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Infection Prevention for Patients with CP-CRE & Other Multi-Drug Resistant Gram-Negative Rods · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the Developments and Transmission-Based Precautions Podcast Series, brought to you by the Society for Healthcare Epidemiology of America, SHAY, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_01: I'm Chad Nix, a medical student at Oracle Science University and former infection preventionist, and I will serve as today's moderator.
• 0:30
  SPEAKER_01: Shea is excited to launch this episode of the podcast series entitled Infection Prevention for Patients with CPCRE and other multidrug resistant gram-negative rods.
• 0:38
  SPEAKER_01: I'm happy to introduce our speakers for today.
• 0:40
  SPEAKER_01: First, we have Charles Nika Evans.
• 0:43
  SPEAKER_01: Dr.
• 0:43
  SPEAKER_01: Evans is a research career scientist and associate director in the Center of Innovation for Complex Chronic Healthcare at the Heinz VA Hospital in the West Suburbs of Chicago.
• 0:52
  SPEAKER_01: She is also a professor in the Department of Preventive Medicine in the Feinberg School of Medicine at Northwestern University in Chicago, Illinois.
• 1:00
  SPEAKER_01: Dr.
• 1:00
  SPEAKER_01: Evans' research is focused on the epidemiology of healthcare associate infections and reducing the spread of antibiotic resistance.
• 1:06
  SPEAKER_02: Oh, thank you for having me.
• 1:08
  SPEAKER_01: Next, we have Dr.
• 1:09
  SPEAKER_01: Christophe.
• 1:10
  SPEAKER_01: Since 2011, Dr.
• 1:11
  SPEAKER_01: Pfeiffer has served as the hospital epidemiologist at the VA Portland Healthcare System and as an ID physician rounding on both general and transplant ID consult services at the Portland VA and Oregon Health and Science University.
• 1:23
  SPEAKER_01: In 2018, he became chief of the ID section at the Portland VA.
• 1:27
  SPEAKER_01: In 2012, he began an ongoing collaboration with the Oregon Health Authority, Oregon's State Health Department, by serving as the medical director for Oregon's Drug Resistant Organism Prevention and Coordinated Regional Epidemiology, or Drop CRE, network.
• 1:41
  SPEAKER_01: The primary goals are to plan and implement the statewide strategy to prevent, detect, and control the spread of multidrug resistant organisms with a focus on carbapen-resistant androbacterales, or CRE, and now also Canada Ores in Oregon.
• 1:55
  SPEAKER_00: Hello, thanks for having me.
• 1:56
  SPEAKER_01: Thank you both for joining us.
• 1:58
  SPEAKER_01: We'll be discussing carbapenamase producing carbapenum resistant androbacterales and other multidrug resistant gram-negative rods that pose significant risks to patients.
• 2:06
  SPEAKER_01: For background, how are these organisms characterized?
• 2:09
  SPEAKER_01: Chris, would you like to begin?
• 2:11
  SPEAKER_00: Sure, thanks, Chad.
• 2:12
  SPEAKER_00: So we'll start with uh CRE and CPCRE and then kind of maybe move out from there because all these organisms have an alphabet soup of acronyms that we can get into.
• 2:24
  SPEAKER_00: So we think of CRE in these two buckets.
• 2:27
  SPEAKER_00: The probably the overall bucket is the carbapenum resistant enterobacteralis, where these organisms become resistant to the antibiotics by a number of different mechanisms.
• 2:38
  SPEAKER_00: And the probably most important mechanism and the one we really are targeting with a lot of our kind of global, national, and hospital-level infection control, are the carbapenamas producing enterobacteralis, CPE, or as known as sometimes CPCRE.
• 2:55
  SPEAKER_00: So carbophenase producing CRE.
• 2:58
  SPEAKER_00: Then we kind of branch out to these other organisms, which the ones of interest are the next two of interest would be Pseudomonas aroudinosa and Acinitobacter species or Acinetobacter baumanii.
