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Prevention and Control of Outbreaks in Long Term Care · The SHEA Podcast

• 1:40
  SPEAKER_01: Thank you so much for joining us today.
• 1:42
  SPEAKER_02: You're welcome.
• 1:44
  SPEAKER_02: Thank you for having us on.
• 1:46
  SPEAKER_01: When you consider the issue of outbreaks in the long-term care settings, which organisms are you most concerned about right now?
• 1:53
  SPEAKER_02: So there are several organisms to be concerned about in the long-term care settings.
• 1:59
  SPEAKER_02: So we will be addressing four primary organisms.
• 2:03
  SPEAKER_02: I would say we will be in depth highlighting three and just touching upon one.
• 2:08
  SPEAKER_02: So the four organisms are Closteroides, difficile, CRE, or carbofen resistant enterabacteraceae, and that's just going to fall into the entire category of multi-drug resistant organisms, Canadaoris, and lastly, which we'll be just briefly highlighting is ESBLs or extended spectrum beta-lactomesis.
• 2:31
  SPEAKER_02: Dr.
• 2:31
  SPEAKER_02: Goldstein, did you want to briefly go over CDAF?
• 2:35
  SPEAKER_00: So the first organism that is prevalent in all types of hospital facilities is Clostridoides difficile infection or CDI.
• 2:46
  SPEAKER_00: And over the last two decades, there has been an increase in severity, so much so that it has been labeled as an urgent clinical worldwide threat through World Health Organization as well as CDC.
• 2:59
  SPEAKER_00: And what's happened over the last decade and a half is that the incidence has increased from 2.8 to 9.3 per 100,000 patient days.
• 3:11
  SPEAKER_00: There's been a 237% increase in C.
• 3:14
  SPEAKER_00: diffecile-related hospitalizations.
• 3:18
  SPEAKER_00: The attributable mortality has doubled from 2.2 to 4.5%, and an increased length of stay associated with these infections of 55%.
• 3:28
  SPEAKER_00: What this does is it has led to approximately$5 billion in medical costs extra for the healthcare system.
• 3:38
  SPEAKER_00: This translates into 225,000 patients hospitalized each year for it, as occurred in 2017, and 15,000 deaths.
• 3:48
  SPEAKER_00: Consequently, it's really a consideration and a problem for all healthcare facilities, and especially in long-term care, both LTACs and ECF's nursing homes, where patients are put together, the disease is often not recognized, and it is the perfect storm for the need of having both antimicrobial stewardship as well as infection prevention aspects occur.
• 4:18
  SPEAKER_00: And so that's really one of our first most important diseases.
• 4:22
  SPEAKER_02: Yeah.
• 4:23
  SPEAKER_02: And so the second one, CRE, carbocam resistant enterabacterceae, it's been identified by the CDC in the recent 2019 list of most worrisome antibiotics resistant threats.
• 4:38
  SPEAKER_02: And the reason why is because there are over 13,000 cases in hospitalized patients that were reported in 2017 with over 1,000 deaths in the U.S.
• 4:50
  SPEAKER_02: If you think of the long-term care patient, typically those patients they have devices, they have catheters, they have long courses of antibiotics, and those patients are most at risk for acquiring CRE or these multidrug resistant organism infections.
• 5:06
  SPEAKER_02: And preventing CRE infections and containing the spread of carbocent resistance is extremely vital.
• 5:13
  SPEAKER_02: And that becomes even more vital in this long-term care patient setting where they already are frail, they already have some other comorbid conditions going on.
• 5:21
  SPEAKER_02: These long-term care settings are a major reservoir for CRE in healthcare facilities, and it's part of this rapid regional dissemination of theory.
• 5:32
  SPEAKER_00: The third organism is one that is emerging and is raising concern across the US and across the world because it's a new type of resistance that we weren't expecting, and this is Canada Auris.
• 5:50
  SPEAKER_02: So Canada Oris was first identified in 2009 in Asia, and as Dr.
