The ‘nightmare bug’: Carbapenem- resistant enterobacteriaceae (CRE) in Arizona

AZID July 20th, 2017

Rachana Bhattarai, BVSc & AH, MS, CIC HAI Epidemiologist

Arizona Department of Health Services

‘Nightmare’ by Luciana Christante (CC BY NC ND 2 0)

Superbug Untreatable and hard-to-treat infections On the rise among patients in medical facilities.

They kill up to 1 in 2 patients with a CRE bloodstream infection. They have been reported in 42 states during the last 10 years. They easily spread their antibiotic resistance to other kinds of germs.

Why do we care about CRE?

https://www.slideshare.net/babasahebkumbhar/enterobacteriaceae-26124036

Enterobacteriaceae

Meningitis

Pneumonia

Sepsis

Diarrhea

UTI

Escherichia coli Enterobacter aerogenes Klebsiella pneumoniae Serratia marcescens Proteus spp. Providencia spp. Citrobacter spp. Salmonella spp. Shigella spp. Yersinia spp.

Four main carbapenems (antibiotics):

MEROpenem

DORIpenem

IMIpenem

ERTApenem

Carbapenem (antibiotic) kills the bacteria by inhibiting cell wall synthesis

X

Normal Enterobacteriaceae

Carbapenem (antibiotic) does NOT kill the bacteria

These enterobacteriaceae are resistant to carbapenem

Carbapenem-resistant enterobacteriaceae (CRE)

Carbapenemase (enzymes produced by bacteria) break antibiotics’ structure providing resistance

ESBL KPC

NDM Amp C

Klebsiella spp. Enterobacter spp.

E. coli Proteus spp.

Etc….

Meropenem Doripenem Imipenem

Ertrapenem

ESBL KPC

NDM Amp C

Carbapenemase

Enterobacteriaceae

Carbapenem

Carbapenemase-producing CRE (CP-CRE)

Proteus spp. Morganella spp. Providencia spp.

Have always been resistant to imipenem due to

inherent structural or functional characteristics.

Meropenem Doripenem Imipenem

Ertrapenem

Intrinsic resistance

Lab tests to identify CRE

Susceptibility testing Carbapenamase production testing and PCR

Meropenem Doripenem Imipenem

Ertrapenem

ESBL KPC

NDM Amp C

Public Health Image Library

CRE Control and Prevention - Providers

Use contact precautions for patients with CRE. Whenever possible, dedicate rooms, equipment, and staff to CRE patients.

Prescribe antibiotics wisely. Use culture results to modify prescriptions if needed.

Control and Prevention -Resources

AHRQ CRE Control and Prevention Toolkit

Facility Guidance for Control of CRE

CRE Control and Prevention - Patients

Tell your doctor if you have been hospitalized in another facility or country. Take antibiotics only as prescribed.

What’s the picture of CRE in Arizona?

What’s the picture of CRE in Arizona?

Hospital Discharge Database (HDD)

Death Records

Available data is of limited use:

CRE is not explicitly identified in the records Data is delayed

But it will likely be reportable by laboratories with updated rules in 2018!

Arizona State Public Health Laboratory (ASPHL) Clinical Labs

2012 State Public Health Lab Special Project: Selected labs submitted isolates for CRE confirmatory testing

656 specimens

436 individuals With sufficient lab information

153 CRE cases Met the 2015 CSTE case definition

Hospital Discharge Database (HDD)

Death Records

We used MR, HDD and death records to assess hospitalization costs, outcomes and other characteristics of the 153 CRE cases.

Medical Records (MR) 153 CRE cases Met the 2015 CSTE case definition

Demographics of CRE cases

52% males 60 years median age

74% White

10% Hispanic

13% Native American

3% Black

90% of samples from Maricopa and Pima Counties.

Urine specimens were the most common.

58% 16%

11%

6% 10% Urine

Respiratory specimen

Wound

Blood

Other

Other: Body fluid, tissue, swab, stool etc.

Klebsiella and Enterobacter spp. were the most common.

1%

1%

3%

5%

8%

8%

27%

46%

Providencia spp.

Morganella spp.

Proteus spp.

Citrobacter spp.

Escherichia spp.

Serratia spp.

Enterobacter spp.

Klebsiella spp.

KPC was the most frequent mechanism of carbapenem-resistance identified.

31%

16% 14%

39%

KPC ESBL Amp-C Unknown

13% of CRE cases did not report any acute infection symptoms.

13% No infection

Other infections

Wound infection

Bacteremia/sepsis

Pneumonia

Urinary tract infection

13%

The vast majority of cases were empirically prescribed antibiotics upon admission, prior to laboratory results.

Prior to hospital visit Empirically before laboratory results

During the course of hospital stay

88%

Most cases either had an external device placed during their hospital visit or a previous surgery.

72%

83%

0% 50% 100%

Previous surgery

External device prior to visit

Transfer from other medical facility

Previous hospitalization

Hemodialysis at time of culture or in the past

Transplant

2 cases did not have any hospital exposures

External device placed during patient visit

The top 5 comorbidities among CRE patients:

56%

36% 33% 32% 27%

Hypertension Anemia Diabetes Renal failure Previous UTIs

ICU

Financial impact and outcomes

1 in 5

Median hospital costs associated with CRE per patient

$23,396 12 days Median length of hospital stay

1 in 2

Only 35% of specimens were truly CRE… why?

68% 24%

8%

Enterobacteriaceae intrinsically resistant to imipenem

Enterobacteriaceae susceptible to all carbapenems

Non-Enterobacteriaceae

n=283

Better communication with labs is needed about which isolates to submit.

What’s the picture of CRE in Arizona?

But it will likely be reportable by laboratories with updated rules in 2018!

CRE will be nationally notifiable in 2018

ESBL KPC

NDM Amp C

Carbapenemase

Enterobacteriaceae

Enterobacteriaceae (Klebsiella spp., Enterobacter spp., E. coli)

producing carbapenemase.

Klebsiella spp. Enterobacter spp.

E. coli

CRE will be nationally notifiable in 2018

• HAI Team – Catherine “Kasia” Golenko – Eugene Livar – Geoff Granseth – Felicia Maclean – Jaiju Thomas

• ASPHL Team

Acknowledgement

THANK YOU! Rachana Bhattarai | HAI Epidemiologist

Rachana.Bhattarai@azdhs.gov | 602-364-3194

azhealth.gov

@azdhs

facebook.com/azdhs