Diseases Update, C-Diff and Antibiotic Resistance L. Clifford McDonald, MD, FACP, SHEA Senior Advisor for Science and Integrity OSAP 2015 Dr. John Zapp Memorial Lecture: May 29, 2015 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
NoFinancial Disclosures The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Objectives Recent global outbreaks of serious viral diseases (SARS, H1N1, MERS, Ebola) Antibiotic resistance: urgent threats and what to do about it Clostridium difficile infection and how it relates to oral healthcare delivery
Infection Risks in Oral Healthcare Delivery "Early dental chair, Shamrock, TX IMG 6151" by Billy Hathorn - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/file:early_dental_chair,_shamrock,_tx_img_6151.jpg#/media/file: Early_dental_chair,_Shamrock,_TX_IMG_6151.JPG
Infection Risks in Oral Healthcare Delivery "Dental office" by Own - Own work. Licensed under GFDL via Wikimedia Commons - http://commons.wikimedia.org/wiki/file:dental_office.jpg#/media/file:dental_office.jpg
Infection Risks in Oral Healthcare Delivery
Infection Risks in Oral Healthcare Delivery Injection safety Instrument cleaning, disinfection, and sterilization Critical and semi-critical items Sharps safety Airborne transmission Tuberculosis, measles Droplet transmission Respiratory viruses, H1N1, SARS, MERS Direct and indirect contact transmission Norovirus, Ebola Antibiotic resistant pathogens, Clostridium difficile
Severe Acute Respiratory Syndrome (SARS), 2003 Coronavirus Enveloped Emerged in China, 2002 Bats Other small mammals Incubation period: 2-7 days, sometimes 10-14 days Symptoms: fever, cough, shortness of breath, diarrhea Transmission Droplet, Contact, Airborne with Aerosol Generating Procedures Disseminated globally via Hong Kong in travelers "Coronaviruses 004 lores" by Photo Credit:Content Providers(s): CDC/Dr. Fred Murphy
SARS Worldwide Dissemination: Only an Airplane Ride Away MMWR Morb Mortal Wkly Rep. 2003 Jul 18;52(28):664-5.
Relative Resistance of Microorganisms to Chemical Germicides Low level disinfectant Bacterial Spores Mycobacteria Non-eveloped or small viruses Fungi Vegetative bacteria Enveloped or medium-sized viruses (Influenza, coronavirus, ebola)
SARS, Toronto, 2003 MMWR Morb Mortal Wkly Rep. 2003 Jun 13;52(23):547-50.
SARS, Toronto, 2003 Healthcare Workers Disproportionately Affected MMWR Morb Mortal Wkly Rep. 2003 Jun 13;52(23):547-50.
Early Recognition and Prevention of SARS Transmission in Outpatient Settings Visual alerts Screening and Triage Travel and symptom history Respiratory hygiene/cough etiquette Droplet precautions Disposition Hospitalization http://www.cdc.gov/sars/guidance/i-infection/healthcare.html
Fundamentals of Infection Control Hierarchy of Infection Control Administrative Controls Environmental Controls Respiratory Protection
Respiratory Hygiene/Cough Etiquette
Make available Surgical face masks, Facial tissue, Receptacles for tissues, and Hand sanitizer in all waiting areas.
Spatial Distancing in Your Waiting Room? McDonald LC et al. Emerg Infect Dis Vol. 10, No. 5, May 2004
Pandemic Influenza Haemophilus influenzae using gram-stain Caused by Influenza A viruses Results from change in viral structure Acquires a new H or H+N Characterized by virus that spreads easily and has high morbidity
Flu Pandemics in the 20 th Negative stain of influenza A Century 1918-19: Spanish Flu A(H1N1) >500,000 deaths in U.S. 50 million deaths worldwide 1957-58: Asian Flu A(H2N2) ~70,000 deaths in U.S. 1968-69: Hong Kong flu A(H3N2) ~34,000 deaths in U.S.