• 5:55
  SPEAKER_02: Goldstein stated, it's a concern now in the U.S.
• 5:58
  SPEAKER_02: And it's spreading like wildfire in the U.S.
• 6:01
  SPEAKER_02: Actually, according to the CDC, by 2018, the U.S.
• 6:05
  SPEAKER_02: recorded over 300 clinical cases of Canada Ourus infections.
• 6:10
  SPEAKER_02: In less than a year, there were these number of cases more than doubled to around 900 confirmed cases and 30 probable cases in 14 states.
• 6:19
  SPEAKER_02: And New York represented uh nearly half of these cases.
• 6:23
  SPEAKER_02: And this deadly fungus, it preys on those patients who have a very weak immune system.
• 6:28
  SPEAKER_02: So you think of those long-term care patients, again, they're frail, they have invasive devices.
• 6:32
  SPEAKER_02: With the average patient being 69 years of age, and it affects those, you know, typically in a long-term care setting.
• 6:40
  SPEAKER_02: And typically when a patient may present with bloodstream infection, uh, may present with an ear infection or um or in the wound.
• 6:47
  SPEAKER_02: And what really makes this organism worrisome is that it's difficult to identify in laboratories.
• 6:54
  SPEAKER_02: And there needs to be, either through MOLDOS, there has to be a specific lab that is able to identify these organisms.
• 7:02
  SPEAKER_02: And that's why in the beginning I said that there's probable cases because there might even be more cases than has been identified by the CDC.
• 7:11
  SPEAKER_02: Up to 60% of patients that end up getting candidoris, they will die within 90 days.
• 7:17
  SPEAKER_02: And you know, the CDC is still trying to figure out where these virulent pathogens are and how it's spread.
• 7:23
  SPEAKER_02: So the solution is washing your hands, keeping the environment clean, and not overusing antibiotics.
• 7:30
  SPEAKER_00: The last organism, which we'll only mention, is ESBL, spectrum beta-lactamase producers, such as E.
• 7:38
  SPEAKER_00: coli, which are very common in urinary tract infections, and these E.
• 7:43
  SPEAKER_00: coli, especially strain type 131, has probably very prevalent in bacteremias, especially when associated with infections, and they're fairly deadly.
• 7:55
  SPEAKER_00: Now, if you look, there are over two billion carriers of this around the world, especially in the Asia, Southeast Asia, and in China, where in some places in Thailand, 55% of the population harbor it.
• 8:11
  SPEAKER_00: In the US and in Canada, cities where there are people who either of Asian descent and visit Asia and go there come back with it.
• 8:20
  SPEAKER_00: And this has been spreading across the U.S.
• 8:22
  SPEAKER_00: It's spreading so much so that while one has to be aware with it, there really isn't infection prevention techniques in isolation in many hospitals, although I assume some might try using infection prevention measures, that this is so prevalent that it's just there, and we're not sure there's much you can do about it.
• 8:46
  SPEAKER_01: That gives us a really great overview of those four organisms and with the potential severity of infections with these organisms.
• 8:54
  SPEAKER_01: It seems like we really do need to be concerned about outbreaks in these long-term care settings.
• 8:59
  SPEAKER_01: What are the consequences of outbreaks in long-term care?
• 9:03
  SPEAKER_00: Well, first you have to be aware of the organisms, and you have to be aware that they might be a problem for your facility.
• 9:14
  SPEAKER_00: A lot of facilities have no plans.
• 9:16
  SPEAKER_00: You know, the government and CDC have now extended uh stewardship and many things to long-term care facilities, and they're just learning how to do surveillance and what data they need.
• 9:31
  SPEAKER_00: One question is how one defines an outbreak, which is what gets reported to CDC, which is often a sudden increase in occurrence of a disease in a particular place, time, and setting.
• 9:44
  SPEAKER_00: Most outbreaks go unrecognized in nursing homes and LTACs because they really involve transmission from one patient to another, and there are one or two cases, and they go under the radar.
