INFECTION PREVENTION CONTROL NURSES COLLEGE CONFERENCE 2019 Update on the CPE epidemic in NZ & progress in the national response over the last year Josh Freeman Clinical Director Microbiology and Virology Department CDHB
Overview • Update on CPE epidemiology in NZ • Community spread internationally • The role of E. coli • Healthcare spread in NZ • Progress in national surveillance and response systems for CPE • Areas of work for the coming year
CPE and mobile genetic ele lements • Carbapenemase genes are carried on mobile genetic elements known as “plasmids” • Self replicating, extra-chromosomal DNA • Travel between different bacterial strains and species ( horizontal spread ) • Inherited by daughter cells ( vertical spread )
Sources of acquisition of CPE in NZ - 2019 No travel history Travel to South 21% /SE Asia (no hospitalisation) 39% Overseas hospitalisation 40%
Overseas Hospital Sources of CPE 2019 6% 6% 6% 6% 47% 6% 6% 6% 6% 5% India Fiji Thailand Cambodia Brazil Egypt Phillipines Israel Samoa Kuwait
Overseas Community Sources of CPE 2019 (no hospitalisation ) 5% 5% 5% 4% 4% 77% India Overseas NOS Vietnam Lebanon Europe China
CPE rate following travel to Indian Subcontinent (no hospitalisation) (2019 data adjusted) Rate / 100 000 arrivals from India 33.68 26.86 23.65 20.59 12.23 9.68 6.7 5.35 0 0 0 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019' year
• Sep-Oct 2010: environmental water samples within 12km radius of New Delhi • Seepage samples - 51/171 (29.8%) positive for NDM-1 • Drinking water - 2/50 (4%) positive for NDM-1 • 14 different species
Travellers with healthcare exposure Travellers without healthcare exposure overseas: breakdown of CPE species overseas: breakdown of CPE species 4% 1% 1% 2% 2% 10% 4% 1% 46% 42% 87% E. coli E. coli K. pneumoniae Enterobacter spp. Citrobacter spp. Enterobacter spp. K. pneumoniae M. morganii P. mirabilis K. oxytoca Providencia spp.
Bacterial species and glo lobal spread of CPE • Carbapenemase genes are spreading in the community in many countries, primarily in E. coli • E. coli acts as a kind of “Trojan horse” for international spread and introduction of carbapenemase plasmids into healthcare facilities in NZ • In healthcare facilities, carbapenemase plasmids have opportunities to spread to other species such as K. pneumoniae which tend to have a higher propensity for clonal spread in healthcare settings
CPE gene subtypes acquired during travel to Indian subcontinent, 2014-2019 other oxa types 3% oxa-181 28% NDM-5 53% other NDM 16%
CPE rate following travel to Indian Subcontinent (no hospitalisation) by CPE gene subtype [Total=blue line, NDM-5=orange line; oxa-181=red line] 40 rate / 100 000 arrivals from India 35 33.68 30 26.86 25 23.65 20.59 20 17.57 12.23 15.05 14.22 14.97 15 10 9.78 9.68 8.79 5.35 6.7 6.45 5 2.45 1.87 2.67 0 0 0 0 0 0 0 0 0 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019' year
Example antib ibiogram, , NDM-5 producing E. . coli li ESBL SCREEN - RECTAL SWAB MINIMUM INHIBITORY CONCENTRATION CULTURE : (1) Escherichia coli isolated Organism : Escherichia coli **This isolate is positive for a NDM carbapenemase.** Antibiotic : Ertapenem * This isolate has a CTX-M group 1 Extended spectrum beta- MIC : > 32 mg/l Resistant lactamase. (1) Antibiotic : Meropenem Amoxycillin R MIC : 4.0 mg/l Resistant Amox/Clav R Antibiotic : Fosfomycin Aztreonam R MIC : 1.0 mg/l Susceptible Cefuroxime R Antibiotic : Aztreonam Cefoxitin R MIC : > 256 mg/l Resistant Gentamicin R Antibiotic : Ceftazidime/avibactam Cotrimoxazole R MIC : > 256 mg/l Resistant Ceftazidime R Antibiotic : Ceftaz-avibactam + aztreonam Ceftriaxone R MIC : 8.0 mg/l Cefepime R Tazocin R Amikacin S Meropenem R R = Resistant S = Susceptible I = Intermediate
Mult ltiple CPE strains in in a patient repatriated fr from a hospital in in In India
Yearly number of known CPE acquisitions in NZ (21% in 2019) 16 number of known newly acquired cases 14 2016 2015 2019 12 Hospital and LTCF 1.Hospital transmission of VIM Age-related transmission OXA- K. pneumoniae , Waikato residential 232 K. pneumoniae, 10 2. Hospital transmission of NDM K. care NDM pneumoniae – haematology unit E. coli , and LTCF - Canterbury Auckland 8 6 2018 MMH Burns Unit 4 Outbreak. NDM – multiple species 2 0 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019' year
