Carbapenemase Producing Enterobacterales (CPE) in Ireland: 2017

Transcription

1 Key pints Intrductin Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 The case definitin has been amended t avid cunting CPE cases in the same hspital mre than nce and thus mre accurately reflect the burden n CPE in Ireland, particularly in Irish hspitals In 2017, 449 cnfirmed CPE islates were reprted by 32 micrbilgy labratries, with the majrity detected frm screening specimens (79%). Seven labratries reprted zer islates The distributin by patient lcatin at specimen cllectin was: hspital inpatient (n=378; 84%), hspital utpatient (n=30), lng-term care facility resident (n=29) and patients attending general practitiners (n=12) Data n patient islatin status within 24 hurs f a suspected CPE labratry result was nt reprted fr 28% f inpatient cases. Where data was reprted, the majrity f inpatients were islated (n=254; 92%), with 20 (7%) wh were discharged prir t the labratry result being available. Three patients were nt islated Due t recent taxnmic changes, many f the species cmprising the family Enterbacteriaceae have nw been re-classified within the Order Enterbacterales). Carbapenemase prducing Enterbacterales (CPE), ften interchangeably knwn as carbapenem resistant Enterbacterales (CRE) are a grwing threat t public health due t very limited ptins fr treatment f infectin. In 2015, the prprtin f invasive carbapenem resistant K. pneumniae islates causing bldstream infectin (BSI) reprted t the Eurpean Antimicrbial Resistance Surveillance Netwrk (EARS-Net) varied frm 0% in sme Nrdic cuntries t 33% in Italy and 62% in Greece. Hwever, BSI represent the tip f the iceberg, as ther mre cmmn infectin types (e.g., urinary tract r wund infectins) and asymptmatic and ften unrecgnised enteric/gut clnisatin als cntribute t the successful disseminatin f CPE, particularly in healthcare settings. In 2011, invasive CRE infectin was made ntifiable in Ireland and a vluntary enhanced surveillance system fr all CRE islates was launched. In 2013, in respnse t an increasing trend in invasive multi-drug resistant K. pneumniae (MDRKP) infectins, a prprtin f which were als carbapenem resistant, a natinal MDRKP utbreak cntrl team was established, alng with a mandatry enhanced surveillance scheme fr all MDRKP islates (frm invasive and nn-invasive infectins, clnisatin and active screening) frm January T the end f 2016, MDRKP was reprted by 88% f Irish hspitals, with cases als bserved in primary and residential care. The surveillance system indicated widespread disseminatin f MDRKP in Ireland. Of particular cncern was the rapid bserved increase in the prprtin f MDRKP that were als carbapenemase prducers (195% increase in 2016 versus 2015). In respnse t this threat, the mandatry MDRKP and vluntary CRE surveillance schemes were replaced with the mandatry CPE enhanced surveillance scheme in January The Natinal Carbapenemase Prducing Enterbacterales Reference Labratry Service (NCPERLS), based at Galway University Hspital has prvided reference services since Octber 2012, with the annual ttal number f patients with newlycnfirmed CPE increasing frm 50 in 2013 t 433 in Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 1

