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Public Health Response to
Carbapenem-Resistant Enterobacteriaceae:
The Role of Health Departments
Alice Guh, MD, MPH
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
CSTE CRE Panel Session – June 14, 2011
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Carbapenem-resistant Enterobacteriaceae (CRE)

Common cause of HAIs
 Found in both acute care hospitals and long-term care settings
 Since 2004, reports of CRE cases from LTACH and LTCF

Similar to the spread of other MDROs
 Movement of colonized patients across the continuum of care
contributes to regional transmission
 Supported by mathematical modeling
Urban C et al. Clin Infect Dis 2008;46:e127030
Endimiani A et al. J Antimicrob Chemother 2009;64:1102-1110.
Smith DL et al. PNAS 2004;101:3709-14.
Inter-Facility Transmission of MDROs
(Including CRE)
Munoz-Price SL. Clin Infect Dis 2009;49:438-43.
Regional Approach to MDRO Prevention is Essential

Rationale for regional approach
 What happens in one facility will impact surrounding facilities
 Individual facilities can reduce MDRO prevalence only to a
certain point

Successful regional coordination by public health
 VRE control in Siouxland region
 CRE containment in Israel
Sohn AH et al. Am J Infect Control 2001;29:53-7.
Schwaber MJ et al. Clin Infect Dis 2011;52:848-55.
How to Operationalize Public Health
Response to Emerging MDROs

Opportunity to apply regional approach to CRE
prevention

HDs in unique position to coordinate local and regional
response to CRE
 Assess CRE prevalence/incidence within their jurisdiction in
order to provide situational awareness to facilities
 Serve as resource to facilities about prevention options

Informs public health response to other emerging
MDROs
DEVELOPMENT OF CRE TOOLKIT
Outline of CRE Toolkit

Facility-level prevention strategy for facilities and HDs

Regional prevention strategy specifically for HDs
 Aggressive approach to contain or prevent CRE emergence
• Regions with no CRE identified
• Regions with few CRE identified
Regional Prevention Strategy
Regional Surveillance for CRE

Determine CRE prevalence within a given jurisdiction
 Make CRE laboratory reportable (in regions with no known or
few CRE)
 Survey IPs or lab directors

Feedback of surveillance results
 Provide specific enough data for facilities to act upon
• Facility name, if possible
or
• Stratify results by geographic area and/or by facility type
Regional Prevention Strategy
Regions With No CRE Identified
Aggressive efforts at detection:

Perform periodic surveillance and feedback
 Frequency may depend on CRE prevalence in neighboring regions
(establish mechanism for communication)

Educate facility staff to increase awareness
 Epidemiologic importance of CRE
 Recommended surveillance and prevention measures*
* http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm
Regional Prevention Strategy
Regions With Few CRE Identified
Aggressive efforts at containment, may target select areas:

Implement infection prevention measures
 Reinforce core prevention measures in all facilities
 Facilities with CRE: use supplemental measures
 Facilities without CRE: targeted surveillance testing, preemptive CP

Use inter-facility patient transfer forms
 Indicate CRE status, open wounds/devices, antimicrobial therapy

Educate facility staff to increase awareness

Perform periodic surveillance and feedback
REGIONAL CRE SURVEILLANCE BY
SELECT HEALTH DEPARTMENTS
Development of CRE Survey

Fall 2010 – CRE conference calls with interested HDs to
identify actionable steps to take
 HDs notified through CSTE HAI listserve

CRE survey template designed to be used by HDs to
assess CRE prevalence within their jurisdiction
 7 questions to administer to IPs of acute care facilities
 Estimate frequency of CRE colonized- or infected-patients
 Assess facility-level surveillance activities for CRE and related
prevention measures*
* http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm
State HDs Conducting CRE Survey (n=7)
 Utah

Illinois

Virginia

Idaho

South Carolina

West Virginia

Wisconsin
Administration of CRE Survey

Targeted acute care hospitals, but included:
 Long-term acute care hospitals (≥3 states)
 Critical access hospitals (≥2 states)

