Whos carrying CPE? Universal admission screening in London

Whos carrying CPE? Universal admission screening in London

Whos carrying CPE? Universal admission screening in London Jonathan A. Otter, Eleonora Dyakova, Karen N. Bisnauthsing, Antonio Querol-Rubiera, Amita Patel, Chioma Ahanonu, Olga Tosas Auguet, Jonathan D. Edgeworth, Simon D. Goldenberg Centre for Clinical Infection and Diagnostics Research (CIDR), Guys and St. Thomas NHS Foundation Trust & Kings College London [email protected] @jonotter www.ReflectionsIPC.com You can download these slides from www.jonotter.net Disclosures I am a consultant to Gama. I have received payment for producing educational material for 3M. Research funding from Pfizer and the Guys & St Thomas Charity. Whats the problem? CRE are nightmare bacteria. Dr Tom Frieden, CDC Director If we don't take action, then we may all be back in an almost 19th Century environment where infections kill us as a result of routine operations. Dame Sally Davies, Chief Medical Officer If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again. David Cameron, Prime Minister, UK The rise of antibiotic-resistant bacteria, however, represents a serious threat to public health and the economy. Barack Obama, President USA Rising threat from MDR-GNR % of all HAI caused by GNRs. % of ICU HAI caused by GNRs.

Non-fermenters Acinetobacter baumannii Pseudomonas aeruginosa Stenotrophomonas maltophilia Enterobacteriaceae Klebsiella pneumoniae Escherichia coli Enterobacter cloacae Hidron et al. Infect Control Hosp Epidemiol 2008;29:966-1011. Peleg & Hooper. N Engl J Med 2010;362:1804-1813. CPE CPO Whats the problem? Resistance Whats the problem? Mortality Enterobacteriaceae Organism Attributable mortality Non fermenters AmpC / ESBL CPE A. baumannii Moderate Massive (>50%) Minimal

Shorr et al. Crit Care Med 2009;37:1463-1469. Patel et al. Iinfect Control Hosp Epidemiol 2008;29:1099-1106. Falagas et al. Emerg Infect Dis 2014;20:1170-1175. Whats the problem? Global domination! Clonal expansion Rapid spread Horizontal gene transfer GI carriage Emergence of CPE in the UK PHE. Introduction Few cases of CPE locally Carriage rate unknown PHE risk factors * not evidence based Questions over the best anatomic site to screen Importance of PCR vs. culture unknown * an inpatient in a hospital abroad, or an inpatient in a UK hospital which has problems with spread of CPE (if known), or a previously positive case. Methods Each patient approached and verbal consent obtained; risk factor questionnaire completed. Target sample

size: 4500. All patients within the first 72 hrs of admission (excluding paediatrics) Rectal swab CRO cultured on MacConkey plus erta (reference method) CRE culured on Chrome plate Perineal swab CPE detected by PCR (Check Direct CPE*) * PCR+ samples repeated on Cepheid PCR. The study was approved by the NHS Research Ethics Committee. ESBL cultured on Chrome plate Results 4843 patients enrolled. Rectal swabs collected from 4207 patients. CPE cultured from 5 (0.1%) patients. Samples from 2 patients were PCR+/culture negative by both PCR systems (Cepheid and CheckDirect).

All were positive by Cepheid, 4/5 positive by CheckDirect. CPO identified in 7 (0.2%) patients. Samples from a further 75 patients were culture negative, and PCR+ by CheckDirect but negative by Cepheid. Working hypothesis: false positives. Results ESBL were cultured from 354 (8.1% of patients overall). Rectal swabs were significantly more sensitive for detecting ESBL than perineal swabs: 331 (7.5%) vs. 165 (3.8%), p<0.001 (Fishers exact test). None of the CPE positives swabs had visible faecal matter; those with visible faecal matter were more likely to fail PCR. The reference lab method (MacConkey plus an erta disc) failed to identify any of the CPEs. Results Designation CheckDirect (Ct) CPE OXA (31.8) CPE OXA (29.0) CPE NDM (23.1) CPE Negative CPE NDM 2(8.2) Cepheid (Ct) OXA (30.2) OXA (27.8) NDM (25.6) OXA (34.1) NDM (28.2) CPO CPO OXA (24.8) VIM (31.7) OXA (31.1) VIM (30.5) Direct culture/PCR Ref lab E.coli OXA+ E.coli OXA+ E.coli NDM+ C.freundii OXA+ E.coli NDM+ K.pneumoniae NDM+ - E.coli OXA+ E.coli OXA+ E.coli NDM+ C.freundii OXA+ E.coli NDM+ K.pneumoniae NDM+ - Prevalence of risk factors Risk factor n pts % pts 55