• 3:12
  SPEAKER_00: And so those are kind of known and kind of have taken the same kind of acronym approach where CPPA would be carbapenemase producing Pseudomonas aroginosa and CPCRPA or CRPA alone would be carbapenum resistant Pseudomonas arugenosa.
• 3:32
  SPEAKER_00: And again, in in this case, a real small subset of the Pseudomonas are actually carbopenemase producing.
• 3:38
  SPEAKER_00: And then we'll move over to Acinitobacter, where it's kind of the same general idea where if it's carbopenomase producing, that'll be the CP in there.
• 3:46
  SPEAKER_00: And so it's either CPA or CPAB for carbopenomase producing acinitabacter species or acynidobacter baumanii versus what you may have heard is CRAB or CRA, which would be carbapenum resistant acynidobacter species or baumanii.
• 4:04
  SPEAKER_00: So again, that's kind of maybe the tour of the major groups of gram-negative resistant organisms and kind of grouped together.
• 4:12
  SPEAKER_00: They're called carbapenum resistant organisms or CROs, to add a couple last uh acronyms, and then and or CPOs, carbapenum ACE-producing organisms.
• 4:23
  SPEAKER_00: I'll stop there and uh hand it over to Charles Nika to maybe discuss the epidemiology a bit in more detail.
• 4:30
  SPEAKER_02: Thank you, Chris.
• 4:30
  SPEAKER_02: I think it's really important to put the epidemiology of these organisms in context.
• 4:35
  SPEAKER_02: And I'm going to particularly point out CRE and carbapenum resistant acinitobacter because they are organisms that the CDC has designated as an urgent threat to the public health.
• 4:47
  SPEAKER_02: So the CDC reports that in the United States, over 13,000 healthcare associated infections caused by anaerobacter rallies are CRE, and this is each year.
• 4:58
  SPEAKER_02: And over 8,000 of them are carbapenum resistant acinitobacter.
• 5:02
  SPEAKER_02: And when looking at whether they are carbapentamase producers, CDC reports that 30% of CRE are carbapentamase producers or CPCRE.
• 5:13
  SPEAKER_02: And we've looked at some health record data in previous studies and found that when looking at CRE cultures that had carbapentamase testing conducted, upwards of 84% of CRE were carbapentamase producers.
• 5:28
  SPEAKER_02: Some important things to note about CRE and the risk factors for them are one of the largest risk factors for them are previous exposure to carbopendems, but also use of invasive devices, mechanical ventilation, having chronic coma conditions such as obesity or lung disease, and even the use of gastric acid-suppressing medications have been found to be associated with risk of CRE.
• 5:54
  SPEAKER_02: So I think these are really important epidemiological factors to be thinking about when thinking about the risk of these CPO organisms in patients.
• 6:04
  SPEAKER_01: Great.
• 6:05
  SPEAKER_01: Thank you so much for that valuable information.
• 6:07
  SPEAKER_01: And Chris, how can we best identify patients who are at increased risk of being colonized with one of these organisms?
• 6:13
  SPEAKER_00: I think of these risks as several buckets and all kind of related in a way.
• 6:20
  SPEAKER_00: And it depends on which organism we're talking about.
• 6:23
  SPEAKER_00: But the first is the local CRO or CPO epidemiology.
• 6:28
  SPEAKER_00: So for us, an organ that looks different than for Charles Nico's group in Chicago.
• 6:35
  SPEAKER_00: For us, our local epidemiology is that all CP CRE and all CPPA and all CPCRA are pretty rare.
• 6:47
  SPEAKER_00: We don't encounter these much.
• 6:48
  SPEAKER_00: I mean, in this last year, for example, we would see under 20 cases of those three of the CPOs combined.
• 6:55
  SPEAKER_00: But that's different in other places.
• 6:58
  SPEAKER_00: So in other, you know, regions and cities and countries, some of these organisms are quite endemic and it's not unusual to encounter them.
• 7:07
  SPEAKER_00: Another bucket is the travel bucket.
• 7:09
  SPEAKER_00: And it's especially relevant for us in Oregon that if patients have undergone travel, particularly outside the United States, and that would hold true for anywhere in the US, but even for us, we think of travel outside the state to certain areas as higher risk of acquiring one of these organisms.
