Download Public Health and Long Term Care: The Next Frontier

Public Health and Long Term
Care: A Cautionary Tale
Susan I. Gerber, MD
Associate Medical Director
Cook County Department of Public Health
Healthcare 1970-1980:
Hospital is Center of Universe
Jarvis WR Emerg Infect Dis 2001;7: 170-3
Healthcare Surveillance Needed Now
Jarvis WR Emerg Infect Dis 2001;7: 170-3
Healthcare Surveillance Needed NowAddendum
Long term care
facility with
ventilator and
psychiatric patients
Long term acute care
hospital
Newspaper Headlines
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 2009-2010
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
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
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; 27:920-925
Recipe for Disaster
• New antibiotics or old antibiotics resurrecteddifficulties with antibiotic stewardship
• Specialty facilities for long term care, LTACHs
and dialysis units
• More demands on ICPs
• Outsourcing microbiology
• Devices and respiratory care
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……..
Burning Issues
• Bloodborne pathogens
• Multidrug-resistant organisms
(MDROs)
Multidrug-resistant Organisms
(MDROs)
MDROs and Long Term Care
• Including:
– KPC (Klebsiella pneumoniae carbapenemase)
containing organisms
– Elizabethkingia meningoseptica
– Clostridium difficile
– Acinetobacter spp, Pseudomonas aeruginosa,
Staphylococcus aureus, etc……….
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
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
Susceptibility Profile of KPCProducing K. pneumoniae
Antimicrobial
Interpretation
Antimicrobial
Interpretation
Amikacin
I
Chloramphenicol
R
Amox/clav
R
Ciprofloxacin
R
Ampicillin
R
Ertapenem
R
Aztreonam
R
Gentamicin
R
Cefazolin
R
Imipenem
R
Cefpodoxime
R
Meropenem
R
Cefotaxime
R
Pipercillin/Tazo
R
Cetotetan
R
Tobramycin
R
Cefoxitin
R
Trimeth/Sulfa
R
Ceftazidime
R
Polymyxin B
MIC >4μg/ml
Ceftriaxone
R
Colistin
MIC >4μg/ml
Cefepime
R
Tigecycline
S
CDC, 2009
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
Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate(s)
CDC, 2009
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;29:1099-1106
CDC, 2009
ise
e
e
an
t
sp
l
as
as
ise
Tr
an
rD
na
lD
ve
Li
as
e
Re
ar
tD
ise
HI
V
et
es
He
ab
Di
Number of
Comorbidities
50
40
*
30
CRKP
CSKP
*p <0.001
20
10
0
CDC, 2009
Healthcare-Associated
Factors
Number of Subjects
100
*
*
80
CRKP
CSKP
*
*
60
* p <0.001
40
20
ics
iot
to
r
An
tib
ior
Pr
IC
U
nt
ila
Ve
Ce
nt
ra
lL
ine
0
CDC, 2009
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
Infection Control ObservationsPuerto 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
CDC, 2009
CRKP OutbreaksLessons 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
E. meningoseptica
• Also known as:
– Flavobacterium meningosepticum
– Chryseobacterium meningosepticum
• Found in soil and water
• Identified in neonatal wards
• Immunocompromised adults
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
E. meningosepticum Jan 2007-April 2008
Reported Patients
10
8
6
4
2
0
JAN
FEB
MAR
APR
MAY
JUN
2007
JUL
AUG
SEPT
OCT
NOV
DEC
JAN
FEB
MAR
APR
2008
Tr
im
ra
c
ill
i
n/
ta
zo
em
ta
m
en
ba
c
M
er
op
ne
m
ic
in
ci
n
To
et
br
ho
am
pr
yc
im
in
/s
ul
fa
m
et
ho
x.
Pi
pe
ip
e
ta
m
Im
m
e
pi
m
e
Ci
pr
of
lo
xa
Ge
n
ci
n
na
m
zid
i
Ce
fe
Ce
f ta
tre
o
Az
Am
ik
a
Percent Susceptible
E. meningosepticum antibiotic susceptibilities
Jan 07 – Apr 08 (N=37)
100
90
80
70
60
50
40
30
20
10
0
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
Number of isolates
EKM blood culture
isolates-aggregate
Year of collection
EKM blood culture
isolates-by hospital
5
Number of isoloates
4
3
2
1
0
1999
2000
2001
2002
2003
2004
Year of collection
2005
2006
2007
2008
Clostridium difficile
• Emergence of the epidemic strain BI/NAP1
• Discharge data indicates an increase
• More severe disease?
C. difficile BI/NAP1 Strain Severity
Miller M. etal. CID 2010;50:194-201
Cases per 1,000 discharges
CDI discharges per 1000 Hospital
Discharges in Illinois, 1999-2007
Year
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
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?
Acknowledgements
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•
•
•
•
•
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Eric Jones
Kingsley Weaver
Judy Schermond
Stephanie Black
Fadila Serdarevic
Shaun Nelson
Mike Vernon
Supriya Jasuja
Megan Patel