Public Health and Long Term Care: A Cautionary Tale

Susan I. Gerber, MDAssociate Medical Director

Cook County Department of Public Health

Healthcare 1970-1980:Hospital is Center of Universe

Jarvis WR Emerg Infect Dis 2001;7: 170-3

Healthcare Surveillance Needed Now

Jarvis WR Emerg Infect Dis 2001;7: 170-3

Healthcare Surveillance Needed Now- Addendum

Long term acute care hospital

Long term care facility with ventilator and psychiatric patients

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

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

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

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

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

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……..

Burning Issues• Bloodborne pathogens

• Multidrug-resistant organisms (MDROs)

Multidrug-resistant Organisms (MDROs)

MDROs and Long Term Care

• Including:– KPC (Klebsiella pneumoniae carbapenemase)

containing organisms– Elizabethkingia meningoseptica– Clostridium difficile

– Acinetobacter spp, Pseudomonas aeruginosa, Staphylococcus aureus, etc……….

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

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

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

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

Geographical Distribution of

KPC-Producers

Frequent Occurrence

Sporadic Isolate(s)

CDC, 2009

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

Comorbidities

0

10

20

30

40

50

Num

ber

of

CRKP

CSKP *

*p <0.001

CDC, 2009

Healthcare-Associated Factors

0

20

40

60

80

100

Num

ber

of S

ubje

cts

CRKP

CSKP

*

* *

*

* p <0.001

CDC, 2009

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

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

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

E. meningoseptica

• Also known as:– Flavobacterium meningosepticum– Chryseobacterium meningosepticum

• Found in soil and water• Identified in neonatal wards• Immunocompromised adults

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

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

E. meningosepticum antibiotic susceptibilitiesJan 07 – Apr 08 (N=37)

0102030405060708090

100

Perc

en

t S

uscep

tib

le

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

EKM blood culture isolates-aggregate

Num

ber

of

isol

ates

Year of collection

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

Clostridium difficile

• Emergence of the epidemic strain BI/NAP1• Discharge data indicates an increase

• More severe disease?

C. difficile BI/NAP1 Strain Severity

Miller M. etal. CID 2010;50:194-201

CDI discharges per 1000 Hospital Discharges in Illinois, 1999-2007

Year

Cases p

er

1,0

00

dis

ch

arg

es

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

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?

Acknowledgements• Eric Jones• Kingsley Weaver• Judy Schermond• Stephanie Black• Fadila Serdarevic• Shaun Nelson• Mike Vernon• Supriya Jasuja• Megan Patel