Under the radar. Two prolonged outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) at a tertiary hospital in Canberra, Australia

Transcription

1 Under the radar Two prolonged outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) at a tertiary hospital in Canberra, ustralia lexandra armor, Kathryn Daveson, Karina Kennedy & David Harley No disclosures or conflicts

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3 ims describe cases detected through routine testing identify past outbreaks based on epidemiological and sequencing evidence investigate possible transmission mechanisms

4 Case definition Enterobacteriaceae spp. carbapenemase gene clinical or surveillance CT Pathology 1 anuary December 2016 ethods Cluster identification species multilocus sequence types gene Epidemiological investigation clinical record review bed movements environmental evidence, arch 2014 ay 2015 Transmission maps opportunity genetic distance (SNPs) plausible undetected carriers

5 CPE detected by CT Pathology, n = 72 2 related cases - ICU

6 CPE detected by CT Pathology, Species Isolates n Carbapenemase gene IP-4 IP-38 Enterobacter cloacae complex 21 (29%) 20 1 Citrobacter freundii 14 (19%) 14 Klebsiella pneumoniae 9 (13%) 7 Escherichia coli 9 (13%) 6 Klebsiella oxytoca 8 (11%) 8 Serratia marcescens 3 (4%) 3 Citrobacter amalonaticus 3 (4%) 3 organella morganii subsp morganii 3 (4%) 2 Hafnia alvei 1 (1%) Enterobacter aerogenes 1 (1%) 1 ll cases (88%) 1 (1%)

7 CPE detected by CT Pathology, Species Isolates n Carbapenemase gene IP-4 IP-38 ND OX-48 Enterobacter cloacae complex 21 (29%) 20 1 Citrobacter freundii 14 (19%) 14 x1 Klebsiella pneumoniae 9 (13%) Escherichia coli 9 (13%) Klebsiella oxytoca 8 (11%) 8 Serratia marcescens 3 (4%) 3 Citrobacter amalonaticus 3 (4%) 3 x1 x1 organella morganii subsp morganii 3 (4%) 2 1 Hafnia alvei 1 (1%) 1 Enterobacter aerogenes 1 (1%) 1 ll cases (88%) 1 (1%) 5 (7%) 2 (3%)

8 Identification of clusters Species Isolates with ST available (n) sequence types (ST) E. cloacae complex 17 7 cases 10 cases 24, 32, 45, 50, 66, 113, 127, 742, 610 C. freundii 12 8, 62, 98 K. pneumoniae 4 383, 661, 1308, 1528 E. coli 5 33, 221, 410, 687 K. oxytoca 3 20, 29, 53

9 E. cloacae complex 2012 arch Haematology ICU Renal Neurosurgical 1 1 CPE identified Probable acquisition 2013 X X X 2 Environmental sample transmission pathway Interward transfer 7

10 E. cloacae complex 2012 arch Haematology ICU Renal Other ward 1 1 CPE identified Probable acquisition 2013 X X X 2 Environmental sample Putative transmission pathway Interward transfer 7

11 C. freundii 2013 F S O N D 2014 F S O N D 2015 F S O N D 2016 CF1 CF10 Haematology ICU Orthopaedic R C or G CF8 CF6 R CF6 C or G CF7 KEY CF2 Probable acquisition edical ssessment CPE-positive specimen collected Transmission pathway Inter-ward transfer or readmission Urology/ Vascular Hospital in the Home T T CF3 CF6 CF8 CF10 R CF6 CF4 R CF5 CF5 CF9 Other/ Outpt CF7 CF9

12 C. freundii 2013 F S O N D 2014 F S O N D 2015 F S O N D 2016 CF1 CF10 Haematology ICU Orthopaedic R C or G CF8 CF6 R CF6 C or G CF7 KEY CF2 Probable acquisition edical ssessment CPE-positive specimen collected Transmission pathway Inter-ward transfer or readmission Urology/ Vascular Hospital in the Home T T CF3 CF6 CF8 CF10 R CF6 CF4 R CF5 CF5 CF9 Other/ Outpt CF7 CF9

13 ain Findings contaminated sinks cases did not share rooms or bathrooms concurrently median of 3 months between case detection environmental persistence multiple undetected carriers

14 Limitations No LST data for 43% of isolates Plasmids not characterised? Transfer of carbapenemase genes between sequence types species genera

15 Conclusions transmission more extensive than previously understood IP&C measures must address prolonged asymptomatic carriage and persistence in the hospital environment WGS in CPE outbreak investigation use methods that account for gene transfer between Enterobacteriaceae species

16 cknowledgements Wendy Beckingham & the TCH Infection Prevention and Control Team Laboratory staff at CT Pathology Dr Nicholas Coatsworth, the Canberra Hospital Dr Glen Carter and Dr Norelle Sherry, Doherty Centre for pplied icrobial Genomics lex armor was supported by an ustralian Government Research Training Scholarship as an E Scholar at NU