1. Do You Know Where your Bugs Are? Optimizing Technology for Outbreak Investigations Sarah J Stewart Microbiology Applications Specialist, BD Diagnostics Lori Jenkins Microbiology Applications Specialist, BD Diagnostics

2. Disclosures We are employed by BD Diagnostics as Microbiology Application Specialists. The content included in this offering is our own, and not endorsed by BD.

3. Objectives Review a case study for Carbapenem-Resistant Enterobacteriaceae (CRE) Understand CDC Guidelines for Outbreak Investigations Demonstrate the advantages of real-time MDRO event notification or alert Understand the advantages of electronic surveillance reporting to detect and investigate outbreaks

4. Here’s Our Story It’s 12:30pm on Friday and you are wrapping up your work week. You have a great weekend planned at a cabin in Big Bear. As you are sitting at your desk, you get an email notification stating, “Mrs. Smith has an E. coli that is a carbapenem-resistant enterobacteriaceae or CRE isolated”. Then the phone rings and it’s Joan, the Microbiology Lab Lead. One of the Intensive Care Unit patients Mrs. Smith has an E. coli that is a CRE isolated from her urine culture. It was from an indwelling catheter, and you realize that the patients name is familiar. Earlier that day, you had received notification that this patient had a positive blood culture with a gram negative rod.

5. What would you do?

6. CDC steps in an outbreak investigation

8. Step 1-Detect Possible Outbreak Alert Email message received by Infection Preventionist when Lab finalizes Isolate

9. Step 1-Detect Possible outbreak Alert Email message received by Infection Preventionist when Lab finalizes Isolate

10. Step 2 - Find

13. What Do You Do with all this Data?

14. Step 3 – Generate Hypotheses

15. Mrs. Smith- CRE isolated from her urine and GNR in blood cultures Mr. White - CRE from the blood Mrs. Jones- CRE from her blood cultures three weeks ago

16. Step 3 – Generate Hypotheses Did they all have central lines, urinary catheters? Where there any other similarities? Who had contact with the patient(s)?

17. Step 3 – Generate Hypotheses 1)Mrs. Jones is our index case. She was admitted from a local long term care facility 3 weeks ago for urosepsis. Her urine cultures yielded mixed results, however the blood cultures contained CRE. 2) Mr. White also admitted from a different SNF, had a central line placed the same week that Mrs. Jones was admitted. 3) Mrs. Smith, our recent case, had a urinary catheter replaced. She resides in the room next to Mr. White.

18. Step 4 - Test

21.  Pull isolates and send for confirmatory fingerprint analysis  Actively seek out specimens for performing point prevalence

22. Step 5 - Solve

23. We have figured out the index case which resulted in infected patients. We have confirmed our hypothesis through testing. We therefore have solved the point of contamination and original source of the outbreak.

24. Step 6 - Control

25. What changes would you make in this circumstance? Improved hand hygiene? In what ways could you improve the communication between laboratory and Infection Prevention?

26. Step 6 - Control Discontinue unnecessary catheters/devices? Hand hygiene education? Review isolation protocols? Configure electronic surveillance software to generate real-time reporting? Anything else?

27. Step 7 - Decide

28. Congratulations Bugs Have Been Found!!!

29. Thank you!