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Public Health and Long Term Care: A Cautionary Tale
Susan I. Gerber, MDAssociate Medical Director
Cook County Department of Public Health
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Healthcare 1970-1980:Hospital is Center of Universe
Jarvis WR Emerg Infect Dis 2001;7: 170-3
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Healthcare Surveillance Needed Now
Jarvis WR Emerg Infect Dis 2001;7: 170-3
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Healthcare Surveillance Needed Now- Addendum
Long term acute care hospital
Long term care facility with ventilator and psychiatric patients
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Newspaper HeadlinesNursing home safety reforms get deadlineTask force chief sets timetable for key proposals to end violence*
Justice Department supports safety reforms for nursing homesRecommendation to move patients with severe mental illness praised*
Nursing home sexual violence: 86 Chicago cases since July 2007 — but only 1 arrestRape allegations were reported in a quarter of city's 119 nursing homes in those two
and a half years, records show*
Nursing home raids net 8 arrestsWarrants target 20 people wanted on charges ranging from domestic battery to indecent exposure* Senators outraged over Illinois nursing home safety'Shame on us, all of the agencies,' one senator says at hearing*
*Chicago Tribune 2009-2010
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Newspaper Headlines
Long-Term Care Hospitals Face Little Scrutiny
“We see such sick people.” Dr. David Jarvis, national medical director for the Select Medical Corporation
By ALEX BERENSONPublished: February 9, 2010
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Long Term Acute Care Hospitals (LTACHs)
• Official definition:– Patients are required to have medically complex
situations and a mean length of stay of ≥ 25 days
• Simple definition:– An island of intensive care
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Long -Term Acute Care Hospitals: LTACHs
• The Perfect Storm:– Device utilization high– Rate of colonization at admission high– Rate of antibiotic use high– Duration of hospitalization prolonged
Gould etal. ICHE 2006; 27:920-925
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Recipe for Disaster
• New antibiotics or old antibiotics resurrected- difficulties with antibiotic stewardship
• Specialty facilities for long term care, LTACHs and dialysis units
• More demands on ICPs• Outsourcing microbiology• Devices and respiratory care
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Long Term Care Facilities (LTCFs)
• Some LTCFs have medically complex patients who are ventilated with prolonged lengths of stay
• They may have combinations of patients:– Ventilated patients with central lines– Older adults with less nursing care requirements– Alzheimers unit– Psychiatric unit
• They are not “LTACHs”--- using medicare definitions……..
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Burning Issues• Bloodborne pathogens
• Multidrug-resistant organisms (MDROs)
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Multidrug-resistant Organisms (MDROs)
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MDROs and Long Term Care
• Including:– KPC (Klebsiella pneumoniae carbapenemase)
containing organisms– Elizabethkingia meningoseptica– Clostridium difficile
– Acinetobacter spp, Pseudomonas aeruginosa, Staphylococcus aureus, etc……….
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Some Background on Enterobacteriaceae
• Bacteria in Enterobacteriaceae group are common causes of community and healthcare acquired infections.
• E. coli is the most common cause of outpatient urinary tract infections.
• E. coli and Klebsiella species (especially K. pneumoniae) are important causes of healthcare associated infections.– Together they accounted for 15% of all HAIs
reported to NHSN in 2007. CDC, 2009
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Klebsiella Pneumoniae Carbapenemase
• KPC is a class A -lactamase– Confers resistance to all -lactams including extended-spectrum
cephalosporins and carbapenems
• Occurs in Enterobacteriaceae– Most commonly in Klebsiella pneumoniae– Also reported in: K. oxytoca, Citrobacter freundii, Enterobacter
spp., Escherichia coli, Salmonella spp., Serratia spp.,
• Also reported in Pseudomonas aeruginosa (South America)
CDC, 2009
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Susceptibility Profile of KPC-Producing K. pneumoniae
Antimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
Amox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4μg/ml
Ceftriaxone R Colistin MIC >4μg/ml
Cefepime R Tigecycline S
CDC, 2009
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KPC Enzymes
• Located on plasmids; conjugative and nonconjugative
• blaKPC is usually flanked by transposon sequences
• KPC-2 and KPC-3 most common in the US
• blaKPC reported on plasmids with:– Normal spectrum -lactamases– Extended spectrum -lactamases– Aminoglycoside resistance– Fluoroquinolone resistance
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Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate(s)
CDC, 2009
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Risk Factors for and Outcomes of CRKP Infections
• Case control studies done by Patel et al. at Mount Sinai in NYC, where CRKP are now endemic. – 99 patients with invasive CRKP infections
compared to 99 patients with invasive carbapenem susceptible K. pneumoniae infections.
Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
CDC, 2009
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Comorbidities
0
10
20
30
40
50
Num
ber
of
CRKP
CSKP *
*p <0.001
CDC, 2009
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Healthcare-Associated Factors
0
20
40
60
80
100
Num
ber
of S
ubje
cts
CRKP
CSKP
*
* *
*
* p <0.001
CDC, 2009
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Recent Outbreaks of KPC Producing Klebsiella
• September 2008: Acute care hospital in Ponce, Puerto Rico.
• November 2008: Long term care facility in IL.• Methodology:
– Review of microbiology data for case finding– Review of infection control practices– Surveillance cultures of patients who were
epidemiologically associated with cases.
CDC, 2009
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Infection Control Observations-Puerto Rico and IL
• Staff entering rooms without donning a gown, occasionally no gloves or hand hygiene
• Reuse of gloves between rooms with no hand hygiene.
• Exiting rooms without removing gowns• Touching patients and equipment without PPE• Inconsistent PPE use during wound care, respiratory
care
CDC, 2009
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CRKP Outbreaks-Lessons Learned
• Healthcare epidemiology/infection control staff at some facilities might not be aware that CRKP are actually present.
• The etiology of outbreaks of CRKP are multi-factorial, but are due in part to:– Non-compliance with infection control– Unrecognized carriers serving as reservoirs
for transmission
CDC, 2009
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E. meningoseptica
• Also known as:– Flavobacterium meningosepticum– Chryseobacterium meningosepticum
• Found in soil and water• Identified in neonatal wards• Immunocompromised adults
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Long Term Acute Care Hospital (LTACH) Facility A
• Converted to LTACH in 2006• Individual patient rooms• Ventilators and wound care• Average daily census = 55 patients • Average patient stay = 30 days
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E. meningosepticum Jan 2007-April 2008
0
2
4
6
8
10
JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR
2008
Rep
ort
ed P
atie
nts
2007
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E. meningosepticum antibiotic susceptibilitiesJan 07 – Apr 08 (N=37)
0102030405060708090
100
Perc
en
t S
uscep
tib
le
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Responses
• Consider targeted active surveillance cultures if clusters or increased cases identified
• Inservices or education• Improve environmental disinfection• No tap water to come into direct contact of patient
devices • Standardize respirator cleaning• Admission screening of trach patients• Specific communications regarding resistant
organism information for patient transfers
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EKM blood culture isolates-aggregate
Num
ber
of
isol
ates
Year of collection
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EKM blood culture isolates-by hospital
0
1
2
3
4
5
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Num
ber
of is
oloa
tes
Year of collection
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Clostridium difficile
• Emergence of the epidemic strain BI/NAP1• Discharge data indicates an increase
• More severe disease?
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C. difficile BI/NAP1 Strain Severity
Miller M. etal. CID 2010;50:194-201
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CDI discharges per 1000 Hospital Discharges in Illinois, 1999-2007
Year
Cases p
er
1,0
00
dis
ch
arg
es
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Clostridium difficile and Long Term Care
• Recent one month surveillance of C. difficile in Cook County, September, 2009
• Patients with the BI strain were frequently transferred between acute care hospitals and long term care facilities in Cook County
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Conclusions
• Increase infection control activities in long term care
• Improved communication between acute and long term care
• Can public health help bridge the gap between acute and long term care?
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Acknowledgements• Eric Jones• Kingsley Weaver• Judy Schermond• Stephanie Black• Fadila Serdarevic• Shaun Nelson• Mike Vernon• Supriya Jasuja• Megan Patel