2 Revised case definitin The first islate per patient f any Enterbacterales species that is a cnfirmed carbapenemaseprducer frm any specimen type, either infectin r carriage: (e.g., if first islate is a screening specimen, a subsequent BSI due t the same islate wn t be cunted in surveillance) If the same carbapenemase is fund in islates f tw r mre species frm the same patient, then nly the first species is included (e.g., OXA-48 E. cli fllwed by OXA-48 Enterbacter clacae; nly the OXA-48 E. cli will be cunted in surveillance) If a different carbapenemase is fund in an islate f any species in a subsequent specimen frm the same patient, then the first islate with this ther carbapenemase is included (e.g., OXA-48 E. cli, fllwed by NDM-1 K. pneumniae; bth will be cunted in surveillance) If an rganism is nt islated r fails t grw, but a carbapenemase is detected by direct PCR n the specimen, such CPEs shuld nt be reprted The case definitin fr enhanced surveillance des nt distinguish between islates frm the same patient identified in different hspitals. Results Appendix 1 summarises the data reprted by acute hspitals and Hspital Grups in Thirty-tw micrbilgy labratries reprted 449 islates frm 447 patients, with seven labratries reprting zer islates. In 2017, ne labratry did nt submit data fr quarters 3 and 4 due t n-ging resurce issues and anther labratry did nt submit data fr quarter 4. If prbable duplicate patients between hspitals are excluded (based n date-f-birth, gender r specific infrmatin supplied), the ttal number f patients reprted t enhanced CPE surveillance in 2017 was 427, which is similar t the NCPERLS ttal f 433 patients with newly-cnfirmed CPE. It is ntewrthy that there are differences in what is cunted: NCPERLS reprts based n the date an islate is received, while CPE enhanced surveillance is based n the specimen cllectin date and reprts n the first islate per patient per year, which may include mre than newly-cnfirmed patients (i.e., when a patient was previusly knwn with CPE in the preceding year) As the case definitin nw nly requires reprting f the first islate f any Enterbacterales species with the same enzyme fr the year, patients are nly cunted nce in this surveillance prgramme, unless a subsequent islate frm the same patient is reprted with a different enzyme: Tw patients had tw different carbapenemases reprted: bth with OXA-48 and NDM islated frm the same screening specimens Tw patients had tw different carbapenemases reprted frm tw separate specimens: OXA-48 Enterbacter clacae frm a clinical specimen and VIM E. clacae frm a screening specimen where bth specimens taken n the same date OXA-48 E. cli frm a screening specimen and OXA-181/232 E. cli frm a subsequent clinical specimen Natinally, the majrity were OXA-48 (73%), with KPC predminant in the mid-west (n=45; 79% f KPC islates). Three species accunted fr 75% f all CPE islates: K. pneumniae (31%), E. cli (23%) and Enterbacter clacae (21%), as displayed in Table 1 and Figure 1 Males (57%) and patients aged 57 years (75%) accunted fr the majrity f cases The majrity f islates were detected frm screening specimens (n=353; 79%), with the remainder frm clinical specimens (n=96; 21%), f which seven were frm BSI Inpatients in 33 hspitals accunted fr the majrity f carbapenemases (n=378; 78%): Admissin and specimen dates were reprted fr 321 (85%), with a median interval between admissin and first psitive result f eight days (range = 0 458) Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 2

3 Of clinical specimens, the majrity were detected frm inpatients (n=72; 75%). Of thse, infrmatin n antimicrbial therapy was prvided fr 45 (63%), with 25 f thse (60%) having required antimicrbial therapy active against a carbapenemase fr suspected infectin prir t case ntificatin. Hwever, fr ver ne-third f clinical islates frm inpatients (37%), infrmatin n antimicrbial therapy by the time f case ntificatin was nt reprted Infrmatin n inpatient islatin status within 24 hurs f the labratry reprting a suspected carbapenemase was prvided fr 277 islates (73%), with the majrity f patients islated (n=254; 92%) and 16 wh were (8%) discharged prir t the result. In three cases, the patient was nt islated within 24 hurs. Hwever, fr 28% f inpatient islates (n=105), islatin status was nt reprted In 2017, the majrity f inpatient CPEs were reprted frm screening specimens (rectal swab r faeces). The fllwing hspitals accunted fr the majrity f reprted CPE and all als reprted and managed CPE utbreaks in 2017: Tallaght Hspital (n=76; 97% n screening) Galway University Hspital (n=45; 88% n screening) University Hspital Limerick (n=39; 87% n screening) Beaumnt Hspital (n=33; 74% n screening) St James s Hspital (n=33; 76% n screening) University Hspital Waterfrd (n=26; 69% n screening) St Luke s Hspital, Kilkenny (n=17; 76% n screening) Naas General Hspital (n=16; 100% n screening) St Vincent s University Hspital (n=15; 78% n screening) In 2017, additinal CPE utbreaks were ntified t Departments f Public Health by the Mater Misericrdiae University Hspital, Our Lady s Hspital, Navan, Slig University Hspital and the Beacn Hspital, as well as by tw lng-term care facilities (LTCF) in different regins The remaining islates were detected frm utpatients attending 12 hspitals (n=30), LTCF residents (n=29) and patients attending general practitiners (GP) (n=12) Outcme data at the time f reprting was nt prvided fr 27% f inpatient islates. Of 276 inpatients, 28 (10%) were reprted t have died at the time f reprting. Hwever, cause f death was nt ascertained Table 1. Summary f Enterbacterales and carbapenemase type in 2017 Enterbacterales species Enzyme OXA-48 KPC NDM VIM IMP Other* Ttal E. cli K. pneumniae Enterbacter spp Citrbacter spp K. xytca Other Enterbacterales** TOTAL *includes tw islates with bth OXA-48 and NDM, tw islates with IMI, tw islates with OXA-181/232 and ne with OXA-181 **includes six islates f K. variicla, three islates f Serratia spp., tw islates f P. stuartii and ne each f P. mirabilis and Leclercia adecarbxylata Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 3

