Chicago’s Regional MDRO

Experience and Response

Robert A. Weinstein, MD

January 21, 2020

The C. Anderson Hedberg, MD Professor of Medicine

Rush University Medical Center

Chairman Emeritus, Department of Medicine

Cook County Hospital

MDRO, MultiDrug-Resistant Organism

Disclosures: Sage Inc (Remote) & CDC (Current) Funding

TOPICS

• Background – State of Infection Control

• Regional Spread of CRE & Candida auris

• Regional Control Experiences

• Tracking MDROs & Interfacility Communication

• Take Home Messages

CRE, Carbapenem-Resistant Enterobacteriaceae

Healthcare Worker Hand Contamination

15-20%

Patient Cross-Colonization

Skin Colonization

(Fecal Patina)

GI/Resp Carriage

Environmental

Contamination Normal

Flora

~100% 0-20%

40%

MDRO, Multi-drug resistant organism

MDRO

Colonization Antibiotics

Colonization Pressure &

More Factors - Situational

10-40+%

Patient Infection

Variable %

Antibiotic Stewardship

Microbiome Restoration?

Other - Situational

Chlorhexidine

Bathing Improved Cleaning

Hand Hygiene

Universal Gloving

Hand Hygiene

Patient Screening

Isolation Precautions

Cluster Detection

Device Guidelines

Reporting Rates

Cluster Detection

PATIENT LEVEL INFECTION CONTROL Base Interventions on Causal Pathway of MDRO Spread

Adapted from Weinstein & Kabins, Am J Med 1981; 70:449-54.

RESISTANCE “ICEBERG”

Regional Spread Intra-facility Spread

Moving Beyond Our Own Icebergs

Factors Relative contribution

Gram (-) Gram (+)

Cross-infection via hands of hospital

personnel 30-40% 60-80%

Antibiotic pressures 30-40% 10-20%

“Community” acquired 20-25% 10-50%

Other (contamination of environment,

food, air: personnel carriers; unknown) 20+% 10-20+%

The Epidemiology of Healthcare-associated

Infections is Generally Understood

U.S. IMPACT — 100,000+ HOSPITAL DEATHS/YEAR

HOW & WHY DO HAIS SPREAD?

Wiener et al, JAMA 1999; 281:517-23.

Long-term Care & Regional Spread – Not a New

Problem Let’s Prevent History from Repeating

MMWR August 2015; 64(30):826.

Regional Spread In The Spotlight

CDC Vital Signs, August 2015 www.cdc.gov/vitalsigns/stop-spread

Legend

LTACH

Nursing Home

Acute Hospital

Patient

Emergence & Rapid Regional Spread of K pneumoniae Carbapenemase-Producing Enterobacteriaceae

HOSPITAL AND LONG-TERM CARE INTERRELATIONS

Social Network depiction of LTACH, Nursing Home, & Hospital spread of KPC (Carbapenem-resistant Klebsiella pneumoniae)

LTACH, Long term acute care hospital; MDRO, Multidrug resistant organism

Won et al, Clin Infect Dis 2011; 53(6):532-40.

REALM Project – Expanded for ICU & LTACH

Surveillance for KPC

REALM, Regional Evaluation of Legislative Mandate to screen patients for MRSA; LTACH, Long-term acute care hospital; KPC, Klebsiella pneumoniae carbapenemase producers

Hospital ICUs (blue) LTACHs (red)

The Importance of Long-term Acute Care Hospitals in the

Regional Epidemiology of Klebsiella pneumoniae Carbapenemase–Producing Enterobacteriaceae (KPC)

Lin et al, Clin Infect Dis 2013; 57(9):1246–52.

KPC colonization

prevalence 9-fold

higher in LTACHs

than in short-stay

acute care hospital

adult ICUs

LTACH, Long-term acute care hospital; ICU, intensive care unit

“SERVICE-LINES” MATTER Transfer from High-Acuity Long-Term Care Facilities Is Associated with Carriage

of K pneumoniae Carbapenemase–Producing Enterobacteriaceae (KPC)

Prabaker et al, Infect Control Hosp Epidemiol 2012: 33(12):1193-9.

KPC carriage (mean, 95% CIs) in patients from long-term care facilities (LTCFs), at acute

care hospital transfer in multi-hospital study. SNF, skilled nursing facility without ventilator

unit; VSNF, SNF with a ventilator unit; LTACH, long-term acute care hospital.

LESSONS LEARNED • MDROs CAN EMERGE AND SPREAD RAPIDLY

• In 2017, CDC outlined a new effort to react rapidly to novel MDROs, encouraging health care facilities and public health authorities to respond to even single isolates of an emerging pathogen (MMWR 20186; 67: 396-401)

• REGIONAL SPREAD REQUIRES REGIONAL CONTROL STRATEGIES

• Example: Friedman et al, Infect Control Hosp Epidemiol 2017; 38: 580-94

• SOME LTC FACILITIES ARE HIGH RISK

• NEED TO ASSESS IMPACT OF REGIONAL CONTROL – HAVE WE MOVED THE NEEDLE?

Ostrowsky et al, N Engl J Med 2001; 344(19):1427-33.

Prevalence of VRE in 30 Acute and Long-term Care Facilities in Siouxland Region*

Type of Facility Colonization with VRE

8/1997 10/1998 10/1999

No. of patients (%)

All 40 (2.2) 26 (1.4) 9 (0.5)

Acute care 10 (6.6) 9 (5.5) 0

Long-term care 30 (1.7) 17 (1.0) 9 (0.5)

*Only data from the 30 facilities that participated in all three years of the study were included. VRE denotes vancomycin resistant enterococci. Chi square for trend, P<0.001.

