Update on the CPE epidemic in NZ & progress in the national - - PowerPoint PPT Presentation

Josh Freeman Clinical Director Microbiology and Virology Department CDHB

Update on the CPE epidemic in NZ & progress in the national response

• ver the last year

INFECTION PREVENTION CONTROL NURSES COLLEGE CONFERENCE 2019

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)

Travel to South /SE Asia (no hospitalisation) 39% Overseas hospitalisation 40% No travel history 21%

Sources of acquisition of CPE in NZ - 2019

47% 5% 6% 6% 6% 6% 6% 6% 6% 6%

Overseas Hospital Sources of CPE 2019

India Fiji Thailand Cambodia Brazil Egypt Phillipines Israel Samoa Kuwait

77% 4% 4% 5% 5% 5%

Overseas Community Sources of CPE 2019 (no hospitalisation )

India Overseas NOS Vietnam Lebanon Europe China

6.7 9.68 5.35 12.23 23.65 20.59 26.86 33.68 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019'

Rate / 100 000 arrivals from India year

CPE rate following travel to Indian Subcontinent (no hospitalisation) (2019 data adjusted)

• 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

46% 42% 4% 4% 1% 2% 1%

Travellers with healthcare exposure

• verseas: breakdown of CPE species
• E. coli
• K. pneumoniae

Citrobacter spp. Enterobacter spp.

• M. morganii
• P. mirabilis

Providencia spp.

87% 1% 10% 2%

Travellers without healthcare exposure

• verseas: breakdown of CPE species
• E. coli

Enterobacter spp.

• K. pneumoniae
• K. oxytoca

Bacterial species and glo lobal spread

• f 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

NDM-5 53%

• ther NDM

16%

• xa-181

28%

• ther oxa types

3%

CPE gene subtypes acquired during travel to Indian subcontinent, 2014-2019

6.7 9.68 5.35 12.23 23.65 20.59 26.86 33.68 2.67 9.78 15.05 14.97 17.57 2.45 6.45 1.87 14.22 8.79

5 10 15 20 25 30 35 40 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019'

rate / 100 000 arrivals from India year CPE rate following travel to Indian Subcontinent (no hospitalisation) by CPE gene subtype [Total=blue line, NDM-5=orange line; oxa-181=red line]

Example antib ibiogram, , NDM-5 producing E. . coli li

ESBL SCREEN - RECTAL SWAB CULTURE : (1) Escherichia coli isolated **This isolate is positive for a NDM carbapenemase.** * This isolate has a CTX-M group 1 Extended spectrum beta- lactamase. (1) Amoxycillin R Amox/Clav R Aztreonam R Cefuroxime R Cefoxitin R Gentamicin R Cotrimoxazole R Ceftazidime R Ceftriaxone R Cefepime R Tazocin R Amikacin S Meropenem R R = Resistant S = Susceptible I = Intermediate MINIMUM INHIBITORY CONCENTRATION Organism : Escherichia coli Antibiotic : Ertapenem MIC : > 32 mg/l Resistant Antibiotic : Meropenem MIC : 4.0 mg/l Resistant Antibiotic : Fosfomycin MIC : 1.0 mg/l Susceptible Antibiotic : Aztreonam MIC : > 256 mg/l Resistant Antibiotic : Ceftazidime/avibactam MIC : > 256 mg/l Resistant Antibiotic : Ceftaz-avibactam + aztreonam MIC : 8.0 mg/l

Mult ltiple CPE strains in in a patient repatriated fr from a hospital in in In India

2 4 6 8 10 12 14 16 2009' 2010' 2011' 2012' 2013' 2014' 2015' 2016' 2017' 2018' 2019'

number of known newly acquired cases year

Yearly number of known CPE acquisitions in NZ (21% in 2019)

2018 MMH Burns Unit

• Outbreak. NDM –

multiple species 2016 Hospital and LTCF transmission OXA- 232 K. pneumoniae, 2019 Age-related residential care NDM

• E. coli,

Auckland 2015 1.Hospital transmission of VIM

• K. pneumoniae, Waikato
• 2. Hospital transmission of NDM K.

