Carbapenemase-producing Enterobacteriaceae: use of a dynamic registry of cases and contacts for outbreak management

Carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium: The value of a computerized monitoring system to limit their spread

OBJECTIVE

To quickly implement Infection Prevention and Control measures ("search and isolate" strategy), a computerized monitoring system for carbapenemase-producing Enterobacteriaceae (CPE) and Vancomycin-resistant Enterococcus faecium (VRE) carrier and contact patients has been developed in our hospital since 2014. The objectives were to assess the value of a computerized monitoring system in CPE and VRE management and to evaluate the relevance of extended monitoring of all contact patients.

METHODS

Using the data extracted from the computerized system, we conducted a descriptive analysis of CPE and VRE carriers detected from 2004 to 2019 and CPE and VRE extensive contact patients (when hospital stay overlapped with the stay of a carrier in the same unit) from 2014 to 2019.

RESULTS

Between 2015 and 2019 (microbiological data only available during this period), 113 CPE and 558 VRE carriers were registered in the database (DB). Among them, 33.9% CPE and 12.8% VRE carriers were infected (p = 0.02). The most frequent infections were urinary tract infections (52.0%), bloodstream infections (20.0%) and pneumonia (16.0%). Close to 8000 (7679) extended contact patients were exposed. Only 26.2% of them were removed from the DB because of appropriate negative post-exposure rectal screenings. No rectal screening was performed in 33.5% of contact patients. Between 2014 and 2019, 16 outbreaks occurred. The proportion of infected carriers differed significantly between outbreaks (index cases) and non-epidemic episodes (50.0% and 20.5% respectively, p = 0.03). The detection system was able to control diffusion in 99.7% of readmissions of known carriers. Among the 360 readmissions detected by the system, only one was involved in an outbreak due to non-compliance with infection control measures.

CONCLUSION

Given the low screening completion rate (26.2%) and the low detection rate (1.3%), extended monitoring of contact patients does not seem relevant. After five years of use, the computerized monitoring system has demonstrated its effectiveness in terms of responsiveness and limitation of the spread of multidrug-resistant organisms.

Prevention and control of highly antibiotic-resistant bacteria in a Pacific territory: Feedback from New Caledonia between 2004 and 2020

OBJECTIVE

Carbapenemase-producing Enterobacteriaceae (CRE) and Enterococcus faecium resistant to vancomycin (VRE) constitute major threats to public health worldwide. The Pacific area is concerned and has implemented strategies to control antimicrobial resistance (AMR). However, accurate epidemiological data are rarely reported. Our study aimed to present the strategies applied to prevent and control the spread of highly resistant bacteria in the Pacific territory of New Caledonia.

PATIENTS AND METHODS

Cohort prospective study of all cases of highly resistant bacteria (HRB) isolated in New Caledonia from September 2004 to December 2020. Evaluation of the impact of the infection control measures implemented in healthcare settings: screening strategy, cohorting unit, IT tools and control of antibiotic prescriptions.

RESULTS

A total of 346 patients with HRB were identified. Most of them (63.0%) were infected or colonized by VRE (n=218) and 128 by CRE. While the number of CREs significantly increased from 2013 to 2020 (P<0.0001), control procedures have limited their dissemination. Most patients were colonized by IMP-4-CRE (n=124/128). The incidence density of VRE significantly decreased from 38.52 for 100,000 hospitalisation-days in 2015 to 4.19 for 100,000 hospitalisation-days in 2019 due to systematic screening of patients before sanitary repatriation from Australia and cohorting implementation. The risk of VRE diffusion is now well under control.

CONCLUSIONS

Our study confirms that it is possible to control the spread of AMR in a circumscribed territory by means of a global control strategy involving screening, cohorting unit, IT tools and antibiotic prescription controls.

KPC-3-Producing Serratia marcescens Outbreak between Acute and Long-Term Care Facilities, Florida, USA

We describe an outbreak caused by Serratia marcescens carrying bla_KPC-3 that was sourced to a long-term care facility in Florida, USA. Whole-genome sequencing and plasmid profiling showed involvement of 3 clonal lineages of S. marcescens and 2 bla_KPC-3-carrying plasmids. Determining the resistance mechanism is critical for timely implementation of infection control measures.

Epidemiology of carbapenem-resistant Enterobacteriaceae in hospitals of a large healthcare system in Miami, Florida from 2012 to 2016: Five years of experience with an internal registry

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) is an urgent public health threat globally. Limited data are available regarding the epidemiology of CRE in South Florida. We describe the epidemiology of CRE within a large public healthcare system in Miami, FL, the experience with an internal registry, active surveillance testing, and the impact of infection prevention practices.

METHODS

Retrospective cohort study in 4 hospitals from a large healthcare system in Miami-Dade County, FL from 2012 to 2016. The internal registry included all CRE cases from active surveillance testing from rectal and/or tracheal screening occurring in the intensive care units of 2 of the hospitals and clinical cultures across the healthcare system. All CRE cases were tagged in the electronic medical record and automatically entered into a platform for automatic infection control surveillance. The system alerted about new cases, readmissions, and transfers.

RESULTS

A total of 371 CRE cases were identified. The overall prevalence was 0.077 cases per 100 patient-admissions; the admission prevalence was 0.019 per 100 patient-admissions, and the incidence density was 1.46 cases per 10,000 patient-days. Rates increased during the first 3 years of the study and declined later to a lower level than at the beginning of study period.

CONCLUSIONS

Active surveillance testing and the use of an internal registry facilitated prompt identification of cases contributing to control increasing rates of CRE by rapid implementation of infection prevention strategies.

Recommendations for detection and rapid management of carbapenemase-producing Enterobacterales outbreaks

There is large heterogeneity in approaches to tackling nosocomial outbreaks caused by carbapenemase-producing Enterobacterales (CPE), however there is limited guidance on how to approach their management. Rapid and robust infection prevention and control interventions can be effective in preventing and reducing the impact of outbreaks in healthcare environments. We present a stepwise approach to aspects of CPE outbreak management, including the development of an action plan, engagement and communication with key stakeholders, developing a dynamic risk assessment, and staff education. These can provide a blueprint for organisations to create templates and checklists to inform their own outbreak response.

Persisting transmission of carbapenemase-producing Klebsiella pneumoniae due to an environmental reservoir in a university hospital, France, 2012 to 2014

In France, the proportion of episodes of carbapenemase-producing Enterobacteriaceae (CPE) with no recent stay or hospitalisation abroad is increasing. In this study, we investigate epidemiological links between apparently unrelated cases of OXA-48-producing Klebsiella pneumoniae (Kp OXA-48) colonisation or infection. We genotyped detected organisms by repetitive sequence-based PCR, and used a dynamic registry of cases and contacts to cross-reference patients' hospital stays. Between 1 November 2012 and 28 February 2014, 23 Kp OXA-48 cases were detected in a university hospital in Montpellier, of which 15 were involved in three outbreaks: outbreaks I and II occurred in November 2012 and outbreak III in October 2013. Molecular comparison of bacterial strains revealed clonal identity between cases involved in outbreaks II and III and four single cases. Cross-referencing of hospital stays revealed that these single cases and the index case of outbreak III had occupied the same room. Active case search among former occupants of that room found an additional Kp OXA-48 carrier. A clonal strain was isolated from the sink of that room. The epidemiological link between the contaminated room and outbreak II remained undetected. This study is a reminder that environmental reservoirs should be considered as a source of CPE transmission.