pho powerpoint template - title and sample slides 2010

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ESBL and CPE: Mutants,

Migrants and Masterminds

Debbie Demizio BA RRT CIC

IPAC-EO Education Day

June 3, 2016

Image source: CDC

PublicHealthOntario.ca

Objectives

MUTANTS

• Describe the characteristics of ESBL and CPE

• Compare the threat of ESBL and CPE

MIGRANTS

• Identify the risk factors

• Consider travel as a risk factor

MASTERMINDS

• Identify infection control measures

• State the criteria to discontinue contact precautions

• Select the appropriate tests for surveillance

• Be aware of the important role of antibiotic stewardship

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How antimicrobial resistance occurs

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Image source: Public Health Ontario

http://www.publichealthontario.ca/


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Antibiotic resistance

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Image source: Conly J. CMAJ 2002

PublicHealthOntario.ca 5


Fluoroquinolone use and correlation to ciprofloxacin resistance among uropathogens in

British Columbia

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Patrick & Hutchinson, CMAJ 2009




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Definitions

• β-lactam antibiotics • Penicillins

• Cephalosporins

• β-lactamase • Enzymes produced by certain bacteria that render the

above antibiotics ineffective

• First detected in E. coli in 1962

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Image Source: PHO


Image source: CDC

“A serious threat is defined as, a significant

antibiotic-resistant threat. These threats are

not considered urgent, but are expected to

worsen and may become urgent without

ongoing public health monitoring and

prevention activities.”




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ESBL

Extended spectrum β lactamase

• Not an organism, but describes the characteristic of some gram negative bacteria; most commonly

• E. coli (1962)

• Klebsiella pneumoniae (1983)

• Others

10 Image source: Microbewiki.kenyon.edu


Characteristics of ESBLs

• Gram negative rods

• Resistance to β lactam antibiotics:

• All Penicillins

• Cephalosporins

• Sensitive to:

• Cephamycins

• Carbapenems

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Image source: CDC


Why ESBL is a concern

1. Difficult to treat infections

2. The ability to produce β-lactamase can transfer to other

strains and species of bacteria

3. Can be difficult to detect by routine susceptibility tests,

causing delay in treatment with an appropriate antibiotic

4. Longer hospital stays, increased cost of care

5. Increased risk of death

6. Outbreaks are possible and can be difficult to control,

especially in long term/chronic care

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Risk factors for ESBL infection

Acute care

• Increased length of stay

• ICU – invasive devices • Catheters

• Feeding tubes

• Trach

• Antibiotics

• Duodenoscopy

Chronic care

• Poor functional status

• Urinary catheters

• Recent/recurrent antibiotic use

• Diabetes

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All provide opportunities for transmission


• https://www.youtube.com/watch?feature=player_detailpage&v=yx7_yzypm5w

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Travel is a risk factor for ESBL Tangden et al. 2010

• A prospective pre-post travel

• Sweden, over a 15-month period (<2008)

• n = 100

• Most were vacationers (89%)

• Median length of stay was two weeks

• 24% of international travellers became colonized with ESBL producing bacteria

• 9% were still positive after six months

• Travellers’ diarrhea was a statistically significant risk factor

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https://www.youtube.com/watch?feature=player_detailpage&v=yx7_yzypm5w




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Travel is a risk factor for ESBL Tangden et al. 2010

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0

10

20

30

40

50

60

70

80

90

100

India Asia Middle East SouthernEurope

Africa NorthAmerica

SouthAmerica

Travel history of ESBL colonized travellers

Adapted from Tangden et al. 2010


Travel is a risk factor for ESBL Paltansing et al. 2013

• Prospective cohort study, pre-post travel

• n = 370, March – September, 2011

• 113 (31%) colonized with ESBL post travel

• 19 (17%) still colonized after six months

• Household contacts

• 11 contacts of four ESBL positive travellers

• 2 (18.1%) ESBL positive

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Duration of ESBL colonization

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• n = 1,884 patients

• 40% were persistent carriers

• Median time to clear was 6.6 months

(Range 3.4 – 13.4 months)




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CPE ESBL’S MUTANT “EVIL COUSIN”

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Image source: CDC


Image source: CDC

“These are high-consequence antibiotic-resistant

threats because of significant risks identified across

several criteria. These threats may not be currently

widespread, but have the potential to become so and

require urgent public health attention to identify

infections and to limit transmission.”


