1. Part II High Priority Resistant Organisms

2. Healthcare Associated Infections NHSN 2009-2010 1.Staphylococcus aureus (16%) 2.Enterococcus spp (14%) 3.Escherichia coli (12%) 4.Coagulase-negative Staphylococcus (11%) 5.Candida spp (9%) 6.Klebsiella spp (8%) 7.Pseudomonas aeruginosa (8%) 8.Enterobacter spp (5%) 9.Proteus spp. (3%) 10.Serratia spp. (2%) Infection Control and Hospital Epidemiology 2013;34(1):1-14 30% are Enterobacteriaceae

3. NHSN Data 2012 4.6% of acute care hospitals reported at least 1 healthcare associated infection due to CRE – 3.9% of short stay hospitals – 17.8% of LTACHs Large increase in proportion of HAIs due to CRE over past decade – CRE: 1.2 % in 2001  4.2% in 2011 – CP-KP: 1.6% 2001  10.4% in 2011 CDC, Vital Signs. March 8, 2013 / 62(09);165-170

4. Enterobacteriaceae Family of bacteria Normal gut flora in mammals and birds Examples: E. coli, Klebsiella, Enterobacter Common cause of community and HA-infections E. coli Klebsiella Enterobacter Classification LevelExample DomainBacteria KingdomEubacteria PhylumProteobacteria ClassGamma Proteobacteria OrderEnterobacteriales FamilyEnterobacteriaceae GenusEscherichia SpeciesEscherichia coli

5. Carbapenem-resistant Enterobacteriaceae Enterobacteriaceae resistant to antibiotics of last resort Two mechanisms of resistance -- bad and really bad ―Usual mechanism: resistance to extended spectrum-  -lactam antibiotics (ESBL) plus a porin mutation, chromosomal inheritance ―Newer mechanism: production of a carbapenemase, an enzyme that hydrolyzes carbapenem antibiotics, plasmid mediated inheritance

6. Chromosomal vs. Plasmid-Mediated Inheritance

7. Phenotype vs. Genotype CR is bad, don’t wait for carbapenemase test results to act!

9. CRE in Washington Statewide surveillance since 2012 Case definition: E. coli, Klebsiella and Enterobacter R to 1 or more carbapenem (MIC >4 for dori, imi or mero, >2 for erta) Labs, healthcare providers and facilities submit isolates to Public Health Lab PHL tests for 5 common carbapenemases in US ―Klebsiella pneumoniae carbapenemase (KPC) ―New Delhi metallo-β-lactamase (NDM) ―Oxacillin-hydrolyzing β-lactamase-48 (OXA-48) ―Verona integron-encoded metallo-β-lactamase (VIM) ―Imipenem-hydrolyzing β-lactamase (IMP) Results: CRE, no carbapenemase—OR— CP-CRE, carbapenemase identified

10. Carbapenem-Resistant Enterobacteriaceae Isolates, Washington Oct 2012-Dec 2015

11. Washington CRE surveillance Oct 2012-Dec 2015 Genus and carbapenemase GenusCRE IsolatesCP-CRE (%)Carbapenemases Enterobacter1453 (2)2 KPC 1 IMP E. coli11412 (11)2KPC 7NDM 3 OXA-48 Klebsiella6629 (43)19 KPC 3 NDM 6 OXA-48 1 IMP Other140 (--)-- Total33944

12. Carbapenemase N=41 Suspected SourceKPC n=22Other Carbapenemase n=19 In-Washington Healthcare15 (68%)3 (16%) Other US State Healthcare7 (32%)-- International Healthcare or Travel--16 (84%) Washington CRE surveillance Oct 2012-Dec 2015 Suspected source location of carbapenemase

13. Found in soil and water Poses little risk to healthy people Frequent cause of healthcare outbreaks Can survive in healthcare environments for months-years Acinetobacter

15. Found in soil, water and other moist environments Serious infections in those with underlying conditions, may cause minor infections in healthy people (hot tub folliculitis, swimmers ear, eye infections) Reservoirs in healthcare settings: disinfectants, respiratory equipment, food, sinks, taps, mops Pseudomonas

17. PeaceHealth Southwest

18. University of Washington

19. Antibiograms Hospitals in your referral area Your laboratory Your IC records

21. Clostridium difficile Lessa FC. Burden of CDI in the US. N Engl J Med 2015; 372:825-834.

22. Clostridium difficile in Washington