• 7:27
  SPEAKER_00: And the higher risk really comes into play when a patient would be hospitalized in one of these places during travel, or for medical tourism, you know, travel for medical tourism, for example.
• 7:39
  SPEAKER_00: We see a decent number of our cases of CPOs come back from that type of exposure, mostly international.
• 7:47
  SPEAKER_00: And then Charles Nikola already kind of touched on this, but then you think about the traditional risks for acquiring an MDRO, such as healthcare exposure, stays in LTAC, vSNFs, especially, so long-term acute care hospitals or ventilator skilled nursing facilities, as well as line drains, tubes, ventilation requirements, ICU stays, and some other kind of other things that we think of more traditional risk factors, antibiotic exposures.
• 8:16
  SPEAKER_00: And those come into play certainly if the CPO is endemic in the area, and or if a patient has been somewhere and brought in a CPO to an area or a unit.
• 8:26
  SPEAKER_02: I think it's important to note and reiterate that these are pretty rare organisms to identify.
• 8:32
  SPEAKER_02: And so when we think about even screening, for instance, if we want to screen, say, people being admitted into the hospital for these organisms, that's pretty limited across the country in terms of who uh would be engaged in those activities and whether you actually should do that or not.
• 8:48
  SPEAKER_02: I think it really all depends on your epidemiology in your community as well as in your facility, and also if you have the resources.
• 8:57
  SPEAKER_02: And again, when we've looked at this in terms of what facilities are doing about screening, we've found that one, it's rare, but two, when they are doing it, they're focused it on different types of populations.
• 9:08
  SPEAKER_02: So those who have been admitted from a facility known to have a problem with MDROs or CRE, those who are known to have a history of CRE or another MDRO or multidrug resistant gram negative.
• 9:22
  SPEAKER_02: Also, um, people who've been hospitalized outside the United States.
• 9:26
  SPEAKER_02: We've seen that as a screening criteria for some facilities or being transferred from some type of long-term care or acute care hospital, or even focusing on specifically very high-risk patients or patients who are high risk for these infections, such as those with like transplantation patients.
• 9:44
  SPEAKER_02: So in thinking through, you know, detection and testing, it's really important for facilities to think about their local epidemiology and also whether they have the resources available to them to be able to do some of the screening or testing that's necessary to be able to identify patients who actually have these organisms.
• 10:06
  SPEAKER_00: Yeah, I also wanted to add that once you figure out kind of who the population of at-risk patients are, it's another matter to get to the actual testing component of it.
• 10:17
  SPEAKER_00: And so, you know, to screen patients for these organisms requires a molecular test to look for carbapenamase production.
• 10:25
  SPEAKER_00: And uh, there's a commercially available molecular test to screen for the major five carbapenomases that are commonly encountered with CPCRE.
• 10:36
  SPEAKER_00: And actually, public health also kind of has a mechanism to pretty easily screen using molecular methods for CPCRE.
• 10:45
  SPEAKER_00: Whereas it's a bit more kind of gray area and difficult to figure out how to screen patients who may be at risk for the other carbopanamase producers in CPPA and CPS and Etabacter in particular.
• 11:00
  SPEAKER_00: And so we take that into account when we're doing our risk assessment as a facility as to which patients and how we're going to think about screening for these organisms.
• 11:10
  SPEAKER_01: Thank you, Charles Nick and Chris.
• 11:12
  SPEAKER_01: What types of transmission-based precautions are indicated?
• 11:15
  SPEAKER_01: Should a patient be identified as having one of these organisms, and are there measures that should take place in addition to them?
• 11:21
  SPEAKER_00: So contact precautions is kind of the main tool that's used across the country for patients infected and colonized with CPO or CPCRE.
• 11:32
  SPEAKER_00: There's a lot of other things that need to happen, though.
