experience from ireland 2014. stephen murchan (ireland)

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  • EARS-Net Ireland ARHAI meeting, Stockholm,

    10-13th February 2015

    Stephen Murchan Surveillance Scientist at the Health Protection Surveillance Centre, Dublin

  • Background Joined EARSS in 1999 Population = 4,588,252 (2011 census) Complete population coverage since 2007

    40 laboratories 58 acute hospitals

    47 public 11 private

    Denominator data [include admissions, bed days used (BDUs), blood cultures processed] on almost all

    Enhanced surveillance on ~50% EUCAST now predominant: just 6/40 still use CLSI

  • Data collected and analysed quarterly Regular reports and feedback to labs/hospitals Supported by reference labs

    MRSA/ Pneumococcal typing/ CRE and other resistant Gram ves

    Background

  • VRE (E. faecium), 2013: A big problem in Ireland

    Median = 6% IE Rank = 1/30 (43%) Next: CY, UK, GR, PO =22-23% IE highest since 2008

  • Reporting PNSP in Europe effect of using different breakpoints/guidelines:

    PNSP, 2013 Using oral bps for CLSI and non-men bps for EUCAST IE rank = 10/30 (20%) Median = 12%

  • PNSP, 2013: alternative scenario 1

    Using non-men bps for CLSI and non-men bps for EUCAST IE = 9%

  • PNSP, 2013: alternative scenario 2

    If all CLSI and using non-men bps IE = 0.3%

  • Invasive E. coli infections

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    YearTotal E. coli %3GC-R %FQREC %GEN-R %GEN/TOB/AMK-R

    AMR trends for E. coli

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    3GC/ESBL trends for E. coli

  • 3GC-R E. coli, 2013

    Median = 11% IE Rank = 13/30 (12%) Increased from 17/28 (9%) in 2010

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    YearTotal E. coli tested for MDR MDR ECO %MDR

    MDR trends for E. coli

  • Invasive K. pneumoniae infections

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    AMR trends for K. pneumoniae

  • 3GC/ESBL trends for K. pneumoniae

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  • 3GC-R K. pneumoniae, 2013

    Median = 30% IE Rank = 19/30 (21%) Increased from 23/29 (8%) in 2011 Big increase in year since 2012

  • MDR K. pneumoniae, 2013

    Median = 16.5% IE Rank = 20/30 (8%) Increased from 24/29 (3%) in 2011 IE and UK doubled in last year

    A3CG-R only

  • MDR K. pneumoniae an emerging problem in Ireland

    138 isolates collected from 17 hospitals between Jan 2011 and Jul 2013

    All ESBL-pos and resistant to CIP and GEN PCR: all harboured blaSHV and a blaCTX-M 15 resistant to ETP (7 to MEM): 5 confirmed CPE

    4 KPC and 1 NDM/OXA-48 2 major clones (MLST/PFGE): ST1236/ST48 (45%

    of isolates) and ST15/ST14 (20%) ST258 (4 isolates) = pandemic; KPC2

    D. Morris, M. Cormican and colleagues, Antimicrobial Resistance and Microbial Ecology (ARME) laboratory, National University of Ireland (NUI), Galway

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    Total KPN tested for MDRKP MDRKP %MDRKP

    MDRKP trends (EARS-Net data)

  • MDRKP outbreak control team Outbreak control team Convened in October 2013 Recommendations regarding surveillance, screening, infection control including isolation, antibiotic stewardship, education & training Establish TASK FORCE Prospective study Carried out throughout 2014 to determine extent of the problem All labs/hospitals participated Case definition The case definition for prospective reporting of MDRKP is: The first isolate per patient per quarter of K. pneumoniae derived from any specimen type (both infection and carriage) that are (1) ESBL-producers and non-susceptible to both ciprofloxacin and gentamicin, or non-susceptible to 3rd-generation cephalosporins and ciprofloxacin and gentamicin in cases where investigations for ESBLs are not routinely carried out [MDRKP/Non-CRE] and/or (2) carbapenemase-producers [MDRKP/CRE].

  • 478 cases of MDRKP reported between Jan and Dec 2014 424 with MDRKP/Non-CRE phenotype 54 with MDRKP/CRE phenotype

    36 KPC, 12 NDM and 6 OXA-48

    403 from clinical samples (70% urines) 75 from screening samples 69% from acute hospitals 31% from GP or nursing homes 75% patients aged 57 years and over

    59% inpatients isolated within 24 hrs: 12% were not (and 28% unknown!)

