Alice Guh, MD, MPH

Division of Healthcare Quality PromotionCenters for Disease Control and Prevention

CSTE CRE Panel Session – June 14, 2011

Public Health Response to Carbapenem-Resistant Enterobacteriaceae:

The Role of Health Departments

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Carbapenem-resistant Enterobacteriaceae (CRE)

Common cause of HAIs Found in both acute care hospitals and long-term

care settings Since 2004, reports of CRE cases from LTACH and

LTCF

Similar to the spread of other MDROs Movement of colonized patients across the

continuum of care contributes to regional transmission

Supported by mathematical modeling

Urban C et al. Clin Infect Dis 2008;46:e127030Endimiani A et al. J Antimicrob Chemother 2009;64:1102-1110.Smith DL et al. PNAS 2004;101:3709-14.

Inter-Facility Transmission of MDROs (Including CRE)

Munoz-Price SL. Clin Infect Dis 2009;49:438-43.

Regional Approach to MDRO Prevention is Essential

Rationale for regional approach What happens in one facility will impact

surrounding facilities Individual facilities can reduce MDRO prevalence

only to a certain point

Successful regional coordination by public health VRE control in Siouxland region CRE containment in Israel

Sohn AH et al. Am J Infect Control 2001;29:53-7.Schwaber MJ et al. Clin Infect Dis 2011;52:848-55.

How to Operationalize Public Health Response to Emerging MDROs

Opportunity to apply regional approach to CRE prevention

HDs in unique position to coordinate local and regional response to CRE Assess CRE prevalence/incidence within their

jurisdiction in order to provide situational awareness to facilities

Serve as resource to facilities about prevention options

Informs public health response to other emerging MDROs

DEVELOPMENT OF CRE TOOLKIT

Outline of CRE Toolkit

Facility-level prevention strategy for facilities and HDs

Regional prevention strategy specifically for HDs Aggressive approach to contain or prevent CRE

emergence • Regions with no CRE identified• Regions with few CRE identified

Regional Prevention Strategy

Regional Surveillance for CRE

Determine CRE prevalence within a given jurisdiction Make CRE laboratory reportable (in regions with

no known or few CRE) Survey IPs or lab directors

Feedback of surveillance results Provide specific enough data for facilities to act

upon • Facility name, if possible

or• Stratify results by geographic area and/or by facility

type

Regional Prevention Strategy

Regions With No CRE Identified

Aggressive efforts at detection: Perform periodic surveillance and feedback

Frequency may depend on CRE prevalence in neighboring regions (establish mechanism for communication)

Educate facility staff to increase awareness Epidemiologic importance of CRE Recommended surveillance and prevention

measures*

* http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

Regional Prevention Strategy

Regions With Few CRE Identified

Aggressive efforts at containment, may target select areas:

Implement infection prevention measures Reinforce core prevention measures in all facilities Facilities with CRE: use supplemental measures Facilities without CRE: targeted surveillance testing,

preemptive CP

Use inter-facility patient transfer forms Indicate CRE status, open wounds/devices,

antimicrobial therapy

Educate facility staff to increase awareness

Perform periodic surveillance and feedback

REGIONAL CRE SURVEILLANCE BY SELECT HEALTH DEPARTMENTS

Development of CRE Survey

Fall 2010 – CRE conference calls with interested HDs to identify actionable steps to take HDs notified through CSTE HAI listserve

CRE survey template designed to be used by HDs to assess CRE prevalence within their jurisdiction 7 questions to administer to IPs of acute care

facilities Estimate frequency of CRE colonized- or infected-

patients Assess facility-level surveillance activities for CRE

and related prevention measures** http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

State HDs Conducting CRE Survey (n=7)

Utah Illinois

Virginia Idaho

South Carolina West Virginia

Wisconsin

Administration of CRE Survey

Targeted acute care hospitals, but included: Long-term acute care hospitals (≥3 states) Critical access hospitals (≥2 states)

Survey methods by HDs Email /online survey (e.g., Survey Monkey) to IPs Paper survey at APIC meetings

Date of survey: ranged Sep 2010-Mar 2011 Survey lasted one day to 2-3 months Sent reminder emails, phone calls to non-

respondents

Survey Respondents

Aggregated state-level data across all 7 states: Median response rate – 67% (range: 26% to 100%)

Breakdown by bed size (n=6 states): Total 360 facilities ≤50 beds – 30% 51-200 beds – 39% 201-500 beds – 27% >500 beds – 4%

Fairly representative of national data (2008 AHA data) Except greater % of facilities with ≤50 beds

captured in survey

CRE Prevalence in Past 12 Months (n=7 states)

Percentage of Facilities Per State

CRE Prevalence Median Range

Identified CRE 30 10-46

Daily or weekly 0 0-16

Monthly or greater 100 84-100

≤48 hrs of admission 92 74-100

>48 hrs of admission 59 25-75

Do not know if have CRE 12 10-18

CRE Surveillance Measures (n=7 states)

Percentage of Facilities Per State

Surveillance measures Median Range

System for micro lab to alert

IP staff77 57-91

Review prior micro data* 37 29-44

If yes, identified CRE 10 0-17

Conduct pointprevalence survey 6 0-11

If yes, identified CRE 33 0-33

Conduct AST of epi-linked

patients12 10-18

*Applies to facilities that have not or have rarely identified CRE cases (data available for 6 states)

CRE Prevention Measures (n=7 states)

Percentage of Facilities Per State

Prevention measures Median Range

Place on Contact Precautions 95 86-100

Place in single-patient rooms 96 73-100

Summary of CRE Survey Results

CRE identified in <50% of all responding facilities, still have opportunity to prevent full emergence

Although there is intra-facility transmission, majority of identified cases are imported Important role of inter-facility patient sharing Supports the need for regional approach to

prevention

Low facility adherence to recommended surveillance practices and need for increased education / awareness Potential under-reporting of CRE

Feedback of Survey Results by HDs

At least 5 states provided feedback to IPs / facilities Email (memo, monthly HAI newsletter) Presentation at APIC meeting

Feedback content Only shared aggregated results

• Some stratified by geographical region (n=2), facility type (n=1)

Some provided streamlined 2009 MMWR guidance* (n=3)

* http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

INTERVIEWS WITH STATE HEALTH DEPARTMENTS

Key Informant Interviews

Primary objective: to understand why some HDs decided to conduct CRE survey and others did not

Participants All 7 states that conducted CRE survey 4 additional states that did not conduct CRE

survey (participants of initial CRE calls via CSTE HAI listserve)

Standardized script with trained interviewer

Key Interview Findings (n=11 states)

All HDs communicated regularly with IPs about HAI topics in previous 12 months (prior to CRE survey)

No difference between states in competing priorities and concerns about CRE survey Main concern – perception of overburdening IPs

Yet perspectives differed regarding conducting survey: opportunity to learn vs concerns about survey intent and logistics and other data source Assess for other confounders and contextual

factors Evaluate alternative sources to IPs for information

CASTING A VISION FOR PUBLIC HEALTH ACTION

Anywhere County, USAStatus Report: Emerging MDRO X

St. Joseph’s Hosp

St. Vincent’s Hosp

St. Mary’s LTACH Orangetown

LTACHSmallville Hosp

Peachtree Hosp Smithville

LTACH

Magnolia LTCF

Appletree Hosp

St. Peter’s Hosp

Jamesville Hosp

Greensville LTCF

St. Claire’s LTACH

Thomasville Hosp

Franklin Hosp

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Thank you