2019: NDM E. . coli tr transmission in in residential care • Mrs B, 94y F, resident at LTCF in • Mrs H, 92y F, same LTCF as Mrs B MMH catchment area • Detected NDM-5 E. coli ST405 • Screened on admission to MMH, carriage on screening as part of May 2019, found to have NDM-5 investigation in July 2019 E. coli ST405 • Previous admissions to MMH in • No travel in past 2 years Jan 2019, Feb 2018, Aug 2017 • Had been to MMH outpatient • No travel clinics over past 12 months
2019: NDM E. . coli tr transmission in in residential care • ESR found the two isolates very • Mr C; 88y M, extensive travel closely genetically related to a history, never hospitalised overseas third isolate from a patient Mr C • cruise Bali to Sydney Dec 2018 • SNP differences in table below • Portugal 2018 • Caribbean 2017 • Ireland 2016 Mr C Mrs B Mrs H • Private hospital for CABG, early March 2019 Mr C 0 1 2 • Transferred to ICU ADHB, screened in and found to have NDM-1 E. coli Mrs B 1 0 1 ST405 carriage • Discharged to LTCF (different to the Mrs H 2 1 0 other two patients
2019 Sp Spread of NDM E. . coli li in in NZ il illu lustrates in interconnectedness of dif ifferent facilit ilitie ies with ithin in healt lthcare system Patient 2 May 2019 Patient 3 July 2019 Patient 1 March 2019 Overseas travel Long term care facility 2 Private surgical hospital Long term care facility 2 ?? Acute care hospital 1 Acute care hospital 2 ICU Gen Med ward Long term care facility 1 Long term care facility 2 Blue arrows represent potential for further spread within the particular facility at each point
Summary ry: : Update on CPE Epidemiology in in NZ • The incidence of CPE acquisition continues to increase • 40% acquired in community overseas • 40% acquired in overseas hospitals • 20% acquired in NZ • Acquisition in the community overseas is • primarily in India (77%) • primarily E. coli (87%) • Primarily NDM-5 (53%) and oxa-181 (28%) carbapenemase gene types • Acquisition in overseas hospitals • 50% India but also Middle East, Pacific, South America, South East Asia • Range of different species with E. coli (46%) and K. pneumoniae (42%) predominating • Acquisition in NZ healthcare / residential care facilities is increasing • Multiple species • Index case / source of introduction not always identified. Burns outbreak related to transfer from an overseas hospital • Haematology unit, Burns unit and residential care / hospital interface
What’s gone well since the guidelines were published? 1. National level outbreak response systems • Compulsory reporting of suspected CPE transmission to the MOH communicable disease team • Formation of TAG to advise affected facilities, particularly where access to highly specialised IPC advice not readily available
What’s gone well since the guidelines were published? 2. Active surveillance for CPE • A number of DHBs have expanded CPE screening criteria to include newly admitted travellers to South and SE Asia in the preceding year • Affected DHBs in 2019 (primarily MMH) have responded in accordance with the guidelines
What’s gone well since the guidelines were published? 3. Laboratory methods for detection of CPE improved and standardised throughout the country
Where further work is needed in 2020… 1. Education and awareness of CPE in residential care • Generally little awareness of CPE or the national CPE IPC guidelines in the ARRC and wider residential care sector • No systematic communication about guidelines to ARRC sector • Likely minimal active surveillance for CPE in ARRC sector NZ despite recommendations in the guidelines to screen all new admissions • Need to further clarify nature and degree of DHB support required for residential care
Where further work is needed in 2020… 2. The guidelines • The current guidelines cover both acute care facilities and residential care in one document • There is now general agreement that specific CPE guidelines for the residential care setting are needed • Guidelines for residential care need to be simple, clear and practical; recognising the need to minimise risk while maintaining the social wellbeing of colonised patients • Also need to improve and simplify presentation and technical content of current guidelines for acute care hospitals 3. The H & D Standards • The threat of CPE and the need for appropriate response systems needs to be incorporated into the revised IPC H&DS - currently under review
Challenges in in residential care
Recommend
More recommend