• 11:35
  SPEAKER_00: And we tried to put a framework in this in Oregon in our CRE toolkit that we called NICE at the time, and that the N would stand for notify, and that you know, really is notification of public health, your pertinent hospital groups, your clinicians, nurses, cleaning staff, your leadership if this is an organism that's you know novelly encountered in your setting.
• 11:58
  SPEAKER_00: And then I for intervene, and that would be really to make sure that your basic infection control is in place and you have solid hand hygiene, private room, contact precautions in place, et cetera.
• 12:12
  SPEAKER_00: And we also suggest cohorting if you've got a couple of cases in an area and cohort staff and patients if possible, depending on kind of the situation.
• 12:22
  SPEAKER_00: Consider chlorhexidine bath, which is a tool that if the patient isn't already receiving for some reason, may help decrease the burden of CRE in the skin and environment.
• 12:34
  SPEAKER_00: And then with the kind of the big question we often deal with is once we identify a case, is what kind of other screening should be done on the ward or the unit or high-risk contacts?
• 12:47
  SPEAKER_00: And to that, that's evolved over time.
• 12:49
  SPEAKER_00: And in and I think CDC now, in their most recent containment strategies guidance framework, which is updated in December 2022 and is easy to Google, is a little more prescriptive on how aggressive to screen case contacts in your facility, and then even in facilities where the patient may have been within the last 30 or so days.
• 13:11
  SPEAKER_00: But often that involves at least screening high-risk any roommates or any people with shared bathrooms, and and usually in a in a ward if the patient's been there for some period of time.
• 13:24
  SPEAKER_00: At this point, we're often doing point prevalence screens for the entire unit where the patient has been on.
• 13:30
  SPEAKER_00: And then for C, we have that as a communicate.
• 13:33
  SPEAKER_00: So we we find really important to communicate with the transferring facilities or units or areas of the hospital where the patient may be going, to just communicate the status and the knowledge that this is a patient that is outcolonized or infected with one of these CPOs and what precautions need to be taken.
• 13:53
  SPEAKER_00: And then finally to educate, and you know, that includes patient staff and visitors about the organism and what needs to be done.
• 14:00
  SPEAKER_00: And there's a lot of like educational material now that is available on state public health websites and or CDC to help with that.
• 14:08
  SPEAKER_00: One thing we do in Oregon is we have a pretty strong public health presence for each of these cases.
• 14:14
  SPEAKER_00: We actually have a group that will meet with the hospital, if it's a hospital that's a nursing home infection preventionist andor leadership and kind of just guide them through what the steps are that should be done or we would like to be done.
• 14:26
  SPEAKER_00: And we really, as coming from the public health side, we try to facilitate any of those steps.
• 14:31
  SPEAKER_00: So we provide help with coordination of colonization screening and recommendations on how to do the colonization screening.
• 14:39
  SPEAKER_00: And then the other thing that public health will provide is on-site infection control assessments using the CDC ICAR tools, and those are available online.
• 14:48
  SPEAKER_00: And then public health really can coordinate regional response activities.
• 14:52
  SPEAKER_00: So we've kind of gotten to the point where you know we're thinking about this more and more is how interconnected facilities are and how they're interconnected.
• 15:00
  SPEAKER_00: So if you've got a case or an outbreak at one facility, thinking about how that affects the other facilities in the region.
• 15:07
  SPEAKER_00: And so I think that's becoming more and more important.
• 15:10
  SPEAKER_02: One thing I wanted to highlight about what you said in terms of the contact precautions and identifying patients who may have MVRs when they come into the hospital.
• 15:21
  SPEAKER_02: We know that spread of infection and outbreaks can occur when a patient is admitted with an MVRO and not placed in contact precautions.
• 15:28
  SPEAKER_02: And studies have shown that knowledge of this information is really a significant gap in prevention of these MVRs.
• 15:35
  SPEAKER_02: We know that there's lots of opportunities for better communication between facilities who are transferring patients to a hospital, whether it's a hospital to hospital or long-term care, nursing homes to hospital.
• 15:48
  SPEAKER_02: And so there needs to be more formal strategies to systematically communicate when patients have specific MDROs or a history of these organisms.
