Robynn Cheng Leidig, MPH Tackling the Nightmare Bacteria Carbapenem-Resistant Enterobacteriaceae (CRE)—Mandatory Reporting and Development of the Extensively Drug-Resistant Organism (XDRO) Registry in Illinois Robynn Cheng Leidig, MPH 2012 PHPS Fellow Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention 2015 PHAP/PHPS Summer Seminar June 2, 2015 Presenters that do not want to use the CDC 24/7 cover, can use the basic title slide with lockup. Note—There are only three acceptable options for text in the lockup bars: Option 1—Use this if the presentation is a collaboration with other CIOs U.S. Department of Health and Human Services Centers for Disease Control and Prevention Option 2—Standard choice for the majority of OSTLTS presentations Office for State, Tribal, Local and Territorial Support Option 3—Use if presentation is specific to a division or office within OSTLTS <insert office or division name only—branch names are not acceptable per CDC guidelines> Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

BACKGROUND

Carbapenem Resistant Enterobacteriaceae What is CRE? Deadly infection Few treatment options (if any) Spreading quickly http://www.cdc.gov/drugresistance/threat-report-2013/

CRE colonization prevalence CRE in Illinois First recognized in Chicago area in December 2007 Chicago area facilities (REALM project), 2010-2011 Facility type CRE colonization prevalence Short stay acute care hospitals (adult ICUs) 3% Long term acute care hospitals (LTACHs) 30% Lin MY et al. CID, 2013 Few prevalence data existed for hospital non-ICU wards, nursing homes, and regions outside of Chicago

METHODS XDRO Registry Development What did we do? Create the XDRO registry! Now I am going to get into the details of how the registry was created.

Present… Illinois Department of Public Health (IDPH) the Chicago CDC Prevention Epicenter and Medical Research Analytics and Informatics Alliance (MRAIA) Present… the Extensively Drug-Resistant Organism (XDRO) registry Collaboration between IDPH, CDC Prevention Epicenter, MRAIA Input from HAI Advisory council, other key stakeholders Amendment to the Control of Communicable Diseases Code (77 Ill. Adm. Code 690) Rules

The XDRO registry addresses 2 critical gaps 1. Need improved inter-facility communication Allows for CRE information exchange 2. Lack of a surveillance system Stores CRE surveillance data Make it clear that the XDRO registry is not just a surveillance system (otherwise could have used INEDSS) Registry is a bi-directional, inter-operable patient record sharing system Part of a larger vision for PH-HC integration, which is an important component of ACA and CDC’s strategic initiatives Surveillance important at a facility, regional, and state level

Patient admit (Unknown CRE status) CRE identified Providers Laboratories Report XDRO registry Query - Different from INEDSS Isolation Precautions (Y/N) Patient admit (Unknown CRE status)

Results

CRE Reporting in Illinois How to report: Extensively Drug-Resistant Organism (XDRO) Registry Began: November 1, 2013 Required to report: Acute care hospitals Long-term acute care hospitals Long-term care facilities Laboratories XDRO registry is a system for CRE reporting Part of the state’s CRE Detect and Protect efforts. Registry implementation happening concurrently with the educational campaign

Unique patients reported to XDRO registry Mandatory reporting - (Numbers taken from XDRO dashboard): unique # of patients reported into the XDRO registry, by culture date. *potential * CRE cases. 2013

XDRO Registry: aggregate data (Nov 1, 2013 – May 13, 2015) Number of unique patients since November 1st: 1,725 Number of unique facilities that: have access to the registry 550 have submitted reports 151 have ever queried 127 Total number of queries that have been made: 2,522 Number of unique patients since November 1st: a patient is only included once even if they have multiple CRE reports  Number of facilities that have access to the registry: includes nearly all of the hospitals in the state Number of unique facilities that have submitted reports: is the number of facilities that are (potentially) detecting CRE. Some of these could include duplicate reports. Number of unique facilities that have ever queried: this is every facility that performed at least one query. (Not on slide)- Number of unique users have logged in: 286

Accessing CRE/ XDRO Data Facilities Local Health Depts.

CRE and XDRO education 30 stakeholder CRE Taskforce 6 webinars: 605 people 2 packets: 470 facilities 2 websites 1 Press release

Challenge Steps taken… Ensuring secure access to the XDRO registry All users must register via IDPH web portal Coordinating among various agencies and key players Meetings, phone calls, internal webinars Developing consistency in facility identifiers Integrating with existing systems (I-NEDSS) Meeting both clinical and public health needs Input from public health and clinical stakeholders  Engaging labs: Illinois Society for Microbiology Understanding surveillance criteria & reporting rules: built logic checks into the registry to improve data quality Understanding surveillance criteria & reporting rules Webinars, educational materials, consultations, registry improvements

Implications Long-term impact Earlier detection of CRE+ patients Better infection control: 63% (N=203) took ≥1 infection control action as a result of the webinars/ presentations Reduced spread of CRE in the region? Source: CDC Vital Signs, March 2013

For more information visit: www.xdro.org Robynn Cheng Leidig, MPH robynn.leidig@illinois.gov 312-814-1631 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

EXTRA slides for questions

CRE surveillance definition (adapted from CDC CRE toolkit) Reporting facilities shall report CRE based on laboratory test results: 1. Molecular test (e.g., PCR) specific for carbapenemase OR 2. Phenotypic test (e.g., Modified Hodge) specific for carbapenemase production 3. Susceptibility tests (for E. coli and Klebsiella species only): non-susceptible to ONE of the carbapenems (doripenem, meropenem, or imipenem) AND resistant to ALL third generation cephalosporins tested (ceftriaxone, cefotaxime, and ceftazidime). Ignore ertapenem. - More details on what is supposed to get reported… http://www.cdc.gov/hai/organisms/cre/cre-toolkit

Resistance mechanisms reported to XDRO registry Denominator is unique patients ever reported to the registry 60% of patient reports have a reported mechanism, 40% have an unreported/ unknown mechanism n=407 n=36 n=22 Not reported/ Unknown: 312 (40% of total patients)

System Maturation * - How INEDSS will be integrated with CRE

Cluster Detection SaTScan: Spacial scanning software Arcview GIS: Provides graphical display