Educational Workshops 2016

Transcription

1 Educational Workshops 2016 Case One: Outbreak of CPE We are grateful to Suzy Fitzgerald, Consultant Microbiologist, St Vincent s University Hospital, Dublin for composing this case.

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3 2011

4 Spring 2011 Sporadic cases of CPE in Ireland February 2011 outbreak of KPC in Mid West hospital Meanwhile Tertiary referral university hospital in Dublin ~ 500 beds Main ward block built in late 1960s Referral surgical centre for: Colorectal Hepatobiliary Pancreatic

5 GI surgical service 3 adjacent wards 77 beds 8 single rooms (1 en suite) 2 x 3 bedded rooms 1 x 4 bedded 1 x 5 bedded 9 x 6 bedded Shared toilets (7) and showers on main corridor

6 Case 1 (March) Ward A Sub phrenic collection post Whipple s procedure February Laparotomy and drainage of collection Transferred to ICU post operatively Proteus mirabilis and E. faecium from theatre swab Piptazobactam and gentamicin good clinical response Drain sample 7 days post op Klebsiella pneumoniae Resistant amox, coamox, cipro, gent, piptazo, ertapenem (MIC 8) Susceptible cefuroxime, cefotaxime, ceftazidime, aztreonam Intermediate meropenem (MIC 4) Modified Hodge positive No inhibition by boronic or dipicolinic acid (Rosco kit) RIP secondary to massive GI bleed day 13 post op

7 Action after Case 1 Confirmed as OXA 48 Contact precautions Screening of all patient contacts (from ward and ICU) all negative Introduction of weekly rectal screening for CPE in ICU (CDC lab method rectal swab inoculated into 5ml TSB with 10μg meropenem disc, then subcultured onto MacConkey agar)

8 Mechanism Carb + clav Carb + boronic acid Carb + EDTA R to aztreonam R to temocillin MBL +++ S KPC +/ +++ R +/ OXA 48 S +++

9 Case 2 (March) Ward A Admitted there early March (2 days after transfer of Case 1 to ICU) Reversal of Hartman s procedure Right subphrenic collection IR drain 2 weeks post op no growth Laparotomy and abscess drainage 2 weeks later Tissue sample from laparotomy Klebsiella pneumoniae Resistant amox, coamox, cipro, gent, piptazo, ertapenem Intermediate meropenem (MIC 4) Susceptible cefuroxime, cefotaxime, ceftazidime, aztreonam, tigecycline Modified Hodge positive No inhibition by boronic or dipicolinic acid Treated with tigecycline clinical improvement Transferred to Ward B end of March

10 Case 3 (April) Ward C in Feb/March Colectomy Left subphrenic collection IR drainage, piptazobactam Drain fluid E. coli resistant amox, cipro only Discharged early March Readmitted to Ward B late March (Case 2 present on ward) Persistent collection E. coli resistant amox, cipro only Piptazobactam MSU (late April) Klebsiella pneumoniae Resistant amox, coamox, cipro, gent, piptazo, ertapenem, meropenem (MIC>16) Susceptible cefuroxime, cefotaxime, ceftazidime, aztreonam, tigecycline Modified Hodge positive No inhibition by boronic or dipicolinic acid

11 Outbreak Cases 2 and 3 confirmed as OXA 48 producers Outbreak declared

12 What would you do now?

13 What about IPC?

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15 JWP guidelines IPC Standard infection control precautions (SICPs) In addition, for patients with MDR GNB Patient isolation in single room Contact precautions (gloves and apron/gown) Continue for duration of stay If insufficient rooms, cohort (following risk assessment) Prioritise single rooms for CRE Hand hygiene monitor when patient cohorting being applied If secondary cases of CRE, monitor and reinforce SICPs and contact precautions

16 PHE toolkit for CPE IPC Single en suite room Use long sleeved gown if any part of the staff uniform not covered by an apron is expected to come into contact with the patient

17 JWP guidelines cleaning Terminal hypochlorite disinfection of vacated areas should be used in the control of outbreaks of MDR Gram negative infection Hydrogen peroxide vapour should be considered as an adjunctive measure following cleaning Increase cleaning frequency to at least twice daily, and every 4 hours for highcontact surfaces in the presence of resistant enterobacteriaceae and Acinetobacter spp.

