experience from ireland 2014. stephen murchan (ireland)
TRANSCRIPT
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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YearTotal E. coli %3GC-R %ESBL+ve
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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2008 2009 2010 2011 2012 2013 2014*
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YearTotal KPN %3GC-R %CIP/OFX-R %GEN/TOB/AMK-R %GEN-R
AMR trends for K. pneumoniae
3GC/ESBL trends for K. pneumoniae
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2006 2007 2008 2009 2010 2011 2012 2013 2014*
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YearTotal KPN %3GC-R %ESBL+ve
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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2008 2009 2010 2011 2012 2013 2014*
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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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MonthMDRKP/CRE MDRKP/Non-CRE
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
Enzy
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101520253035404550
KPC OXA-48 NDM IMP IMI VIM
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Enzyme2013 2014
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2013 2014
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YearESCO KLEB CITRO ENTER
Data courtesy of M. Cormican, E. McGrath and colleagues at the CRE Reference Laboratory, Galway University Hospital
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Total KPN tested for MDRKP MDRKP %MDRKP
MDRKP trends (EARS-Net data)
A cause for hope: signs of a reduction in MDRKP in 2014 or still too early to tell!
Thanks! Buíochas! 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 O’Connor, 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 O’Flanagan, Dearbhaile Morris, Karen Burns, Martin Cormican, Robert Cunney, Sinead Kelly, Stephen Murchan