Brian Sandoval Richard Whitley Governor Director State of Nevada Department of Health and Human Services Nevada Division of Public and Behavioral Health Carbapenem-resistant Enterobacteriacea (CRE) in Nevada Kimisha Causey, MPH HAI Coordinator May 31, 2018 Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do.
Objectives • Define Carbapenem-resistant Enterbacteriacea (CRE) • Review current cases in Nevada • Discuss Centers for Disease Control and Prevention (CDC) CRE prevention education and isolation recommendations • Explain upcoming state reporting requirements and current voluntary reporting Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 2
Objectives • Discuss Nevada State Public Health Lab (NSPHL) mechanism testing • Discuss DPBH assistance • Infection Control Assessment and Response (ICAR) tool • Target Assess Prevent (TAP) assessment tool • Antimicrobial Resistance Regional Laboratory (ARLN) Sentinel Lab Program Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 3
CRE Definition • General definition: Enterobacteriaceae that are nonsusceptible (i.e., intermediate or resistant) to a carbapenem • Resistant to any carbapenem antimicrobial (i.e., minimum inhibitory concentrations of ≥4 mcg/ml for doripenem , meropenem, or imipenem OR ≥2 mcg/ml for ertapenem) OR • Documented to produce carbapenemase Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 4
CRE Background • Carbapenem ‐ resistant organisms are becoming increasingly common in Western region. • Of particular concern are those that produce a carbapenemase, an enzyme that neutralizes carbapenem antibiotics, the antibiotics of last resort. Carbapenemases in Gram ‐ negative organisms include: • Klebsiella pneumoniae carbapenemase (KPC) • New Delhi metallo ‐ β ‐ lactamase (NDM) • Oxacillin ‐ hydrolyzing β ‐ lactamase ‐ 48 (OXA ‐ 48) • Verona integron ‐ encoded metallo ‐ β ‐ lactamase (VIM) • mipenem ‐ hydrolyzing β ‐ lactamase (IMP) • US Centers for Disease Control and Prevention (CDC) and regional AR Lab Networks recommend public health action Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 5
Current Cases • March - May 2018 in Las Vegas • 18 CRE cases • 10 Klebsiella pneumoniae • 1 Pseudomonas aeruginosa • 4 CRO Enterobacter cloacae complex • 1 K. pneumoniae & Enterobacter cloacae • 1 K. pneumonia & P. aeruginosa • 1 K. Pneumoniae, E. faecalis, & VRE Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 6
Current Cases • 7 sputum • 6 urine • 2 blood • 1 sputum/blood • 1 wound drainage • 1 sputum/urine Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 7
Current Cases • 5 Acute care • 5 Long term acute care • 4 Skilled nursing facilities • 1 Assisted living facility Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 8
Current Cases • Washoe County 2018 Quarter 1 • January • 3 CRE • 5 Carbapenem Resistant Pseudomonas aeruginosa (CRPA) • February • 4 CRE • 2 CRPA • March • 2 CRE • 9 CRPA Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 9
Current Cases • 14 Inpatient • 8 Outpatient • 2 ICU • 1 SNF Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 10
Recommendations for Control of CRE 1. Hand Hygiene (soap and water or alcohol based hand rub) 2. System in place to identify patients with a history of CRE upon admission 3. Empiric Contact Precautions 4. Education and training for Healthcare Personnel on the proper use of Contact Precaution 5. Minimize device use (discontinue devices when possible) Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 11
Recommendations for Control of CRE 6. Inter-facility Communication/ Identification of CRE Patients at Admission 7. Patient and Staff Cohorting 8. Screening Contacts of CRE Patients 9. Active Surveillance Testing Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 12
Environmental Cleaning In order to decrease the risk of transmission, facilities should: • Perform daily cleaning that include areas in close proximity to the patient (e.g., bed rails, patient tray) • Terminal clean the rooms of CRE patients once discharged • Monitor the cleaning process to ensure all surfaces are adequately cleaned and disinfected Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 13
Recommendations for Control of CRE Proper Use of Contact Precautions Includes: Removing the gown and Donning gown and Performing hand gloves and performing gloves before entering hygiene before donning hand hygiene prior to the affected patient’s a gown and gloves exiting the affected room patient’s room Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 14
Contact Precaution • Identify patients with CRE prior to admission • Place patients who are colonized or infected with CRE on Contact Precautions • Ensure proper signage is posted for staff, visitors, etc. • Ensure proper PPE is available before entering patient room • Instruct visitors to visit the nurses station for education Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 15
Contact Precautions • Provide CP training and regular PPE competency audits • No firm recommendation on when to discontinue CP for infected or colonized patients • CRE colonization can be prolonged (> 6 months) • CDC states: "If surveillance cultures are used to decide if a patient remains colonized, more than one culture should be collected to improve sensitivity." Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 16
State Reporting Requirements & Current Voluntary Reporting • CDC approved the addition of Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) to the National Notifiable Diseases Surveillance System as of January 2018 • CP-CRE Enterobacter spp. • CP-CRE E. Coli • CP-CRE Klebsiella spp. • Nevada reporting is voluntary, state mandates for reporting are in the process of being drafted Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 17
State Reporting Requirements Current Voluntary Reporting • Voluntary State reporting • CRE • Fax reports to 702-486-0490 • Patient Name, DOB, +labs • Mandatory State reporting will include: • Acinetobacter baumannii , carbapenem-resistant (CRAB) • Enterobacteriaceae, carbapenem-resistant (CRE) • Pseudomonas aeruginosa , carbapenem-resistant (CRPA) Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 18
Nevada State Public Health Lab (NSPHL) Mechanism Testing • NSPHL provides shipping supplies • Test isolate for carbapenemase producing (CP) mechanism • Any healthcare facility can submit isolates for further testing to determine non CP-CRE vs CP- CRE • Contact the state HAI Program for supplies and shipping information Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 19
Sentinel Lab Program ARLN • Antibiotic Resistance Laboratory Network (ARLN) is seeking laboratories in Nevada to serve as sentinel sites and voluntarily submit specific organisms for further testing and tracking at the Public Health Laboratories • Benefits • Access to advanced laboratory testing • Free shipping • Certificate of participation • Receipt of statewide multidrug-resistant organism reports Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 20
Sentinel Lab Program ARLN • Submitting isolates to ARLN is for facilities that have signed commitment letters and serve as sentinel labs for Washington State regional lab ONLY. Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 21
Sentinel Lab Program ARLN • Sentinel labs submit the following isolate-types to West Regional Antibiotic Antimicrobial Resistance Regional Laboratory (ARLN): • All carbapenem-resistant Acinetobacter species • E. coli and Klebsiella pneumoniae resistant to third- generation cephalosporins (all, or only a subset, depending on volume) • All Candida auris • All Candida species, EXCEPT C. albicans, C.parapsilosis, C. dubliniensis, C.lusitaniae, C.tropicalis, and C.krusei (For C. glabrata, submit all, or only a subset, depending on volume.) Helping People. It’s who we are and what we do. Helping People. It’s who we are and what we do. 22
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