Why Was H1N1 Infection Of Concern? Lack of pre-existing immunity No vaccine available early on As a result, illness may be more severe and widespread Patients who required hospitalization were younger than most patients with seasonal flu (avg age 27 years as of 5/20/09) Fear that it could mutate again before next flu season 25% with diarrhea and vomiting could introduce a new route for transmission
Administrative Controls for H1N1? Identify patients with flu-like symptoms Defer elective treatment until patient is no longer infectious Advise patients to contact their HCP to report illness (by phone or other remote means) before seeking care
H1N1 Timeline of Events First case In CA, April Increased child Cases through Summer Vaccine Becomes Available, Sept First cases In MX, Mar WHO declares Pandemic, Jun Severity in Obesity Becomes Established Human strain Jan 2009 Dec 2009 by 2013-14 H1N1becomes most prominent circulating human strain
Middle East Respiratory (MERS) Syndrome Caused by MERS coronavirus (MERS-CoV) Emerged in Saudi Arabia in 2012 Camels Incubation: 5-6 days, may range 2-14 Symptoms: similar to SARS Transmission: Close contact (Droplet, Contact, Airborne with Procedures?) No sustained transmission in community Healthcare workers again at increased risk As of January 2015: 956 cases, 351 deaths Cynthia Goldsmith/Azaibi Tamin http://www.cdc.gov/coronavirus/mers/photos.html
Early Recognition and Prevention of MERS Transmission in Outpatient Settings Visual alerts Screening and Triage Travel, risk factor, and symptom history Respiratory hygiene/cough etiquette Droplet precautions Disposition Hospitalization
People Who May Be at Increased Risk for MERS Recent Travelers from the Arabian Peninsula Close Contacts of an Ill Traveler from the Arabian Peninsula Close Contacts of a Confirmed Case of MERS Healthcare Personnel Not Using Recommended Infection-Control Precautions People with Exposure to Camels Avoid contact with camels Do not drink raw camel milk or raw camel urine Do not eat undercooked meat, particularly camel meat
MERS in the Arabian Peninsula http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-arabian-peninsula-uk
Filoviridiae Ebola Virus Disease (EVD), 2015 Ebolavirus: Taï Forest, Sudan, Zaire, Reston and Bundibugyo Marburgvirus Thread-like, lipid-enveloped viral particles African fruit bat reservoir Incubation: 8-10 days, anywhere 2-21 days Symptoms: Fever, Severe headache, Muscle pain, Weakness, Fatigue, Diarrhea, Vomiting, Abdominal pain, Unexplained hemorrhage http://www.cdc.gov/vhf/ebola/
http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html
Transmission of Ebola Blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with or has died from Ebola, Objects (like needles and syringes) that have been contaminated with body fluids from a person who is sick with Ebola or the body of a person who has died from Ebola, Infected fruit bats or primates (apes and monkeys), and Possibly from contact with semen from a man who has recovered from Ebola http://www.cdc.gov/vhf/ebola/
2014 Ebola Outbreak in West Africa Total cases Days since last case http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html
Key Points for EVD Triage in Ambulatory Care Most patients with fever and other symptoms coming to an ambulatory care facility don't have EVD, but it is important that staff members know how to identify and manage patients who might have EVD. Staff members should be ready to take 3 steps: Identify, Isolate, and Inform. Ask every patient if, in the last 21 days, they traveled to Guinea, Liberia, or Sierra Leone or had contact with someone with confirmed EVD. If a patient appears to be at risk for EVD, isolate the patient immediately, avoid unnecessary direct contact, determine personal protective equipment needed, and notify the health department to arrange a transfer to a facility that can further assess the patient. Do not transfer the patient without first notifying the health department; these patients should only be transferred to a facility approved by public health authorities.