Definitions

• Carbapenem antibiotics • Imipenem

• Meropenem

• Ertapenem

• Dorapenem

• Carbapenemase • Enzyme produced by certain bacteria that render the above

antibiotics ineffective

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Image source: PHO




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CRE / CPE

• Gram negative bacteria

• Carbapenem-resistant enterobacteriae (CRE) or Carbapenemase-producing enterobacteriae (CPE)

• Resistant to carbapenems and 3rd generation cephalosporins

• Types

• Serine based • IMP – Japan, 1987

• VIM – Verona Italy, 1999

• KPC – North Carolina, 1996

• Zinc based (metallo β lactamase) • NDM-1 – New Delhi, 2009

• Treatment options – Colistin, Polymixin, Tigecycline

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Image source: CDC


Why CPE is a concern

• Very limited therapeutic options

• 40-50% mortality rate

• Can spread

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Image source: CDC.org


Risk factors for CPE

• Male

• > 60 years old

• Hospitalized within past 12 months

• Hospitalized outside Canada

• Chronic medical conditions

• End stage renal disease

• Cancer/chemotherapy

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Image source: CDC




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Is travel is a risk factor for CPE? Paltansing et al. 2013

• Prospective cohort study, pre-post travel

• n = 370

• 0 (0%) colonized with CPE post travel

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Is travel is a risk factor for CPE? Peirano et al. 2014

Alberta, 2010-2013

n = 12 patients

• Healthcare encounters outside Canada

• Most had UTIs

• One case of spread resulting in death

17 strains of CPE

Conclusion:

“Clinical microbiology labs should remain vigilant in detecting bacteria with carbapenemases”.

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NDM-1

• Now found in many countries worldwide

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• Associated with “medical tourism”

Image source: Globe and Mail

Reproduced with permission from the Hindawi Publishing Corporation. Copyright © 2014. Dortet L, Poirel L, Nordmann P. Worldwide dissemination of the NDM-type carbapenemases in gram-negative bacteria. Biomed Res Int. 2014;2014:249856.4




https://www.dovepress.com/impact-of-the-new-delhi-metallo-beta-lactamase-on-beta-lactam-antibiot-peer-reviewed-fulltext-article-IDR

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NDM-1

“We estimate that the carriage of NDM-1 in India is between 100 and 200 million”

- The Times of India, Oct 9, 2011

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NDM-1

“We estimate that the carriage of NDM-1 in India is between 100 and 200 million”

- The Times of India, Oct 9, 2011

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Image source: www.healthmap.org/mcjaysavage





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Prevalence of CPE in Ontario

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CPE positive isolates by LHIN in Ontario, January to December, 2015

Public Health Ontario, CPE surveillance report, April 2016


CPE by type

32 Image source: Public Health Ontario


PHO - Ontario Health Profile

33 Image source: Public Health Ontario




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PHO – Ontario Health Profile

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Image source: Public Health Ontario


Duration of colonization

• Follow up screening (rectal swabs) of 97/137 CRE patients post-discharge

• Time to clear – mean 387 days (95% CI; 312-463)

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Infection Prevention & Control

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Prevention strategies

1. Hand hygiene

2. Contact precautions

3. Cohorting

4. Minimize use of invasive devices

5. Promote antibiotic stewardship

6. Screening

37 Image source: PHO stock


Accommodation and precautions

• Private or cohorted with like

• Contact precautions

• Dedicated toilet/commode

• Dedicated equipment

• Wheelchair

• IV pump

• Feeding pump

• BP cuff

• Stethoscope

• Remove catheters if possible

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Image source: PHO


PHO’s Antimicrobial Stewardship Program

• Current focus is to help promote, build, sustain and enhance ASPs in Ontario community hospitals.