4 Number f islates Number f cases Number f cases Organism OXA-48 KPC NDM VIM IMP Other Figure 1. Enterbacterales and carbapenemase type in Other* IMP VIM NDM KPC Hspital Grup Figure 2. Distributin f carbapenemase type by Hspital Grup in 2017 CHG, Children s Hspital Grup; DM, Dublin Midlands Grup; DNE, RCSI, RCSI Grup; IE, Ireland East Grup; Other, Other nn-acute; Salta Grup, West Nrth-West Grup; SSW, Suth Suth-West Grup; UL, University f Limerick Grup *Other=IMI, OXA-181/232, OXA-48/NDM OXA % Screening % 69% 72% 75% 70% 80% 54% 84% Clinical Hspital Grup Figure 3. Distributin f islates frm screening and clinical specimens (and prprtin frm screening) by Hspital Grup in 2017 Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 4

5 Table 2. Summary f CPE (based n 1 st islate per patient, as per revised case definitin) in 2017 n % CPE cases (based n case definitin f 1st islate per patient) 449 Carbapenemase detected First rganism frm each patient in which carbapenemase was detected E. cli % K. pneumniae % Enterbacter spp % Citrbacter spp % Klebsiellae xytca 43 10% Other Enterbacterales species 13 3% Clinical vs screening TIME PERIOD 2017 COMMENT OXA % KPC 57 13% NDM 37 8% VIM 11 2% IMP 9 2% Other 7 2% 3 OXA-181/232, 2 IMI, 2 OXA-48/NDM Clinical 96 21% Screening % Surce (specimen type fr clinical islates nly) Bld/ther nrmally sterile site 10 10% Urine 50 52% Sputum/respiratry 13 14% Swab/tissue/pus/ther 23 24% Lcatin DEMOGRAPHICS Hspital* % Inpatient (nn-icu) % ICU 26 6% ED 27 6% Outpatient 30 7% Nursing hme&ltcf/gp 41 9% Nursing hme&ltcf 29 6% GP 12 3% Interventins (fr in-patients nly) Ttal n. CPE cases frm inpatients w/ clinical samples** 72 Cases treated fr CRE infectin? Treated fr infectin 25 35% Nt treated fr infectin 18 25% Unknwn/Nt answered 29 40% Ttal n. CPE cases frm inpatients** 378 Islatin within 24 hurs f CRE identified? Islated within 24 hurs % Nt islated within 24 hurs 3 1% Nt applicable (discharged befre cnfirmed) 16 4% Unknwn/Nt answered % COMMENT Male % Age range Median age 69 Inter-quartile range % f patients are aged 57 years r lder Ptential assciatin with hspital (fr inpatients nly) Prprtin detected >3 days after admissin, which may be indicative f ptential acquisitin in the facility 63% Date f admissin prvided fr 321 f 378 inpatients Outcme by time f reprting (fr inpatients nly) Died (but nt knwn if cause f death) 29 8% Survived % Unknwn/Nt answered % * includes Inpatients (nn-icu), ICU, ED and Outpatients ** includes in-patient (nn-icu), ICU and ED f which 418 cases (91%) assciated with 40 (f 60) acute hspitals (including utpatients) Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 5

