The Public Health Benefit of CRE Colonization Testing...7/8 CP-CRE upon testing at local clinical...
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The Public Health Benefit of CRE Colonization Testing Allison C Brown, PhD MPH Team Lead, AR Capacities and Special Studies Division of Healthcare Quality Promotion CDC
Transcript of The Public Health Benefit of CRE Colonization Testing...7/8 CP-CRE upon testing at local clinical...
The Public Health Benefit of CRE Colonization TestingAllison C Brown, PhD MPHTeam Lead, AR Capacities and Special StudiesDivision of Healthcare Quality PromotionCDC
Carbapenem Resistance
• Serious threat to public health
• Infections are difficult/impossible to treat
• Up to 50% mortality from carbapenem-resistant Enterobacteriaceae (CRE)
• Patients can spread CRE as they move throughout the healthcare system
• Carbapenemase-producing CRE (CP-CRE) spread rapidly via plasmids
• “Big 5” carbapenemases in the United States
• KPC
• NDM
• OXA-48-like
• VIM
• IMP
Geographical distribution of KPC-CRE *
*As of January 6, 2017
Geographical distribution of NDM-CRE*
*As of January 6, 2017
Geographical distribution of OXA-48-CRE*
*As of January 6, 2017
Geographical distribution of VIM-CRE*
*As of January 6, 2017
Geographical distribution of IMP-CRE*
*As of January 6, 2017
State/Local CRE and CRPA testing
P H DState/Local testing
Species identificationConfirmatory ASTPhenotypic screening for
carbapenemase productionMolecular detection of mechanism
CRE/CRPA isolates
Network of participating clinical laboratories
Tiered testing
P H DState/Local testing
Species identificationConfirmatory ASTPhenotypic screening for carbapenemase
productionMolecular detection of mechanism
CRE/CRPA isolates
Network of participating clinical laboratories
A R L NRegional lab testing
Isolates with suspected novel resistance*
*Positive for carbapenemase production but PCR-negative
Confirmatory testingWGSApplied research
Confirmatory testing forfull directory
Targeted surveillance for CR-Acintobacter and mcr genes in ESBLs
Colonization screening
CDC testing
Presenter
Presentation Notes
Targeted surveillance activities Colonization screening
Reporting results
• Testing results reported back to submitting clinical laboratories within 2 working days of completion
• Results support infection prevention measures
• Alert notifications sent to HAI program and CDC within 1 day
• Pan-resistant*, non-KPC carbapenemase in Enterobacteriaceae, unknown/novel** mechanism, mcr-positive, or CP-Acinetobacter or –Pseudomonas
• Alerts sent to CDC shared with epi and lab outbreak response groups; provide additional testing and epi support if needed
• Monthly summary of all CRE and CRPA testing results reported sent to HAI coordinator and CDC
• All CRE testing results, including any non-target Enterobacteriaceae species tested
• Lab and epi coordination essential
• Results may be impetus for outbreak investigation, facility assessment, colonization screening
*Resistant to all drugs tested by clinical and public health labs; **Positive for carbapenemase production but PCR-negative
• 24 states ≥1 monthly report
• 861 CRE tested
• 289 carbapenemase producers
• 3 mcr-1 positive isolates
• 168 CRPA tested
• 1 carbapenemase producer
State testing through April
34%CP-CRE
<1%CP-CRPA
CRE CRPA
CP-CRE organisms reported through April
62%18%
10%
2% 1%1% 0%
6%
KlebsiellaEnterobacterE coliCitrobacterSerratiaProvidenciaProteusUnknown
Carbapenemase genes detected through April
238
29 16 3 3 10
50
100
150
200
250
KPC NDM OXA VIM IMP IMP
CRE CRPA
Num
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f Iso
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Carbapenemase Gene
Emerging epidemiologic trends
Non-KPC carbapenemases reported in Enterobacteriaceae other than Klebsiella, Enterobacter, and E. coli
0
1
2
3
4
5
6
7
2011 2013 2014 2015 2016 2017
Num
ber o
f Iso
late
s
Year of Specimen Collection*
OrganismNumber of
isolatesProteus mirabilis 5Providencia rettgeri 5Morganella morganii 4Citrobacter freundii 3Serratia marcescens 3Providencia stuartii 1Total 21
*Graph excludes 2 non-KPC CP-CRE with unknown year of collection* *Graph includes data on specimens collected through Q1 of 2017
Emerging epidemiologic trends
Increased detection of IMP, VIM, and OXA-48
0
5
10
15
20
25
30
35
2010 2011 2012 2013 2014 2015 2016 2017 Q1
Num
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f Iso
late
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Year of Specimen Collection
VIMOXA-48IMP
*
*Graph includes data on specimens collected through Q1 of 2017
MDRO response is dependent on epidemiology
• Tier 1• Novel resistance mechanisms (never or very rarely identified previously) in U.S.
• No current treatment options exist (pan-R) and have potential to spread more widely
• Organisms and resistance mechanisms for which our experience is extremely limited and a more extensive evaluation
might better define the risk for transmission
• Tier 2• MDROs found primarily in healthcare settings but not believed to be found regularly in the region
• Tier 3• MDROs already established in the U.S. and in the region but not thought to be endemic
MDRO response is dependent on epidemiology
• Tier 1• Novel resistance mechanisms (never or very rarely identified previously) in U.S.
