1. Antibiotic Resistance Prevention
New York City
Department of Health & Mental Hygiene
Antibiotic Resistance Prevention
Program Initiatives
Molly M. Kratz, MPH
AR Prevention Program Director
Bureau of Communicable Disease
APIC Meeting
November 15, 2017

2. AR Prevention Program Background
Funded in 2016 by the CDC’s Epidemiology and Laboratory Capacity Grant for HAI/AR initiatives in all state and select city public health jurisdictions
Includes two programmatic/epidemiology staff and two laboratorians at the Public Health Laboratory (PHL)
Other units at DOHMH work on disease-specific issues related to antibiotic resistance, including:
Bureau of STD Control
Bureau of TB Control
Bureau of Healthcare Systems Readiness in the Office of Emergency Preparedness and Response

3. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

4. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

5. NYC AR Prevention Advisory Group
Stakeholders include lab and microbiology lab directors, medical directors, infection control practitioners, representatives from trade associations and other frequent DOHMH collaborators in the community, etc.
Representation from NYS DOH and Wadsworth Center
Intend to maintain over time with the following structure:
Convene roughly quarterly (three conference calls and one in-person meeting) with entire group
Convene smaller, focused working groups to address specific issues as they arise, then will report back to full group
Kick-off call was held on October 27, 2017

6. NYC AR Prevention Advisory Group
Overarching objectives: leverage the experience and expertise of stakeholders across NYC, discuss and collaborate on citywide efforts to detect, prevent, and control AR, solicit input on AR Prevention Program initiatives
Concrete goals and topics will evolve over time, and currently include:
Foster antibiotic stewardship, primarily in outpatient settings
Share best practices for preventing the transmission of multi-drug resistant organisms
Obtain input on plans for establishing surveillance of carbapenem resistant Enterobacteriaceae in NYC

7. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

8. Collaboration with NYS DOH
NYC DOHMH representatives participate in the NYS Antimicrobial Resistance Prevention and Control Task Force and its four committees
Hospital-acquired infections are reportable to NYS DOH, responsible for the investigation of outbreaks and incidents in Article 28 facilities across the state, including in NYC
In some cases, NYC DOHMH is asked to participate in these investigations or conduct additional follow up

9. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

10. Carbapenem Resistant Enterobacteriaceae
Carbapenem resistant Enterobacteriaceae (CRE) are a group of bacteria that are difficult to treat because they have high levels of resistance to many antibiotics
Designated by the CDC as an “urgent” threat, the highest level
Commonly occur in hospitals, nursing homes, and other healthcare settings; less is known about transmission in the community
In July 2017, the Council of State and Territorial Epidemiologists (CSTE) issued a Position Statement recommending that all health departments mandate reporting of CRE

11. CRE Surveillance in NYS
Many hospitals in NYS currently report healthcare-acquired CRE infections via the National Healthcare Safety Network (NHSN)
In 2015, participating NYS hospitals reported 3,618 CRE cases; 1,727 were reported in NYC
Mandating CRE reporting will enable Health Officials to learn about prevalence and incidence in other healthcare settings, and
NYS DOH also plans to mandate CRE reporting in the future

12. CRE Surveillance in NYC
NYC Health Code is being amended to mandate reporting of CRE by laboratories via the Electronic Clinical Laboratory Reporting System (ECLRS)
Proposed to the NYC Board of Health in September and published for public comment
Comment period closed in late October
Board will vote to adopt at their next meeting in December
If approved for adoption, will go into effect in January
DOHMH ECLRS team will provide a technical implementation guide and work with laboratories to bring them on board

13. CRE Reporting Framework in NYC
Based on the July 2017 CSTE Position Statement
Built to leverage labs’ existing capacity to identify CRE
Organisms of interest are:
Enterobacter species, E. coli, and Klebsiella species
Resistance to a carbapenem defined as:
Minimum inhibitory concentration (MIC) of > 4 mcg/ml for meropenem, imipenem, and doripenem
MIC of > 2 mcg/ml for ertapenem
Labs with the capability to conduct additional testing to identify the mechanism of resistance should report these results

14. Identify Enterobacteriaceae species Antibiotic susceptibility testing
CRE Testing Process
Identify Enterobacteriaceae species
Antibiotic susceptibility testing
Phenotypic testing to determine if isolate produces a carbapenemase
(the most concerning mechanism of resistance)
Molecular testing to determine which carbapenemase is present:
Klebsiella pneumoniae carbapenemase (KPC)
New Delhi metallo-β-lactamase (NDM)
Verona integron-encoded metallo-β-lactamase (VIM)
Imipenemase (IMP) metallo-β-lactamase
Oxacillinase-48 (OXA-48)