Carbapenem-resistant Enterobacteriaceae (CRE) Multidrug-resistant organisms, including CRE, pose a significant public health threat Most common type of CRE is resistant to almost ALL antibiotics New and frightening resistance patterns emerging CRE has spread across US found in one state in 2001, now spread to 38 states Outbreaks show importance of longterm care, acute care, and nursing homes as source of HAIs in hospitals Regional prevention efforts effective in preventing infections (e.g., Chicago, Florida)
Facility-level recommendations Regional prevention strategy for health department implementation CDC CRE Toolkit 2012 http://www.cdc.gov/hai/organisms/cre/cre-toolkit
Gaps in knowledge of antibiotic resistance Limited national, state, and federal capacity to detect and respond to urgent and emerging antibiotic resistance threats Currently there is no systematic international surveillance of antibiotic resistance threats Data on antibiotic use in human healthcare and in agriculture are not systematically collected Programs to improve antibiotic prescribing are not widely used in the United States Advanced technologies that can identify threats much faster are not being used in current practice
Antibiotic development is dwindling
Antibiotic prescriptions per 1000 persons of all ages according to state, 2010 Hicks LA et al. N Engl J Med 2013;368:1461-1462.a
Clostridium difficile infection (CDI) Anaerobic bacterium Not normal intestinal bacterium Fecal-oral spread Forms spores that persist Toxins produce colitis Diarrhea More severe disease, death 2-steps to infection Antibiotics result in vulnerability New acquisition via transmission Figure courtesy of D. Gerding and S. Johnson
Important Host Defense and Risk Factors for CDI Host Defense Intact/undisturbed lower intestinal microbiota Intact appendix? Infancy Humoral immune response Stomach acid? Spores are acid resistant Risk factors Medications that disrupt microbiota Antibiotics Proton pump inhibitors? Older age Immunosuppressant's Inflammatory bowel disease Tube feeds Factors increasing acquisition Proximity to other infected patients--hospitalization
CDI Discharges / 1,000 Discharges Discharges (primary and secondary) coded for Clostridium difficile infection (CDI), United States 12 10 8 6 4 2 0 HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/
BI/NAP1/027, toxinotype III Historically uncommon epidemic since 2000 More resistant to fluoroquinolone antibiotics Higher MICs compared to historic strains and current non-bi/nap1 strains More virulent Increased toxin A and B production Polymorphisms in binding domain of toxin B Binary toxin McDonald et al. N Engl J Med. 2005;353:2433-41. Warny et al. Lancet. 2005;366:1079-84. Stabler et al. J Med Micro. 2008;57:771 5. Akerlund et al. J Clin Microbiol. 2008;46:1530 3.
Preventing CDI Hand hygiene Spore acquisition C D I Patient susceptibility Antimicrobial exposure Environmental cleaning Early detection & Contact Isolation Reducing asymptomatic shedding? Gastric acid suppression
Six Steps to Prevention of Hospital-Onset CDIs Prescribe and use antibiotics carefully Focus on an early and reliable diagnosis Isolate patients immediately Wear gloves and gowns for all contact with patient and patient care environment Assure adequate cleaning of the patient care environment, augment with EPA-registered C. difficile sporicidal disinfectant Notify facilities upon patient transfer Source: http://www.cdc.gov/vitalsigns/hai/stoppingcdifficile/
Epidemiologic Classification of CDI Cases HA or CA* Healthcare-associated Communityassociated Admission 3days Discharge 12 weeks > 12 weeks HCFO** CO-HCFA CA-CDI Time * classification will depend on healthcare exposure in the prior 12 weeks ** includes hospital-onset and nursing home-onset Modified from CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007;28:140-5
U.S. BURDEN (453,000) Community Associated Hospital Onset Lessa FC et al. N Engl J Med 2015;372:825-34. Post Discharge Nursing Home Onset
Chitnis et al. JAMA Intern Med. 2013;173(14):1359-1367
Jury LA et al. PLoS ONE 8(7): e70175.
Jury LA et al. PLoS ONE 8(7): e70175.
Medication Use in Community-associated CDI, 2009-2011 Most common reasons for antibiotics: upper respiratory and dental procedures Chitnis et al. JAMA Intern Med. 2013;173(14):1359-1367
Antibiotic Exposures and Transmission Events in One Setting Impact Infections in Other Settings
Summary Preparing oral healthcare delivery settings for internationally emerging infectious diseases requires situational awareness and informed triage Essential to communicate with local and state public health authorities Monitor CDC website While transmission of antibiotic resistance and Clostridium difficile could occur in oral healthcare delivery settings it appears unlikely such that antibiotic stewardship should be emphasized in responding to these threats
Summary Consider patients underlying risk for Clostridium difficile infection (CDI) in deciding when to prescribe an antibiotic Educate patients about symptoms and signs of CDI and what to do if they develop diarrhea Follow current guidance for antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infection
For More Information Cliff McDonald cmcdonald1@cdc.gov 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: cdcinfo@cdc.gov 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