1. Carbapenemase- Producing Carbapenem-Resistant Enterobacteriaceae Nicole Hearon, HAI Epidemiologist Surveillance and Investigation Division Indiana State Department of Health 1

2. 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 2

3. Definitions 3 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

4. 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) 4

5. 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-beta- lactamase (VIM), Oxacillinase-48 (OXA-48), Imipenemase Metallo-beta- lactamase (IMP) 5

6. 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 6

7. 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) 7

8. Transmission 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) 8

9. 9 States with CP-CRE in 2006 https://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre- webinar-presentation-2014-09-25-final.pdf

10. 10 http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html Current States with CP-CRE

11. 11 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

12. 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 12

13. Types of Infections CP-CRE can cause: –Bloodstream infections –Ventilator-associated pneumonia –Surgical site infections –Intra-abdominal abscesses –Urinary tract infections 13

14. Detection Appropriate specimens: –Stool –Blood –Urine –Wound Laboratory tests: –Modified Hodge Test –Carba NP (Carbapenemase Nordmann-Poirel) –Polymerase chain reaction (PCR) 14 – Sputum – Bile

15. 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 15 Treatment

16. 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. 16

17. 17 http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

18. Infection Control Measures (cont’d) 3.Supplemental measures for a healthcare facility with CP-CRE transmission include the following: A.Refer to the most recent CRE Toolkit from CDC at http://www.cdc.gov/HAI/organisms/cre/ http://www.cdc.gov/HAI/organisms/cre/ B.Consider screening patients to determine if they are epidemiologically linked C.Consider chlorhexidine gluconate bathing 4.Case definition is established by the department. 18

19. 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 19

20. 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 20

21. WHAT’S NEXT? 21

22. 22 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

23. 23 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 Investigation (cont’d)

24. 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 multidrug- resistant organism –Symptoms –Antibiotic use, vaccines –Contact information for person completing transfer form 24 http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf

25. 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 25

26. 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 26 http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

27. References 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-webinar- presentation-2014-09-25-final.pdfhttps://www.ihaconnect.org/Quality-Patient-Safety/Documents/Webinars/CfC-cre-webinar- presentation-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 27

28. Questions or Remarks? Email: nhearon@isdh.in.govnhearon@isdh.in.gov 28