• See: http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/AntimicrobialStewardshipProgram/Pages/Antimicrobial-Stewardship-Program.aspx

• Resources on the PHO ASP website: • PowerPoint presentations, webinars, FAQ’s

• Hospital profiles and links to selected institutional ASP websites

• Antimicrobial prescribing poster series *NEW*

• 32 antimicrobial stewardship strategy documents *NEW*

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http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/AntimicrobialStewardshipProgram/Pages/Antimicrobial-Stewardship-Program.aspx








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ASP Strategy Documents *NEW*

• List of 32 antimicrobial stewardship tools, activities and interventions (strategies)

• Detailed descriptions of each strategy, includes advantages, disadvantages, metrics, and resources required to implement

• Samples and examples from Canadian hospitals and other applicable tools and resources included where available

• Rated according to priority and difficulty levels

• Search wizard to help select suitable strategies based on various categories

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Antimicrobial prescribing poster series *NEW*

• 5 Posters to encourage appropriate prescribing and remind healthcare professionals of “One thing you can do to improve antimicrobial use”

• Can be downloaded and posted one at a time or all at once to promote antimicrobial stewardship in the hospital

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PHO’s Antimicrobial Stewardship Team

• To contact:

[email protected]

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mailto:[email protected]

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Surveillance

• Admission screening is targeted to at risk patients only because ESBL and CPE are not endemic in this region

• CPE is a critical result

• In the event of a new Healthcare Associated Infection (HAI) case conduct point prevalence

• Screen known carriers, room-mates, outbreak exposed

• Colonization is possible, so patient may be capable of transmission (direct/indirect)

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Risk-factor based admission screening for ESBL and CPE

Questions Screening Positive for ESBL? Specimens for ESBL screening

1. Fecally stained rectal swab/stool 2. Urine for ESBL (sterile container)

Positive for CPE? Has the patient received health care in another country in the previous 12 months? Is the patient a direct transfer from another healthcare facility outside Canada?

Specimens for CPE screening 1. Fecally stained rectal swab/stool 2. Urine for CPE (sterile container) 3. Swab wounds 4. Swab exit sites (critical care) 5. Endotracheal suction (critical care)

44 Adapted from PIDAC Annex A, page 48


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Criteria to discontinue contact precautions (PIDAC)

ESBL

• ESBL infection is resolved

AND

• Cleared of carrier status

• Screen for ESBL x 3, at least one week apart; not on Abx

AND

• Consultation with Infection Prevention and Control

CPE

• Maintain precautions for the duration of hospitalization

46 Image source: PHO


Resources

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Conclusions

• The prevalence of ESBL and CPE is increasing

• History of travel outside North America or hospitalization out of country is an important part of the risk assessment for ESBL and CPE

• Active surveillance is required for those at risk

• Laboratory testing and notification of results is necessary

• Transmission should be prevented with consistent use of routine practices

• Colonization takes a very long time to clear

• Infection prevention and control and Antibiotic stewardship play key roles

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“To avoid taking action to resolve antimicrobial resistance is to commit

Canadians to the perils of living in the pre-antibiotic era”

- Canadian Committee on Antibiotic Resistance

49 Image source: www.delpiano.com


• The Star Jan 5, 2016

• MCR-1 – E coli,

resistant to colistin

• 62 year old patient

Ottawa, ON

• 2 specimens from

lean ground beef (ON)

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References

Birgand G, Armand-Lefebvre L, Lolom I, Ruppe E, Andremont A, Lucet JC. Duration of colonization of extended-spectrum beta-lactamase producing enterobacteriaceae after hospital discharge. American Journal of Infection Control. 2013; 41: 443-7.

Boucher HW et al. Bad drugs, no drugs: No ESKAPE! Clin. Infect. Dis.2009; 48(1): 1-12.

Centers for Disease Control. CPE guidance for control of CPE. C2012. Available from http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

Centers for Disease Control. 2013. Antibiotic resistance threats within the United States. Available from http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

Centers for Disease Control. Get smart for healthcare: Inpatient stewardship. Available from http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html#Facts

Centers for Disease Control. Vital signs. C2013. Available from http://www.cdc.gov/vitalsigns/HAI/CRE/infographic.html

Conly J. Antimicrobial resistance in Canada. CMAJ 2002; 167(8): 885-91.

