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CPE Surveillance Report: January 2016 – December 2016 Page 1 of 14
SURVEILLANCE REPORT
Carbapenemase-producing Enterobacteriaceae (CPE)
January 2016 – December 2016
Carbapenemase-producing Enterobacteriaceae (CPE) is resistant to carbapenem antimicrobials through
the production of carbapenemases. Formerly referred to as carbapenem-resistant Enterobacteriaceae
(CRE), Public Health Ontario (PHO) has changed the terminology to CPE to more accurately reflect the
mode of resistance.
In December 2011, PHO, in collaboration with the Ministry of Health and Long-Term Care, initiated a
voluntary surveillance program to assess the epidemiology of CPE in Ontario. Epidemiological data is
critical for defining the extent of the problem – it enables ongoing measurement over time which then
informs infection prevention and control policies and procedures that will help prevent the likelihood of
CPE becoming endemic in Ontario.
Through the voluntary CPE surveillance program, laboratory isolates from patients with carbapenem
resistance are sent to Public Health Ontario Laboratory (PHOL) for confirmatory testing. Hospitals with
confirmed isolates are requested to complete the CPE surveillance form on the patient’s demographics,
underlying conditions and travel history. This form is completed online and submitted to PHO, where
the data is analyzed. Patient information from community laboratories is not collected. Further
information on the voluntary CPE surveillance program including the online surveillance form can be
accessed on the CPE webpage.
This report summarizes the data on CPE between January and December 2016. There are two sections in
this report: the first section describes the epidemiological data from hospital patients who were
diagnosed with CPE; the second section provides the laboratory surveillance data.
CPE Surveillance Report: January 2016 – December 2016 Page 2 of 14
PART I: CPE Epidemiological Data Summary
Between January 1 and December 31, 2016, 900 isolates were received by PHOL for CPE confirmatory
testing; 8 were submitted to laboratories other than PHOL for CPE confirmatory testing (Figure 1).
Of the 908 isolates, 276 (30.4%) positive CPE isolates were identified. Among these positive isolates, 62
(22.5%) were submitted by community laboratories, and 74 (26.8%) positive isolates were found to be
repeat isolates collected from 48 patients. Epidemiological information was submitted by hospital
laboratories for the remaining 148 (53.6%) positive isolates from unique patients, representing a 100%
sample response rate.
Figure 1. Total number of laboratory isolates and positive patients received by the CPE surveillance
program from January–December 2016.
Since the CPE surveillance program was initiated in 2012, the total number of isolates has increased
from 458 isolates submitted in 2012 to 908 isolates submitted in 2016 (Figure 2), with a 43.9% increase
in total isolates submitted between 2015 and 2016. The number of positive isolates increased 2.4-times,
from 115 positive isolates in 2015 to 276 positive isolates in 2016 (Figure 2).
CPE Surveillance Report: January 2016 – December 2016 Page 3 of 14
Figure 2. Total number of submitted isolates received by the CPE surveillance program, 2012–2016.
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
2012–2016 data, extracted by Public Health Ontario [2017/03/31].
PATIENT DEMOGRAPHICS
Between January and December 2016, 148 unique patients positive for CPE were reported. Median age
of patients was 70 years (range 2 to 95 years); 86 (58.1%) patients were male.
Among 134 patients with known colonization/infection status, 84 (62.7%) were colonized and 50
(37.3%) were infected (Figure 3). The majority of cases occurred in patients aged ≥60 years (93 (69.4%)
of 134 patients).
CPE Surveillance Report: January 2016 – December 2016 Page 4 of 14
Figure 3. Patients with newly confirmed CPE isolates by age group and colonization/infection status in
Ontario, January–December 2016 (n=134*).
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: Excludes 14/148 cases of unknown colonization/infection status.
PATIENT HOSPITAL DETAILS
Among 148 patients with a CPE positive isolate, 120 (81.1%) were hospitalized at the time of specimen
collection, 16 (10.8%) were seen at an emergency department, 9 (6.1%) at an outpatient clinic, and 3
(2.0%) at a hospital extended-stay unit. CPE was identified in clinical specimens from 71 (48.0%) CPE
positive patients, screening specimens from 58 (39.2%) patients, and contact tracing specimens from 6
(4.1%) patients. The remaining specimens from 13 (8.8%) patients were collected for other reasons.