1.2% Overseas travel in the past 12 months 1524 32.4% Overnight hospital stay in the past 12 months - GSTT 1658 35.3% Overnight hospital stay in the past 12 months - within M25 1964 41.8% Overnight hospital stay in the past 12 months - North West 8 0.2% 2187 46.5% Overnight hospital stay in the past 12 months - overseas hospital (CRE risk countries) 20 0.4% Overnight hospital stay in the past 12 months - overseas hospital (any country) 49

1.0% Antibiotics in the past 6 months - any 2628 55.9% Antibiotics in the past 6 months - one course 1399 29.8% Antibiotics in the past 6 months - more than one course 1229 26.1% At least one risk factor 3618 77.0% At least one risk factor (excluding antibiotics) 2961 63.0% Non-UK residents Overnight hospital stay in the past 12 months - any UK hospital (including London) n=4701. Risk factors for CPO % CPO+ with risk

factor %CPO+ without risk factor p value Overnight hospital stay in the past 12 months - overseas hospital (any country) 6.4% 0.1% <0.01 Overnight hospital stay in the past 12 months - overseas hospital (CPE risk countries as defined by PHE) 5.0% 0.1% <0.01 Risk factors excluding antibiotics 0.2% 0.0% 0.07 Antibiotics in the past 6 months - any 0.2% 0.1% 0.12 Overnight hospital stay in the past 12 months - within M25 0.1% 0.2% 0.13 Overseas travel in the past 12 months 0.3% 0.1% 0.16 Antibiotics in the past 6 months - more than one course 0.3% 0.1% 0.19 Overnight hospital stay in the past 12 months - GSTT 0.1% 0.2% 0.23 All risk factors 0.2% 0.0% 0.23 Antibiotics in the past 6 months - one course

0.2% 0.1% 0.28 Overnight hospital stay in the past 12 months - any UK hospital (including London) 0.2% 0.1% 0.60 Non-UK residents 0.0% 0.2% 0.78 Overnight hospital stay in the past 12 months - North West 0.0% 0.2% 0.91 Risk factors Standard of care screens, and isolation % Standard of care screening* %

253 6.5% 250 6.5% 55 1524 0 77 0.0% 5.1% 4 78 7.3% 5.1% 1658 135 8.1% 88 5.3% Overnight hospital stay in the past 12 months - within M25 1964 153 7.8%

112 5.7% Overnight hospital stay in the past 12 months - North West 8 1 12.5% 0 0.0% Overnight hospital stay in the past 12 months - any UK hospital (including London) 2187 167 7.6% 165 7.5% Overnight hospital stay in the past 12 months - overseas hospital (CRE risk countries) 20 2 10.0% 5 25.0%

Overnight hospital stay in the past 12 months - overseas hospital (any country) 49 5 10.2% 5 10.2% Risk factors Number of patient with at least one risk factor (out of all approached patients) Non-UK residents Overseas travel in the past 12 months Overnight hospital stay in the past 12 months - GSTT * Within the first 48 hours of admission. Number of approached patients Patients in isolation 3874 Discussion How do we interpret a PCR+ culture-? Questions over the quality of risk factor data collection. Is all the extra screening worth it? Economic analysis to follow! Implementation of the PHE Toolkit is challenging: only 8% of the admissions that met the PHE screening trigger were in pre-emptive isolation, and only 6% were screened..

Discussion: whos carrying CPE? Author Adler1 Mack Zhao3 Location Israel London East Delhi, 2014 India 2014 Fujian, China Birgand4 2014 Paris, France Kim5 Girlich6 Lin7 2014 2014 2013 Rai2 Villar8 Kothari9 Day10 Year 2015 2014

Seoul, Korea Morocco Chicago, USA Buenos Aires, 2013 Argentina New Delhi, 2013 India. 2013 Pakistan Swaminathan11 2013 New York NeschInderbinen12 ArmandLefvre13 Wiener-Well14 2013 Zurich, Switzerland 2013 Paris, France 2010 Jerusalem, Israel Setting CRE carriage in post-acute hospitals, 2008 CRE carriage in post-acute hospitals, 2013 High-risk inpatients and admissions. n patients 1147 1287 2077 n carriers 184 127 7

% carriers 16.0 9.9 0.3 Outpatients 242 24 9.9 Stool samples from hospitalized patients Patients repatriated or recently hospitalized in a foreign country ICU admissions Hospitalized patients Long term acute care hospitals Short stay hospital ICU 303 20 6.6 132 9 6.8 347 77 391 910 1 10 119

