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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.

https://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServices/Pages/CPEForm.aspx

http://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServices/Pages/Management-of-Carbapenem-Producing-Enterobacteriaceae-(CPE).aspx


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).


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).


Figure 3. Patients with newly confirmed CPE isolates by age group and colonization/infection status in

Ontario, January–December 2016 (n=134*).


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.


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)



*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


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




Patients with unknown hospitalization history 23/148






*Note: Patients may have travelled to >1 country for hospitalization outside of Canada


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*)



*Note: Number of CPE positive isolates submitted to PHOL for confirmatory testing from unique patients


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



*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


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



*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




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



*Note: One isolate may be positive for more than one type of carbapenemase


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.



*Note: An isolate may be positive for more than one type of carbapenemase †Date received was unknown for one positive isolate


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.


extracted by Public Health Ontario [2017/03/31


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.

http://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf

http://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf

https://iqmh.org/

https://iqmh.org/

http://www.publichealthontario.ca/en/eRepository/PHO%20Laboratory-Based%20Detection%20of%20CRE_061211%20final.pdf

http://www.publichealthontario.ca/en/eRepository/PHO%20Laboratory-Based%20Detection%20of%20CRE_061211%20final.pdf


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.

mailto:[email protected]

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SURVEILLANCE REPORT - · PDF fileCPE Surveillance Report: ... confirmed isolates are requested to complete the CPE surveillance form on the ... Number and proportion of CPE isolates