CPE: seek and ye shall find

We recently published a study in the Journal of Antimicrobial Chemotherapy relating the impact of introducing an enhanced testing* programme for CPE in London. (And yes, this is the first post for a while that isn’t on COVID-19!) Following an outbreak of NDM-producing Klebsiella pneumoniae affecting 40 patients in 2015 (published elsewhere, here and here), we ramped up our CPE testing programme. The number of patients carrying CPE increased substantially, from around 10 patients per month in June 2015 to around 50 per month in March 2018. However, the proportion of tests that were positive for CPE remained constant at around 0.4%, suggesting this was more effective carrier identification rather than a swelling pool of carriers per se; seek and ye shall find! Curiously, the majority of CPE identified were not linked in time and space with other CPE, suggested they represented a ground-swell of CPE coming into the hospital, rather than frequent in-hospital transmission. Also, the number of patients with CPE infections during the study period did not increase, which was reassuring.

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CPE has landed in East London

The team at Barts Health, one of the largest NHS hospital groups in the country, has published the findings of a point prevalence screen of all inpatients for carbapenemase-producing organism (CPO) carriage. Overall, 30 (3.1%) of the 977 patient tested were carrying 35 different CPOs (all but one of which were CPE). Risk factors for CPO carriage included hospitalisation abroad, any hospitalisation, and overseas travel (especially to India, Pakistan, and Bangladesh). These findings help us to understand an emerging picture of CPO in the UK.

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ESPAUR 2019: a snazzy facelift

The 2019 edition of the ESPAUR report has recently been published, including data up to and including 2018. The report is an excellent read – here’s a few summary points.

  • There’s a series of lovely infographics at the start of the report. I gave myself a challenge: to select the one infographic that told the story of the report. I toyed with the one about a small but increasing number of CPE BSIs (aghhhhh!), and the stark grave-stone themed image of mortality related to carbapenemase-producers, but ended up with this one: alarmingly, the rate of BSI for the seven priority bacterial pathogens rose 22% between 2014 and 2018 to 145 per 100,000 population. (Around half of these were coli). And there’s a certain inexorability about the antimicrobial resistance trends included in this report, with a 32% increase in AMR BSIs comparing 2014 to 2018.

Figure: Trends in BSIs (blue line) and AMR BSIs (green line).

  • There were more than 60k antibiotic resistant severe infections in 2018, <150 per day.
  • Confirmed CPEs have topped 4k (but this is a gross underestimate of true prevalence). The report makes the case that the rarity of CPE BSIs (142 reported nationally) represents a success of prevention. This is probably true if we compare across the pond and towards the southern reaches of Europe. But difficult to be sure without a control (i.e. what would have happened without the national initiatives etc)? Also, reporting of CPE BSIs to PHE is voluntary and not mandatory, so there will be some degree of under-reporting.
  • Related to this, only 50% of diagnostic labs have introduced methods to detect CPE locally. Which links closely with the change in surveillance system for CPEs going forwards – rather than manual voluntary reporting, locally confirmed CPEs will be reported automatically to PHE. However, if only 50% of diagnostic labs have appropriate methods, we’ll still end up under-reporting (but it will be more a more accurate picture than the current process provides).
  • 30 day all-cause mortality of invasive CPE infections is 24% (along with the arresting gravestone-themed infographic)! Not sure how helpful it is to make a big point based on unadjusted mortality data…
  • Overall consumption of antibiotics continues to decline. Consumption fell from 20 to 18 DDDs per 1,000 population per day between 2014 and 2018. However, consumption increased by 3% in hospitals over this period.
  • There’s a nice section on Candida auris
  • ESPAUR reports some good work and outcomes related to training, education, and awareness (e.g. Keep Antibiotics Working and Antibiotic Guardian).
  • What a wonderful resource the AMR Fingertips module is: automated data from >90% of NHS laboratories on a range of AMR indicators at our…ahem…fingertips. I am one of the 15k users over the past three years. (As an aside, the volume of traffic is fairly low by popular website standards – but I guess it is somewhat niche!)

ESPAUR is a fantastic resource – it seems that this is the last ESPAUR report related to the UK AMR Strategy from 2013-2018, but I’m confident that ESPAUR will continue to report the successes and challenges of implementing the new five year action plan (from 2019-2024).