PATIENT UNDERLYING CONDITIONS
The most commonly reported chronic medical conditions were diabetes mellitus (42.6%), renal disease
(22.3%), and cancer (13.5%) (Table 1). Several other conditions were identified besides the chronic
conditions provided as options in the surveillance form, including critical conditions as a result of severe
illness, surgical procedure, or paralysis. Among these patients, high risk of urinary tract infection due to
urinary catheterization can be inferred.
CPE Surveillance Report: January 2016 – December 2016 Page 5 of 14
Table 1. Chronic medical conditions in CPE-positive patients in Ontario, January–December 2016
(n=148).
Chronic medical condition* Number and proportion (%) of all patients
Diabetes mellitus 63 (42.6)
Renal disease 33 (22.3)
Cancer 20 (13.5)
Hypertension 17 (11.5)
Chronic liver disease 8 (5.4)
Stroke 4 (2.7)
Not applicable/specified 22 (14.9)
Other 67 (45.3)
Total patients 148 (100)
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: Patients may report ≥1 chronic medical condition
HOSPITALIZATION AND TRAVEL HISTORY
Among 148 patients, 97 (65.5%) were hospitalized in the past 12 months. Additionally, 85 (57.4%)
patients had travel history outside of Canada. Table 2 provides further information on the
hospitalization and travel history of CPE positive patients.
Table 2. Hospitalization and travel history of CPE-positive patients in Ontario, January–December 2016
(n=148).
Patient classification by hospitalization history
Patients hospitalized outside of Canada* 62/148
India 38
Pakistan 5
Sri Lanka 3
United States 3
Egypt 2
CPE Surveillance Report: January 2016 – December 2016 Page 6 of 14
Patient classification by hospitalization history
Greece 2
Thailand 2
Cuba 1
Ethiopia 1
Italy 1
Korea 1
Lebanon 1
Mexico 1
Philippines 1
Turkey 1
Thailand 1
Patients hospitalized within Canada 35/148
Patient with a travel history outside Canada 2
Patient with no travel history outside Canada 15
Patient with an unknown travel history 18
Patients with no hospitalization history 28/148
Patient with a travel history outside Canada 8
Patient with no travel history outside Canada 16
Patient with an unknown travel history 4
Patients with unknown hospitalization history 23/148
Patient with a travel history outside Canada 14
Patient with no travel history outside Canada 1
Patient with an unknown travel history 8
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: Patients may have travelled to >1 country for hospitalization outside of Canada
CPE Surveillance Report: January 2016 – December 2016 Page 7 of 14
PART II: CPE Laboratory Testing Data Summary
Part II of this report describes the 908 isolates submitted for CPE testing at PHOL between January and
December 2016. The summary information is presented in the following tables and figures. Because
more than one isolate may have been submitted per patient, the number of isolates tested may not
correspond with the number of patients.
Figure 4 and Table 3 show CPE positive isolates by Local Health Integration Network (LHIN) in Ontario.
Central West reported the highest proportion of unique patients with positive isolates (58 (41.4%) of 140
positive isolates). Toronto Central submitted the greatest number of isolates among all the LHINs (246
(27.1%) of 908 total isolates).
Figure 4. CPE positive isolates by Local Health Integration Network (LHIN) in Ontario, January–December
2016 (n=140*)
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: Number of CPE positive isolates submitted to PHOL for confirmatory testing from unique patients
CPE Surveillance Report: January 2016 – December 2016 Page 8 of 14
Table 3. Number and proportion of CPE isolates by LHIN, January–December 2016.
LHIN No. of CPE
positive isolates
Proportion of all positive isolates
(%*)
Total submitted isolates
Central West 58 41.4 176
Toronto Central 25 17.9 247
Mississauga Halton 20 14.3 115
Hamilton Niagara Haldimand Brant 12 8.6 85
Waterloo-Wellington 6 4.3 28
Central East 6 4.3 36
Central 5 3.6 51
Champlain 3 2.1 32
South West 2 1.4 20
Erie St. Clair 2 1.4 25
North East 1 0.7 32
South East 0 0.0 25
North Simcoe Muskoka 0 0.0 22
North West 0 0.0 14
Total 140 100 908
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Notes: Proportion may not be equal to 100% due to rounding
‒ The geographic region of the testing laboratory was used for isolates where the reporting
hospital was unknown
‒ Prior to December 2011, negative isolates were not recorded in the CPE database
CPE Surveillance Report: January 2016 – December 2016 Page 9 of 14
There were 106 (75.7%) positive isolates submitted by large community hospitals and 33 (23.6%) positive
isolates submitted by acute teaching hospitals (Table 4).
