HealthcareAntibioticResistancePrevalence—DC(HARP-DC)

JacquelineReuben,MHSCenterforPolicy,PlanningandEvaluationDistrictofColumbiaDepartmentofHealth

October29,2016

2

CRE:AGrowingConcern

• Common

• Resistant

• Deadly

• Spreading

WorkingTogetherisVital!

3Source:http://www.cdc.gov/vitalsigns/stop-spread/

WashingtonD.C.– AUniqueLandscape

• Metropolitancitythatisnotpartofanystate

• 6th largestmetropolitanstatisticalareaintheU.S.withpopulationover6million

• Allhealthcarefacilitiesclusteredwithin61squaremiles

• PatientpopulationcomprisedofresidentsfromD.C.,MD,andVA,

aswellasnationalandinternationalvisitors

• Facilitiesthatsharepatientsarealsocompetingformarketshare4

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Infected

Colonized

• Colonizationamongasymptomaticpatientscommon

• Identifiedandunidentifiedcolonizedpatientsserveasreservoirfortransmission

• Burdencanonlybedeterminedthroughactivesurveillance

• D.C.doesnotmandateCREreporting• HealthcarefacilitiesdonotroutinelyconductactiveCREsurveillance

YouCan’tManageWhatYouDon’tMeasure

StudyDesignandMethods

6

StudyDesign• Studyteam:– D.C.DepartmentofHealth– D.C.DepartmentofForensicScience– PublicHealthLab– DistrictofColumbiaHospitalAssociation– OpGen Laboratories

• 16participatinghealthcarefacilities:– All8short-termacutecare(STAC)– Bothlong-termacutecare(LTAC)– 5skillednursingfacilities(SNF)– Soleinpatientrehabilitationfacility(IRF) 7

8

• Surveillanceconductedovera1to3dayintervalforeachfacilitybetweenJanuary11,2016andApril14,2016

• UsedCDC2015CREsurveillancedefinition

– IdentifiedbycultureandsusceptibilityORpossessingacarbapenemase

• Approvedbyindependentexternalreviewboard

• Verbalconsentobtained

• Peri-analswabsamplescollectedbyfacility-basedvolunteers

StudyDesign

• Exclusioncriteria:

– PsychorOB/GYNpatients,inabilitytoconsent,orclinicallyinappropriate

• Patientbasedvariablescollected:

– Age,sex,andzipcode

• Unitlocationvariablesgroupedas:

– Criticalcare,step-downunits,wards,inpatientrehabilitation,andlong-termcare(withSNFandLTACcombined)

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StudyDesign

CREDetectionAnalyzedatOpGenlaboratories

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HARP-DCResults

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12†=8testsnotperformed*=6testsnotperformed

HARP-DCResultsOverview

n=1,504

n=2,217

n=1,036

ResultsbyFacilityandFacilityType

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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

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

3.6

7.1

0

1

2

3

4

5

6

7

8

Prevalen

ce(%

Resistan

ce)

Female Male

p=0.01

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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

HARP-DCConclusions

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• Limitedriskfactoranalysis• Resultsde-identified• Verbalconsentchallenges• Selectionofperi-analsite– Patientacceptability– Difficultyforpatientswhowereobese,bed-bound,orinchair

• Variabilityinacceptancerateacrossfacilities20

Limitations

• OneoffewstudiestoassessregionalprevalencealigningwithCDC’srecommendedcollaborativeapproach– 4facilitytypessampled

• Usedsurveillanceculturesratherthanclinicalcultures– Allparticipatingwardtypessampled,ratherthanselectedareas

• Samplesobtainedfromasingleperi-analsourceratherthanmultiplesource-types

• Alltestingperformedwithasinglemolecular/culturemethodtoallowforstandardizationacrosssites 21

Strengths

• CREisendemicinD.C.healthcarefacilities– Averageprevalenceof5.2%– Widevariationacrossfacilities

• Importanceofsurveillancehighlighted– GenotypicprofilingidentifiedpossibleCREtransmissionwithinandbetweenfacilities

• D.C.successfullyinitiatedacollaborativeapproachforfurtherassessmentandcontrolefforts

• HARP-DCprovidesamodelforotherregionstocollaborateonMDROprevalencemeasurement

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Conclusions

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

• BridgePoint – CapitolHill• BridgePoint – NationalHarbor• Children’sNationalMedicalCenter• GeorgeWashingtonUniversityHospital

• HowardUniversityHospital• Medstar GeorgetownUniversityHospital

• MedStar NationalRehabilitationHospital

• MedStar WashingtonHospitalCenter

• ProvidenceHospital• SibleyMemorialHospital• SibleyRenaissance• TransitionsHealthcare• UnitedMedicalCenter

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Acknowledgements

SupplementalSlides

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.