1. Alison Holmes, Jonathan Otter
Risk factors for patients with carbapenemase-producing Enterobacteriaceae (CPE) at Imperial College Healthcare NHS Trust, 2014 – 2015
Siddharth Mookerjee, Jonathan Sullivan, Frances Davies, Hugo Donaldson, Eimear Brannigan,
Alison Holmes, Jonathan Otter

2. What’s this talk about? Introduction Methods: What we did at Imperial
Let’s talk CPE!!
European picture
Methods: What we did at Imperial
Live surveillance
Analysis
Summary
What did we learn?

3. Why do they pose a threat?
What are CPEs? Anyone?
C – Carbapenemase
P – Producing
E – Enterobacteriaceae
CPO! CRE! CRO?!
Why do they pose a threat?
Key resistance mechanisms acquired – HGT
Establish community reservoir – asymptomatic carriage
Prior hospital stay – key risk factor
Large at-risk group
Carbapenem resistance conferred by carbapenemase production, ESBL –encoding genes, AmpC

4. European picture
Carbapenemase-producing Enterobacteriaceae (CPE) present an important and emerging threat to healthcare facilities worldwide (Schwaber MJ et al . Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention)
The prompt identification and subsequent isolation of CPE carriers is vital to preventing the transmission of CPE (Schwaber MJ et al . Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention)
Risk factors for CPE include hospitalisation abroad, but the role of overseas travel or residence without direct healthcare contact, and the important of hospitalisation in the UK are less certain (ECDC. Risk assessment on the spread of Carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer. Stockholm, ECDC. 2011)
Enterobacteriaceae are fermentative GNB, who with a combination of inherent and primarily acquired antibiotic resistant mechanisms are responsible for increased mortality among patients in acute care settings (Schwaber MJ, et al. Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality. Antimicrob Agents Chemother 2008; 52:1028–33.)
Recent situation report from PHE (PHE. Level 3 Situation Report 4: Carbapenemase Resistant Enterobacteriacaea. June 2015) noted that in Q4 of 2014, 71% of CRE were from patients in NHS Trusts. And reflecting the important of CPE – PHE have launched the Enhanced Surveillance system for Carbapenemase-producing Gram-negative bacteria.
ECDC

5. Methods: What we did at Imperial
Live surveillance system established in May positive CPO isolates (May 14 – Mar 15) 43 patients
Enterobacteriaceae
38 isolates
28 patients
Non – fermenters
18 isolates
15 patients

6. Previous hospitalisation within UK/abroad Travel abroad
Patient hospital number
PHE reference no
DOB
Previous hospitalisation within UK/abroad
Travel abroad
Gender
Ward location where specimen taken
VNTR
Patient name
Specimen collection date
Isolate
Ethnicity
Co-morbidities, hospital diagnosis
High dependency care history
Molecular mechanism
MICROBIOLOGY results fed LIVE to INFECTION CONTROL server + send sample to PHE lab
MICROBIOLOGY informing INFECTION CONTROL TEAM
We began recording detailed risk factor information for each new case of CPE from May 2014 to April Risk factors included, within the year prior to the first CPE specimen, hospitalisation abroad, travel abroad without hospitalisation, hospitalisation in the UK, and known epidemiological contact with another CPE case. 
Microbiology sent out s to Infection control team of high suspect cases of CRE, detailing patient current ward location, specimen detail (whether screen or clinical sample), specimen number, patient number, confirmation of in-house PCR result (confirm what is done in-house)
Microbiology sent sample to PHE AMRHAI (confirm what exactly is done at PHE).
Infection control team commencing gathering of risk factor information for that patient – awaiting confirmation as CPE
Once PHE send confirmation of mechanism by which Carbapenemase resistant – then confirmed as a CPE
All details stored on a centrally available database
New software programmes like ICNET can do this for you
Sample type
Lab number for specimen

7. Distribution of CPO
(May-14 to Mar-15) – based on 56 isolates, as per slide 5

8. Distribution of CPE by isolate and mechanism of resistance
May 14 to Mar 15 – 38 CPE – as per slide 5

9. Comparison of risk factors – Enterobacteriaceae vs. Non-fermenters
May 14 – Mar 15 – 38 isolates CPE – 28 patients – 25 on which RF information available
May 14 – Mar isolates NF – 15 patients – 12 on which RF information available
Detailed risk factor data was not available for all patients.