pneumoniae – haematology unit and LTCF - Canterbury

2019: NDM E. . coli tr transmission in in residential care

• Mrs B, 94y F, resident at LTCF in

MMH catchment area

• Screened on admission to MMH,

May 2019, found to have NDM-5

• E. coli ST405
• No travel in past 2 years
• Had been to MMH outpatient

clinics over past 12 months

• Mrs H, 92y F, same LTCF as Mrs B
• Detected NDM-5 E. coli ST405

carriage on screening as part of investigation in July 2019

• Previous admissions to MMH in

Jan 2019, Feb 2018, Aug 2017

• No travel

2019: NDM E. . coli tr transmission in in residential care

• Mr C; 88y M, extensive travel

history, never hospitalised overseas

• cruise Bali to Sydney Dec 2018
• Portugal 2018
• Caribbean 2017
• Ireland 2016
• Private hospital for CABG, early

March 2019

• Transferred to ICU ADHB, screened

in and found to have NDM-1 E. coli ST405 carriage

• Discharged to LTCF (different to the
• ther two patients

Mr C Mrs B Mrs H Mr C 1 2 Mrs B 1 1 Mrs H 2 1

• ESR found the two isolates very

closely genetically related to a third isolate from a patient Mr C

• SNP differences in table below

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

Private surgical hospital Acute care hospital 1 ICU Long term care facility 1 Long term care facility 2 Acute care hospital 2 Gen Med ward Long term care facility 2

Patient 1 March 2019

Overseas travel

Patient 2 May 2019 Patient 3 July 2019

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
• verseas 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
• ne 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

Victorian Guidelines for residential care

• Resident placement
• When single rooms with ensuite are available, assign priority for these rooms to

residents with CPE. Give highest priority to those residents who have conditions that may increase the risk of transmission of CPE, for example, uncontained secretions or excretions. When single rooms are not available, residents with the same strain of CPE can be cohorted in the same room. When cohorting is not possible you will need to consider lesser alternatives to reduce the risk of transmission, for example, shared room but dedicated bathroom facilities, shared room using a dedicated commode etc.

• If sharing a room is unavoidable, consider the following.
• Resident who shares a room with a CPE case should not have indwelling medical devices or
• pen wounds.
• Regularly screen roommate(s) for CPE (for example every 3–6 months).
• If roommate is transferred to a health care facility, notify the facility that the resident shares a room with

a CPE case.

Victorian Guidelines for residential care

• Participation in group activities and attending communal areas
• It is extremely important to maintain a resident’s ability to socialise and have

access to rehabilitation opportunities. Residents with CPE can continue to participate in group activities unless they are unwell (for example, diarrhoea). Any oozing wounds should be covered with a dressing that contains the wound

• oze.
• For cases and uncleared close contacts:
• Avoid use of toilets outside of their room. It is always best to toilet residents in their own

toilet so as to minimise potential contamination outside their room. If the toileting of a resident does need to occur outside their own room the toilet must be cleaned immediately after its use, or use a commode and ensure it is cleaned as well.

• Ensure strict hand hygiene by the resident if using equipment as part of a group session, and clean

and disinfect equipment after use. Staff may need to assist residents with their hand hygiene.

• Residents can attend a shared dining area and use regular dishes and cutlery. Dishes and

cutlery used by residents with CPE can be processed in the usual manner (for example, dishwasher).

Summary ry

• The CPE epidemic in NZ is continuing to evolve, with increasing acquisition among travellers to

South Asia without healthcare exposure

• Sporadic outbreaks of CPE are becoming more frequent in both acute and residential care facilities
• CPE national surveillance and response systems, coordinated by the MOH Communicable Disease

team, have made significant steps forward over the last year

• Acute care hospitals, long term residential care facilities and private surgical hospitals in NZ should

perform active surveillance for CPE in accordance with the national guidelines:

• All new admissions / new residents who have travelled to South /SE Asia in the preceding year
• Anyone admitted to an overseas hospital in the preceding year
• More work is needed in the coming year including
• Publication of specific CPE guidelines for residential care
• Educational efforts targeting the residential care sector
• Changes to the H&DS IPC Standard to reflect the importance of appropriate CPE surveillance and response at

the facility level