15. CRE Surveillance in NYC
Labs without the ability to detect or identify carbapenemases should report CRE that are resistant to meropenem, imipenem, doripenem, or ertapenem
Labs with the ability to detect and/or identify carbapenemases should report these results
Positive on a phenotypic test for carbapenemase production
Positive for a known carbapenemase resistance mechanism
Select isolates should be submitted to PHL for additional testing and reporting via the CDC’s Antimicrobial Resistance Laboratory Network (ARLN)
All results will be reported on a monthly basis; certain results (e.g., those that suggest a novel carbapenemase) will be reported urgently and the isolate sent to Wadsworth/ARLN

16. Antimicrobial Resistance Lab Network
The CDC’s ARLN transforms much of the current national AR lab landscape by boosting local capacity and technology to address AR
Establishes 7 regional labs that:
Have comprehensive capacity for 7+ AR pathogens
Are local gold-standard labs with cutting-edge technology
Enable faster outbreak detection and response support, and better tracking of resistance
Provide real-time, actionable data to prevent and combat future AR threats
Our regional lab is Wadsworth Center

17. CRE Workgroup in NYC
Kick-off call of the AR Prevention Advisory Group focused on plans for establishing CRE surveillance
Call for volunteers to participate in a focused CRE Workgroup to pilot a system for sentinel isolate submission, and later to devise a NYC-wide sampling strategy
Will leverage existing capacity for CRE testing (have asked all labs to complete a brief survey of diagnostic capabilities and CRE burden)
Will target neighborhoods in NYC where non-KPC and novel carbapenemases are more likely to be introduced
Please contact if interested in learning more or participating.

18. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

19. NYC Antibiogram Background
An antibiogram is an aggregate table of susceptibility patterns of organisms
Generated by analyzing results on patient isolates
Geographic location
Defined period of time
Species specific
Percent susceptible to routinely tested antimicrobials
Helps guide empiric selection of antimicrobial therapy
Critical to the success of antimicrobial stewardship efforts

20. CLSI Guidelines for Antibiogram Preparation
Clinical and Laboratory Standards Institute (CLSI) M39-A41
Include species with data for > 30 isolates
First patient methodology
Include antimicrobial agents routinely tested
Report only percent susceptible
Recommend stratified analyses
1CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data; Approved Guideline- Fourth Edition. M39-A4. Wayne, PA: Clinical and Laboratory Standards Institute; 2014.

21. NYC Antibiogram Methods
Proof of concept project
Data collected from 16 health facilities
January – December 2016
Limited to outpatient populations (specialty clinics, acute care hospitals, urgent care centers, and other health care systems)
Focused on 6 key pathogens causing urinary tract infections (UTIs) and 8 treating antimicrobials
Stratification
Borough
Adult and pediatric populations

22. NYC Antibiogram

23. NYC Antibiogram Dissemination & Next Steps
Full citywide report circulated to participating laboratories and will be linked to on the Health Department’s website
Borough-specific wall charts have been printed and are being distributed to Infection Control Practitioners at all NYC hospitals
Exploring options for disseminating via an app
Will begin seeking participants and data for 2017 UTI version of NYC Antibiogram soon; intend to expand to new diseases and populations going forward
Please contact if interested in obtaining a wall chart, learning more, or participating.

24. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

25. Antibiotic Stewardship Certificate Program
We support the work of the Greater New York Hospital Association (GNYHA)
Hosted two trainings (with in-person and online components) in June 2017 for representatives of nursing home facilities
Those who completed and passed the training were able to:
Define components of an ASP
Identify factors contributing to AR growth
Develop and implement evidence-based treatment guidelines using local microbiology data
Develop strategies for engaging commitment from all members of a facility’s ASP team
Will be holding two more sessions in 2018; details forthcoming

26. AR Prevention Program Overview
Collaboration with stakeholders
Coordination with NYS DOH
Surveillance and response
Data initiatives
Antibiotic stewardship
Policy proposals
Education and awareness
with questions or comments.

27. 10th Annual U.S. Antibiotic Awareness Week
Launch of CDC’s new Be Antibiotics Aware educational effort (formerly the “Get Smart About Antibiotics” campaign)
Features messaging targeted to providers and patients and digital and print educational materials
to obtain copies of resources.

28. 10th Annual U.S. Antibiotic Awareness Week
Launch of the new Be Antibiotics Aware educational effort (formerly the “Get Smart About Antibiotics” campaign)
Features messaging targeted to providers and patients and digital and print educational materials

29. 10th Annual U.S. Antibiotic Awareness Week
Launch of the new Be Antibiotics Aware educational effort (formerly the “Get Smart About Antibiotics” campaign)
Features messaging targeted to providers and patients and digital and print educational materials

32. Thank You
Please with questions, requests for CDC Be Antibiotics Aware materials, or an interest in participating in any of the AR Prevention Program initiatives covered today.
Molly M. Kratz, MPH
AR Prevention Program Director
New York City Department of Health & Mental Hygiene