• 9:59
  SPEAKER_00: And so we need to think of innovative ideas of what we're doing and how we do it.
• 10:06
  SPEAKER_00: One thing that has been of interest in uh Southern California is Dr.
• 10:13
  SPEAKER_00: McKinnell has done a report called the Shield Orange County Project, where they started looking at multi-drug-resistant organism prevalence in 21 nursing homes in LTAX in Southern California.
• 10:29
  SPEAKER_00: And so you have to be aware of the issue.
• 10:32
  SPEAKER_00: And one of the things is the transfer of care is exceedingly poor that not only facilities don't communicate, physicians probably don't communicate to other physicians in the facilities of what is going on.
• 10:48
  SPEAKER_00: And with Dr.
• 10:49
  SPEAKER_00: McKinnall's project, which was published in Clinical Infectious Diseases the 1st of November of this year, it's volume 69, page 1566 for anyone who's interested.
• 11:02
  SPEAKER_00: He showed that the prevalence of MDROs was 65% in nursing homes and 80% in LTAC.
• 11:09
  SPEAKER_00: Most commonly, the MDROs in nursing homes were MRSA as 42%, ESBLs is 34%, and in LTACs it was different.
• 11:19
  SPEAKER_00: It was VRE in 55% and ESPLs in 38%.
• 11:25
  SPEAKER_00: Additionally, he noted that LTACs or nursing homes that care for ventilated patients, these are the ones that were more likely to have MDROs, including CREs, than those that don't, probably because of a lot of antibiotic use and concomitant comorbidities that occur in these patients.
• 11:48
  SPEAKER_00: And studies done by other people at UCSD in Orange County have shown that a single patient in an LTAC is going to be transferred to a hospital, to another nursing home, to a third hospital, and there's so much spread that the LA County Department of Health tried to have a transition of care form to let people know what they're getting so that what they can do about it.
• 12:14
  SPEAKER_00: But as yet, this is not mandatory.
• 12:16
  SPEAKER_00: But communication between transferring facilities is really important, especially from the acute care facility to the LTAC and also from the LTAC to the acute care when these patients are transferred back.
• 12:31
  SPEAKER_00: In fact, in one of our hospitals, certain LTACs have such a high prevalence rate of MDROs that we put them on isolation automatically until they are cleared from isolation by surveillance cultures.
• 12:45
  SPEAKER_02: Yeah, I mean I think Dr.
• 12:46
  SPEAKER_02: Goldstein brings up a good point here.
• 12:48
  SPEAKER_02: So you look at these poor transitions of care, there's a handoff from one facility to the other.
• 12:54
  SPEAKER_02: You know, I think there's a paradigm shift here that we're seeing in healthcare where it's all about transition of care.
• 13:00
  SPEAKER_02: And so unless you control the multidrug resistance organisms, MDRO in one setting, it's going to be transferred to the other setting.
• 13:08
  SPEAKER_02: That's why really controlling these outbreaks is extremely vital.
• 13:12
  SPEAKER_02: There's uh, you know, your original question asking about you know what are the consequences of these outbreaks.
• 13:17
  SPEAKER_02: There's data which has shown increased mortality, increased readmission rates.
• 13:22
  SPEAKER_02: You know, with CRE, for instance, you have a 50-50 chance of dying, just like you know, for Canada Oris, you have a high mortality rate too.
• 13:30
  SPEAKER_02: So unless you control the outbreak, your mortality and your outbreak situation is not going to get any better.
• 13:37
  SPEAKER_00: And from acute care hospital point of view, often they have trouble transferring these patients to LTAX because of the extra cost that goes into isolation and the other care that they need.
• 13:50
  SPEAKER_00: So this is a problem for patient care, transfer, and the whole system, and we all have to work together in these transitions of care and getting best care for our patients.