10. K. pneumoniae NDM outbreak
Most of the CPE isolates were K. pneumoniae, with either OXA-48 or NDM carbapenemases, in line with other UK hospitals. 88% of 25 CPE patients for whom risk factor data was available had one or more of the risk factors that we recorded. It was notable that more than half of the patients had been hospitalised in the UK and 12% had been hospitalised abroad, supporting previous findings that hospitalisation is the most important risk factor for CPE. A greater understand of CPE risk factors is crucial for developing effective and efficient screening strategies
Add to notes – Ask Jon about key points we learnt from the outbreak – note the Live surveillance system helped us identify an outbreak of Kleb NDM at a couple of wards at Imperial
Implementation of CRE screening
Live surveillance
Getting those side rooms up and ready
Staff awareness
Key linkages between microbiology infection control and staff on the wards
Epi curve in the right direction
Equals an Epi curve going in the right direction!

11. Summary: What did we learn?
CPE are emerging at ICHT
We experienced a clonal outbreak in the background of sporadic cases
Sporadic cases have the ‘classic’ CPE risk factors (related to overseas travel etc), which do not seem to be shared by non-fermenters
Real-time surveillance proved used in detecting and tracking the outbreak and wider CPE picture at ICHT
Most of the CPE isolates were K. pneumoniae, with either OXA-48 or NDM carbapenemases, in line with other UK hospitals. 88% of 25 CPE patients for whom risk factor data was available had one or more of the risk factors that we recorded. It was notable that more than half of the patients had been hospitalised in the UK and 12% had been hospitalised abroad, supporting previous findings that hospitalisation is the most important risk factor for CPE. A greater understand of CPE risk factors is crucial for developing effective and efficient screening strategies
Add to notes – Ask Jon about key points we learnt from the outbreak – note the Live surveillance system helped us identify an outbreak of Kleb NDM at a couple of wards at Imperial
Implementation of CRE screening
Live surveillance
Getting those side rooms up and ready
Staff awareness
Key linkages between microbiology infection control and staff on the wards
Epi curve in the right direction

12. Imperial researchers at IPS
Oral presentations
Abstract ID: Otter J, Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S. Who’s carrying CRE? Universal admission screening in London
Abstract ID: Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Goldenberg S, Otter J. “Can I swab your rectum, please?”: Improving compliance with rectal screening for CRE
Abstract ID: Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Risk factors for patients with carbapenemase-producing Enterobacteriaceae (CPE) in a Northwest London hospital Trust, 2014 – 2015
Posters
Abstract ID: Ahmad R, Castro-Sanchez E, Iwami M, Husson F, Holmes A. Knowledge, perceptions and decision making: What matters to patients?
Abstract ID: Record C, Gilchrist M, Patel D, Jiao L. Infection prevention in splenectomy patients: An audit of practice in a regional hepatobiliary centre
Abstract ID: Turnbull A, Moore L, Azadian B. To PPE or not to PPE
Abstract ID: Batten L, Holmes A, Otter J, Castro-Sanchez E. Estimating the isolation burden if overseas residents are pre-emptively isolated during CRE admission screening
Abstract ID: Mookerjee S, Sullivan J, Davies F, Donaldson H, Brannigan E, Holmes A, Otter J. Real-time surveillance of carbapenem-resistant Enterobacteriaceae (CRE) using live microbiology culture data in a North-West London Hospital Trust, 2014–2015
Abstract ID: Alexander M, Mookerjee S, Nelson D, Holmes A, Otter J. An audit of single room capacity for isolation at a London hospital Trust  
Abstract ID: Galletly T, Bateman A, Brannigan E, Holmes A, Otter J. Thematic analysis of post 48-hour bloodstream infections: What did we learn?
Abstract ID: Acharya A , Samarasinghe D , Singleton J, Brannigan E, Galletly T, Donaldson H, Holmes A, Otter J. Pilot evaluation of environmental hygiene using fluorescent markers and microbiological cultures
Abstract ID: Gilchrist M , Galletly T, Brannigan E, Holmes A, Otter J. How much Clostridium difficile is preventable?
Abstract ID: Goldberg S, Dyakova E, Bisnauthsing K, Querol-Rubiera A, Girdham S, Patel A, Ahanonu C, Tosas Auguet O, Edgeworth J, Otter J. Poor sensitivity of perineal compared with rectal swabs for detecting ESBL Enterobacteriaceae

13. Alison Holmes, Jonathan Otter
Risk factors for patients with carbapenemase-producing Enterobacteriaceae (CPE) at Imperial College Healthcare NHS Trust, 2014 – 2015
Siddharth Mookerjee, Jonathan Sullivan, Frances Davies, Hugo Donaldson, Eimear Brannigan,
Alison Holmes, Jonathan Otter
jonotter.net