The ‘nightmare bug’: Carbapenem- resistant enterobacteriaceae (CRE) in Arizona
AZID July 20th, 2017
Rachana Bhattarai, BVSc & AH, MS, CIC HAI Epidemiologist
Arizona Department of Health Services
‘Nightmare’ by Luciana Christante (CC BY NC ND 2 0)
Superbug Untreatable and hard-to-treat infections On the rise among patients in medical facilities.
They kill up to 1 in 2 patients with a CRE bloodstream infection. They have been reported in 42 states during the last 10 years. They easily spread their antibiotic resistance to other kinds of germs.
Why do we care about CRE?
https://www.slideshare.net/babasahebkumbhar/enterobacteriaceae-26124036
Enterobacteriaceae
Meningitis
Pneumonia
Sepsis
Diarrhea
UTI
Escherichia coli Enterobacter aerogenes Klebsiella pneumoniae Serratia marcescens Proteus spp. Providencia spp. Citrobacter spp. Salmonella spp. Shigella spp. Yersinia spp.
Four main carbapenems (antibiotics):
MEROpenem
DORIpenem
IMIpenem
ERTApenem
Carbapenem (antibiotic) kills the bacteria by inhibiting cell wall synthesis
X
Normal Enterobacteriaceae
Carbapenem (antibiotic) does NOT kill the bacteria
These enterobacteriaceae are resistant to carbapenem
Carbapenem-resistant enterobacteriaceae (CRE)
Carbapenemase (enzymes produced by bacteria) break antibiotics’ structure providing resistance
ESBL KPC
NDM Amp C
Klebsiella spp. Enterobacter spp.
E. coli Proteus spp.
Etc….
Meropenem Doripenem Imipenem
Ertrapenem
ESBL KPC
NDM Amp C
Carbapenemase
Enterobacteriaceae
Carbapenem
Carbapenemase-producing CRE (CP-CRE)
Proteus spp. Morganella spp. Providencia spp.
Have always been resistant to imipenem due to
inherent structural or functional characteristics.
Meropenem Doripenem Imipenem
Ertrapenem
Intrinsic resistance
Lab tests to identify CRE
Susceptibility testing Carbapenamase production testing and PCR
Meropenem Doripenem Imipenem
Ertrapenem
ESBL KPC
NDM Amp C
Public Health Image Library
CRE Control and Prevention - Providers
Use contact precautions for patients with CRE. Whenever possible, dedicate rooms, equipment, and staff to CRE patients.
Prescribe antibiotics wisely. Use culture results to modify prescriptions if needed.
Control and Prevention -Resources
AHRQ CRE Control and Prevention Toolkit
Facility Guidance for Control of CRE
CRE Control and Prevention - Patients
Tell your doctor if you have been hospitalized in another facility or country. Take antibiotics only as prescribed.
What’s the picture of CRE in Arizona?
What’s the picture of CRE in Arizona?
Hospital Discharge Database (HDD)
Death Records
Available data is of limited use:
CRE is not explicitly identified in the records Data is delayed
But it will likely be reportable by laboratories with updated rules in 2018!
Arizona State Public Health Laboratory (ASPHL) Clinical Labs
2012 State Public Health Lab Special Project: Selected labs submitted isolates for CRE confirmatory testing
656 specimens
436 individuals With sufficient lab information
153 CRE cases Met the 2015 CSTE case definition
Hospital Discharge Database (HDD)
Death Records
We used MR, HDD and death records to assess hospitalization costs, outcomes and other characteristics of the 153 CRE cases.
Medical Records (MR) 153 CRE cases Met the 2015 CSTE case definition
Demographics of CRE cases
52% males 60 years median age
74% White
10% Hispanic
13% Native American
3% Black
90% of samples from Maricopa and Pima Counties.
Urine specimens were the most common.
58% 16%
11%
6% 10% Urine
Respiratory specimen
Wound
Blood
Other
Other: Body fluid, tissue, swab, stool etc.
Klebsiella and Enterobacter spp. were the most common.
1%
1%
3%
5%
8%
8%
27%
46%
Providencia spp.
Morganella spp.
Proteus spp.
Citrobacter spp.
Escherichia spp.
Serratia spp.
Enterobacter spp.
Klebsiella spp.
KPC was the most frequent mechanism of carbapenem-resistance identified.
31%
16% 14%
39%
KPC ESBL Amp-C Unknown
13% of CRE cases did not report any acute infection symptoms.
13% No infection
Other infections
Wound infection
Bacteremia/sepsis
Pneumonia
Urinary tract infection
13%
The vast majority of cases were empirically prescribed antibiotics upon admission, prior to laboratory results.
Prior to hospital visit Empirically before laboratory results
During the course of hospital stay
88%
Most cases either had an external device placed during their hospital visit or a previous surgery.
72%
83%
0% 50% 100%
Previous surgery
External device prior to visit
Transfer from other medical facility
Previous hospitalization
Hemodialysis at time of culture or in the past
Transplant
2 cases did not have any hospital exposures
External device placed during patient visit
The top 5 comorbidities among CRE patients:
56%
36% 33% 32% 27%
Hypertension Anemia Diabetes Renal failure Previous UTIs
ICU
Financial impact and outcomes
1 in 5
Median hospital costs associated with CRE per patient
$23,396 12 days Median length of hospital stay
1 in 2
Only 35% of specimens were truly CRE… why?
68% 24%
8%
Enterobacteriaceae intrinsically resistant to imipenem
Enterobacteriaceae susceptible to all carbapenems
Non-Enterobacteriaceae
n=283
Better communication with labs is needed about which isolates to submit.
What’s the picture of CRE in Arizona?
But it will likely be reportable by laboratories with updated rules in 2018!
CRE will be nationally notifiable in 2018
ESBL KPC
NDM Amp C
Carbapenemase
Enterobacteriaceae
Enterobacteriaceae (Klebsiella spp., Enterobacter spp., E. coli)
producing carbapenemase.
Klebsiella spp. Enterobacter spp.
E. coli
CRE will be nationally notifiable in 2018
• HAI Team – Catherine “Kasia” Golenko – Eugene Livar – Geoff Granseth – Felicia Maclean – Jaiju Thomas
• ASPHL Team
Acknowledgement
THANK YOU! Rachana Bhattarai | HAI Epidemiologist
[email protected] | 602-364-3194
azhealth.gov
@azdhs
facebook.com/azdhs