• 14:01
  SPEAKER_02: Yeah, and you know, lastly, before we go on to essentially summarizing, is there was a great study by Mazi Aud in CID in 2015 that did a decade experience in the Canadian facility, and it had volunteers washing hands of CDI patients, and so two times most likely to uh decrease spores.
• 14:24
  SPEAKER_02: So that expanded hand washing, I think it's a very innovative study because it shows that not only are CDI patients that transmit the organism, it's also their family members that come in.
• 14:35
  SPEAKER_02: It's also the healthcare workers that come in and take care of them.
• 14:39
  SPEAKER_02: So they show that hand washing is vital.
• 14:41
  SPEAKER_02: It's also containing these outbreaks, and that's another point for these long-term care facilities.
• 14:48
  SPEAKER_00: C difficile, the problem is not just the original infection, the problem is recurrence, and the recurrence rates are increased in people over 65, which is just the population in these long-term care facilities, people with renal insufficiency, any compromised host status.
• 15:05
  SPEAKER_00: And they've found that the admission rates in 30 days with recurrence C.
• 15:10
  SPEAKER_00: diffacil is 75% compared to 46% for those without C difficile, and the 30-day mortality is 36% compared to 25% for people with recurrence C diff compared to controls.
• 15:26
  SPEAKER_00: And both of those have uh a p-value of less than or equal to 0.001.
• 15:32
  SPEAKER_00: And in regards to that, a study, again, just published on December 1st of this year in Clinical Infectious Disease by Modi it all, M O D Y, volume 69, page 1837, looked at what are people coming in with and how does that impact?
• 15:48
  SPEAKER_00: And they looked at multidrug resistant organisms in hospitals, what's on the patient's hands and in their room.
• 15:55
  SPEAKER_00: And they found that patients had contamination of MDROs was very common and correlated with contamination of high-touch surfaces in their room.
• 16:05
  SPEAKER_00: So it's not only the house staff and the hospital personnel that need to do it.
• 16:11
  SPEAKER_00: We really need to pay more attention to washing our patients' hands in the hospital so that we don't have more high-contact surface colonization and therefore transmission through other parts of the personnel.
• 16:27
  SPEAKER_01: That's great.
• 16:27
  SPEAKER_01: So you mentioned the need for improvement in transition of care, and then also the need for improved hygiene, both for our healthcare workers and actually for our patients, as ways that some of these outbreaks can be prevented.
• 16:41
  SPEAKER_01: And are there other steps that healthcare workers can take to prevent outbreaks in long-term care settings?
• 16:47
  SPEAKER_02: There's also a bundle approach that has been shown to be effective.
• 16:50
  SPEAKER_02: So there was a study done in clinical infectious diseases March 1st, 2019, by Tomzik.
• 16:57
  SPEAKER_02: Uh, it was a quasi-experimental study that showed how to contain uh and control CRE.
• 17:03
  SPEAKER_02: And it showed a bundle approach was effective.
• 17:06
  SPEAKER_02: So contact precautions, about 90%, active surveillance cultures, 80%, monitoring, audit, and feedback was 80% cohorting patients.
• 17:18
  SPEAKER_02: That was shown to be effective, hand hygiene as well as environmental cleaning.
• 17:22
  SPEAKER_02: So I think it's not just one measure that's gonna help these outbreaks, it's gonna be a bundle approach that has been uh shown to be effective.
• 17:31
  SPEAKER_02: And that's been shown in various other studies as well.
• 17:35
  SPEAKER_01: Great.
• 17:36
  SPEAKER_01: So given these different organisms that can cause these outbreaks and the different steps that can be taken for prevention, what's a take-home message that you have for our listeners regarding outbreaks in long-term care settings?
• 17:48
  SPEAKER_00: Well, I think as we've said, you have to be aware what's in your locality as well as what is in your facility itself.
• 17:59
  SPEAKER_00: What hospitals and nursing homes transfer to each other, as we said, the transfer of care and communication is very important.
