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Containing CRE spread
Jon Otter, PhD FRCPath
Scientific Director, Healthcare, Bioquell
Research Fellow, King’s College London
www.micro-blog.info
@jonotter
Contents
What’s the problem?
A brief overview of CRE including an update on the current spread in the US, UK and elsewhere
Sizing the threat to EU countries and elsewhere
Infection prevention and control challenges and strategies
What’s the problem? Resistance
Enterobacteriaceae Non fermenters
Organism AmpC / ESBL CPE A. baumannii
Attributable mortality Moderate
Massive (>50%)
Minimal
Shorr et al. Crit Care Med 2009;37:1463-1469. Patel et al. Iinfect Control Hosp Epidemiol 2008;29:1099-1106. Falagas et al. Emerg Infect Dis 2014;20:1170-1175.
What’s the problem? Mortality
What’s the problem? Rapid spread
Rapid spread
Clonal expansion
GI carriage
Horizontal gene
transfer
Understanding the enemy
Pathogen CRE1 MRSA VRE C. difficile
Resistance +++ + + +/-
Resistance genes Multiple Single Single n/a
Species Multiple Single Single Single
HA vs CA HA & CA HA HA HA
At-risk pts All Unwell Unwell Old
Decolonisation No Yes No No
Virulence +++ ++ +/- +
Environment +/- + ++ +++
1. Carbapenem-resistant Enterobacteriaceae.
0
2
4
6
8
10
12
2001 2011
% C
RE
K. pneumoniae / oxytoca
All Enterobacteriaceae
NHSN / NNIS data; MMWR 2013;62:165-170.
CRE in the USA
Invasive carbapenem-resistant K. pneumoniae
i.e. CRE (EARS-Net)
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
2005 2006 2007 2008 2009 2010 2011 2012 2013
% r
esis
tant
Greece
Italy
Portugal
UK
France
Invasive multidrug-resistant K. pneumoniae
(EARS-Net)
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
2005 2006 2007 2008 2009 2010 2011 2012 2013
% r
esis
tant
Greece
Italy
Portugal
UK
France
Emergence of CRE in the UK
PHE ARMRL, 24/01/14
Courtosy of Dr Neil Woodford
Available guidelines (not exhaustive list!)
UK CRE Toolkit US CRE Toolkit ESCMID Guidelines
CRE prevention & control
Hand hygiene
Cleaning / disinfection
SDD?
Topical CHX?
Education?
Contact precautions
/ single room
Active screening
Antibiotic stewardship
Tacconelli et al. Clin Microbiol Infect 2014;20 Suppl 1:1-55
CRE toolkits in the US and UK compared
Insert comparison table
US Toolkit UK Tookit
Isola
tion
Contact precautions, confirmed cases Recommended Recommended
Preemptive contact precautions Suggested Recommended
Contact precautions for duration of stay No recommendation Recommended
Screen
ing
Screen „high risk‟ patients on admission Suggested Recommended
Point prevalence on high risk units Recommended Suggested
Contact screening Recommended Recommended
Screen staff / household contacts No recommendation Not recommended
Oth
er
„Enhanced‟ infection control measures Recommended Recommended
Enhanced disinfection No recommendation Recommended
Cohort patients and staff Suggested Recommended
Flag patient record & inform receiving facilities Recommended Recommended
Tiered local approach Recommended Recommended
Develop action plan, education of all staff Recommended Recommended
Implement antimicrobial stewardship Recommended Recommended
Topical decolonisation during outbreaks Suggested Suggested
Curran & Otter. J Infect Prevent 2014;15:193-198.
Standardise standard precautions.
Avoid an „acronym minefield‟.
Simple outbreak epidemiology.
Guideline writing dream team.
“Road-test” guidelines.
Who do I screen?
PHE CPE Toolkit screening triggers:
a)an inpatient in a hospital abroad, or
b)an inpatient in a UK hospital which has problems with spread of CPE (if known), or
c)a ‘previously’ positive case.
Also consider screening admissions to high-risk units such as ICU, and patients who live overseas.
You have positive case: now what?
‘Contact precautions’
Single room+glove/gown Consider staff cohort
Contact tracing
Trigger for screening contacts or whole unit?
Flagging
Patient notes flagged Receiving unit informed
Education
Staff Patient / visitor
Cleaning / disinfection Use bleach or H2O2 vapor
at discharge
Decolonization?
„Selective decontamination‟ /
chlorhexidine bathing?
Single room isolation: Bioquell Pod
Single room isolation: Bioquell Pod
Bioquell Pod
Bespoke, semi-permanent
Infectious patients
Privacy & dignity
Reduce forced transfer
Observation & single room
The challenge of endoscopes
Cluster of 39 cases of NDM-producing CRE linked to contaminated duodenoscopes.1
No failures in endoscope reprocessing identified, yet outbreak strain cultured from reprocessed endoscope.
Prompted calls for more sterilization rather than high-level disinfection of endoscopes.2
1. Epstein et al. JAMA 2014;312:1447-1455. 2. Rutala & Weber. JAMA 2014;312:1405-1406.
Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it. (FDA Feb 23 2015).
