1. Public Health and Long Term Care: A Cautionary Tale
Susan I. Gerber, MD
Associate Medical Director
Cook County Department of Public Health

2. Healthcare 1970-1980: Hospital is Center of Universe
Jarvis WR Emerg Infect Dis 2001;7: 170-3

3. Healthcare Surveillance Needed Now
Jarvis WR Emerg Infect Dis 2001;7: 170-3

4. Healthcare Surveillance Needed Now- Addendum
Long term care facility with ventilator and psychiatric patients
Long term acute care hospital

5. Newspaper Headlines *Chicago Tribune 2009-2010
Nursing home safety reforms get deadline
Task force chief sets timetable for key proposals to end violence*
Justice Department supports safety reforms for nursing homes
Recommendation to move patients with severe mental illness praised*
Nursing home sexual violence: 86 Chicago cases since July 2007 — but only 1 arrest
Rape 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 arrests
Warrants 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

6. 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 BERENSON
Published: February 9, 2010

7. 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

8. 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:

9. 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

10. 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……..

11. Burning Issues Bloodborne pathogens
Multidrug-resistant organisms (MDROs)

12. Multidrug-resistant Organisms (MDROs)

13. MDROs and Long Term Care
Including:
KPC (Klebsiella pneumoniae carbapenemase) containing organisms
Elizabethkingia meningoseptica
Clostridium difficile
Acinetobacter spp, Pseudomonas aeruginosa, Staphylococcus aureus, etc……….

14. 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

15. Klebsiella Pneumoniae Carbapenemase
KPC is a class A b-lactamase
Confers resistance to all b-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

16. Susceptibility Profile of KPC-Producing K. pneumoniae
Antimicrobial
Interpretation
Amikacin I
Chloramphenicol R
Amox/clav
Ciprofloxacin
Ampicillin
Ertapenem
Aztreonam
Gentamicin
Cefazolin
Imipenem
Cefpodoxime
Meropenem
Cefotaxime
Pipercillin/Tazo
Cetotetan
Tobramycin
Cefoxitin
Trimeth/Sulfa
Ceftazidime
Polymyxin B
MIC >4μg/ml
Ceftriaxone
Colistin
Cefepime
Tigecycline S
CDC, 2009

17. 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 b-lactamases
Extended spectrum b-lactamases
Aminoglycoside resistance
Fluoroquinolone resistance

18. Geographical Distribution of KPC-Producers
Mixed; 29 reported Yes, they conducted some surveillance activity for MRSA; 23 had MRSA reportable in some form and all or selected area.
Frequent Occurrence
Sporadic Isolate(s)
CDC, 2009

19. 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:
CDC, 2009

20. Comorbidities *
*p <0.001
CDC, 2009

21. Healthcare-Associated Factors* * * *
* p <0.001
CDC, 2009

22. 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

23. 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
Examples of breaches of infection control noticed during observation on patient care floors include:
CDC, 2009

24. 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

25. E. meningoseptica Also known as: Found in soil and water
Flavobacterium meningosepticum
Chryseobacterium meningosepticum
Found in soil and water
Identified in neonatal wards
Immunocompromised adults

26. 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

27. E. meningosepticum Jan 2007-April 2008
Reported Patients
2007
2008

29. E. meningosepticum antibiotic susceptibilities Jan 07 – Apr 08 (N=37)
Percent Susceptible

30. 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
Gram negative bacteria point prevalence
Standardize training of staff, respiratory therapy practices and environmental cleaning through periodic inservices
Cleaning sinks with bleach, pouring body fluids into the toilet instead of sinks
No longer using tap water for ventialtors and g tubes
CDPH wrote a letter to support ICP efforts?

31. EKM blood culture isolates-aggregate
Number of isolates
Year of collection

32. EKM blood culture isolates-by hospital
Number of isoloates
Year of collection

33. Clostridium difficile
Emergence of the epidemic strain BI/NAP1
Discharge data indicates an increase
More severe disease?

34. C. difficile BI/NAP1 Strain Severity
Miller M. etal. CID 2010;50:

35. CDI discharges per 1000 Hospital Discharges in Illinois, 1999-2007
Cases per 1,000 discharges
This investigation was prompted by rising rates of CDI discharges in IL as demonstrated in this chart. We wanted to take a closer look at Chicago to find several pieces of information.
Year

36. 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

37. 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?

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