1. Division of Public Health CRE Surveillance and Prevention of Transmission in Healthcare Settings Gwen Borlaug, CIC, MPH Coordinator, Healthcare-Associated Infections Prevention Program WSLH AST Conference May 10, 2012

2. Key premise The laboratory is a critical partner in preventing transmission of carbapenem- resistant Enterobacteriaceae (CRE) in healthcare settings.

3. Enterobacteriaceae Gram negative bacteria usually residing in the GI tract Ferment glucose Examples – Klebsiella spp. – E. coli – Enterobacter spp. – Serratia marcescens – Citrobacter spp. – Proteus spp.

4. Enterobacteriaceae E. coli, Klebsiella spp., and Enterobacter spp. made up 21% of all healthcare- associated infections (HAI) in 2006-07. Hidron et al. Infect Control Hosp Epidemiol 2008;29:996-1011

5. CRE Important healthcare-associated pathogens Resistant to almost all antimicrobial agents Infections associated with high morbidity and mortality Present in US hospitals since 1999, routinely recovered in NY and NJ hospitals From 2000-2007, HAI data reported to CDC indicate the percentage of CR Klebsiella isolates increased from 1% to 8% Sporadic cases known to occur in WI

6. Rationale for action Because these organisms pose a threat to patients in acute care settings, are difficult to treat and cause increased mortality, cost, and length of stay, CDC is urging state health departments to determine prevalence and contain these organisms before they become endemic.

7. Statewide surveillance In Wisconsin, the approach is to determine prevalence in acute care facilities using the National Healthcare Safety Network, to detect patients with CRE infections/colonization quickly through recommended laboratory methods, and to promptly apply strict infection control methods.

8. Surveillance design Active surveillance for CR Klebsiella spp. and for CR E. coli based on unique clinical isolates detected per inpatient per month in each facility 6 months: December 1, 2011-May 31, 2012 All WI acute care, critical access, and long-term care hospitals (n = 137) – Includes specialty acute care such as children’s, orthopedic, heart – Excludes behavioral, AODA, psychiatric, rehabilitation hospitals

9. Findings to date 11 reported events; 8 cases – 5 cases from same acute care facility, 4 of which were residents of same LTC facility – 5th case was a patient on same unit as a resident from the LTC facility – PFGE analysis suggests transmission within the LTC facility and transmission in the acute care facility Remaining 6 events represent 3 sporadic cases

11. Preventing transmission of CRE Strict contact precautions for all known infected and colonized patients Regional collaboration and communication across all healthcare settings Active surveillance testing in certain situations Advanced measures when needed (e.g. cohorting of patients, staff)

12. Reference Centers for Disease Control and Prevention. Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR 58 (10); 256-260 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

13. Questions Gwen Borlaug, CIC, MPH Division of Public Health 1 West Wilson Street Room 318 Madison, WI 53702 608-267-7711 gwen.borlaug@wi.gov