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HealthcareAntibioticResistancePrevalence—DC(HARP-DC)
JacquelineReuben,MHSCenterforPolicy,PlanningandEvaluationDistrictofColumbiaDepartmentofHealth
October29,2016
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2
CRE:AGrowingConcern
• Common
• Resistant
• Deadly
• Spreading
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WorkingTogetherisVital!
3Source:http://www.cdc.gov/vitalsigns/stop-spread/
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WashingtonD.C.– AUniqueLandscape
• Metropolitancitythatisnotpartofanystate
• 6th largestmetropolitanstatisticalareaintheU.S.withpopulationover6million
• Allhealthcarefacilitiesclusteredwithin61squaremiles
• PatientpopulationcomprisedofresidentsfromD.C.,MD,andVA,
aswellasnationalandinternationalvisitors
• Facilitiesthatsharepatientsarealsocompetingformarketshare4
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5
Infected
Colonized
• Colonizationamongasymptomaticpatientscommon
• Identifiedandunidentifiedcolonizedpatientsserveasreservoirfortransmission
• Burdencanonlybedeterminedthroughactivesurveillance
• D.C.doesnotmandateCREreporting• HealthcarefacilitiesdonotroutinelyconductactiveCREsurveillance
YouCan’tManageWhatYouDon’tMeasure
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StudyDesignandMethods
6
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StudyDesign• Studyteam:– D.C.DepartmentofHealth– D.C.DepartmentofForensicScience– PublicHealthLab– DistrictofColumbiaHospitalAssociation– OpGen Laboratories
• 16participatinghealthcarefacilities:– All8short-termacutecare(STAC)– Bothlong-termacutecare(LTAC)– 5skillednursingfacilities(SNF)– Soleinpatientrehabilitationfacility(IRF) 7
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• Surveillanceconductedovera1to3dayintervalforeachfacilitybetweenJanuary11,2016andApril14,2016
• UsedCDC2015CREsurveillancedefinition
– IdentifiedbycultureandsusceptibilityORpossessingacarbapenemase
• Approvedbyindependentexternalreviewboard
• Verbalconsentobtained
• Peri-analswabsamplescollectedbyfacility-basedvolunteers
StudyDesign
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• Exclusioncriteria:
– PsychorOB/GYNpatients,inabilitytoconsent,orclinicallyinappropriate
• Patientbasedvariablescollected:
– Age,sex,andzipcode
• Unitlocationvariablesgroupedas:
– Criticalcare,step-downunits,wards,inpatientrehabilitation,andlong-termcare(withSNFandLTACcombined)
9
StudyDesign
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CREDetectionAnalyzedatOpGenlaboratories
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HARP-DCResults
11
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12†=8testsnotperformed*=6testsnotperformed
HARP-DCResultsOverview
n=1,504
n=2,217
n=1,036
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ResultsbyFacilityandFacilityType
13
PatientCareType CRE(%) Range(%)
InpatientRehabilitation 0.0 --
LongTermCare 7.0 0.0-29.4
ShortTermAcuteCare 5.0 0.0-7.7
-- CriticalCare 6.7 0.0-11.6
-- Stepdown 1.6 0.0-3.7
-- Ward 5.0 0.0-9.5
Total 5.2 0.0-29.4
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1.8
8.0
5.6 5.9
2.2
0
1
2
3
4
5
6
7
8
9
<20 20-39 40-59 60-79 over79
55 88 285 442 137
Prevalen
ce(%
with
CRE
)
Age
n14
CREPrevalencebyAgeGroup
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3.6
7.1
0
1
2
3
4
5
6
7
8
Prevalen
ce(%
Resistan
ce)
Female Male
p=0.01
15
CREPrevalencebySex
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CREIdentificationbyDetectionMethod
OrganismsIdentifiedbyID-AST
CarbapenemaseGenes Total(%oftotal
CRE)KPC NDM OXA-48NoCarbapenemase
Detected(cultureonly)
Klebsiella pneumoniae 16 3 19(35.8)Enterobacter cloacae 6 1 7(13.2)
Escherichiacoli 1 3 4(7.5)Serratia marcescens 1 1(1.9)
Citrobacter sp. 2 2(3.8)Indeterminant 1 1(1.9)
Nogrowth(geneonly) 19 1 19*(35.8)Total(%oftotalCRE) 44(83.0) 1(1.9) 1(1.9) 8(15.1) 53*
*OnesamplewithoutgrowthwaspositiveforbothKPCandOXA-48.Thetotalcolumncorrectsforthedoublecount.
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DistributionofOrganisms
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DNAProfilesbyFacility
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HARP-DCConclusions
19
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• Limitedriskfactoranalysis• Resultsde-identified• Verbalconsentchallenges• Selectionofperi-analsite– Patientacceptability– Difficultyforpatientswhowereobese,bed-bound,orinchair
• Variabilityinacceptancerateacrossfacilities20
Limitations
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• OneoffewstudiestoassessregionalprevalencealigningwithCDC’srecommendedcollaborativeapproach– 4facilitytypessampled
• Usedsurveillanceculturesratherthanclinicalcultures– Allparticipatingwardtypessampled,ratherthanselectedareas
• Samplesobtainedfromasingleperi-analsourceratherthanmultiplesource-types
• Alltestingperformedwithasinglemolecular/culturemethodtoallowforstandardizationacrosssites 21
Strengths
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• CREisendemicinD.C.healthcarefacilities– Averageprevalenceof5.2%– Widevariationacrossfacilities
• Importanceofsurveillancehighlighted– GenotypicprofilingidentifiedpossibleCREtransmissionwithinandbetweenfacilities
• D.C.successfullyinitiatedacollaborativeapproachforfurtherassessmentandcontrolefforts
• HARP-DCprovidesamodelforotherregionstocollaborateonMDROprevalencemeasurement
22
Conclusions
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DCHA• NancyDonegan,MPH• JoAnneNelson,DC• BrendanSinatro,MPH
OpGen• TrevorWagner,PhD• ClaytonCollier,PhD
DFS-PHL• MorrisBlaylock,PhD• Kimary Harmon,MBA,MPH
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Acknowledgements
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• BridgePoint – CapitolHill• BridgePoint – NationalHarbor• Children’sNationalMedicalCenter• GeorgeWashingtonUniversityHospital
• HowardUniversityHospital• Medstar GeorgetownUniversityHospital
• MedStar NationalRehabilitationHospital
• MedStar WashingtonHospitalCenter
• ProvidenceHospital• SibleyMemorialHospital• SibleyRenaissance• TransitionsHealthcare• UnitedMedicalCenter
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Acknowledgements
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SupplementalSlides
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ProjectedImpactofCoordinatedApproach
26Slayton, Rachel B., et al. "Vital signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistantinfections in health care facilities—United States."MMWR. Morbidity and mortality weekly report 64.30 (2015): 826.