30 0.3 13.0 30.4 3.3 Non-hospitalized individuals 164 8 4.9 Healthy neonates 75 1 1.3 Patients attending a military hospital 175 All admissions to 7 units, including ICU, of 2 5676 hospitals Healthy community residents and 605 outpatients 32 18.3 306 5.4 0

0.0 ICU patients 50 6 12.0 Hospitalized patients 298 16 5.4 For refs see: http://reflectionsipc.com/2014/12/22/whos-harbouring-cre/ Summary The first study to evaluate the rate of CPE carriage in a non-selected acute hospital cohort. Carriage rate of CPE is extremely low at GSTT (around 0.1%). PCR may be useful, but no way of differentiating CPE from nonfermenters if an organism cannot be grown. If youre interested in resistant Enterobacteriaceae, only rectal swabs will do. Be careful when using the brown test; properly collected rectal swabs may not have any faecal matter. Overseas hospitalisation seemed to be the most important risk factor for CPO (but difficult to be certain with so few cases). Imperial researchers at IPS Oral presentations Abstract ID: 3865 - Otter J, Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S. Whos carrying CRE? Universal admission screening in London Abstract ID: 3866 - Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S, Otter J. Can I swab your rectum, please?: Improving compliance with rectal screening for CRE Abstract ID: 3860 - Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Risk factors for patients with carbapenemase-producing Enterobacteriaceae (CPE) in a Northwest London hospital Trust, 2014 2015 Posters Abstract ID: 3785 - Ahmad R, Castro-Sanchez E, Iwami M, Husson F, Holmes A. Knowledge, perceptions and decision making: What matters to patients?

Abstract ID: 3798 - Record C, Gilchrist M, Patel D, Jiao L. Infection prevention in splenectomy patients: An audit of practice in a regional hepatobiliary centre Abstract ID: 3799 - Turnbull A, Moore L, Azadian B. To PPE or not to PPE Abstract ID: 3858 - Batten L, Holmes A, Otter J, Castro-Sanchez E. Estimating the isolation burden if overseas residents are pre-emptively isolated during CRE admission screening Abstract ID: 3859 - Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Real-time surveillance of carbapenem-resistant Enterobacteriaceae (CRE) using live microbiology culture data in a North-West London Hospital Trust, 20142015 Abstract ID: 3861 - Alexander M, Mookerjee S, Nelson D, Holmes A, Otter J. An audit of single room capacity for isolation at a London hospital Trust Abstract ID: 3862 - Galletly T, Bateman A, Brannigan E, Holmes A, Otter J. Thematic analysis of post 48-hour bloodstream infections: What did we learn? Abstract ID: 3863 - Acharya A , Samarasinghe D , Singleton J, Brannigan E, Galletly T, Donaldson H, Holmes A, Otter J. Pilot evaluation of environmental hygiene using fluorescent markers and microbiological cultures Abstract ID: 3864 - Gilchrist M , Galletly T, Brannigan E, Holmes A, Otter J. How much Clostridium difficile is preventable? Abstract ID: 3867 - Goldberg S, Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Otter J. Poor sensitivity of perineal compared with rectal swabs for detecting ESBL Enterobacteriaceae Whos carrying CPE? Universal admission screening in London Jonathan A. Otter, Eleonora Dyakova, Karen N. Bisnauthsing, Antonio Querol-Rubiera, Amita Patel, Chioma Ahanonu, Olga Tosas Auguet, Jonathan D. Edgeworth, Simon D. Goldenberg Centre for Clinical Infection and Diagnostics Research (CIDR), Guys and St. Thomas NHS Foundation Trust & Kings College London [email protected] @jonotter www.ReflectionsIPC.com You can download these slides from www.jonotter.net ESBL risk factor data Risk factor Non-UK residents N pts with risk % ESBL (risk factor factor) % ESBL (without risk factor) p value 47

10.6% 8.4% 0.6171 Overseas travel in the past 12 months 1358 9.1% 8.1% 0.3489 Overnight hospital stay in the past 12 months - GSTT 1459 9.9% 7.7% 0.0242 Overnight hospital stay in the past 12 months - within M25 1703 10.0% 7.4% 0.0059 Overnight hospital stay in the past 12 months - any UK

1895 9.3% 7.7% 0.0936 Overnight hospital stay in the past 12 months overseas 42 23.8% 8.3% 0.0019 Antibiotics in the past 6 months - one course 1269 7.6% 8.8% 0.2697 Antibiotics in the past 6 months - >1 course 1103 11.8% 7.2% 0.00002

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