Survey methods by HDs
 Email /online survey (e.g., Survey Monkey) to IPs
 Paper survey at APIC meetings

Date of survey: ranged Sep 2010-Mar 2011
 Survey lasted one day to 2-3 months
 Sent reminder emails, phone calls to non-respondents
Survey Respondents

Aggregated state-level data across all 7 states:
 Median response rate – 67% (range: 26% to 100%)

Breakdown by bed size (n=6 states): Total 360 facilities





≤50 beds – 30%
51-200 beds – 39%
201-500 beds – 27%
>500 beds – 4%
Fairly representative of national data (2008 AHA data)
 Except greater % of facilities with ≤50 beds captured in survey
CRE Prevalence in Past 12 Months (n=7 states)
Percentage of Facilities Per State
CRE Prevalence
Median
Range
Identified CRE
30
10-46
0
0-16
Monthly or greater
100
84-100
≤48 hrs of admission
92
74-100
>48 hrs of admission
59
25-75
Do not know if have CRE
12
10-18
Daily or weekly
CRE Surveillance Measures (n=7 states)
Percentage of Facilities Per State
Surveillance measures
Median
Range
System for micro lab to alert
IP staff
77
57-91
Review prior micro data*
37
29-44
If yes, identified CRE
10
0-17
6
0-11
33
0-33
12
10-18
Conduct point
prevalence survey
If yes, identified CRE
Conduct AST of epi-linked
patients
*Applies to facilities that have not or have rarely identified CRE cases (data available for 6 states)
CRE Prevention Measures (n=7 states)
Percentage of Facilities Per State
Prevention measures
Median
Range
Place on Contact Precautions
95
86-100
Place in single-patient rooms
96
73-100
Summary of CRE Survey Results

CRE identified in <50% of all responding facilities, still
have opportunity to prevent full emergence

Although there is intra-facility transmission, majority of
identified cases are imported
 Important role of inter-facility patient sharing
 Supports the need for regional approach to prevention

Low facility adherence to recommended surveillance
practices and need for increased education / awareness
 Potential under-reporting of CRE
Feedback of Survey Results by HDs

At least 5 states provided feedback to IPs / facilities
 Email (memo, monthly HAI newsletter)
 Presentation at APIC meeting

Feedback content
 Only shared aggregated results
• Some stratified by geographical region (n=2), facility type (n=1)
 Some provided streamlined 2009 MMWR guidance* (n=3)
* http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm
INTERVIEWS WITH STATE HEALTH
DEPARTMENTS
Key Informant Interviews

Primary objective: to understand why some HDs
decided to conduct CRE survey and others did not

Participants
 All 7 states that conducted CRE survey
 4 additional states that did not conduct CRE survey
(participants of initial CRE calls via CSTE HAI listserve)

Standardized script with trained interviewer
Key Interview Findings (n=11 states)

All HDs communicated regularly with IPs about HAI
topics in previous 12 months (prior to CRE survey)

No difference between states in competing priorities and
concerns about CRE survey
 Main concern – perception of overburdening IPs

Yet perspectives differed regarding conducting survey:
opportunity to learn vs concerns about survey intent and
logistics and other data source
 Assess for other confounders and contextual factors
 Evaluate alternative sources to IPs for information
CASTING A VISION FOR PUBLIC
HEALTH ACTION
Anywhere County, USA
Status Report: Emerging MDRO X
St. Joseph’s Hosp
St. Vincent’s Hosp
Appletree Hosp
St. Mary’s LTACH
Orangetown LTACH
Smallville Hosp
Peachtree Hosp
Smithville LTACH
Franklin Hosp
St. Claire’s LTACH
Greensville LTCF
Magnolia LTCF
St. Peter’s Hosp
Jamesville Hosp
Thomasville Hosp
Thank you
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion