CarbapenemaseProducing
Carbapenem-Resistant
Enterobacteriaceae
Nicole Hearon, HAI Epidemiologist
Surveillance and Investigation Division
Indiana State Department of Health
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Objectives
• At the end of the presentation attendees should be able to:
– Understand and describe the basic epidemiology of
carbapenemase-producing carbapenem-resistant
Enterobacteriaceae (CP-CRE)
– Report cases of CP-CRE via I-NEDSS
– Determine appropriate and efficient interventions that can prevent
CP-CRE transmission in healthcare settings
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Definitions
•
Enterobacteriaceae: a family of bacteria normally found in
human intestines; can become carbapenem-resistant; can
cause serious infection when spread outside the gut
•
Carbapenem: a class of broad-spectrum antibiotics used to
treat severe infections; antibiotics of last resort when other
antibiotics are not available (e.g., imipenem, meropenem,
doripenem, ertapenem)
•
Carbapenemase: enzymes that break down (inactivate)
carbapenem antibiotics, causing resistance
•
CRE: a family of germs that are difficult to
treat because they are highly resistant to
antibiotics
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CP-CRE Definition
• Organisms that are non-susceptible
to at least one carbapenem antibiotic
with MIC ≥ 2 µg/ml or zone diameter
≤ 22 mm (≤ 21 mm for ertapenem)
AND
• Meet one of the following criteria:
(next slide)
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CP-CRE Definition (cont’d)
A. Positive for carbapenemase production by a phenotypic test (e.g.,
Modified Hodge or Carba NP)
OR
B. Nonsusceptible to at least three (3) carbapenem antibiotics with MIC ≥
2 µg/ml or zone diameter ≤ 22 mm (≤ 21 mm for ertapenem)
OR
C. Positive for a carbapenemase gene marker
•
Examples: Klebsiella pneumoniae carbapenemase (KPC), New Delhi
Metallo-beta lactamase (NDM), Verona Integron-Encoded Metallo-betalactamase (VIM), Oxacillinase-48 (OXA-48), Imipenemase Metallo-betalactamase (IMP)
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Why are CRE epidemiologically
important?
• Cause infections with high mortality rates (up to 50%)
• Carry genes with high levels of resistance to many
antimicrobials, limiting treatment options
– Resistance can be transmitted between organisms or between
patients
• Spread rapidly and require the most rigorous infection control
measures
• Have spread throughout many areas of the U.S. and can spread
more widely
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Carbapenem Resistance
• Enterobacteriaceae can become resistant to carbapenems by:
– The transmission of resistance genes from one bacterium to
another
– The production of enzymes that inactivate carbapenems (i.e.,
carbapenemases)
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Transmission
• Person to person
– via contact with infected or colonized
individuals
– via hands of healthcare personnel
– via contaminated medical equipment
• Contact with stool or wounds
• Contact with contaminated environmental surfaces (e.g., bed
rails)
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States with CP-CRE in 2006
https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-crewebinar-presentation-2014-09-25-final.pdf
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Current States with CP-CRE
http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html
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Global Dissemination of CRE
Molton J, et al. Clin Infect Dis 2013;56:1310-1318
http://cid.oxfordjournals.org/content/56/9/1310.full?sid=b2bcabcc-cb4d-41ab-ba19-b91734089663
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Risk Factors
• Exposure to acute care or long-term
care facilities
• Exposure to an ICU
• Presence of other medical conditions
• Compromised immune system
• Invasive devices (e.g., ventilators,
central venous catheters, or
urinary catheters)
• Invasive procedures (e.g., endoscopic
procedures)
• History of extensive antibiotic use
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Types of Infections
• CP-CRE can cause:
–
–
–
–
–
Bloodstream infections
Ventilator-associated pneumonia
Surgical site infections
Intra-abdominal abscesses
Urinary tract infections
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Detection
• Appropriate specimens:
–
–
–
–
Stool
Blood
Urine
Wound
– Sputum
– Bile
• Laboratory tests:
– Modified Hodge Test
– Carba NP (Carbapenemase
Nordmann-Poirel)
– Polymerase chain reaction (PCR)
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Treatment
• Colonized patients
– No antibiotics needed
• Infected patients
– Antibiotics are limited
– Other therapies (e.g., draining the infection)
• Strains that have been resistant to all antibiotics have been
reported
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Infection Control Measures
• When CP-CRE are identified:
1.
An investigation shall be performed by the local health officer
within seventy-two (72) hours and include individuals who have
shared a residence with the patient in an acute care or long term
care facility.
2.
The facility should initiate Contact Precautions; additional
precautions should be added if any other transmissible condition is
present.
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http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
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Infection Control Measures
(cont’d)
3.
Supplemental measures for a healthcare facility with CP-CRE
transmission include the following:
A.
B.
C.
4.
Refer to the most recent CRE Toolkit from CDC at
http://www.cdc.gov/HAI/organisms/cre/
Consider screening patients to determine if they are
epidemiologically linked
Consider chlorhexidine gluconate bathing
Case definition is established by the department.
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Reporting
• CP-CRE must be reported to the health department within 72
hours
• IP can create a communicable disease report (CDR)
– Select “Carbapenemase producing – Carbapenem resistant
Enterobacteriaceae (CP-CRE)” from the drop down list
• ISDH HAI Epidemiologist will assign CDR to the LHD
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Reporting (cont’d)
• Electronic lab reports (ELRs) are also be submitted to ISDH via
I-NEDSS by laboratories
• ISDH HAI Epidemiologist will assign ELR to LHD
• Laboratories must submit isolates within 3 business days of
isolation
– Only submit one isolate per patient
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WHAT’S NEXT?
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Investigation
• LHD contacts facility IP within 72 hours of notification
– Ensure facility places patient on Contact Precautions
– Determine if patient has shared a room or staff with other patients
– Determine if there is a potential for transmission
within facility
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Investigation (cont’d)
• Local health departments should also:
– Promote antimicrobial stewardship
– Ensure facility communicates patient’s infection/colonization status
to receiving facility (e.g., LTC facility) if patient will be
transferred
• Inter-facility transfer form with laboratory reports
– Complete case investigation in I-NEDSS
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Inter-facility Transfer
• If a CP-CRE patient will be transferred to a different facility:
– Infection Preventionist or designee should notify the accepting
facility AND send an “inter-facility infection control transfer form”
which should include:
–
–
–
–
Patient name, date of birth, medical record number
Sending facility contact information
Type of isolation precautions for patient
Infection, colonization, or history of positive culture of a multidrugresistant organism
– Symptoms
– Antibiotic use, vaccines
– Contact information for person completing transfer form
http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf
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Prevention Recommendations
• Healthcare personnel should:
–
–
–
–
–
Practice hand hygiene
Clean & disinfect patient rooms and medical equipment
Don PPE before entering patient room
Doff PPE and wash hands before exiting patient room
Keep colonized or infected patient in a single room on Contact
Precautions
– Dedicate equipment and staff
– Only prescribe antibiotics when necessary
– Remove temporary medical devices
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Patient Screening
• Point prevalence surveys:
– Used to quickly evaluate the prevalence of CP-CRE in specific
wards/units
– Screen all patients in a specific high-risk ward/unit
– Could be conducted once or multiple times (e.g., if colonization is
more widespread or during an intervention)
• Screening of epidemiologically linked patients:
– Screen contacts of patients to identify transmission
– Contacts:
• Roommates of CP-CRE patients or patients who may have been cared
for by the same healthcare personnel
http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
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References
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http://www.cdc.gov/hai/organisms/cre/index.html
http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html
http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
http://phil.cdc.gov/phil/home.asp
http://ce.nurse.com/RVignette.aspx?TopicId=8822
http://www.cdc.gov/vitalsigns/hai/cre/infographic.html
https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinarpresentation-2014-09-25-final.pdf
https://www.youtube.com/watch?v=-FfMCv8FUXI&feature=youtu.be
https://www.youtube.com/watch?v=vnAtuG9ULB4
http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf
http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=53
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm
http://www.mayoclinic.org/ercp-procedure/IMG-20007655
http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=11
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Questions or Remarks?
Email: nhearon@isdh.in.gov
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