• 15:58
  SPEAKER_02: And so one of the areas that I want to point out that's been happening in the VA, and Chris is actually one of the creators of this system, is where the VA has a system to alert infection prevention personnel in real time when they have an acute or long-term care patient or resident who's admitted to their facility with a history of colonization or infection with a multidrug resistant organism.
• 16:24
  SPEAKER_02: And CRE is one of these organisms that are highlighted.
• 16:27
  SPEAKER_02: So I think it's definitely going in the right direction.
• 16:31
  SPEAKER_02: This is a system that allows VA infection prevention personnel to identify when a patient comes in from any other VA facility who's had a history of colonization or infection.
• 16:44
  SPEAKER_02: So I think that this is a really innovative and forward-looking system that I think could be definitely beneficial to have systems like this in place for other units and facilities as well across the country that are not VA facilities.
• 16:59
  SPEAKER_02: I also wanted to just point out the contact precautions is sort of the standard of managing these infections or people who are colonizing with them.
• 17:09
  SPEAKER_02: But we also need to understand that implementation of those contact precautions may be varied across healthcare facilities.
• 17:18
  SPEAKER_02: And understanding the barriers and facilitators to appropriate implementation of contact precautions is really important.
• 17:27
  SPEAKER_02: Thinking about facilities that have shared rooms and how do you deal with that?
• 17:32
  SPEAKER_02: Chris already talked about shared bathrooms.
• 17:34
  SPEAKER_02: So, how does a facility work through being able to effectively prevent transmission when you have some of these types of physical barriers, maybe resources may be an issue?
• 17:46
  SPEAKER_02: We talked a little bit about testing already, and some facilities don't have the capabilities to do the next level testing that's needed for identifying a carbopenamase producer.
• 17:57
  SPEAKER_02: And so knowing what resources are out there and available are really important for healthcare facilities.
• 18:03
  SPEAKER_02: The CDC's antimicrobial resistant laboratory network actually provides testing for some of these highly resistant organisms.
• 18:12
  SPEAKER_02: So I think that's really important to point out.
• 18:15
  SPEAKER_02: We should all keep in mind that we can say and think about that these practices should just be implemented, but a lot more has to go into it in order to get them fully implemented into healthcare practice and healthcare facilities.
• 18:31
  SPEAKER_01: Charles Nico, what do you foresee as changing in the context of infection prevention for CPCR and other multi-drug resistant gram-negative rods?
• 18:38
  SPEAKER_02: I would say that one of the areas that has really started to grow in infection prevention and antimicrobial stewardship is a focus on looking at disparities in equity.
• 18:51
  SPEAKER_02: We know from the COVID-19 pandemic that the pandemic had a deleterious impact on people of color.
• 18:59
  SPEAKER_02: And we haven't really explored that much for other infectious diseases beyond, you know, sort of HIV.
• 19:08
  SPEAKER_02: But this area, I think, is a really important evolving area for many of those who do health disparities work and equity work in the stewardship and infection prevention space.
• 19:19
  SPEAKER_02: There are very few studies that have reported on differences in, say, race or ethnicity or social determinants of health in these highly resistant organisms.
• 19:32
  SPEAKER_02: There was a recent scoping review looking at antibiotic prescribing and antibiotic stewardship in equity and seeing what differences are being shown.
• 19:42
  SPEAKER_02: But there's very little around looking at resistance, what type of practices are associated with infection prevention for different patients.
• 19:51
  SPEAKER_02: What are we seeing in terms of rural versus urban facilities or other geographic locators?
• 19:59
  SPEAKER_02: We've seen that the South tends to have a higher prevalence of some of these organisms than other regions.
• 20:06
  SPEAKER_02: So I think the area of addressing health disparities and ensuring that equity is happening across all the infection prevention strategies that we're using, as well as in terms of management of these infections.
• 20:21
  SPEAKER_00: Chris, do you have any thoughts?
