surveillance Needed Now- Addendum Long term care facility with ventilator and psychiatric patients Long term acute care hospital

  5. Newspaper Headlines Nursing home safety reforms get deadline Task force chief sets timetable for key proposals to end violence* Justice Department supports safety reforms for nursing homes Recommendation to move patients with severe mental illness praised* Nursing home sexual violence: 86 Chicago cases since July 2007 — but only 1 arrest Rape allegations were reported in a quarter of city's 119 nursing homes in those two and a half years, records show* Nursing home raids net 8 arrests Warrants target 20 people wanted on charges ranging from domestic battery to indecent exposure* Senators outraged over Illinois nursing home safety 'Shame on us, all of the agencies,' one senator says at hearing* *Chicago Tribune 2009-2010

  6. Newspaper Headlines Long-Term Care Hospitals Face Little Scrutiny “We see such sick people.” Dr. David Jarvis, national medical director for the Select Medical Corporation By ALEX BERENSON Published: February 9, 2010

  7. Long Term Acute Care Hospitals (LTACHs) • Official definition: • Patients are required to have medically complex situations and a mean length of stay of ≥ 25 days • Simple definition: • An island of intensive care

  8. Long -Term Acute Care Hospitals: LTACHs The Perfect Storm: Device utilization high Rate of colonization at admission high Rate of antibiotic use high Duration of hospitalization prolonged Gould etal. ICHE 2006; 27:920-925

  9. Recipe for Disaster New antibiotics or old antibiotics resurrected- difficulties with antibiotic stewardship Specialty facilities for long term care, LTACHs and dialysis units More demands on ICPs Outsourcing microbiology Devices and respiratory care

  10. Long Term Care Facilities (LTCFs) • Some LTCFs have medically complex patients who are ventilated with prolonged lengths of stay • They may have combinations of patients: • Ventilated patients with central lines • Older adults with less nursing care requirements • Alzheimers unit • Psychiatric unit • They are not “LTACHs”--- using medicare definitions……..

  11. Burning Issues • Bloodborne pathogens • Multidrug-resistant organisms (MDROs)

  12. Multidrug-resistant Organisms (MDROs)

  13. MDROs and Long Term Care • Including: • KPC (Klebsiella pneumoniae carbapenemase) containing organisms • Elizabethkingia meningoseptica • Clostridium difficile • Acinetobacter spp, Pseudomonas aeruginosa, Staphylococcus aureus, etc……….

  14. Some Background onEnterobacteriaceae • Bacteria in Enterobacteriaceae group are common causes of community and healthcare acquired infections. • E. coli is the most common cause of outpatient urinary tract infections. • E. coli and Klebsiella species (especially K. pneumoniae) are important causes of healthcare associated infections. • Together they accounted for 15% of all HAIs reported to NHSN in 2007. CDC, 2009

  15. Klebsiella Pneumoniae Carbapenemase KPC is a class A b-lactamase Confers resistance to all b-lactams including extended-spectrum cephalosporins and carbapenems Occurs in Enterobacteriaceae Most commonly in Klebsiellapneumoniae Also reported in: K. oxytoca, Citrobacterfreundii, Enterobacter spp., Escherichia coli, Salmonella spp., Serratia spp., Also reported in Pseudomonas aeruginosa (South America) CDC, 2009

  16. Susceptibility Profile of KPC-Producing K. pneumoniae

  17. KPC Enzymes Located on plasmids; conjugative and nonconjugative blaKPC is usually flanked by transposon sequences KPC-2 and KPC-3 most common in the US blaKPC reported on plasmids with: Normal spectrum b-lactamases Extended spectrum b-lactamases Aminoglycoside resistance Fluoroquinolone resistance

  18. Geographical Distribution of KPC-Producers Frequent Occurrence Sporadic Isolate(s) CDC, 2009

  19. Risk Factors for and Outcomes of CRKP Infections • Case control studies done by Patel et al. at Mount Sinai in NYC, where CRKP are now endemic. • 99 patients with invasive CRKP infections compared to 99 patients with invasive carbapenem susceptible K. pneumoniae infections. Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106 CDC, 2009

  20. Comorbidities * *p <0.001 CDC, 2009

  21. Healthcare-Associated Factors * * * * * p <0.001 CDC, 2009

  22. Recent Outbreaks of KPC Producing Klebsiella • September 2008: Acute care hospital in Ponce, Puerto Rico. • November 2008: Long term care facility in IL. • Methodology: • Review of microbiology data for case finding • Review of infection control practices • Surveillance cultures of patients who were epidemiologically associated with cases. CDC, 2009

  23. Infection Control Observations-Puerto Rico and IL Staff entering rooms without donning a gown, occasionally no gloves or hand hygiene Reuse of gloves between rooms with no hand hygiene. Exiting rooms without removing gowns Touching patients and equipment without PPE Inconsistent PPE use during wound care, respiratory care CDC, 2009

  24. CRKP Outbreaks-Lessons Learned • Healthcare epidemiology/infection control staff at some facilities might not be aware that CRKP are actually present. • The etiology of outbreaks of CRKP are multi-factorial, but are due in part to: • Non-compliance with infection control • Unrecognized carriers serving as reservoirs for transmission CDC, 2009

  25. E. meningoseptica • Also known as: • Flavobacterium meningosepticum • Chryseobacterium meningosepticum • Found in soil and water • Identified in neonatal wards • Immunocompromised adults

  26. Long Term Acute Care Hospital (LTACH) Facility A Converted to LTACH in 2006 Individual patient rooms Ventilators and wound care Average daily census = 55 patients Average patient stay = 30 days

  27. E. meningosepticum Jan 2007-April 2008 Reported Patients 2007 2008

  28. E. meningosepticum antibiotic susceptibilitiesJan 07 – Apr 08 (N=37) Percent Susceptible

  29. Responses Consider targeted active surveillance cultures if clusters or increased cases identified Inservices or education Improve environmental disinfection No tap water to come into direct contact of patient devices Standardize respirator cleaning Admission screening of trach patients Specific communications regarding resistant organism information for patient transfers

  30. EKM blood culture isolates-aggregate Number of isolates Year of collection

  31. EKM blood culture isolates-by hospital Number of isoloates Year of collection

  32. Clostridium difficile • Emergence of the epidemic strain BI/NAP1 • Discharge data indicates an increase • More severe disease?

  33. C. difficile BI/NAP1 Strain Severity Miller M. etal. CID 2010;50:194-201

  34. CDI discharges per 1000 Hospital Discharges in Illinois, 1999-2007 Cases per 1,000 discharges Year

  35. Clostridium difficileand Long Term Care • Recent one month surveillance of C. difficile in Cook County, September, 2009 • Patients with the BI strain were frequently transferred between acute care hospitals and long term care facilities in Cook County

  36. Conclusions • Increase infection control activities in long term care • Improved communication between acute and long term care • Can public health help bridge the gap between acute and long term care?

  37. Acknowledgements Eric Jones Kingsley Weaver Judy Schermond Stephanie Black Fadila Serdarevic Shaun Nelson Mike Vernon Supriya Jasuja Megan Patel

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