    By end of year, 43/58 (74%) of acute hospitals *data correct as of 1st February 2015

    MDRKP trends (Prospective study 2014)

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  • CRE from invasive infections (EARS-Net) 2011 2012 2013 Q1-3 2014 2011-Q3 2014

    Total CRE 5 1 4 4 14% CRE 1.6% 0.3% 1.2% 1.5% 1.1%

    CPE 4 0 2 2 8OXA-48 (3) OXA-48 (2) OXA-48 (1) OXA-48 (6)

    KPC (1) KPC (1) KPC (2)

    Non-CPE 1 1 2 2 6

  • CRE the wider problem 2013 2014

    KPC 14 44OXA-48 29 17

    NDM 3 17IMP 1 2IMI 1 0

    VIM 0 2TOTAL 48 82

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    Enzyme2013 2014

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    Data courtesy of M. Cormican, E. McGrath and colleagues at the CRE Reference Laboratory, Galway University Hospital

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    MDRKP trends (EARS-Net data)

    A cause for hope: signs of a reduction in MDRKP in 2014 or still too early to tell!

  • Thanks! Buochas! EARS-Net Steering Group: Ajay Oza, Belinda Hanahoe, Brian Carey, Brian O'Connell, Dearbhaile Morris, Grainne Brennan, Margaret McIver, Martin Cormican, Robert Cunney, Sinead Kelly, Stephen Murchan EARS-Net Participants: Agnes Szymanowska, Aine O'Callaghan, Ann McDermott, Anne Gilleece, Anne MacLellan, Anne Marie Meenan, Annette Darcy, Bartley Cryan, Belinda Hanahoe, Binu Dinesh, Bob McWade, Breda Boyle, Brendan Crowley, Brian Carey, Brian O'Connell, Bronagh O'Leary, Cara Wrenn, Carmel Hooton, Carmel O'Reilly, Carol OConnor, Carole Troy, Caroline Doherty, Cathal Collins, Cathal O'Sullivan, Catherine Mahon, Colm Power, Dan Corcoran, Dave LeBlanc, Dearbhaile Morris, Deirbhile Keady, Deirdre O'Brien, Donal Lanigan, Ed Smyth, Eddie McCullagh, Eithne McCarthy, Eleanor McNamara, Eoghan O'Neill, Fidelma Fitzpatrick, Fiona Kenny, Frank Dennehy, Gabriela Dornikova, Grace O'Keeffe, Grace O'Mahony, Grainne Bowens, Grainne Brennan, Hazel O'Connor, Helen McDermott, Hilary Humphreys, Jackie Leavy, James Powell, Jean Wellwood, Jennifer Cleary, Jerome Fennell, John Flynn, Karen Burns, Karen Logan, Kirsten Schaffer, Larry O'Neill, Lorraine Power, Louise Barry, Lynda Fenelon, Maeve Doyle, Mairead O'Hanlon, Mairead Skally, Majella Sharkey, Margaret Bernard, Margaret Hannan, Marianne Fraherk, Marianne Nolan, Martin Cormican, Mary Corcoran, Mary Coughlan, Mary Hickey, Mary Kelleher, Mary Meehan, Maureen Lynch, Michael Mulhern, Michelle Dowling, Michelle Flanagan, Milada Tavodova, Niall Wall, Niamh O'Flaherty, Niamh O'Sullivan, Niamh Purcell, Nuala O'Connell, Olive Murphy, Paul Bennet, Philip Murphy, Ray Sheehan, Rebecca Rush, Regina Monahan, Richard Drew, Robert Cunney, Rose Sexton, Rosemary Curran, Sandra Baldwin, Sarah Warner, Sinead Kelly, Siobhan Boothman, Susan Kelly, Susan Knowles, Suzanne Chute, Suzanne Corcoran, Suzy Fitzgerald, Teck Wee Boo, Una Ni Riain, Una Reidy, Ursula Fox, William Dibb CRE Reference Laboratory, Galway University Hospital: Elaine McGrath, Martin Cormican MDRKP Outbreak Control Team: Darina OFlanagan, Dearbhaile Morris, Karen Burns,

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