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References – con’t Conly J, Pitout J, Dalton B, Sabuda D. National Collaborating Centre for Infectious Diseases. The

W-5 of NDM-1: the pinnacle of antimicrobial resistance. Nov 2011. Available from http://www.nccid.ca/files/Purple_Paper_Note_mauve/PP_33_EN.pdf

Johnson SW, Anderson DJ, May DB, Drew RH. Utility of a clinical risk factor scoring model in predicting infection with ESBL-producing Enterobacteriaceae on hospital admission. ICHE, April 2013

Paltansing S, Vlot A, Kraakman MEM, Mesman R, et al. Extended-Spectrum β-Lactamase producing Enterobacteriaceae among travellers in the Netherlands. Emerging Infectious Diseases. 2013; 19:8. Available from http://wwwnc.cdc.gov/eid/article/19/8/13-0257_intro.htm

Parker VA, Logan CK, Currie B. Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit. (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No. 290-2006-0012-l.) AHRQ Publication No. 14-0028. Rockville, MD: Agency for Healthcare Research and Quality. April 2014. Available from http://www.ahrq.gov/sites/default/files/publications/files/cretoolkit.pdf

Patrick DM, Hutchinson J. Antibiotic use and population ecology: How you can reduce your

“resistance footprint”. CMAJ 2009; 180(4): 416-421.

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






http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf













http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html





http://www.cdc.gov/vitalsigns/HAI/CRE/infographic.html

http://www.cdc.gov/vitalsigns/HAI/CRE/infographic.html


http://www.nccid.ca/files/Purple_Paper_Note_mauve/PP_33_EN.pdf

http://wwwnc.cdc.gov/eid/article/19/8/13-0257_intro.htm



http://www.ahrq.gov/sites/default/files/publications/files/cretoolkit.pdf

http://www.ahrq.gov/sites/default/files/publications/files/cretoolkit.pdf

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References – con’t Peirano G, Ahmed-Bentley J, Fuller J, Rublin JE, Pitout JD. 2014. Travel-related carbapenemase-

producing Gram negatives in Alberta, Canada: the first three years. 2014. J. Clin. Microbiol.

PIDAC. Routine Practices and Additional Precautions, Annex A, Feb 2012. Available from http://www.oahpp.ca/resources/documents/pidac/Annex%20A%20-%20PHO%20template%20-%20REVISION%20-%202012Apr25.pdf

Public Health England. Acute trust toolkit for the early detection, management and control of

Carbapenemase-producing Enterobacteriaceae. 2013. Available from

http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317140378646

Public Health Ontario. Ontario Health Profile, CPE report. Available from

http://www.publichealthontario.ca/en/DataAndAnalytics/OntarioHealthProfile/Pages/OHP-

IWR-AR.aspx

Public Health Ontario. Quarterly CPE surveillance report, April 2016. Available from http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/Carbapenemase_Producing_Enterobacteriaceae_(CPE)_Surveillance_Report_April_2016.pdf

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References – con’t

Tangden T, Cars O, Melhus A, Lowdin E. 2010. Foreign travel is a major risk factor for colonization

with Escherichia coli producing CTX-M type Extended-Spectrum β-Lactamases: a prospective

study with Swedish volunteers. Antimicrobial Agents and Chemotherapy; 54:9;3564-3568.

Walsh TR, Weeks J, Livermore DM, Toleman MA. Dissemination of NDM-1 positive bacteria in the

New Delhi environment and its implications on human health. The Lancet Infect. Dis. 2011;

11(5): 355-62.

Zimmerman RS, Assous MV, Bdolah-Abram T, Lachish T, Yinnom AN, Wiener-Well Y. Duration of

carriage of carbapenem-resistant Enterobacteriaceae following hospital carriage. AJIC 2013;

41:190-4.

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http://www.oahpp.ca/resources/documents/pidac/Annex A - PHO template - REVISION - 2012Apr25.pdf










http://www.publichealthontario.ca/en/DataAndAnalytics/OntarioHealthProfile/Pages/OHP-IWR-AR.aspx






http://www.publichealthontario.ca/en/DataAndAnalytics/Documents/Carbapenemase_Producing_Enterobacteriaceae_(CPE)_Surveillance_Report_April_2016.pdf