• 20:23
  SPEAKER_00: A couple of the other almost kind of more, I guess, practical things that we're working on and or thinking about is really the need, as I kind of mentioned, it's the CPCRE screening is fairly straightforward, but the CRA screening and how to screen for carbapenamases and understand what that means in acinitabacter is somewhere I think that as technology comes on, I think we're getting closer to better understanding.
• 20:49
  SPEAKER_00: We're just starting to look at our carbapenum resistant acinetobacters more closely in organ now that we have the technology and trying to understand what our epidemiology actually is within that group of organisms.
• 21:03
  SPEAKER_00: And really that requires whole genome sequencing, which is coming online through public health, thankfully.
• 21:11
  SPEAKER_00: And so that's, I think, one place that would help us a lot.
• 21:14
  SPEAKER_00: We've talked about ways of identifying patients at risk of CRO and CPOs.
• 21:21
  SPEAKER_00: And as we are talking about this, I kind of just realized that we think about identifying these patients, but very few facilities and healthcare systems are actually able to successfully implement a screening process.
• 21:36
  SPEAKER_00: And you know, in that's partly because the swabs are perirectal or rectal swabs.
• 21:41
  SPEAKER_00: That's you know a hard pill to swallow for kind of every admitted patient or it's the subset of admitted patients that one might want to screen.
• 21:48
  SPEAKER_00: So if there were some way to get away from that, that would be uh great.
• 21:52
  SPEAKER_00: But other other things about thinking about how a CR CPO, how to identify a CPO coming into your system, wastewater became a big way of detecting COVID in the community over the last couple of years, and we're wondering about trying to leverage that to start to detect CPOs in the wastewater.
• 22:10
  SPEAKER_00: And you know, do we see a signal that we may have a problem in the community by that measure?
• 22:16
  SPEAKER_00: And the other thing is just better ways than contact precautions to limit the spread.
• 22:21
  SPEAKER_00: And there's a lot of issues with implementation of contact precautions, as Charles Nika mentioned.
• 22:27
  SPEAKER_00: And even if they're done well, it's still just not a perfect uh state.
• 22:32
  SPEAKER_00: And there's so many opportunities for spread of these organisms in various healthcare settings.
• 22:38
  SPEAKER_00: So, you know, how do we improve what we would say just kind of horizontal general infection control prevention methods?
• 22:46
  SPEAKER_00: And thinking about things as like improved disinfectants and CPOs may not be the best example, but thinking about C.oris, where if a hospital is using a C oris active disinfectant for routine cleaning, then you're much better off if you encounter a C.O.S.
• 23:05
  SPEAKER_00: case than if you hadn't been using one of those disinfectants for cleaning.
• 23:08
  SPEAKER_00: Unfortunately for CPOs, it appears that kind of all hospital-level disinfectants do a good job on those.
• 23:15
  SPEAKER_00: But additional measures of cleaning stuff such as you know, UV light or some sort of automated room cleaning for terminal cleaning, and or better ways to wash hands if people are looking at improve ways to monitor the methods and maybe better ways to actually wash hands or clean hands.
• 23:34
  SPEAKER_00: So I think there's just a ton of room here to grow in uh figuring out how to improve our general infection prevention and and then also CPO kind of specific infection prevention.
• 23:47
  SPEAKER_01: Thank you both for such a fantastic conversation.
• 23:50
  SPEAKER_01: We appreciate you joining us today.
• 23:52
  SPEAKER_00: Thank you, Chad.
• 23:52
  SPEAKER_00: I appreciate the opportunity to come on and really enjoyed having this with Charles Nika.
• 23:57
  SPEAKER_00: So I appreciate Charles Nika, your your comments and input as well.
• 24:01
  SPEAKER_02: Thank you, Chris, and Chad as well in Society for Healthcare Epidemiology of America for inviting me.
• 24:07
  SPEAKER_01: You can find more educational content like this podcast on Shay's Online Education Center, Learning CE, at www.learningce.shay hyphenonline.org.
• 24:19
  SPEAKER_01: This concludes today's episode of the Developments and Transmission Based Precaution Series.
• 24:23
  SPEAKER_01: Thank you for tuning in.