18 PHE toolkit for CPE cleaning No increased frequency of cleaning; scrupulous routine cleaning is required Cleaning of hand contact areas and mattresses highlighted

19 How about screening other patients?

20 JWP guidelines screening during outbreaks Extensive active screening during outbreaks of CRO (e.g., follow up screening of negative cases at weekly intervals and/or all inpatient contacts of confirmed cases) If secondary cases of CRE, screening of patients not identified as carriers should be repeated weekly and on discharge from affected units, until no new cases are identified for more than 7 days

21 PHE toolkit for CPE screening during outbreaks Screen patient contacts if CPE patient had spent time in an open bay or ward No screening of household or staff contacts

22 JWP guidelines routine screening Screen all patients transferred from, or with a history of admission to, healthcare facility with known endemic CPE in last year Patients with previous samples with carbapenem resistant or other MDR Gram negative bacteria should be screened on admission Active screening for high risk specialities Patients at high risk of CRE include ICU Long term care facilities Don t screen family or staff contacts

23 PHE toolkit for CPE routine screening Screen for CPE if Inpatient in hospital abroad within last year Inpatient in UK hospital with spread of CPE within last year Previously colonised/infected with CPE Close contact of patient with CPE

24 Would you screen the environment?

25 JWP guidelines environmental screening Controversial Consider when unexplained transmission of MDR Gram negative organisms or a possible common source for an outbreak Choose sites likely to be relevant for cross transmission Work surfaces close to patient Equipment/surfaces that are likely to be touched frequently (PHE toolkit for CPE no recommendation)

26 Further cases Case 4 Inpatient on Ward A (end April early May) Whipple s procedure OXA 48 Kleb. pneumoniae from out patient MSU in May No treatment required Case 5 Inpatient on Ward A (April) Readmitted June to Ward A for Whipple s procedure Admission rectal swab negative Biliary stent removed at op Kleb. pneumoniae resistant amox only Drain fluid 5 days post op OXA 48 Kleb. pneumoniae

27 Further cases 6 surgical patients with OXA 48 producing K. pneumoniae identified from rectal screening 4 in June 1in August 1 in September 1 medical patient had OXA 48 Kleb. pneumoniae isolated from sacral pressure sore in August Had been on Ward B in 2010

28 Epidemiological investigation Admission to surgical wards common feature in all cases No evidence of transmission in radiology, endoscopy, theatre No history of foreign travel

29 Antimicrobial susceptibility (EUCAST)

30 JWP guidelines AST Meropenem susceptibility in all significant Gram negative isolates Cefpodoxime in all enterobacteriaceae Ceftazidime in all Pseudomonas spp.

31 OXA 48 Usually susceptible to 3 rd and 4 th generation cephalosporins Monobactams Variable carbapenem susceptibility Modified Hodge positive Will not be inhibited by boronic or dipicolinic acid Use temocillin in carbapenemase phenotypic screen

32 Phenotypic testing for carbapenemase production Mechanism Carb + clav Carb + boronic acid Carb + EDTA R to aztreonam R to temocillin MBL +++ S KPC +/ +++ R +/ OXA 48 S +++

33 Molecular investigation PFGE Lanes 2 5 = cases 1 4 MLST ST 221

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35 Bed management CPE cases Isolated in single rooms for entire admission Exposed patients Cohort ward As patients discharged, all exposed patients centralised in Ward B (Wards A and C cleaned and opened) If readmitted, exposed patients placed in exposed ward and screened on admission Not possible to flag these patients on PAS, so list of patients kept in ED and bed management

36 Non exposed patients Initially in temporary ward Wards A and C (when re opened) Outbreak declared over and Ward B re opened in Spring 2012

37 Case 2 Admitted March 2011 Discharged home mid December short admissions December 2011 (2 days and 5 days) Rectal swab positive Admitted June 2013 Admission rectal screen negative Repeat rectal screen on day 11 positive (on antimicrobial treatment for Serratia marcescens bloodstream infection) Isolated in single ensuite room during all admissions

38 Since 2011 First isolate CPE First isolate CPE from clinical specimen from rectal swab (3 other CRE*) 3 (2 x urine, 1 x wound) (5 other CRE) 1 (urine) (3 other CRE) 1 (urine) (7 other CRE) 3 (1 each of sputum, urine, wound) 2016 (YTD) 0 (2 other CRE) 4 (2 x urine, 1 x wound) * Other CRE usually ESBL or AmpC with porin loss

39 Take home points OXA 48 can be difficult to detect Importance of SICPs and contact precautions Active screening of contacts useful in outbreak situation Active screening for high risk patients

40 References Wilson APR et al. Prevention and control of multi drug resistant Gramnegative bacteria: recommendations from a Joint Working Party. J Hosp Infect. 2016; S1 44 Acute trust toolkit for the early detection, management and control of carbapenemase producing Enterobacteriaceae. PHE (2013) Wrenn C et al. Investigation of the first outbreak of OXA 48 producing Klebsiella pneumoniae in Ireland. J Hosp Infect. 2014; 87(1):41 6 O Brien DJ et al. First isolation and outbreak of OXA 48 producing Klebsiella pneumoniae in an Irish hospital, March to June Euro Surveill. 2011;16(29)