Breaking the GLASS shroud around the global AMR crisis

WHO have published the first report of the Global Antimicrobial Resistance Surveillance System (GLASS) network. GLASS was launched a couple of years ago to try and address the massive black hole in our knowledge of global AMR resistance rates. The extensive report details progress to date, focussing on which countries have established surveillance systems, and how the initial data looks (which you can also view via an online database).

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“HCAI”

Airquotes

I read a Controversies blog today, reflecting on a recent editorial suggesting that, because of frequent over-diagnosis, we should use quote marks every time we write “CAUTI” – and even use air quotes every time we say it! But why stop at CAUTI? Should we be talking about “CLABSI”, “CDI”, “SSI” and, well, any “HCAI” really?

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Hydrogen peroxide vs. Clostridium difficile

This study has just been published in the Journal of Hopsital Infection, showing that the introduction of hydrogen peroxide vapour (HPV) for the terminal disinfection of rooms vacated by patients with CDI was assocaited with a significant reduction in the rate of CDI, from 1.0 to 0.4 cases per 1000 patient days.

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Review on AMR: Report on Infection Prevention and Control, and Surveillance

amr review hcai

The Review on AMR published their final instalment today: a report on Infection Prevention and Control, and Surveillance. A report on IPC was not planned at the start of the Review, so the existence of this report illustrates the responsiveness of the Review team. Also, having been peripherally involved in reviewing this report, I am aware that it was written within an extremely short timeframe but it does not show: it is comprehensive and thought-provoking (as it should be) with some useful recommendations.

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Being bitten by antibiotic resistant CRAB hurts! (Acinetobacter that is.)

Acinetobacter pink

Guest bloggers Dr. Rossana Rosa and Dr. Silvia Munoz-Price (bios below) write…

In everyday practice of those of us who work in intensive care units, a scenario frequently arises: a patient has a surveillance culture growing carbapenem-resistant Acinetobacter baumannii (CRAB). While the ultimate course of action we take will be dictated by the patient’s clinical status, that surveillance culture, in the appropriate context, can provide us with valuable information.

For this study1, we looked at a cohort of patients admitted to a trauma intensive care unit, and sought to identify the risk factors for CRAB infections. We found that patients who had surveillance cultures positive for CRAB had a hazard ratio of 16.3 for the development of clinical infections with this organism, compared to patient’s who remained negative on surveillance, even after adjusting for co-morbidities and antibiotic exposures. Since our results were obtained as part of a well-structured surveillance program, we know that colonization preceded infection.  Unfortunately for some of our patients, the time from detection of colonization to development of clinical infections was a matter of days. With therapeutic options for the effective treatment of infections with CRAB limited to tigecycline and polymixins, the consequences of delaying therapy are often fatal. As described by Lee et al, a delay of 48 hour in the administration of adequate therapy for CRAB bacteremia can result in a 50% difference in mortality rate2.

Surveillance cultures are not perfect, and may not detect all colonized patients, but they can be valuable tools in the implementation of infection control strategies3, and as we found in our study, can also potentially serve to guide clinical decision that impact patient care and even survival.

Bio:

TICU_photo1_031914

Dr. Silvia Munoz-Price (centre left) is an Associate Professor of Clinical Medicine at the Institute for Health and Society, Medical College of Wisconsin, currently serving as the Enterprise Epidemiologist for Froedert & the Medical College of Wisconsin. Dr. Rossana Rosa (centre right) is currently an Infectious Diseases fellow at Jackson Memorial Hospital-University of Miami Miller School of Medicine. She hopes to continue developing her career in Hospital Epidemiology and Infection Control.

References

  1. Latibeaudiere R, Rosa R, Laowansiri P, Arheart K, Namias N, Munoz-Price LS. Surveillance cultures growing Carbapenem-Resistant Acinetobacter baumannii Predict the Development of Clinical Infections: a Cohort Study. Clin Infect Dis. Oct 28 2014.
  2. Lee HY, Chen CL, Wu SR, Huang CW, Chiu CH. Risk factors and outcome analysis of Acinetobacter baumannii complex bacteremia in critical patients. Crit Care Med. May 2014;42(5):1081-1088.
  3. Munoz-Price LS, Quinn JP. Deconstructing the infection control bundles for the containment of carbapenem-resistant Enterobacteriaceae. Curr Opin Infect Dis. Aug 2013;26(4):378-387.

Image: Acinetobacter.