6 Salta (West/Nrthwest) Dublin Nrth East (RCSI) Private Suth/Suth West Midwest (UL) Ireland East Dublin Midlands Ttal CPE GP r Lng-term care Outpatients Hspitalised patients nly % f cases detected n screening %Hspitalised, clinical cases that were treated %Hspitalised cases that were islated Appendix 1. Ttal CPE cases reprted by acute hspitals in 2017 Hspital Grup HOSPITAL Categry CHG 2 Cmbe Wmens and Infants University Hspital Specialist % NA NA Midland Reginal Hspital, Prtlaise General NA NA NA Midland Reginal Hspital, Tullamre General % NA NA Naas General Hspital General % NA 100% St James's Hspital Tertiary % 71% 100% St Luke's Hspital, Rathgar Specialist % NA 100% Tallaght Hspital Tertiary % NA NA Beaumnt Hspital Tertiary % 50% 97% Cavan General Hspital General NA NA NA Cnnlly Hspital, Blanchardstwn General % NA 100% Luth Cunty Hspital, Dundalk General NA NA NA Our Lady f Lurdes Hspital, Drgheda General % NA NA Rtunda Hspital Specialist NA NA NA Cappagh Natinal Orthpaedic Hspital Specialist NA NA NA Mater Misericrdiaie University Hspital Tertiary % 75% 91% Midland Reginal Hspital, Mullingar General % NA 100% Natinal Maternity Hspital, Hlles St. Specialist % NA NA Our Lady's Hspital, Navan General % 100% NA Ryal Victria Eye and Ear Hspital, Dublin Specialist NA NA NA St Clumcille's Hspital, Lughlinstwn General NA NA NA St Luke's Hspital, Kilkenny General % 100% 100% St Michael's Hspital, Dun Laghaire General % NA NA St Vincent's University Hspital, Elm Park Tertiary % 0% 83% Wexfrd General Hspital General % NA 100% Crm Hspital Specialist NA NA NA Ennis Hspital General % NA 100% Nenagh Hspital General NA NA NA St Jhn's Hspital, Limerick General % NA 100% University Hspital Limerick Tertiary % 0% 100% University Maternity Hspital Limerick Specialist NA NA NA Bantry General Hspital General NA NA NA Crk University Hspital Tertiary % 100% 100% Kerry General Hspital, Tralee 1 General NA NA NA Kilkreene Orthpaedic Hspital, C. Kilkenny Specialist NA NA NA Mallw General Hspital General % 100% 100% Mercy University Hspital General % 25% 100% Suth Infirmary/Victria University Hspital, Crk General NA NA NA Suth Tipperary General Hspital, Clnmel General % NA 100% University Hspital Waterfrd Tertiary % 100% 100% Galway University Hspitals Tertiary % 60% 100% Letterkenny General Hspital General % 100% NA May General Hspital, Castlebar General % 50% 100% Prtiuncula Hspital, Ballinasle General NA NA NA Rscmmn Cunty Hspital General % NA 100% Slig Hspital General % 0% 100% Children's University Hspital, Temple St. Specialist % NA 100% Our Lady's Children's Hspital, Crumlin Specialist % NA 100% Tallaght Hspital (Natinal Children's Hspital) Specialist NA NA NA Aut Even Hspital, Kilkenny Private % NA NA Beacn Hspital, Sandyfrd 3 Private % 50% 100% Blackrck Clinic Private NA NA NA Bn Securs Hspital, Crk Private % NA 100% Bn Securs Hspital, Galway Private NA NA NA Bn Securs Hspital, Glasnevin Private % NA 100% Bn Securs Hspital, Tralee Private % NA NA Galway Clinic, Dughiska Private % 0% 100% Hermitage Medical Clinic, Lucan Private NA NA NA Mater Private Hspital, Crk Private NA NA NA Mater Private Hspital, Dublin Private % NA NA St Vincent's Private Hspital Private NA NA NA Other nn-acute % NA NA Ttal % 58% 99% Data nt necessarily cmplete fr each hspital (% nly calculated if respnse given t >50% f cases); * N data r insufficient data prvided; N/A, nt applicable 1 N data fr Q due t resurce issues; 2 CHG, Children s Hspital Grup; 3 N data submitted fr Q Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 6

7 Glssary f terms Carbapenems Carbapenemases CPE CRE Enterbacteriaceae Enterbacterales IMI IMP KPC NDM OXA-48 VIM Brad spectrum beta lactam antibitics ften reserved fr treatment multi-drug resistant infectins and infectins in critically-ill patients. They bind t prteins in the bacterial cell wall, thereby stpping the cell wall frm being synthesised. Examples include merpenem and ertapenem Enyzmes prduced by bacteria that hydrlyse r break dwn beta lactam antibitics rendering them ineffective, thus enabling the bacteria t survive in their presence. Examples include KPC, OXA-48, NDM, VIM and IMP Carbapenemase prducing Enterbacterales (was Enterbacteriaceae) Carbapenem resistant Enterbacterales (was Enterbacteriaceae) Family f bacteria, ften referred t as clifrms, which are fund in the enteric tract/gut f humans and animals where they make up a large part f the nrmal flra and are usually harmless. They are imprtant causes f infectins such as; urinary tract and wund infectins, BSI, meningitis and pneumnia. Examples include; E. cli, Klebsiella pneumniae, Prteus mirabilis, Enterbacter clacae Recent taxnmic studies have narrwed the definitin f the family Enterbacteriaceae. Sme previus members f this family are nw included in ther families within the Order Enterbacterales; hence Enterbacterales is nw mre apprpriate than Enterbacteriaceae fr gruping the different species cnsidered as clifrms Less cmmn type f carbapenemase Less cmmn type f carbapenemase Cmmn type f carbapenemase (Klebsiella pneumniae-carbapenemase) Cmmn type f carbapenemase (New Delhi metall-beta-lactamase) Cmmn type f carbapenemase Less cmmn type f carbapenemase Carbapenemase Prducing Enterbacterales (CPE) in Ireland: 2017 (prduced May 2018) Page 7