Arkansas CRE Update-TGulley - AFMC

ARKANSAS DEPARTMENT OF HEALTH


Understanding the Nightmare Bacteria: an Arkansas CRE Update

Trent Gulley, MPHAntimicrobial Resistance Epidemiologist

7/18/2019


What is CRE?• Carbapenem-resistant Enterobacteriaceae (CRE) are gram-negative bacteria that

are resistant to carbapenem antibiotics through several different mechanisms including enzymes, efflux pumps, and porin mutations.

• CRE is defined as any Enterobacteriaceae isolate that is resistant to any of the carbapenems (imipenem, meropenem, ertapenem, and doripenem) or documents production of carbapenemase enzymes.

• Expanded spectrum beta-lactamases (ESBL) can put antibiotic pressure, specifically carbapenem use, on the community.

Centers for Disease Control and Prevention (2018). Antibiotic Resistance Threats in the United States, 2013. Retrieved from https://www.cdc.gov/drugresistance/biggest_threats.html


Enterobacteriaceae Family

Octavia S., Lan R. (2014) The Family Enterobacteriaceae. In: Rosenberg E., DeLong E.F., Lory S., Stackebrandt E., Thompson F. (eds) The Prokaryotes. Springer, Berlin, Heidelberg


What is CP-CRE• Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-

CRE) is an Enterobacteriaceae that produces a carbapenemase enzyme that makes it resistant to carbapenem antibiotics.

• The plasmid-mediated carbapenemase genes include Klebsiella pneumonia carbapenemase (KPC), New Delhi metallo-beta-lactamase (NDM), Verona integron-mediated metallo-beta-lactamase (VIM), imipenemase (IMP), oxacillinase (OXA).

• These genes can be transferred horizontally to other organisms through plasmids.– Plasmids are small circular DNA molecules independent of the bacteria’s chromosomal

DNA.

• Carbapenemases will hydrolyze penicillins, cephalosporins, monobactams, and carbapenems.Centers for Disease Control and Prevention (2015). Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE). Retrieved from https://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html


CP-CRE plasmid locations

van Duin, D., & Doi, Y. (2016). The global epidemiology of carbapenemase-producing Enterobacteriaceae. Virulence, 8(4), 460–469. doi:10.1080/21505594.2016.1222343


CDC’s Tiered Strategies for Containment

• CDC has issued guidance for highly drug resistant organisms that defines three different categories (Tiers 1-3) and the recommended approach to control each.

• General definitions of each tier are included in the next slide.

• Classification of an organism’s tier is dependent on the regional and state epidemiology for that resistance mechanism.

CDC. Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs). Retrieved from https://www.cdc.gov/hai/outbreaks/docs/Health-Response-Contain-MDRO.pdf.


Tiered Containment Response• Tier 1:

– Resistance mechanisms novel to the United States (i.e., never previously or only very rarely identified in the United States).

– Organisms for which no current treatment options exist (pan-resistant) and that have the potential to spread more widely within a region.

• Tier 2:– Organisms found in healthcare settings but not believed to be found regularly in the region.

– Includes organisms that might have been found more commonly in other areas in the United States.

– For Arkansas, this includes resistance mechanisms for carbapenem-resistant Enterobacteriaceae that are not found to be the Klebsiella pneumoniae carbapenemase (KPC) type.

• Tier 3:– Organisms that are already established in the United States and have been identified before in

the region but are not thought to be endemic.


Response Element Comparison

Yes No Sometimes

Element Tier 1 Tier 2 Tier 3

Infection Control Assessment

Prospective Surveillance

Lab Lookback

Screening of Healthcare Roommates

Broader Screening of Healthcare Contacts

Household Contact Screening

Environmental Sampling

Healthcare Personnel Screening

Adapted from CDC “KPC, Containment, and ARLN” presentation on January 17, 2018.


Controlling CRE and CP-CRE in acute care settings

• Hand hygiene is the best action for preventing transmission.

• Contact precautions should be implemented for patients colonized or infected with CRE or CP-CRE.

– CP-CRE patients can be cohorted if a private room is not available.

• Intra- and inter-facility communication is key in controlling CRE and CP-CRE.

• All healthcare personnel should be educated about CRE and appropriate control measures.

Centers for Disease Control and Prevention (2015). Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE). Retrieved from https://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html


Controlling CP-CRE in long-term care (LTC) facilities

• Patients with specific risk factors should be placed in isolation.

– Risk factors include mechanical ventilator-dependent, incontinent, draining secretions or draining wounds that cannot be controlled.

– Residents without these risk factors do not need to be restricted from common areas.

• Promote standard precautions when providing care to residents with CP-CRE.

• Consider having an Infection Control Assessment and Response (ICAR) visit to evaluate your infection program by the Healthcare-Associated Infections (HAI) team from the Arkansas Department of Health.

Centers for Disease Control and Prevention (2015). Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE). Retrieved from https://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html


mCIM

Zwaluw, K.V., Haan, A.D., Pluister, G.N., Bootsma, H.J., Neeling, A.J., & Schouls, L.M. (2015). The Carbapenem Inactivation Method (CIM), a Simple and Low-Cost Alternative for the Carba NP Test to Assess Phenotypic

Carbapenemase Activity in Gram-Negative Rods. PloS one


CRE Rules in Arkansas

• CRE became reportable through the mandatory reporting communicable disease rules in January 2019.

• Notification and guidance about the new rules were emailed on 3/1/2019.

• All CREs should be reported to the Arkansas Department of Health on a communicable disease reporting form.

• CRE isolates can be submitted for additional testing.


CRE submissions in AR

0

2

4

6

8

10

Januray Feburary March April May June

2019 isolates submitted compared to 2018

Number of isolates submitted in 2018 Number of isolates submitted in 2019


CP-CRE isolates in AR

• 85 isolates have been submitted for carbapenemase testing

– 2018: • 47 isolates submitted• 8 confirmed carbapenemase

producers

– 2019: • 38 isolates submitted• 18 confirmed carbapenemase

producers

• Carbapenemase identified: – KPC

– NDM

– VIM

– IMP

– Dual Mechanism NDM & OXA

Confirmed CP-CRE cases by organism

Organism Submitted Positive mCIM

Pseudomonas aeruginosa 13 1 (7%)

Escherichia coli 3 2 (67%)

Klebsiella species 6 4 (67%)

Enterobacter cloacae 10 8 (73%)Other 6 3 (50%)

Total 38 18 (47%)


Available Resources• If you have any questions about multi-drug resistant organisms (MDRO), infection

prevention, or additional laboratory testing please contact the Arkansas Department of Health’s HAI team.

• Consider participating in an Infection Control Assessment and Response (ICAR) visit to evaluate your infection prevention program.

• Please refer to the Centers of Disease Control and Prevention’s (CDC) CRE toolkit for additional information on CRE, CP-CRE, and infection prevention.


Questions?

Trent Gulley, MPHAntimicrobial Resistance Epidemiologist

Healthcare-Associated Infections Program

Phone: (501) 614-5362

[email protected]

Documents

Arkansas CRE Update-TGulley - AFMC