Table 4. Number and proportion of CPE isolates by source of submission in Ontario,
January–December 2016.
Source of submission No. of CPE
positive isolates
Proportion of all positive isolates (%)
Total submitted isolates
Large community hospital 106 75.7 379
Acute teaching hospital 33 23.6 297
Community laboratory 1 0.7 224
Small community hospital 0 0.0 8
Complex continuing care & Rehabilitation
0 0.0 0
Total 140 100 908
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Notes: Hospital types were classified according to the Ontario Hospital Association categories
The type of the testing laboratory was used for isolates where the reporting hospital was unknown
Further, 72 (51.4%) positive isolates were obtained from rectal swab; 43 (30.7%) were obtained from
urine sample (Table 5).
Table 5. Number and proportion of CPE isolates by site in Ontario, January–December 2016.
Site No. of CPE positive
isolates (%) Proportion of all
positive isolates (%) Total submitted
isolates
Rectum 72 51.4 253
Urine 43 30.7 382
Blood 4 2.9 51
Sputum 3 2.1 24
Wound 2 1.4 39
Other 16 11.4 159
Total 140 100 908
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
CPE Surveillance Report: January 2016 – December 2016 Page 10 of 14
Among patients with positive test results, 69 (49.3%) had E. coli with NDM-1 (Table 6).
Table 6. Test results by species and type of carbapenemase* in Ontario, January–December 2016.
Species KPC NDM-1 NDM/ OXA-
48
OXA-48
VIM VIM/ KPC
IMP Total
submitted isolates
Escherichia species
E. coli 6 69 8 41
256 E. vulneris
1
Enterobacter species
E. cloacae 5 1
7 1
322 E. aerogenes
34
Unspecified 2
3
17 Klebsiella species
K. pneumoniae 17 34 13 47 1
200
K. oxytoca 2
4 Unspecified
1
2
Citrobacter species
C. freundii complex 8
21 Unspecified 2 1
6
Serratia species
S. marcescens 1
15 Proteus species
P. mirabilis
2
Unspecified
1 Acinetobacter species
A. baumannii
4
Unspecified
5 Hafnia species
H. alvei
4
Providencia species
P. stuartii
1 Unspecified
2
Pseudomonas species
P. aeruginosa
1
2
1 7 Morganella species
M. morganii
1
2
Kluyvera species
K. ascorbata
1
1 Achromobacter species
A. xylosoxidans
1
Total 43 109 21 88 13 1 1 908
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: One isolate may be positive for more than one type of carbapenemase
CPE Surveillance Report: January 2016 – December 2016 Page 11 of 14
Figure 5 shows the number of CPE positive isolates by month received and type of resistance from
December 2011 to December 2016. Prior to December 2011, information on negative isolates was not
captured in the CPE database. An increasing trend in the number of CPE positive isolates can be
observed especially those identified with NDM-1 and OXA-48. The number of positive isolates was
highest in March 2016, followed by November 2016.
Figure 5. Number of CPE positive isolates* by month received† and type of resistance in Ontario,
December 2011–December 2016.
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31]
*Note: An isolate may be positive for more than one type of carbapenemase †Date received was unknown for one positive isolate
CPE Surveillance Report: January 2016 – December 2016 Page 12 of 14
Figure 6 shows the number of isolates by test result and month received in Ontario, between December
2011 and December 2016. An increasing number of isolates are being submitted to PHOL for testing.
Additionally, this graph shows that the proportion of positive isolates is increasing overall.
Figure 6. Number of isolates by test result and month received in Ontario,
December 2011–December 2016.
Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database,
extracted by Public Health Ontario [2017/03/31
CPE Surveillance Report: January 2016 – December 2016 Page 13 of 14
Editorial Note
Monitoring the incidence and prevalence of CPE in Ontario is essential in preventing spread of these
organisms in hospital and community settings. This report provides the current Ontario perspective of
CPE from January to December 2016 and describes CPE in patients in Ontario. Delaying further spread of
these organisms requires attention to Routine Practices and Additional Precautions, hand hygiene
adherence, antimicrobial stewardship and surveillance. Further information can be found in the
Provincial Infectious Diseases Advisory Committee (PIDAC) guidance document Annex A: Screening,
Testing and Surveillance for Antibiotic-Resistant Organisms (AROs) in all healthcare settings. Information
on laboratory testing for CPE can be accessed on the Institute for Quality Management in Healthcare
site and the Laboratory Recommendations for the Identification of CRE: Screening for colonization with
carbapenem-resistant Enterobacteriaceae (CRE) on the PHO website.
In the 2012 inaugural CPE surveillance annual report, 458 isolates were submitted for testing, and 82
(17.9%) positive isolates were identified. Since 2012, there has been an increased number of isolates
submitted for testing, and either consistent or increased numbers of CPE positive isolates identified in
subsequent years. In 2015, there were 631 total isolates submitted and 115 (18.2%) positive isolates
from 70 unique patients identified, compared to 908 isolates submitted in 2016, with 276 (30.4%)
positive isolates from 148 unique patients. Though there appears to be a noticeable increase in CPE
positive isolates in 2016 compared to 2015, the trend towards increasing CPE positive isolates remains
inconclusive until data from 2017 and beyond have been collected.
The median age of CPE-positive patients was 70 years of age, and the majority of CPE positive isolates
were from male patients (58.1%). Of those with known colonization/infection status, a greater
proportion of CPE positive isolates were identified as colonized with CPE (62.7%) than infected. Diabetes
mellitus and renal disease were the most commonly reported chronic conditions; however several
critical conditions requiring indwelling urinary catheters were identified in CPE positive patients, thus
placing susceptible patients at high risk for urinary tract infections.
Among hospital patients identified with CPE, 62 (41.9%) had been hospitalized outside Canada; 38
(61.3%) of those were reported to be hospitalized in India. Additionally, 35 (23.6%) were hospitalized
within Canada; of these 35, one travelled to India positive for NDM-1 and one travelled to Cambodia
positive for OXA-48, both isolated in E. coli. Of the remaining 51 patients with no or unknown
hospitalization history, 22 travelled to various locations outside of Canada (15 travelled to India), 17 did
not travel, and 12 had unknown travel history. Given that 31 (20.9%) CPE positive patients did not have
either hospitalization or travel history outside of Canada, it is possible that CPE transmission has
occurred within our local hospitals and community.
A total of 58 CPE positive isolates tested by PHOL came from the Central West region in 2016 (41.4%).
This may be related to the possible travel patterns of the residents and testing practices of hospitals in
this region.
CPE Surveillance Report: January 2016 – December 2016 Page 14 of 14
From a laboratory perspective, NDM-1 isolated in E. coli continues to be the most commonly reported
isolate from January to December, followed by OXA-48 isolated in K. pneumoniae, and OXA-48 isolated
in E. coli. The number of CPE submissions to PHOL continued to increase in 2016 when compared to
previous years, although no seasonal trends in the number of positive isolates have been observed.
The data summarized in this report is only a snapshot of the information that has been collected to date
and may not be completely representative of the provincial picture. The number of CPE organisms
identified by PHOL may not be the total number of CPE organisms found in Ontario as PHOL may not
receive all CPE suspected isolates for confirmatory testing.
Epidemiological data from the patient population served by community laboratories is not being
captured in the current surveillance system. Between January and December 2016, 62 (22.5%) of the
total positive isolates were received from community laboratories. We request that laboratories
continue to submit confirmed CPE isolates to PHOL which will allow for more accurate reporting on CPE
prevalence. While we continue to monitor the proportion of positive isolates from community
laboratories, an increase from these laboratories indicates that additional surveillance measures may
need to be implemented to accurately capture the emerging epidemiology of CPE in Ontario. The
assistance of Ontario laboratories and hospital infection prevention and control staff are essential in
understanding the impact of CPE across the province. The epidemiological data obtained through this
surveillance program will help to inform recommendations to prevent the spread of CPE within our
province.
Feedback by email to [email protected] is welcome.
Acknowledgements
We would like to acknowledge the support and contribution of the infection prevention and control
professionals and laboratory staff of the participating hospitals and community laboratories for their
help in collecting and reporting these data.