Schwaber et al, Clin Infect Dis 2011; 52(7):848-55.

National Intervention to Control

KPC: Israel

• National Task Force with authority to collect data and intervene as needed

• Mandatory reporting

• Mandatory isolation of hospitalized KPC carriers

• Contact precautions (index & subsequent admissions)

• Cohort nursing

KPC, Klebsiella pneumoniae carbapenemase producers

Schwaber et al, Clin Infect Dis 2011; 52:1-8.

National guidelines for active surveillance and intervention in long term care facilities issued

Success of a National Intervention to Control

Carbapenem-resistant Enterobacteriaceae in

Israel’s Long-term Care Facilities – A Marathon

Percentage of patients with positive results on screening for CRE carriage

among patients with no CRE history in 5 cross-sectional surveys, by type of

ward. Abbreviation: CRE, carbapenem-resistant Enterobacteriaceae.

Ben-David et al, Clin Infect Dis 2019 Mar 5;68(6):964-71.

X = Intervention Bundle Introduced

Hayden et al, Clin Infect Dis 2015; 60:1153-61.

Hayden et al, Clin Infect Dis 2015; 60:1153-61.

INTERVENTION BUNDLE

• Admission & every other

week rectal culture

screening

• Contact precautions;

cohorts or private rooms

for CRE patients

• Daily bathing with

chlorhexidine-impregnated

cloths all patients

• HCW education &

adherence monitoring

Incidence Rate of KPC–producing

Enterobacteriaceae Rectal Colonization

During the Intervention Period

Before After

LTACH, Long-term acute care hospital;

CRE, Carbapenem-resistant Enterobacteriaceae

Axillary Cultures (LTACH patient) for CREs

Before and After Chlorhexidine Bathing

LTACH, long-term acute care hospital;

KPC, Klebsiella pneumoniae carbapenemase

Pre-Intervention Intervention

No. of

events

Events/

1000 pt-days

No. of

events

Events/

1000 pt-days P-value

KPC in any clinical

culture 656 3.7 285 2.5 .001

KPC bloodstream

infection 165 0.9 48 0.4 .008

Bloodstream

infection due to any

pathogen

2004 11.2 870 7.6 .006

Hayden et al, Clin Infect Dis 2015; 60:1153-61.

Effect of Bundled Intervention on Positive

Clinical Cultures at 4 LTACHs

Lee et al, JAMIA 2013; 20:e139

Denotes ego hospital

Lee et al, Plos One 2011; 6:e29342

Lee et al, Health Aff 2012; 31:2295

…for healthcare-associated infections that spread between hospitals as a

result of patient movements… once 10–20% hospitals are recruited as

sentinels, only modest reductions are seen as more hospitals are

recruited Ciccolini et al, PNAS 2014; 111(6):2271-6

Regional Focal Points For Controls?

KPC, Klebsiella pneumoniae carbapenemase; ICU,

Intensive Care Unit; LTACH, Long-term acute care hospital

REALM data courtesy of Michael Lin, MD, MPH; unpublished data, not for distribution

Measuring Durability and Regional Impact

Candida auris – A KEY EMERGING PATHOGEN

• Multi-continent emergence in 4 “unrelated” outbreaks

• In U.S., huge iceberg effect in some LTACHs

• Heavy environmental contamination in affected nursing home and hospital wards

• Some clades resistant to multiple anti-fungals

• Clinically, high morbidity and mortality impact

• Already subject of a feature story in the NEW YORK

TIMES (APRIL 6, 2019)

Candida auris is Infecting Patients in Hospitals and Nursing

Homes Around the World and Seems to Have Emerged in

Several Locations* at Once, Not From a Single Source

*Four Clades: South Asian (C I), East Asian (C II), African (C III), and South American (C IV)

A Proposed Scheme for Emergence of C. auris

Casadevall A, Kontoyiannis DP, Robert V, 2019 mBio 10:e01397-19.

https://doi.org/10.1128/mBio.01397-19

Candida auris by State Most Cases in the U.S. have been in Nursing Homes in

New York City, Chicago and New Jersey

https://www.chicagohan.org/cauris

Illinois C. auris Cases (856) by Culture

Date, As of 10/8/19*

Challenges

• Patients move around, but their health information may not move with them

• Inconsistent communication at transfer

• Emergent transfers (SNF → acute care hospital)

• Off-hours movement

• Some facilities have different definitions of MDRO colonization

REALM provides point prevalence surveys in high-risk sites

Would be great to have real-time tracking for antibiotic resistance and problem pathogens throughout a region

Tracking Regional MDRO Spread & Control

www.XDRO.org for Illinois

Bottom-line

• Develop Infection Controls Based on Epidemiology

• Traditional control measures work

• But new problem pathogens continue to emerge

• And spread among acute care, long-term acute care, & skilled nursing facilities is common

• So, controls must be applied proactively & regionally (& beyond)

• Resistance Must be Tracked Regionally (& Beyond)

• Our approach — Citywide culture surveys (REALM Project) & Statewide XDRO registry

Make the World Happier

ACKNOWLEDGEMENTS

• IDPH & CDPH

• Chicago CDC Prevention & Intervention Epicenter Colleagues