Barriers
Carbapenem usage Single rooms
ICD staffing
ECDC Point Prevalence Survey, 2013.
Debt
Cataldo et al. ECCMID 2014. 0125.
Type n studies Failure rate Odds ratio
Bundled intervention 75 28% 1.9
Single intervention 11 45%
What works? Israel
Schwaber et al. Clin Infect Dis 2011;52:848-855.
* Physical segregation of CRE carriers; cohorted staff; appointed taskforce.
*
Conclusions
This is a new an evolving problem
Recognition of patient carriers is vital
Appropriate management of identified carriers is crucial
Information may change in time if we see more cases in the EU / US
Important to try and stay up to date and carry on with safe infection prevention precautions…
Acknowledgements
Pat Cattini for some of the slides
Image credits:
– ‘Cotton swabs’ by Jan Gottweiß
Resources
CDC CRE Toolkit
AHRQ CRE Tookit
UK Public Health England CPE Tookit
Bioquell CRE resources
UK ESBL guidelines
ECDC risk assessment on the spread of spreading (CPE)
Canadian guidelines for carbapenem resistant GNB
Australian recommendations for CRE control
ESCMID MDR-GNR control guidelines
Webinar on CRE infection control challenges
Increased risk; prior room occupant
Otter et al. Am J Infect Control 2013;41(5 Suppl):S6-11.
0 1 2 3 4
Huang MRSA
Huang VRE
Nseir P. aeruginosa
Drees VRE (2 weeks)
Drees VRE
Shaughnessy C. difficile
Nseir A. baumannii
Odds ratio
+71%
+58%
+55%
+49%
+42%
+37%
+28%
CRE – is surface contamination a risk?
Havill et al. Infect Control Hosp Epidemiol 2014;35:445-447.
0
1
2
3
4
5
6
7
8
0 5 10 15 20
log(1
0)
cfu
per
dis
c
Time / days
K. pneumoniae (TSB)
K. pneumoniae (water)
C. freundii (TSB)
C. freundii (water)
Error bars represent plus one standard deviation of the mean.
Conclusion CRE surface contamination
Lerner et al. J Clin Microbiol 2013;51:177-1781.
0
5
10
15
20
25
30
35
Pillow Crotch Legs Infusionpump
Bedsidetable
% s
ites c
onta
min
ate
d w
ith
CRE
An Israeli hospital investigated CRE environmental contamination in the vicinity of 34 CRE-carriers; mainly K. pneumoniae.
CRE was detected in the surrounding environment of most (88%) of the patients sampled.
Conclusion
K. pneumoniae seems to be more environmental than E. coli.1,2
Surface contamination on five standardized sites surrounding patients infected or colonized with ESBL-producing Klebsiella spp. (n=48) or ESBL-producing E. coli (n=46).1
K. pneumoniae vs. E. coli
1. Guet-Revillet et al. Am J Infect Control 2012;40:845-848.
2. Gbaguidi-Haore. Am J Infect Cont 2013 in press.
0
5
10
15
20
25
30
35
Rooms contaminated Sites contaminated
% c
on
tam
inate
d
Klebsiella spp.
E. coli
P<0.001
P<0.001
Enterobacteriaceae “less environmental”
Nseir et al. Clin Microbiol Infect 2011;17:1201-1208.
Ajao et al. Infect Control Hosp Epidemiol 2013;34:453-458.
0
1
2
3
4
5
6
7
8
9
Nseir A.baumannii Nseir P.aeruginosa Nseir ESBL Ajao ESBL
Od
ds
ra
tio
Terminal decontamination using HPV
0
2
4
6
8
10
12
14
16
MDRO-standard No MDRO-standard MDRO-HPV
Acquis
itio
n r
ate
/ 1
000 p
t days
Patients admitted to rooms decontaminated using HPV were 64% less likely to acquire any MDRO (incidence rate ratio [IRR]=0.36, CI=0.19-0.70, p<0.001)
Passaretti et al. Clin Infect Dis 2013;56:27-35.
Eradication of Serratia from a NICU in Sheffield.1
Eradication of Acinetobacter and Enterobacter from an ICU in Holland.2
Terminal disinfection of patient rooms and cohort areas during outbreaks of CRE at Howard County Hospital3 and the NIH hospital.4
Control of Gram-negative outbreaks using HPV
3,7
6,6
1,7
0
1
2
3
4
5
6
7
Baseline Outbreak Post-Bioquell
Rate
/ 1
00
0 I
CU
days
Rate of A. baumannii at Washington Hospital Center5
0
0,5
1
1,5
2
Baseline
(2004)
Standard
methods
(2005-2007)
Enhanced
surveillance
(2008-2009)
Post-HPV
(2010)
Rate
/ 1
00
0 p
ati
en
t d
ays Rate of A. baumannii at Albany6
1. Bates & Pearse. J Hosp Infect 2005;61:364-366. 2. Otter et al. Am J Infect Control 2010;38:754-756. 3. Gopinath et al. Infect Control Hosp Epidemiol 2013;34:99-100. 4. Snitkin et al. Sci Transl Med 2012;4:148ra116. 5. Donegan et al. SHEA 2010. 6. Kaiser et al. IDSA 2011.