• No current treatment options exist (pan-R) and have potential to spread more widely
• Organisms and resistance mechanisms for which our experience is extremely limited and a more extensive evaluation
might better define the risk for transmission
• Tier 2• MDROs found primarily in healthcare settings but not believed to be found regularly in the region
• Tier 3• MDROs already established in the U.S. and in the region but not thought to be endemic
Containment of MDROs
• Conduct investigation of patient’s healthcare exposures
• Conduct investigation of patient contacts and epidemiologically-linked patients to identify those
infected or colonized
• Implement improved infection control measures
Colonization screening following MDRO detection
Tier 1 Tier 2 Tier 3Lab lookbackHealthcare roommate screeningProspective surveillanceBroader healthcare contact screeningHousehold contact screeningEnvironmental samplingHealthcare personnel screening
Yes Sometimes No
Colonization screening in ARLN
Swabs from CP-CRE+ patient
contacts
Regional lab
Rapid PCR-based detection from swab (Cepheid)
R L
Swabs positioned regionally for rapid deployment to facilities where screening taking place
Presenter
Presentation Notes
Replace with piece-by-piece walk through of colonization slide if we can rectify missing PHL piece
Colonization screening in ARLN
P H D
Swabs from CP-CRE+ patient
contacts
Regional lab
≤1 day turnaround
R L
Report within 1 working day of results
Report within 1 working day of results
Initiate infection control practices and contact precautions
Provide or request assistance;Initiate investigation
Screening for KPC-producing K. pneumoniae
First colonization screenings conducted through ARLN in December
• In late 2016, a skilled nursing facility (SNF) had reported 13 CR-K. pneumoniae cases since 2015
• 7/8 CP-CRE upon testing at local clinical laboratory
• 5 patients still at facility
• State conducted site visit; noted multiple areas of concern for infection control.
• Screened roommates of cases during 2015-2016 and any patients with history of CRE since 2015
• KPC-producing K. pneumoniae identified in 1 roommate and 4 CRE patients
• Facility-wide point prevalence survey (PPS) conducted
• ARLN regional lab identified 13 positives from 77 patients swabbed (17% CP-CRE)
Screening for IMP-producing Proteus mirabilis
• IMP-Proteus mirabelis detected in patient of SNF on 3/9
• Roommate screened 4/26; positive
• PPS 1: conducted on same wing of SNF on 5/8; 3 new positives detected among 9 patients screened
• PPS 2: 1 new positive among 21 patients screened on 5/22 in same wing
• Infection control recommendations now being implemented
• Investigations are ongoing
Models simulated spread of CRE among patients• acute care hospitals, long-term acute care hospitals, nursing homes
3 intervention scenarios • Common approach: infection control activity currently in common use
• Independent efforts: augmented efforts implemented independently
• Coordinated approach: augmented efforts coordinated across a health care network
Projected prevalence of CRE, based on models
Projected regional prevalence of CRE over 5-yr period under 3 intervention scenarios10 facility model, Veterans Health Administration
Projected countywide prevalence of CRE over 15-year period under 3 intervention scenarios102 facility model, Orange County, California
Coordinated prevention approaches assisted by public health agencies have the potential to more completely address emergence and dissemination of MDROS and in comparison to independent facility based efforts
Presenter
Presentation Notes
With the common approach, after 5 years the prevalence of CRE could be 12.2%., Independent efforts resulted in an 8.6% prevalence, and the coordinated approach resulted in a 2.1% prevalence, a 74% reduction when compared with independent efforts. Orange county: no intervention 15%, independent approach 14%, 8% (55% reduction in comparison with independent efforts Interventions: better communication between hospitals when transferring CRE patients, increased surveillance when certain triggers are met (based on clinical culture results), other hospitals screening patients from index facility, enhanced attention to infection control (boosting adherence with refreshers, etc.) High level answer: The 10 facility model assumes that the health department has more granular information about CRE incidence from each of the facilities (i.e. needs precise case counts), and has a lower threshold for taking action in comparison to the 102 facility model. In addition, the 10 facility model assumes a more proactive role by the health department, relies more on health department resources, and is more selective in targeting hospital activities and resources. In contrast, the 102 facility model assumes a less proactive role by the health department, and less selective in targeting hospital activities and resources. Mid-level answer: Threshold for independent augmented efforts is lower in the 10 facility model, and independent facility efforts assume more action steps (more screening, improved implementation of contact precautions, and improved recognition of CRE patients when they are re-admitted) than in the 102 facility model In the 10 facility model coordinated approach: there are some coordinated actions that take place even before there is a problem recognized in a facility-improved communication steps are taken that make it more likely that hospitals will be aware of CRE patients upon transfer or admission (i.e. they are more aware of positive CRE tests performed during previous admissions anywhere in the network). Additional coordinated actions triggered when a single facility in the network reaches a threshold Varies by whether triggering facility is a long term acute care hospital or short stay acute care hospital, involves: 1) more widespread use of routine screening, with additional screening in facilities that receive transfers/admissions from the trigger facility, and 2) improved implementation of contact precautions When a second facility reaches a threshold, all hospitals screen transfers and admissions with recent care in other facilities in the network. In the 102 facility model coordinated approach: No coordinated action is taken until evidence of CRE has been detected in 10 hospitals in the network Once 10 hospitals in the network have had evidence of having a CRE patient, all acute care hospitals implement screening patients transferred from other facilities No change in implementation of contact precautions
Benefits of colonization testing
• Help detect additional cases/colonizations
• Help facilities identify infection control problems
• Help facilitate infection control when CP-CRE-positive patient is transferred or readmitted
• States asked to maintain database of colonization screening results
Presenter
Presentation Notes
Double check registry
ARLN testing and screening: detect, contain, and prevent
• Detection is the key to containing, controlling, and preventing the spread of resistance
• State and regional lab testing and colonization screening for CP-CRE are essential for public health response
• Coordinated approach to infection control will be our most effective means of preventing additional AR infections
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you
Contact:Allison Brown [email protected] [email protected]