• 18:07
  SPEAKER_00: Whether you need to do surveillance cultures to see what's coming in.
• 18:11
  SPEAKER_00: We did a study in one of our LTECs and found that 7% of patients coming in had unrecognized C.
• 18:18
  SPEAKER_00: difficile from the facility, and another 7% were colonized, and there's a risk of people who are colonized to transmit, although it's only 20%, to other patients in the facility.
• 18:31
  SPEAKER_00: So you want to know about that.
• 18:34
  SPEAKER_00: You have to have active cohorting every day.
• 18:37
  SPEAKER_00: You have to pay most attention to not only personal hygiene and PPI of the staff, but what about your patients, their hygiene, and how they transmit it?
• 18:49
  SPEAKER_02: Dr.
• 18:49
  SPEAKER_02: Golstein and I, we believe in a proactive response rather than reactive.
• 18:53
  SPEAKER_02: So there needs to be an outbreak response plan which is identified ahead of it ahead of time before the outbreak has even happened.
• 19:01
  SPEAKER_02: You need to have a multidisciplinary performance improvement plan to ameliorate, to educate, and then implement that plan.
• 19:08
  SPEAKER_02: And that needs to be put into effect before the outbreak has even happened.
• 19:13
  SPEAKER_02: And I think that's crucial to understand in being proactive rather than reactive.
• 19:19
  SPEAKER_00: So people working together with ASP stewardship is very important so that we don't put selective pressure on it.
• 19:27
  SPEAKER_00: And uh, we've found by restricting fluoroquinolones, C.
• 19:32
  SPEAKER_00: difacil and the severity of C.
• 19:33
  SPEAKER_00: dipacil has gone down.
• 19:35
  SPEAKER_00: But that's a combination of action of ASP and infection prevention.
• 19:40
  SPEAKER_00: And you need to work with uh environmental cleaning of the area.
• 19:44
  SPEAKER_00: There are many new things with ultraviolet as well as the regular quaternary uh compounds that we're using, and to make sure things are done, to make sure that all things are done, that you've legislated to make sure that uh people understand and to deal with these things, because long-term care facilities are areas where there is a congregation of people who are highly treated with antibiotics with multiple comorbidities, who are really the actual best hosts for all the MDROs, and we have to be able to get a handle on them and look at each facility and what it means to control a specific outbreak.
• 20:31
  SPEAKER_02: Yeah, and I think we need to also keep our eyes out for any new outbreaks coming out.
• 20:36
  SPEAKER_02: So, hepatitis B, that remains to be a common and major issue in dialysis patients.
• 20:41
  SPEAKER_02: Some of these long-term care patients, they're on dialysis, something to stay aware of.
• 20:46
  SPEAKER_02: CRAB, which is carbofentin-resistant acinated or bacteria bumani, that's recently just been added to the CDC urgent threat list.
• 20:56
  SPEAKER_02: And there were over 8,700 cases in hospitalized patients that were reported, close to a thousand deaths in 2017.
• 21:04
  SPEAKER_02: And what makes that organism very scary is that you have a 50-50 chance of death, and it's very easily transmissible.
• 21:11
  SPEAKER_02: So there's an organism to plan for and be proactive about CUBA outbreak response put in place that if you end up having an outbreak of crab at your facility, how you can really plan for that.
• 21:25
  SPEAKER_02: And then also you have your hypervalient mucoid variant of Klebsiella pneumonia, and also your cover pen resistance and pneumonia discoids as well.
• 21:33
  SPEAKER_02: So I think keeping your eye out for other new outbreaks is is also important.
• 21:39
  SPEAKER_01: So it seems like there are a lot of current and future concerns about the possibility of new outbreaks and new organisms.
• 21:46
  SPEAKER_01: And this was really incredibly informative of Dr.
• 21:50
  SPEAKER_01: Clara Dr.
• 21:51
  SPEAKER_01: Silver, and I'm not sure.